KOKAIN. Téma: Kokain, crack a jeho uživatelé. Autoři: Jiří Valnoha, Tomáš Přikryl

V rámci projektu Nový kontakt se pracovníci Sdružení Podané ruce, o. s. zúčastnili týdenní stáže ve Velké Británii, kde se seznámili s tamními postupy uplatňovanými v drogové oblasti. Stáže se týkaly následujících témat: Mobilní uživatelé drog Kokain, crack a jeho uživatelé Gender problematika v drogové oblasti Nové preventivní postupy v rámci činnosti nízkoprahových klubů Nové motivační postupy v práci kontaktních center Účastníci stáží poté vypracovali ke svému tématu manuál, ve kterém popisují daný problém, jak je tento problém řešen ve Velké Británii, které postupy by bylo možné zavést také u nás a další otázky nabízející se k tématu.

Téma: Kokain, crack a jeho uživatelé Autoři: Jiří Valnoha, Tomáš Přikryl

KOKAIN Co to je? Kokain je silná stimulační droga, výrazně ovlivňující CNS. Působí také jako lokální anestetikum. Nejčastěji se s kokainem můžeme setkat jako s jemným krystalickým práškem bílé barvy (hydrochlorid kokainu), který je bez zápachu, hořké chuti. Kokain se získává z lístků rostlin Erythoxylum coca a Erythoxylum novagranatense. Konzumování samotných lístků spolu s vápenatým materiálem (spálené mušle nebo zrní) je nejstarší známý způsob užívání kokainu. Tímto způsobem jej užívá až 90 procent andských indiánů. Z lístků se za použití silných chemikálií (kyselina sírová, benzin, manganistan draselný, čpavek, vápenná voda a několik dalších kyselin) louhuje kokainový sulfát tzv. pasta, base, bascudo nebo pitilitio. Jedná se o hnědou, někdy navlhlou látku, která kromě kokainu obsahuje řadu zmíněných nečistot. Pasty se získá přibližně 400 gramů z jednoho akru keřů. Používání chemikálií při výrobě způsobuje vážné ekologické problémy (devastace půdy, eroze, ničení lesů, vznik pouští, znečištění vody a vzduchu, úhyn rostlinných a živočišných druhů,…) v zemích, které jsou hlavními producenty kokainu (Peru, Bolívie, Kolumbie). Kokainový sulfát, který se většinou kouří společně s tabákem nebo marihuanou, způsobuje vážné zdravotní problémy. Čistý (90%) hydrochlorid kokainu se získává další rafinací sulfátu za použití petroleje, kyseliny sírové, metylalkoholu, benzolu, uhličitanu sodného a hypermanganu. Zpětným procesem se za použití dalších chemikálií získává crack. Ten není rozpustný ve vodě, nedá se proto šňupat ani aplikovat injekčně. Většinou se kouří spolu s tabákem nebo marihuanou, nebo se spaluje a vdechují se jeho výpary.

TENTO PROJEKT JE SPOLUFINANCOVÁN EVROPSKOU UNIÍ, STÁTNÍM ROZPOČTEM ČESKÉ REPUBLIKY A JIHOMORAVSKÝM KRAJEM.

Účinky Jihoamerickým indiánům žvýkání listů koky pomáhá snášet fyzickou námahu a bolest. Koka jim poskytuje důležité látky - tiamin, riboflavin a vitamín C. Vápenatý popel se přidává pro lepší extrahování alkaloidu. Oproti tomu užívání všech dalších forem kokainu zdravé není ani zdaleka. Kokain se aplikuje většinou šňupáním. Při injekční aplikaci mohou způsobit vážné problémy příměsi, kterými kokain „řežou“ pouliční prodejci (pudr, mouka, škrob, chinin, glukóza, amfetamin, lidokain, atd.). Dlouhodobé užívání vede ke zvýšení tolerance (nutnosti zvyšovat dávku pro dosažení stejného účinku), u některých lidí se naopak zvyšuje citlivost na drogu a stačí jim dávka stejná nebo i mírně nižší. Na kokain může vzniknout silný psychický návyk s velice silnou touhou po další dávce. Abstinence vyvolává stavy deprese, úzkosti, únavy a neklidu, které mohou trvat i několik měsíců. Historie Předpokládá se, že andští Indiáni žvýkali listy koky už před 6 000 lety. V říši Inků bylo žvýkání koky výsadou vládnoucí třídy, ale později se rozšířilo mezi všechny společenské vrstvy. Do Evropy koku přivezli španělští kolonizátoři. Kokové lístky však vysušením a transportem ztráceli na účinnosti a nezískali si příliš velkou oblibu. V roce 1855 poprvé izoloval aktivní alkaloid z lístků koky německý chemik Friedrich Gaedcke a pár let po něm Albert Niemann. Po roce 1880 začali objevovat účinky kokainu lékaři, Rus Vasilij von Anrep a Němec Theodor Aschenbrant. V roce 1884 zkoumal účinky kokainu Sigmund Feud (v té době lékař ve vídeňské nemocnici). Varoval, že kokain způsobuje psychické a intelektuální poškození, slabost, vyhublost, a morální zkaženost. Zároveň prohlásil, že užívání koky v rozumné míře spíš zdraví podporuje, než mu škodí. Jeho pokusy prokázat, že kokain lze použít k léčbě morfiové závislosti skončily neúspěšně. Na přelomu 19. a 20. století bylo zaregistrováno velké množství léků, které obsahovaly extrakt z kokových lístků a používaly se téměř proti všem nemocem. Během dvou desetiletí se kokain rozšířil po Evropě a Americe a v průběhu 20. století prožíval různé vlny obliby střídané jinými drogami. Největší rozmach dosahovalo užívání kokainu v USA kolem roku 1985, kdy se počet narkomanů odhadoval až na 12 milionů. Rizika Po užití kokainu se zrychluje srdeční tep a tlak, objevuje se pocení a sucho v ústech. Při dlouhodobém užívání způsobuje nechuť k jídlu, srdeční arytmii. Při šňupání nastává podráždění nosní sliznice a výtok z nosu podobný rýmě. Kouření způsobuje chronické respirační potíže, záchvaty kašle, někdy i ztrátu hlasu. Smrt z předávkování se vyskytuje jen zřídka. Při vyšších dávkách kokain působí jako anestetikum na mozková centra kontrolující dýchání - nastává třas, křeče, zmatenost, závratě a specifické dýchací potíže - rychlé střídání lapání po dechu a mělkého dýchání (tzv. reakce Caseyho Jonese). Při injekční aplikaci hrozí abscesy, srážení krve a přenos infekcí (hepatitidy a HIV). Ani psychika nepřijde zkrátka. Při pravidelném užívání vyvolává kokain nespavost, střídání nálad, někdy i paranoiu, zmatenost, agresi, halucinace, přecitlivělost, atd. www.extc.cz TENTO PROJEKT JE SPOLUFINANCOVÁN EVROPSKOU UNIÍ, STÁTNÍM ROZPOČTEM ČESKÉ REPUBLIKY A JIHOMORAVSKÝM KRAJEM.

Užívání kokainu ve světě a ve Velké Británii Počet uživatelů kokainu (v milionech) a jako procento populace nad 15 let Milion

% populace

Severní Amerika

7.0

2.2

Jižní Amerika

3.1

1.1

Oceánie

0.2

0.9

Západní Evropa

2.2

0.7

Východní Evropa

0.1

0.04

Afrika

1.3

0.3

Asie

0.2

0.01

Globálně

14

0.3 Global Illicit Drug Trends, United Nations, 2001

Velká

Británie

V Anglii a Walesu byla celoživotní prevalence užití kokainu (včetně cracku) u mládeže ve věku 16 – 24let 8% v roce 1998 a 9% v roce 2001. (BCS, 2002, in press). V roce 2001 byla celoživotní prevalence užití kokainu u mužů 16 – 59 let 7% a žen pouze 3%, v roce 1998 to bylo u stejné skupiny 6% mužů a žen 3%. Prevalence užití kokainu za posledních 12 měsíců byla v roce 2001 7% u mužů ve věku 16 – 24let a % žen, oproti tomu to v roce 1998 byly 4% mužů ve věku 16 – 24 let a 3% žen. Polyvalentní užívání (včetně alkoholu, léků na předpis atd.) tvořilo v roce 2001 47% veškerých užití drogy. Pouze 8% z 24 458 respondentů uvedlo spolužití heroinu jako podružné drogy. Nejčastěji TENTO PROJEKT JE SPOLUFINANCOVÁN EVROPSKOU UNIÍ, STÁTNÍM ROZPOČTEM ČESKÉ REPUBLIKY A JIHOMORAVSKÝM KRAJEM.

uváděnými podružnými drogami byly benodiazepiny, jejichž užití spolu s jinou drogou přiznalo 89% uživatelů, dále pak extáze 75%, kokain 70% a kanabis 66 V roce 2000 se zvýšil počet úmrtí souvisejících s užitím kokainu a cracku a rovněž tak počet zabaveného kokainu a cracku. Zvýšilo se užívání kokainu mladými lidmi a také počet uživatelů s kokainem/crackem jako hlavní drogou v indikátorech léčby.


Kokain - formulář zhodnocení (assessment) Datum_______________ Pracovník jméno: _____________________________________________________________________ Organizace jméno: _______________________________________________________________________ Osobní údaje: Jméno: Příjmení: Datum narození: ______

Věk:

Sex: M / F

Současná adresa:

Poslední stálá adresa:

Kontaktní telefonnní čísla:

Bezpečné pro kontaktování?

1.

Ano/Ne

2.

Ano/Ne

3.

Ano/Ne

Jméno praktického lékaře:

Adresa ordinace:

Telefonní číslo:

Etnický původ: Prosím určete skupinu

________________ nebo

Jak si klient přeje sám sebe popsat :


Bílý Brit Bílý & černý African Ind Černý Karibik Číňan

Bílý Ir Bílý & Asiat Pakistanec Černý African Jiný

Bílý jiný Other mixed Bangladešan Černý jiný

Bílý / Černý Karibik Jiný Asiat

Doporučení: Prosím určete odkud byl klient poslán do této organizace

_.

A Koordinátor péče

F Dobrovolná drogová organizace

B Probační služba

G Sám

C Sociální služby

H Praktický lékař

D Primární péče

I Jiný (prosím specifikujte):

E Místní drogový tým Užívání drog: Způsob:

A - Kouření

B - Šňupání

C - IV

D - Orálně

E - Jiné

Frekvence: Prosím specifikujte jestli užívají denně, týdně nebo měsíčně a také obvyklý počet aplikací během jednotlivé drogové “akce” . Typ

Užití

Užití v posledních 30 dnech

Množství & frekvence

Způsob

sdílení “nádobíčka”

Věk prvního užití

Kokain Hydrochloride Crack kokain

Freebase kokain Speedballing kokain & heroin Amfetamin

Heroin

Cannabis

Ecstasy

Ilegální benzodiazepin


Ilegáln methadon

Alkohol

Preskribované Drogy Jiné Drogy 1

Jiné Drogy 2

Jiné Drogy 3

Harm reduction: Dostal klient někdy jakoukoli radu ohledně užívání cracku a kokainu? Ano

_

Ne

_

Ohledně jakého způsobu užívání dostal harm reduction informace? Kouření___

Šňupání___

IV___

Orálně___

Jiné___

Dluhy: Prosím zjistěte jestli má klient nějaké problémy v souvislosti s dluhy a odhadně te částku kterou dluží: Plyn, elektřina etc: £ Bankovní půjčky etc: £ Jiné:

Daně: £ Přátelé / rodina: £

Nájem: £ Dealeři: £

Support networks: Prosím zjistěte jaké formy podpory momentálně jsou, nebo mohou být pro klienta dostupné? Typ podpory Partner

Nyní dostupný

Možná dostupný

Nedostupný

Rodina Neužívající přátelé Podpůrný pracovník Podpora péče o děti Zaměstnání


Poradce Vzdělávací podpora Drogová podpůrná skupina (NA, CA, jiné) Náboženství (kostel, mešita etc) Jiné: 1. 2. 3.

Prosím zajistěte, aby klient dostal informace o podpůrné síti, které může být zajišťována nebo přímo prováděna organizací .


Ubytování: Prosím zjistěte současný typ ubytování klienta: Vlastní nemovitost:

Bydlení s partnerem:

Obecní byt:

Bydlení s přáteli:

Hostel:

NFA(?):

Podnájem (Bed and Breakfast):

Jiné:

Jak dlouho klient žije v současném ubytování / been NFA? Týdny

Měsíce

Roky

Je ubytování v oblasti známe užíváním drog?

Ano

/

Ne

Jsou zde nějaké nedoplatky, soudní vystěhování?

Ano

/

Ne

Ano

/

Ne

Popis:

Žije v tom samém ubytování ještě jiný uživatel drog? Popište vztah (partner, přátelé, známí etc):

Právní situace: Prosím zjistěte současnou právní situaci klienta , obvinění / aktuální rozsudky a veškeré relevantní záležitosti: Nic (přejděte k dalšímu oddílu)

Poslán do vyšetřovací vazby(b):

Podmínečný trest (a):

Nařízená léčba a testy (a):

Kauce (c):

Nedokončené záležitosti(e):

Výkon trestu (b):

Veřejně prospěšné práce (a):

Obvinění/ Aktuální rozsudky: 1. 2. 3. 4.


5. 6. 7. a. Pokud je klient v současnosti v podmínce nebo veřejně prospěšné práce: Pověřený úředník: Probační úřad:

Telefon:

Fax:

Datum začátku nařízeného dohledu:

______

Datum konce nařízeného dohledu:

______

b. Pokud je aktuálně ve věznici: Číslo věznice: Pracovník: Věznice: Telefon:

Fax:

Typ rozsudku: Vyšetřovací vazba

Vězení (1 - 3 years)

Vězení (3 - 7years)

Vězení (doživotí)

Očekávané datum soudu: _____________ Očekávané datum propuštění: ___________ c. Pokud je aktuálně propuštěn na kauci: Kontakt s Pracovníkem Arrest Referral?

Ano

/

Ne

Pokud ano je možné ho kontaktovat?

Ano

/

Ne

/

Ne

Jméno pracovníka:

Telefon:

d. Je si klient vědom nevyřešených záležitostí? Obvinění:

Ano

/

není si jist

Odhadované datum:

1.


2. 3. 4. 5. Jméno právníka: Adresa:

Telefon: Jak je užívání drog financováno: Prosím zjistěte jak klient financuje své užívání drog (včetně kombinací metod): Mzda/plat: Úspory: Půjčky: Komerční sex průmysl: Jiné (prosím specifikujte):

Příjem: Dealování ilegálních drog: Krádeže v obchodech: Podvody:

Pouliční loupeže: Využívání partnera: Krádeže: Vloupání:

Péče o děti: Má klient nějaké děti? Číslo dítěte 1.

Věk

Ano

/

Ne (přejděte k dalšímu oddílu)

Žije s klientem

Žije tady

Číslo dítěte závislého na klientovi

2. 3. 4. 5. Jsou zde nějaké právní záležitosti týkající se dětí?

Ano

/

Ne

Ano

/

Ne

Jestli ano upřesněte:

Je zde nějaké kontakty se sociálními službami? Pokud ano zjistěte podrobnosti:


Určený pracovník: Adresa:

Telefon: Prosím zjistěte jaký typ podpory by klient uvítal vzhledem k rodinným příslušníkům? Podpora rodičovských dovedností:

Podpora v právních otázkách:

Podpora v práci se sociálními službami:

Péče o děti během léčby:

Podpora v kontaktu se soc. službami:

Rodinné poradenství:

Jiné formy podpory:

Budoucí akce: Prosím specivikujte akce, které budou provedeny po tomto zhodnocení: Podání informací o harm reduction Doporučení k vhodné somatické lékařské péči Informace o podpůrných sítích (NA, CA etc)

Doporučení ke zhodnocení (community assessment) Doporučení k vhodné psychické lékařské péči Domluva schůzky s rodinou či přáteli

Podpora či doporučení v záležitostech péče o děti

Informace ohledně drogových služeb / užívání drog

Doporučení do vhodnější drogové organizace Doporučení k podpoře bydlení Udržovat spojení s pracovníky kriminální služby / právníky Odeslání k poradenství

Domluva dalších schůzek Podpora v oblasti dluhů Rozvoj základních strategií prevence relapsu Žádná akce

Souhlasí:

Klient:

Podpis:

Pracovník:

Podpis:

Poznámky pracovníka:


Cocaine assessment form - Checklist A: Physical health Please indicate if client has experienced any of the following ever and in the last 30 days. NB If in any doubt at all about any physical health problem(s) please refer to appropriate healthcare agency. When more than one symptom present, possible indicators of: A - TB Symptom: Weight loss (A)

B - 'Crack Lung' C - Stroke Ever experienced

D - Cardiovascular problems In last 30 days

Night sweats (A) Insomnia (A) Loss of appetite (A) Persistent cough (A) Coughing up blood (A) Coughing up dark bile (B) Breathing difficulties (B) Speech difficulties (C) Loss of movement (face, limbs etc) (C) Chest pains (D) Numbness / tingling (arms and hands) (D) Pains in shoulder (D) Kidney pains (D) Convulsions / fitting Blackouts Tiredness / fatigue Nausea Stomach pains Muscle pains Tremors / shakes Vein damage / abscesses


Nasal damage / bleeding Other problem (s):

Physical health cont. Health problems that have been diagnosed / or have had treatment for in the past: 1. 2. 3. 4. If sickle cell or epilepsy diagnosed is client experiencing an increased amount of attacks? Yes

/

No

Any current medication (please list): 1. 2. 3. Is medication being regularly taken?

Yes

/

No

Other issues:


Cocaine assessment form - Checklist B: Mental health Mental health Please indicate if client has experienced any of the following ever and in the last 30 days. NB If in any doubt at all about any mental health problem(s) please refer to appropriate healthcare agency. Symptom:

Ever experienced

In last 30 days

Anxiety Panic attacks Paranoia Mood swings Depression Suicidal thoughts Visual hallucinations Auditory hallucinations Lethargy Difficulty in concentrating Memory problems Other

Mental health cont. Mental health problems that have been diagnosed / or have had treatment for in the past:

Any current medication:

Is medication being regularly taken?

Yes

/

No


Cocaine assessment form - Checklist C: Client self perception Self perceptions: Please indicate how the client feels about themselves: Depressed:

Disillusioned:

Angry:

Anxious:

Positive about self:

Low self esteem:

Other:

Please indicate how the client feels about receiving treatment for their drug use: Doesn't think treatment will work:

Coerced into treatment:

Worried about entering into treatment:

Looking forward to treatment:

Its an opportunity:

Not sure:

Other:

Please indicate how the client feels about their drug use: Dissatisfied with lifestyle:

Doesn't want to take drugs again:

Would like to control drug use:

Only wants to address problematic drug use:

Doesn't feel drug use is a problem:

Not sure:

Other:


Client care plan Name_________________

Sheet Number_____

Goal:

Action:

Action:

Action:

Action:

Action:

Action:


Cocaine care plan form Client's name: _____________________________________________DOB________________________ Agency name: _________________________________________________________________________

Action completed from assessment form : Please indicate the action agreed after initial assessment and date achieved: Action agreed

Date

Sign

Harm reduction information given: Referral to appropriate physical health care: Information on support networks given: Referral / support given with childcare issues: Referral for community assessment: Referral to appropriate mental health care: Appointment arranged with family or friends: Information given on service / cocaine use: Referral for accommodation support: Liaised with criminal justice worker / solicitor: Referral for counselling: Support given regarding debt issues: Developed initial relapse prevention strategies: Other (specify): BBV Risk assessment completed:

Yes

/

No

Yes

/

No

Has BBV test been requested?


Has client been informed of Pre / Post test counselling?

Yes

/

No

Information consent: I give the __________________________ consent to contact and share information with the following people / agencies: Agency / Person:

Date:

Sign:


Care plan: Care plans should be agreed upon and involve the client in the process: Main identified needs: 1. 2. 3. Date:

Agreed Action:

Sign:


Care Plan Review:

Date:

Care plan reviews may be done in conjunction with other significant agencies that are working with the client. Other agencies involved in care plan review: 1. 2. 3.

Main needs identified: 1. 2. 3. 4. 5. 6. Are the main needs identified still relevant to client? Yes

/

No

If 'no' what areas are not being addressed? 1. 2. 3. What is clients perception of progress:

Any other issues / comments:

Signed:


Blood borne virus (BBV) risk assessment (cocaine) Assessment date: _____________ Personal information:

Worker ________________

Forename(s): Surname: Date of birth: ______

Age:

Sex: M / F

Sexual health: Please indicate whether client has practised safer sex (explain)? Always

Most of the time

Sometimes

Never

How many sexual partners has client had over last 10 years? None

1-5

5-10

10-20

20-30

More

Equipment sharing: Age at first equipment sharing ___ Never shared equipment ___ Route of use Shared equipment in Ever shared last 30 days? equipment? Intravenous

Ever passed on using equipment?

Smoking (pipe) Snorting History of previous testing for Hep B/C and HIV: Date of first test __ __ __ BBV Never tested

Date of last test __ __ __ More than Dates once Hep B 1. 2. 3. Hep C 1. 2. 3. HIV 1. 2. 3. Clients understanding about contracting or transmitting BBVs: Tested once

Results P/N

Clients concerns about contracting or passing on BBVs: If client has not had any tests would they like to be tested: Yes

/

No


Patterns of use Answer the questions as truthfully as possible so that you can become more aware of when you are going to use or are building up to use. Once you have identified them, develop strategies that will either help you avoid them or cope with them. Tick all the box’s that apply to you or write alternatives down.

1.

How do you physically feel before you use?

Shaking

_

Heart beating

_

Energised

_

Fast breathing

_

Sweating

_

Stomach churning

_

Other:

2.

How do you feel emotionally before using?

Anxious

_

Depressed

_

Excited

_

Happy

_

Guilty

_

Angry

_

Other:

3.

Is there a specific time of day, week, and month when you use?

Afternoon

_

Evening

_

Friday’s

_

Weekends

_

Monthly

_

Anytime

_

Other:

4.

What places do you use in?

Home

_

Partners/friends house

_

Street

_

Crack house

_

Club

_

Pubs/bars

_

Home area

_

Work area

_

Social area

_

Dealing area

_

Other:

5.

What areas do you use in?


Where user friends live

_

Area changes

_

Other:

6.

Who do you use with?

Alone

_

Partner

_

Friends

_

Other users

_

Smoking partner

_

Dealer

_

Other:

7.

How do you get the money to use?

Giro

_

Work

_

Dealing

_

Crime

_

Savings

_

Selling/borrowing

_

Other:

8.

How much money gets you thinking about using?

£5 -£10

_

£15 - £20

_

£40 - £50

_

£90 - £100

_

£150 - £200

_

£200 - £300

_

Other:

9.

What equipment do you use?

Cigarette papers

_

Home-made pipe

_

Straws & cards

_

Glass pipe

_

Burner/lighter

_

Syringes etc

_

Binge using

_

Other:

10. What pattern of use do you have? Daily use

_


Whenever I can

_

When I get the money

_

When socialising

_

Depends on mood

_

Other:

Now look at the answers and use the next page to help you try to develop some basic Relapse Management strategies.

Awareness Action Plan Name: 1. How do you physically feel before using? Become aware of how you feel physically and use this as an indicator. Most of the physical feelings before use are down to the release of adrenaline and can be controlled. Anything that helps you relax and bring your breathing rate down. Try acupuncture, breathing exercises, relaxing oils, herbal teas, massage etc. Find out what works for you. Personal plan:

2.

How do you emotionally feel before using?

Again use these as indicators, but also be aware of situations that may develop these feelings. E.g. if you know a situation or person usually makes you feel angry or depressed look at ways of coping with this or avoiding the situation. Also look at the part that you have to play, are you sparking off the situation to be able to use it as a justification? Personal plan:

3.

Is there a specific time of the day, week, and month when you use?

This will very much depend upon your pattern of use, but once you are aware of your danger times you can develop strategies that make these times less of a problem. E.g. if your using time usually begins every Friday then look for alternatives, try to be in a safe place with people that will support you and are not connected with your use. Personal plan:

4.

What places do you use in?

Most places that you use in can be avoided if you really want to. Places have strong associations and will almost always contain the people that you use with. Avoid them no matter the reason. If you use at home try to change the


environment, move furniture around, get rid of particularly strong associations like tables etc. Decorate or clean and make it fresh. Personal plan:

5.

What areas do you use in?

Some of the areas that are associated with using for you can be difficult to avoid so you need to develop strong strategies. Streets can be avoided and you can change your route it may be less convenient but will help to keep you safe. Other areas can be avoided altogether and there should be no reason to enter them other than to use. Be aware! Personal plan:

6.

Who do you use with?

Avoid people that you use with. Most of these will be drug using acquaintances with the relationship based around using rather than friends. If they are friends then they will understand why you cannot have contact with them. If you use alone then try to be with people at your danger times. Members of the family and partners can be difficult and you have to look at what you want most? Personal plan:

7.

How do you get the money to use?

Receiving money or knowing when you are going to get it, can be one of the biggest triggers to use. These times can be extremely dangerous and you need to work out ways of coping with this. E.g. always cash your giro when your with someone you trust, change the post office if the dealers hang around the usual one. Get rid of cash point cards, arrange for someone else to control finances etc. Crime also triggers adrenaline so will make your cravings more acute, avoid. Personal plan:

8.

How much money gets you thinking about using?

As stated before money is one of the biggest triggers to use, and having the money with you or available to use can be a major temptation. You need to be aware of the amounts that spark you off. Whatever that amount try not to carry the money around with you especially at danger times. Also be aware that when you stop using your pattern may change and the amount becomes less. Personal plan:


9.

What equipment do you use?

If you are serious about giving up you need to get rid of everything that you associate with using. Throw these things away and check your house for any things that may be lying around including foil, rubber bands, pens etc. Be aware that you don’t buy anymore without thinking. If you use on an inhaler then ask your Doctor to change it to one that works on a propeller system. Personal plan:

10. What pattern of use do you have? Awareness of your individual pattern is really important and can combine with the answers to the previous 9 questions. Be aware of how money, moods, social contacts fit in as well as the frequency of your use. If you binge use, be especially aware that the periods of clean time between each use can lull you into a false sense of security. Also be aware of the amounts of money involved. Personal plan:

Now that you're more aware of patterns and have developed plans to cope with these, stick to them.

Cocaine monitoring form

To be able to gain an accurate record of a client's progress / change this assessment should be undertaken once a week. Scores should be added together and entered into the score sheet.

Assessment No:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15


a) Drug and alcohol Use Drug combinations: 1 Cocaine and cannabis 2 Cocaine and alcohol 3 Cocaine and heroin 4 Cocaine and more than one combination

Alcohol use: 1 No alcohol use 2 Some use of alcohol (units) 3 Regular use of alcohol 4 Daily use of alcohol

Cocaine use: 1 No cocaine use at all 2 Some use of cocaine (1-2 x/wk)) 3 Regular use of cocaine (3-5 x/wk)) 4 Daily use of cocaine (or binge use of 2–4 days per week)

Other drug use: 1 No other drug use 2 Some use of other drugs (1-2 x/wk) 3 Regular use of other drugs (3-5 x/wk) 4 Daily use of other drugs Total of section a) =

b) Risk behaviour Amounts of cocaine used: 1 No cocaine used 2 £25 - £100 per week 3 £100 - £500 per week 4 Over £500 per week used

Route of cocaine use: 1 Ingested 2 Snorted 3 Smoked 4 Injected

Harm reduction: 1 Always practices harm reduction 2 Safer drug use but unsafe sex 3 Sometimes shares using equipment 4 Ignores / unaware of harm reduction when using

General risk taking behaviour: 1 Not taking risks 2 Some risks to get drugs (+ previous) 3 Takes risks to fund habit (+ previous) 4 Takes risks whilst using (+ previous) Total of section b) =

c) Triggers and cravings Trigger situations: (events that start craving episodes) 1 No trigger situations 2 Some trigger situations (1-5 x/wk) 3 Regular trigger situations (daily) 4 Frequent trigger situations (5+ daily) Cocaine cravings: (thoughts of using) 1 No cravings for cocaine 2 Some cravings (1-5 x/wk) 3 Regular cravings (daily) 4 Virtually constant craving

Ability to not use when craving: 1 Always, never use 2 Most of the time 3 Some of the time 4 Never, always use Type of craving: (main type experienced) 1 No cravings 2 False or misinterpreted cravings 3 Hidden cravings 4 Open cravings Total of section c) =

d) Health Physical Health: 1 No physical health problems 2 Minor health problems (weight loss, aches and pains etc) 3 Medium health problems (Hep C, crack lung, seizures) 4 Major health problems (recent heart attack, stroke, severe respiratory problems)

Mental Health: 1 No mental health problems 2 Minor problems (anxiety, low self esteem) 3 Medium problems (depression, paranoia, panic attacks) 4 Major problems (psychosis or suicidal ideations) Total of section d) =


e) Criminogenic factors Involvement with other drug users: 1 No contact with other users 2 Occasional contact with other users 3 Regular contact with other users 4 Constant contact with other users

Perceptions of crime: (workers perceptions) 1 Not committing any crime 2 Occasional minor crime committed (shoplifting, fraud etc) 3 Regular minor crime committed 4 Regular serious crime committed (dealing, burglary, robbery etc)

Leisure: (not including drug or alcohol use) 1 Most free time spent constructively 2 Some time spent on leisure activities 3 Very little leisure time taken 4 No leisure activities

Perceptions of crime: (users perceptions) 1 Will not commit crime to support habit 2 Understands connections with cocaine use (avoiding crime situations) 3 Would only commit crime as last resort 4 Crime is necessary to support habit Total of section e) =

f) Social / lifestyle factors Eating Habits: 1 Regular meals (1-3 meals per day) 2 At least one meal per day 3 Irregular meals / snack eating 4 Sometimes doesn’t eat for days

Accommodation: 1 Safe drug free accommodation 2 Safe accommodation in drug area 3 Lives with other drug users (hostels) 4 Living in crack houses / with users

Sleeping Habits: 1 No problems sleeping (6+ hrs per night) 2 Some problems (hard to get to sleep or difficulty waking up) 3 Moderate problems (awake during night, some sleep gained) 4 Severe problems (no pattern, awake for days sometimes, little sleep gained)

Debt: 1 2 3 4

No money owed anywhere Some debt but regular payments (managing the situation) Lots of debt, no regular payments (lots of final notices etc) Chaotic debt on all levels (rent, services, dealer etc)

Total of section f) = g) Support networks Family and friends: 1 Has good support from family and friends 2 Has some support from family and friends 3 Little support available 4 No support at all

Other support networks: 1 Is receiving support from wide range of organisations (inc drug agencies) 2 Support mainly gained from drug or criminal justice agencies etc 3 Support offered but not utilised (except for current service) 4 No support networks at all Total of section g) =

h) Self perceptions Self esteem: 1 Feels positive about self 2 Feels disappointed with self 3 Feels worthless sometimes 4 Feels worthless most of the time

Paranoia: 1 Does not feel paranoid 2 Has suspicions about new people 3 Feels suspicious of known people 4 Very suspicious / feels persecuted

Depression:

Anxiety:


1 2 3 4

Does not feel depressed Feels depressed sometimes Feels depressed a lot of the time Depressed most of time / suicidal ideas

1 2 3 4

Does not feel anxious Some anxiety in new situations Anxiety felt a lot of the time Severe anxiety / panic attacks

Total of section h) = Sources: Cocaine Monitoring Tool, Minnesota University. Christo Inventory of Drugs

Cocaine monitoring form: evaluation sheet Please enter the scores from each sheet under the week it was undertaken rather than the number of assessments if some were missed. Increases in score may not necessarily mean that crack or cocaine has been used but could point to the increased likelihood of use. If increases are identified they should be worked with in conjunction with the client. Client Name: Date of first assessment: CMF score: Weeks Nos Drug & alcohol use: Risk behaviour: Triggers & cravings: Health: Criminogenic factors: Social / lifestyle factors: Support networks: Self perceptions: Totals:

Needs identified from assessment: Drug & Alcohol Use:

Risk Behaviour:

Triggers & Cravings:

Health:


Criminogenic Factors:

Social / Lifestyle Factors:

Support Networks:

Self Perceptions:

Triggers Chart Everybody is an individual and so is your habit. In order for you to increase your chances of getting off crack or cocaine you need to understand what your main triggers are. Once this is understood you can then start to develop strategies that will help you avoid / cope with these triggers. Take a little time and think about the events leading up to your use. Trace the steps back and try and identify the first things / events that set you upon a course to use. List these in the first column. Once this is done look at each individual trigger think of ways that these can be avoided or coped with. Talking to other people about these triggers can sometimes help to develop new ideas.

Trigger

Action

1.

2.

3.

4.

5.

6.

7.


If you think that an action to avoid triggers may be difficult to do then seek support for this or discuss with somebody else to come up with an alternative. Once you are happy with your actions stick to them. Don’t be tempted to put yourself in danger for a test! Trigger areas Areas can have very strong connections to using and can be associated with particular places, other users and most importantly dealers. It is vitally important to be able to avoid these. Even if you live in a dealing you can avoid ‘hot spots’ by taking alternative routes, catching a different bus and changing what shops / post offices you use. Identify the areas that are most dangerous for you, why are they dangerous, think of all the possible reasons that you may have to go there and then work out the action needed to make it safer.

For example: Danger area? 1. Local shops

Possible dangers? Dealers and users present.

Why go in area? Cigarettes / Post Office.

2. Main Street

Crack House on street

Good friend lives on same street.

Actions Change Post Office / where I get cigarettes. Get him to meet me elsewhere.

Danger area? 1.

Possible dangers?

Why go in area?

Actions

2.

3.

4.

5.


Make it a rule that you avoid these areas and if you find that you have entered them be aware that you might be setting yourself up and will have a higher likelihood of coming across trigger situations and developing a craving.

Dangerous situations Developing awareness of dangerous situations that may lead to using can be difficult when you have only just stopped the use of crack or cocaine. This is because situations that are now dangerous where once thought of as opportunities. It is vitally important that you start to anticipate these situations as much as possible and develop plans to cope with them if they do arise. In anticipating these situations you need to have an awareness of situations, emotions, people and places that may have lead to a using event (refer to you triggers chart or complete one if you haven't already done so). Use the table below to help develop plans for dangerous situations: Suggested plans 1. Anticipate dangerous situations

Personal plans Situations that lead me to crave: 1. 2.

2. Leave or change the situation

Safe places I can go: 1. 2.

3. Distract yourself with things you like to do

Good distracters: 1. 2.

4. Have a list of emergency numbers

People I can call in an emergency: 1. 2.

5. Remind yourself of you success to date

My main successes to date are: 1. 2.

6. Change the thoughts of using to positive thoughts

Positive thoughts: 1. 2.

7. I will put off the decision to use for 15 minutes

Techniques I can use to relax me during those 15 minutes:


1. 2. Source: Adapted from All Purpose Coping Plan, Kathleen M. Carroll Ph.D, 1998 Remember that dangerous situations may be normal parts of everyday life such as going to the corner shop, receiving money or being upset. It is impossible to anticipate everything so make sure you know your personal emergency plan and stick to it!

Cravings Cravings will be one of the biggest areas that you will have to deal with when coming off crack and cocaine. There are four main areas of craving associated with crack and cocaine use and you need to be able to understand where they come from, how they work, how they were triggered and more importantly how to avoid / stop them. There are two main things to remember: • •

They always need a trigger (face, place, £ etc) They are not a need, they are a want

What is a craving? Cravings with crack and cocaine are a combination of physical, chemical & emotional factors: • • •

Physical feelings of sweating, heart beating faster, butterflies in stomach, anxiety and increased breathing rate come from the release of adrenaline into the system triggering off the flight or fight response. Compulsion to use, single minded behaviour (the mission) and a belief that you need the drug come from the imbalance caused to the brain chemicals. Also you may not be thinking clearly due to lack of sleep. Emotional factors like depression, celebration, boredom and isolation can provide justifications to use and contribute to irrational thinking.

Types of craving? 1. Craving when using: These are usually triggered by the initial ‘crash’ or ‘come down’ which can be experienced after each hit. The down experienced, when you have felt so high, makes you want to use more even when you know that the ‘buzz’ felt is not going to be as high as the last one. 2. Open Craving: As the name suggests you are fully aware of what is happening and what you want. This type of craving may fit into your pattern of use such as time of day, day of the week, faces and places. The important thing to remember is that you know about it and can choose whether you act on it. 3. Hidden Craving: This type of craving is a little more complicated and often appears when you are trying to give up. A string of events may build up to lead you into a using position so that you are not fully aware of it until it too late. In effect you end up kidding yourself into a using situation. 4. False Craving: This usually happens further down the line of recovery. You have been drug free for some time and are feeling confident about life. An event happens that you may feel anxious about (first day at college, work etc) or that generates real fear (threats, dental treatment etc). These events will trigger off the fight or flight response. This can feel like a craving and start you thinking about using.


How to cope with cravings? If you are feeling the need to use just remember:

S.C.A.R.E. Support: Dealing with a craving on your own can sometimes be very hard. Is there anybody that can offer you support and make it less likely that you will use. Support networks like Cocaine Anonymous, drug free friends and family can all be useful. Whatever your support networks are, make sure you use them. Be aware of picking the wrong support (hidden craving). Make sure you are not going to get support from someone who is likely to feed your craving so that you end up using together! Consequences: Most of the time when you crave you are just thinking about the ‘buzz’. Its like playing a video reaching the good bit of a film and then pressing pause. Take time to play the tape forward. How will you feel with the come down? Will you be likely to commit crime to support your binge? How will the loss of money effect you? What risks to your health? How will you feel about yourself? You have probably been through all of the above and will therefore be able to predict the possible consequences of use. Do you want these to happen? Awareness: Once you understand where they come from it is easier to deal with them. Understanding your individual triggers is essential for this process. Think of them as a ladder with each rung taking you a step closer to using. The earlier you spot what is going on, the easier it is to jump off. If you wait before its one step off using then most of the time it's too high to jump! Relaxation: Nature has given you a cut off switch for coping with the release of adrenaline. This is very simple and effective. Just remember:

Deep breathing kills the feeling This is how most complementary therapies work and also why you found using a ‘downer’ drug worked when you were feeling ‘prang’ or ‘wired’. Education: If you get close to using or have a lapse, remember to learn from the experience. Your crack and cocaine use will be littered with times when you have repeated the same mistake again and again. Learn from these so that you can strengthen your prevention strategies and stop them from happening again. Word of warning Be careful not to set yourself up. Putting yourself in dangerous situations to test how far you have come is not a good idea. This sets up a situation whereby you can ignore danger. ‘ It’s OK because I was OK the last time’ doesn’t mean that its going to be OK now. Never take anything for granted and remember that emotional factors like depression, boredom and celebration can effect the way that you are going to react to a situation. How I feel when I crave

How I can stop the cravings


1.

2.

3.

4.

5.

6.

7.

Euphoric recall Euphoric recall is basically looking at something with rose tinted glasses on or just remembering the good bits. Imagine that you are watching a trailer of a movie, the general plot is given but only the highlights (good bits) are shown. Highlights of a movie can make it seem really good and make you want to watch it. The reality is often that these were the best bits of the film and the rest is not up to expectations and you wonder why you bothered going to see it. Euphoric recall with crack and cocaine can act in the same way in that only good memories are shown which help to build up your expectations and anticipation of drug use. The reality however of living the film ‘Some of My Using Experiences’ is that you’re left feeling unsatisfied, depressed, anxious and paranoid etc. As well as these feelings you may also be in debt, facing consequences of your actions and in trouble with partners, family and friends. You need to build up an awareness of how euphoric recall works with you and also how other people can help to spark this off. Think off how many times you have been talking with other users about experiences and how that has triggered off a craving. Once you are aware of how these discussions about the ‘good times’ effects you try and avoid them.

The good and bad of using Look at the reality of using so that the reality of you using is understood. List both the good and bad elements of crack and cocaine use. Be truthful and honest don’t fool yourself!


Good

Bad

This is your reality of using, no trailers and no highlights, remember this next time you want to see the film. Ask yourself: Is it worth it? Is this what I really want to do?

Listed below are a number of methods that you can use to deal with euphoric recall: Forced Memory Connection: This involves you remembering the reality of crack and cocaine use for you. In effect it’s remembering that you have seen the film lots of times before and it doesn’t get any better. Use the good and bad list to help you remember the realities of your use and what has brought you to this point of wanting to stop using.

Thought Stopping: When you have become aware that you are thinking about the so called ‘good times’, stop the thought. Recognise where you are heading and stop it there, look at what has sparked off these thoughts and deal with the situation. This will usually be a trigger.

Thought Replacement: Once you are aware of what you are doing you can replace these thoughts with ones that are more positive for you. Think about the things that you want to achieve and positive things in your life, no matter how small they may seem. Don’t get into depressive thoughts as this can lead you back into thinking about using crack or cocaine to make you feel better.

Points to remember: Euphoric recall will often lead to feelings of craving. Remember that this is just an exaggeration of your ‘fight and flight’ response. You don’t really need crack or cocaine you just think that you do. Use some of the following techniques to help reduce the levels of adrenaline in your system: •

Slow breathing

•

Burn relaxing oils


•

Have auricular acupuncture

•

Use relaxing herbal teas

•

Talk to somebody you trust and that will offer positive support

•

Get yourself into a safer environment

Also be aware that you don’t start to set yourself up and provide yourself with justifications to as to why you should use such as: X

I'll only have one 'rock'/line

X

Its boring being straight

Using dreams On occasions you may find yourself dreaming about the lead up to using and when you awake it feels like you really are just about to use. This is a similar process to having a nightmare. When you feel threatened and scared in the nightmare you release adrenaline and wake up with your heart beating, fast breathing and the sweats. The same is happening in a using dream, adrenaline is being released because of the anticipation of using and when you awake the physical feelings of use feel very real.

The points above can be used to help reduce the adrenaline levels after a dream.

Learning from lapses A lapse does not mean that you have gone back to square one. If you feel totally negative about the incident then you will miss the opportunity to learn from your mistakes and maybe make the same mistake again.

What you need to do is understand: • • •

What happened? How it happened? How can you stop it happening again?

Start by tracing the events that led to you using. You may need to go over things a few times going one step further back to trace the initial set up. Look at whom you were with? How did you feel emotionally / physically? Where did you get the money? What justifications were used?


Using event

What happened before that?

And before that?

And before that?

And before that?

And before that?

Now that you have a better understanding of what happened and how it happened, how can you stop it happening again? 1.

2.

3.


KOKAIN. Téma: Kokain, crack a jeho uživatelé. Autoři: Jiří Valnoha, Tomáš Přikryl

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