Tolerance is evident when a person requires a greater dose of a substance to get the same effect originally produced by a smaller dose. Different substances have different levels of tolerance attached to them. Tolerance develops for most substances. Tolerance develops quite rapidly for some (eg heroin and associated substances), and also fairly quickly to some others (eg alcohol and benzodiazepines: eg Rohypnol or Valium).
Tolerance is very important for young people and workers to be aware of. If a young person abstains or cuts down their use of a substance, then their tolerance will drop quite rapidly (particularly to depressants). If tolerance drops and the young person takes the same amount of a substance that they have previously taken, it is possible that they could overdose. It is vitally important that workers make young people aware of this likelihood. If a worker is aware that a young person is going to inject after a period of abstinence or minimal use, then there are a number of key messages to convey to the young person:
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Smoke it or snort it until your tolerance levels have stabilised, as this will decrease the speed at which the drug enters the bloodstream
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Use smaller amounts initially than what you used to
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Never mix drugs (no matter how you take the drug); overdosing is so much more likely if you drink, or take benzodiazepines and opioids together
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Have a 'taste' first and wait at least 30 minutes before using more. This period will help you to check purity and your dropped tolerance
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Never use alone; always use and stay with a friend after using
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If a friend overdoses, then call an ambulance; you could be saving their life. The police are not likely to come to a non-fatal overdose.
Withdrawal
This term denotes the physical and psychological symptoms associated with cessation or reduction of a substance.
Often we hear constant calls for more "detoxes" for young people. In reality, many of the young people you deal with in your work will have withdrawn many times; for example when they are unable to get their substance of choice, either due to not having enough money, not being able to score, being too sick to raise the funds, etc. Subsequently, these young people will go through withdrawal, often many times.
The severity of the withdrawal depends on a number of factors:
- Type of substance(s) being used
- Levels of use
- Length of time used
- Young person's experience of previous withdrawal(s)
- Use of other substances
- Physical health of the young person
- Method of use
- Environment that the young person is in (supportive versus unsupportive).
It has to be acknowledged that most young people, given their age and access to substances, do not generally develop as severe dependencies as older individuals. Thus, they may not experience as serious or difficult withdrawals. Most need safety, calm, rest, sleep, good food and to be off the streets or away from substance-using peers.
The most severe withdrawal occurs for those dependent on hypnosedatives and alcohol. Withdrawal from either of these substances can be quite serious and in some cases life threatening. For this reason it is important that withdrawal from these substances be dealt with under medical supervision. For other substances, withdrawal is less hazardous; however, it is still good practice to encourage and assist the young person in accessing appropriate medical support as necessary.
The signs of withdrawal are different for the various categories of substances used. Often withdrawal is the opposite of the effect of intoxication. So, after heroin use, where one generally becomes relaxed, content, quiet, constipated, and pain-free, withdrawal usually results in restlessness, inability to sleep, diarrhoea, and feelings of pain (especially back and legs). Use of amphetamines makes one alert and energetic, and withdrawal can result in depression, lethargy and tiredness (often associated with a 'crash'; long unsettled sleep).
One thing that we can be sure of is that withdrawal is not a pleasant experience, no matter what the substance. Ensuring the young person is in a safe, supportive environment can assist them during this difficult time. Remember that a person's present experience of withdrawal will often determine how they will 'think' of their next withdrawal. In the knowledge that this may not be their last withdrawal we need to ensure it is as painless as possible for the young person. This does not mean, however, that all young people withdrawing need to do so in medically supervised settings. Most do not, but facilities need to ensure medical back up is available as required.
If young people do not need medically-based or residential withdrawal programs, what do they need?
Cravings
Cravings are urges or intense desires to use. Cravings are more likely to occur in the early stages when a young person is cutting down or ceasing their use, but they can continue for some time.
These urges and desires can arise due to particular cues; internal or external.
Internal cues include feeling particular emotions, brought on by internal factors (memories) or external factors (relationships, conflict etc).
External cues can include talking about drug and drug-related activities, seeing dealers, drug paraphernalia (syringes, foil, fit bins, swabs, lemons), particular places, smells, and sounds.
What can be done?
Precravings
Early in your contact (pre-cravings):
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Explain that cravings may occur - they are normal
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Assist the young person to draw up a list of practical, doable and enjoyable activities that they might do when they experience cravings. They can then refer to this when / if the cravings occur
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Teach some strategies known to help cravings, such as meditation and breathing exercises. Practice these (again and again and again).
During cravings
Talking a young person through the experience:
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Explain that it will pass, and encourage the young person to think of it as a number of waves on the ocean, and that the young person is on the surfboard riding over the tops of the waves. Each wave they ride is one less they have to deal with.
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Acknowledge that it must be difficult (empathise)
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Ask them how have they dealt with cravings before (problem solve)
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Help the young person think of reasons why they've decided to change their use (motivation)
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Look at achievements thus far (motivation)
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Offer appropriate options; for example, go for a jog, listen to music, problem solve, have a shower, talk to others, watch TV, etc
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Get advice/support from peers as to how they've dealt with these.
After cravings have passed
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Help the young person think of what was helpful/unhelpful in dealing with the craving
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What brought on the craving? What can they do about this in the future (avoid it? confront it?)
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Update / change / revisit alternate activities list.
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Working with Young People with Alcohol or Other Drug Issues: A self-paced learning package Published: 2006 Funded by NSW Drug & Alcohol Workforce Development Council. Written & compiled by Kristy Delaney, YAPA, and Matt Stubbs & John Howard, Ted Noffs Institute. Additional material by Nick Manning, YAPA, & by Shopfront Youth Legal Centre. Opinions are the author's.
Be careful! YAPA and the authors took reasonable care to ensure that this information was correct at the time of publishing. However health information, and government regulations, laws and standards are complex and changing. The authors may not have health, safety, or legal qualifications, and information provided is general - it is not specific health, legal or professional advice. Do not rely on it - check with other publications and authorities and if necessary get qualified, medical, legal or professional advice for your situation.
