STAYING SAFE A Manual to Train Clinical Staff in IDU Interventions

1. STAYING SAFEA Manual to Train Clinical Staff in IDU Interventions

2. INTRODUCTION TO THE TRAINING PROGRAM Day 1, Session One

3. Ground Rules • Respect: Everyone has a right to his or her opinion. We need to listen to whoever is talking and to respect them even if some of us disagree. • Punctuality: Be here on time so you won’t miss out.  • Active Participation:Be alert so you can get as much out of this training as possible. • Confidentiality: We need to trust each other; we will not talk about the private lives of other group members to our friends and families. • Honesty and Openness: It is important to be honest and open without talking about extremely personal things about others and ourselves.

4. BASICS OF DRUGS Day 1, Session Two

5. The term ‘drug’ is also referred to a‘substance’; and‘Drug users’ are referred to as ‘substance users’.

6. What is a drug? What is a psychoactive substance? • Any substance (with the exception of food and water) which when taken into the body alters its functions, physically and/or psychologically is a drug. • Any substance which when taken into the body alters the functions of the mind is called a psychoactive substance.

7. Drugs that are Widely Used in India • Alcohol • Tobacco • Benzodiazepines and Sedatives • Diazepam, Alprazolam, Nitrazepam • Cannabis

8. Drugs that are Widely Used in India (contd.) • Opioids • Heroin, Opium, Buprenorphine, Pethidine, Morphine, Pentazocine, Proxyvon • Hallucinogens • LSD, PCP, Mushrooms • Amphetamine type stimulants (ATS) • Ecstasy, Methamphetamine • Cocaine

9. Categories of Drugs • Depressants • Stimulants • Hallucinogens

10. Depressants • Depressants slow down the activity of the brain or other body functions. • Depressants slow down the messages going to and coming out of the brain. • Bodily functions such as breathing and heart rate are slowed down. • Depressants may be useful to relieve pain, reduce anxiety and deal with stress.

11. Depressants (contd.) • Opioids • Alcohol • Benzodiazepines • Solvents

12. Stimulants • Stimulants speed up the messages going to and coming out of the brain. • They can lead to increased body metabolism, elevated heart rate and wakefulness. • Stimulant users experience increased energy levels, feeling of power and strength.

13. Stimulants (contd.) • Amphetamine type stimulants • Methamphetamine, Ecstasy • Cocaine • Tobacco

14. Hallucinogens • Hallucinogens include a range of naturally occurring and synthetic drugs. • They confuse or mix up the messages that are going into and coming out of the brain. • Hallucinogen users experience hallucinations and sensory distortion.

15. Hallucinogens (contd.) • LSD (Lysergic Acid Diathylamide) • PCP (Phencyclidine) • Ketamine • Certain mushrooms • Certain cactus plants

16. Drug Misuse • Drug misuse involves taking of a drug which is illegal or harms or threatens to harm the physical or mental health or social well-being of an individual, or other individuals, or of society at large.

17. Hazardous and Harmful Drug Use • Hazardous use: use of a drug that will probably lead to harmful consequences for the user - either to dysfunction or to harm. • Dysfunctional use: use of a drug that is leading to impaired psychological or social functioning (e.g. loss of job or marital problems). • Harmful use: use of a drug that is known to have caused tissue damage or mental illness in the user.

18. ICD-10 Diagnostic Guidelines – WHO A definite diagnosis of dependence syndrome should usually be made only if three or more of the following have been present together at some time during the previous year: • Evidence of tolerance • A physiological withdrawal state when substance use has ceased or reduced

19. ICD-10 Diagnostic Guidelines – (contd.) • A strong desire or sense of compulsion to take the substance • Difficulties in controlling substance-taking behaviour in terms of its onset, termination or levels of use • Progressive neglect of alternative pleasures or interests • Persisting with substance use despite clear evidence of overtly harmful consequences

20. Abuse/harmful use • Maladaptive pattern of use resulting in physical, social, legal harm • Continued use in spite of negative consequences The same 40-year old man continues drinking alcohol after the incident

21. A ‘Dependent’ Person... • May experience: Narrowing of repertoire (range) Focus of all interest on drug Awareness of compulsion Craving Loss of control Reinstatement or relapse • Withdrawal syndrome • Tolerance to certain substance/s Source: World Health Organization Geneva: Definition of drug dependence.

22. Drug Dependence • Drug dependence is a chronic relapsing disorder. • It is a brain disorder in which biological, psychological and social factors operate.

23. How are drugs used? • Smoking • Snorting • Swallowing • Injecting • Chasing

24. Progression of Drug Use Experimental Use Recreational Use Regular Use Compulsive Use

25. Initiation of Substance Use Towards Dependence Intermittent use Susceptible Environmental EXPOSURE No use Individual Modifiers Dependence

26. Risk and Protective Factors

27. NIDA, 2008

28. Key Messages • Any substance which, when taken into the body, alters the functions of the mind (brain) is called a psychoactive substance. • Three categories of drugs: depressants, stimulants, hallucinogens • The progression of drug use is over time and goes through experimental, recreational, regular and compulsive use. • Drug dependence is recognized by characteristic symptoms such as progressive neglect of other pleasures, craving, withdrawal, tolerance, loss of control and use despite harm. • Drug dependence is a long term brain disorder and is a relapsing disorder.

29. UNDERSTANDING DRUG RELATED HARMS AND INJECTING DRUG USE Day 1, Session Three

30. Drug Related Harms Harms associated with drug use: • Opioid overdose/ death • Crime/ theft/ imprisonment/ drug syndicates • Suicide/ accidental death/ murder • Sex work • Financial/ poverty/ community/ legal/ stigma

31. Drug Related Harms (contd.) Harms associated with injection use: • Infection • Blood-borne infection from shared equipment– hepatitis, HIV, malaria • Systemic contamination infections – endocarditis, fungal abscess, osteomyelitis • Local infection from poor hygiene

32. Injecting Drug Use Related Harms - Needle and the Damage Done Sharing heroin from same bottle cap (‘cooker’), Chennai

33. Injecting Drug Use Related Harms -Unsafe Injecting Leads to HIV

34. Injecting Drug Use Related Harms -Unhygienic Settings for Injecting Heroin injecting in a public toilet, Chennai

35. InjectingDrug Use Related Harms - Some Untreated Abscesses in IDUs

36. Key Messages • Multiple harms are associated with drug use: overdose, criminality, loss of employment, financial problems, marital/ family problems. • Harms associated with injection drug use include: acquisition and transmission of blood-borne pathogens, injection related injuries and infections. • Sharing of needles and syringes and unsafe injecting practices contribute to injection drug use related harms.

37. HARM REDUCTION: UNDERSTANDING THE PRINCIPLES Day 1, Session Four

38. What are the effective approaches to drug use and HIV? • Approaches that are beneficial to drug users, their families and communities. • Approaches that can be attractive to drug users. • Approaches that address the needs of the drug users.

39. What are the effective approaches to drug use and HIV? (contd.) • Approaches that are practical. • Approaches that can effectively contain HIV among drug users. • Approaches that have ‘public health perspective’.

40. PRINCIPLES IN THE DEVELOPMENT OF EFFECTIVE APPROACHES

41. Effective Approaches • Start early (HIV prevalence among IDUs < 5%) • IDUs need to be attracted (provide need-based services) • Implement multiple programs such as • Outreach • Drug treatment such as opioid substitution therapy • Needle and syringe programs • HIV testing and counselling

42. Effective Approaches (contd.) • Target several risk behaviours at the same time • Provide access to multiple means for behaviour change: • Risk reduction information (media, pamphlets etc) • Needles and syringes, cleaning materials, condoms etc. • HIV testing with pre and post test counselling

43. Effective Approaches (contd.) Implement programs in various places: • Streets • Health settings • New outlets Rely on local drug users and ex users to serve as • Outreach workers • Role models • Peer educators • Advocates

44. Effective Approaches (contd.) • Implement programs at several levels for drug users to make and sustain behavioural changes in supportive environment • Government policy • Legal • Health institutions • Community • Network • Individual • Provide reinforcement education

45. Important Things to Consider (contd.) • Creation of a supportive environment • Working together with law enforcement and health agencies • Using a range of approaches

46. Important Things to Consider • Reaching out to IDUs who are out of treatment • Providing means for safer practices (sterile injecting equipment, condoms) • Establishing substitution programs • Offering counselling, care and support services

47. Important Things to Consider (contd.) • Ensuring adequate coverage • Undertaking rapid assessments of the nature and extent of the problem

48. Major Issue for Consideration • Supply and demand reduction on its own has not been effective in dealing with the problem of drug use and HIV. • But the effective approach is….. HARM REDUCTION

50. OVERVIEW OF HARM REDUCTION