Indonesia assist and hr2014

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Screening and Brief Intervention: ASSIST

Harm Prevention During Counseling

Assoc Prof Robert AliDASSA World Health Organization Collaborating Centre

for Research in the Treatment of Drug and Alcohol Problems University of Adelaide

Global Burden

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All Deaths

All DALYs*

Tobacco

8.8% 4.1%

Alcohol 3.2% 4.0%

Illicits**

0.4% 0.8%Source: WHO, 2002

World extent of psychoactive substance use

Attributable Mortality and

Morbidity

University of Adelaide ©

Public Health Challenge

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A vast majority of individuals with substance use disorders are unaware of the problem or do not feel they need help.

Source: SAMSHA National Survey on Drug Use and Health (2008) University of Adelaide ©

SCREENING FOR SUBSTANCE ABUSE

• Likelihood of identifying individuals with lower level psychoactive substance use who are more likely to respond to a brief interventionOpportunity to identify harmsBI are Cost and Time efficient

• Negative screen for substance abuse also warrant discussion with patient

• Strong evidence for the effectiveness of brief interventions in primary care for alcohol and tobacco low costtime efficient

University of Adelaide © 4

INTRODUCTION TO THE ASSIST

• What is ASSIST?• What does the ASSIST do?• Why use the ASSIST?• Development of the ASSIST• Where to use the ASSIST?• Who can use the ASSIST?• Resources


What is ASSIST?• Alcohol, Smoking & Substance Involvement Screening

Test

• 8 item interviewer adminstered-questionnaire

• Administration time approx. 10 minutes

• Developed for general health and welfare workers in primary care and welfare settings

• Have the potential to be used in other areas

• Cross-culturally neutral


What does the ASSIST do?• Screens for risky substance use

• tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, sedatives, hallucinogens, inhalants, opioids, ‘other drugs’

• Determines risk score for each substance • Low, moderate or high risk

• Provides an opportunity to start discussion (Brief Intervention) with client about their substance use


OVERVIEW OF THE ASSIST• Questions asked for all substance groups

– Lifetime use • Q1 Ever used

– Last 3 months• Q2 Frequency of use• Q3 Desire to use• Q4 Health, social, legal, financial problems• Q5 Failure to fulfil role obligations

– Lifetime use• Q6 Concern by others• Q7 Failed attempts to control use• Q8 Injecting behaviour


Linking ASSIST scores to the appropriate intervention

•Low Risk• Support, Promote Healthy behaviour

• Moderate Risk• Brief Intervention• Take-home materials

• High Risk• Further assessment and referral to specialist drug &

alcohol treatment service • Use Brief Intervention as referral tool


Feedback from participants• 83% attempted to cut down on their drug use

after receiving the BI

“Made me see how I was using drugs - made me more aware, more conscious of the problems associated with drug use. I did cut down my

amphetamine use”

“Gave me self worth - changed my whole life. We changed our entire environment, cut connection with all users. Didn't go to parties and made a decision to stop using. My health has improved

and I feel great”10

Humeniuk et al. (2008) Technical Report of Phase III Findings of the WHO ASSIST Randomised Controlled Trial

Where to use the ASSIST?• Primary Health Care

“Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.” (Declaration Alma Ata,1978)


SETTINGS

Health Care Centres General Welfare Speciality Centres Organizations

Primary care Correctional Services STD Clinics Any Work place

Community care Vocational Services Psychiatry NGOs, Youth Org.

Tertiary care Drop-in –Centres/VCTC

VCTC: Voluntary Counselling and Testing Centre : centres for HIV testing

Who can use the ASSIST?

• Anyone who is involved in delivery of Primary Health and Welfare Care


Personnel

Health Professionals Para-medical General Welfare

General Practitioners Health Workers Social Workers

Nurses Mid Wives Correctional Officers

Interns Health Educator Managers at workplace

Counsellors

What is the ASSIST-linked Brief Intervention?• A simple and brief discussion with the client about their ASSIST

scores and what they mean

• Intended for clients scoring in ‘moderate risk’ range

• Not intended for ‘high risk’ / dependent clients as stand-alone intervention

• Use BI to facilitate referral to specialist treatment

• Read from the ASSIST Feedback Report Card

• Can do in as little as 3 mins (usually 5-10 mins)

• Can be used as basis of ongoing support


ASSIST-linked BI is based on principles of…• FRAMES model of behaviour change (Sanchez-Craig & Miller)

• Personalised Feedback about ASSIST scores

• Client has Responsibility for their choices

• Given simple Advice about how to reduce risk associated with substance use

• Given Menu of alternative strategies to promote personal choice, goals & control

• Shown Empathy which is a potent determinant of client motivation & change

• Self-efficacy to instil optimism

• Simple Motivational Interviewing techniques (Miller & Rollnick)


Resources

• “The Alcohol, Smoking & Substance Involvement Screening Test (ASSIST): Manual for use in Primary Care”

• “The ASSIST-linked Brief Intervention for Problematic Substance Use: A manual for use in Primary Care”

• “Self-Help Strategies for Cutting Down or Stopping Substance Use: Self-Help Guide”

http://www.who.int/substance_abuse/activities/assist/en/index.html




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ASSIST Train the Trainer Online Course and

ASSIST training online course

Available: [email protected]


Harm Prevention During Counseling

RISK REDUCTION RECOGNISES THAT:

• Most people use some drugs • Many people do not want to stop using drugs• There are different level of harm a drug can

cause• The risks of drug use can be reduced• The risk reduction approach does not promote

use• risk reduction encourages drug users to lower

risk and thus reduce the harm associated with drug use

Vein CareHow to prevent vein damage

and look after veins

TYPES OF INJECTINGSubcutaneous(under the skin)

Intramuscular(into muscle)

Intravenous(into a vein)

NEEDLES – KEY POINTS

Bevel - sloping edgeBore - hole Gauge – measure of thickness

Slide under the skin at a shallow angle with the bevel facing up

VEINS AND ARTERIESVeins • carry blood towards heart• carry oxygen depleted blood• dark red blood• thin walls/not elastic or muscular• valves• no pulse – ooze bloodArteries• carry blood away from heart• carry oxygen rich blood• bright red blood• thick walls, very elastic/muscular• no valves• recognisable pulse – spurts blood

• VEIN COLLAPSE

Long term consequences of vein damage

• Ulcers – broken down skin • Abscesses - localised areas of pus within

inflamed tissue• Phlebitis – irritation of smooth inner lining of

vein• Cellulitis – painful inflammation of the skin• Gangrene – death of body tissue

Seek medical advice

• Infection – Hep C/HIV, bacterial, fungal• Missed hits – swelling around injection site• Scar tissue – filling collapsed veins• Lumps and bumps under skin

VEIN CARE

• Use a new sterile needle & syringe every time• Use smallest size needle (27G)• Clean injection site • Go slow and be gentle• Rotate sites• Learn to inject in both arms• Don’t inject where there is redness, swelling &

pain• Never inject pills • Healthy diet & adequate sleep

Opioids

Opioids

Opioids

Overdose Risk

OVERDOSE – INTRODUCTION

• Overdose is now the largest cause of death amongst injecting heroin users.

• Many drug users overdose because they don’t realize the risks they are taking

• Many deaths happen because people who see overdoses often don’t know WHAT TO DO to help

OVERDOSE RISKS

• Not knowing the strength of drugs • Not knowing body tolerance• Mixing drugs (multiple drug use)• Using alone (no one to rescue you

may death)

RECOGNIZING OVERDOSE

• Respiratory depression

- very slow and ultimately no breathing • Cyanosis

-turning blue on the lips and fingertips first

• Extreme somnolence

-hard to awaken: sleepiness• Hypotension

WHAT TO DO IF AN OVERDOSE HAPPENS?

• Stay CALM (check for danger, send for help) • A B C Airway

Breathing- look, listen & feel Compression

• Not breathing? Do Chest Compression and Rescue Breathing

• No breathing, no Pulse? Do Chest Compression and Rescue Breathing

• Breathing and Pulse: Recovery Position

THE RECOVERY POSITION

WHAT NOT TO DO IF AN OVERDOSE HAPPENS?

DON’T walk the person around – they may fall !

DON’T put the person in a bath or shower – they could drown or die by hypothermia !

DON’T check whether they are conscious by hurting them

DON’T inject them with salt water, milk, or other drugs (such as cocaine or speed).

TIPS FOR PREVENTING OVERDOSE

• Have an OD plan with the people you get high with

• Be careful if you switch dealers• Ask around, drug strength will vary• Prepare your own drugs–so you know

how strong you've made it and exactly what's in it

• Avoid mixing heroin with other drugs• Avoid shooting alone

CONCLUSION• Risk reduction provides an alternative approach &

framework to deal with IDU problems

• Risk reduction principles have been adopted in a number of countries. They have been shown to be:

Pragmatic

Humane

Effective

Holistic

• Risk reduction: a public health approach assisting in the control of HIV infection among IDUs

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Thank you


Health & Medicine

Indonesia assist and hr2014