substance misuse -awareness and interventions - Simone Black and Sean Wood Plus Service Users.
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substance misuse -awareness and interventions - Simone Black and Sean Wood Plus Service Users drug definitions A heavy smoker? Just the one? definitions •drug •physical vs. psychological dependence •dependency vs. addiction •alcoholic vs. problem drinker •harm reduction vs. abstinence definitions Drug – any substance taken into the body for the purposes of creating a psychoactive effect in the user Tolerance – to require more of the substance to produce the same or original effect Withdrawal – physical and psychological effects user experiences when they stop using for whatever reason Addiction – an absolute Dependency – a continuum Physical dependency – when a substance effects the body in such a way that when it is removed the body undergoes physical withdrawal symptoms (sweats, shakes etc) definitions Psychological dependency – mental compulsion to use a drug. Most important factor when trying to understand use Abstinence – not using any of the substance. Tolerance subsides after period of abstinence Harm Reduction –reduce harm to the user, their family/friends and society at large Alcoholic/Addict – an identity (big change). Suggests dependence reached level causing serious detrimental effects. Problem Drinker/User – a behaviour (easier to change). Not blindly implying dependence drug related deaths p.a. estimated figures for England and Wales Tobacco c. 114 000 Alcohol c. 36 000 – 60 000 All illicit drugs c. 1500 - 2500 drug related deaths •opiate/opioid/GHB overdose [mostly with alcohol] •solvent related deaths – esp. young people •‘ecstasy’ related deaths [heatstroke, too much water] •stimulant induced heart failure/seizure cannabis, LSD , magic mushrooms – no known overdoses national trends •4% - 8% adults are ‘alcohol dependent’ •11 -15 year olds - drinking doubled in 10 years •illicit drugs - more choice + more affordable = more use • consistent across race, class, gender and geographical area national trends • over 90% of people have been in ‘drug offer’ situations by age of 17. • cannabis = most widely used illicit drug • followed by, ecstasy, amphetamine and cocaine • crack cocaine more and more prevalent the local hit parade [illicit drugs] 1. Cannabis [over 40 years at number one!] 2. Cocaine 3. Ecstasy 4. Amphetamine 5. Heroin [on the way up!] trends - young people “…we urgently need to acknowledge that for many young people drug taking has become the norm ...… their motives appear to be less concerned with peer group status and more with rational consumption as part of their approach to their leisure time.” Howard Parker, University of Manchester 18 – 24 year old males are the biggest risk takers spectrum of use very high risk, social exclusion, homelessness etc chaotic dependent long term problems health, social etc problematic recreational experimental most of us more than just the drug…. set – e.g. why using? feelings? knowledge? the risks and substancee.g. what? how used? what mixed with? the rewards setting – when? where? who with? culture? drug sources - 3 of them • plants/herbs/fungi e.g. cannabis, magic mushrooms • illicitly produced chemicals e.g. mdma, cocaine hydrochloride, amphetamine sulphate • pharmaceuticals e.g. benzodiazepines, codeine, OTC medications 2 exceptions = reindeer urine and toad-licking! how do we classify them? • legally by class A, B or C and schedules [1 to 5] outlined in The Misuse of Drugs Act 1971 – of limited use • socially ‘hard’, ‘soft’, ‘medicinal’, ‘recreational’, ‘dance’ etc. – of almost no use • by their effect on our bodies - the most helpful DRUGS DO NOT EASILY FIT INTO PIGEON HOLES… types of effect – 3 broad categories • stimulant • depressant • hallucinogenic stimulants energy up concentration social confidence pos. psychosis ‘alive’ & ‘alert’ big crashes - physical & mental paranoia over agitation depressants life management ‘warm blanket’ euphoria relaxation treadmill of dependency criminalisation? self neglect/isolation? [fear of] withdrawal hallucinogenics • change ‘reality’ by distorting perception • induce hallucinations – sight, sound, touch • tend to ‘amplify’ mood state • v. unpredictable, ‘bad trips’ etc • often long acting the scale of effect where do they fit? stimulant ? ? hallucinogen ? ? depressant 4 main ways of taking drugs • injection [very quick, very economical] • smoking [quick, not so economical] • snorting [fairly quick] • orally [slower] many drugs can be taken at least 2 of these ways the scale of effect STIMULANTS Crack Cocaine Tobacco Caffeine Speed Ecstasy Cannabis Magic M’rooms LSD HALLUCINOGENS Glue/Solvents Alcohol Ketamine Benzos Methadone Heroin DEPRESSANTS cycle of dependence - depressants use to manage or suppress feelings feelings return drug effectiveness decreases OUT? mood changes/ feelings hidden dependency pattern reinforced tolerance increases stimulants - crash and craving 1. USE 5.The ‘MISSION’ [Highs & Lows ] [anticipation] 2. EARLY CRASH 4. FEELING OK [big comedown] [‘normal’] 3. LATE CRASH [regret] all inter-related… HEROIN CRACK BENZOS METHADONE cannabis – things to know • more home grown, less resin • smoked/eaten • use in young people rising • paranoia = v. common • increases likelihood of psychotic episode • linked to schizophrenic illness • affects memory, learning and co-ordination • long term carcinogenic? [lungs, head, neck] • detectable in urine for up to 28 days cannabis as a treatment? • MS • acute pain? • crohn’s and IBS (Irritable bowel syndrome)? • glaucoma • mental health and general stress • asthma • epilepsy • AIDS/cancer “the weed keeps me sane, man” ecstasy – things to know • neurotoxicity – research inconclusive • long term use - memory impairment? depression? • harm reduction advice = key to preventing deaths • ‘ecstasy’ = MDMA and other things [LSD, speed etc] • poly drug patterns [10:1 smokers] • comedowns can be crashes [heroin?, benzos?] crack/cocaine - dopamine flood crack/cocaine what goes up …. N dopamine depletion – thereafter adrenaline buzz only TIME COCAINE CRACK amphetamine benzodiazepines cannabis cannabis paraphernalia cocaine and crack crack paraphernalia ecstasy heroin heroin paraphernalia ketamine LSD magic mushrooms methadone HEROIN METHADONE 0 hr Duration 24 hr volatile substances benzodiazepines •widely available prescription drugs [class C] •many varieties, short & long-acting [3 – 9 hours] •NOT anti-depressants •tolerance develops quickly [symptoms return] •high levels of dependency •withdrawal = protracted and potentially fatal benzos – common symptoms • fear and phobias • sleep disturbances e.g. insomnia, nightmares etc • mood disorders – e.g. anger, anxiety, depression • sensory effects – e.g. tinnitus, giddiness, blurred vision • physical – e.g. exhaustion, twitching, aches and pains • extreme – e.g. delirium, convulsion and even death! street leakage • benzos! – especially diazepam and nitrazepam • methadone and subutex! • dihydrocodeine, MST, diconal • coproxamol and some codeine based painkillers • cyclizine - potentiates heroin, users report more cerebral or ‘trippy’ effect • some tricyclics – esp. amitriptyline and dothiepin • procyclidine [rare] – apparently psycho-active OTC drugs of misuse • codeine based medications [e.g. Nurofen Plus Solpadeine] • decongestants [e.g. Sudafed, Dodo] • sleep aids [e.g. Nytol] • cough/cold cures [e.g. Collis Browne, Benylin] • antihistamines [e.g. Piriton] – esp. with alcohol • • Ephedrine, Caffeine – stimulants Codeine, Dextromethorphan- depressants • Diphneydramine/Promethazine Hydrochloride - sedatives on the horizon? • HEPATITIS B and C [already here] • more alcohol related disease – esp. in young women? • more psychoses in young people? • ecstasy/hallucinogenic related mood disorders methamphetamine? • more use of hallucinogens – mushrooms, salvia, 2-CT-7 etc • Ketamine use drug trends are changing all the time the political landscape • crime and social disorder • providers v. NTA v. DAATs v. PCTs v. CDRPs • ££ in drugs not alcohol • MOC and MoCAM – where do GPs fit? Models of Care - treatment tiers tier 1 2 3 4 type non-specific open access service examples GPs, housing, probation advice and info, needle exchange, drop–in structured specialist - community community detox, CDTs, care planned structured psycho-social interventions, SDP structured specialist -residential in-patient detox, residential rehab The Drug and Alcohol Action Team ‘A Framework for Partnership’ STATUTORY BODIES CENTRAL GOVERNMENT •Education •Home Office •Health •Nat. Treatment Agency [NTA] •Police •Prisons/Probation •GODT [regional] •Social Services •Community safety etc. SHARED INFO SERVICE PROVIDERS •CDTs •Counselling Services •Street Agencies etc. etc. DAAT Strategy and Implementation Team – JOINT INITIATIVES SPECIAL PROJECT GROUPS – POOLED BUDGETS Models of Care treatment modalities • advice and info • needle exchange • care planned structured psycho-social interventions • structured day programmes • community prescribing • inpatient treatment • residential rehab types of service 1 • community drug and/or alcohol teams [clinical] • day services [e.g. drop-in, wet house] • drug/drink counselling • education/prevention/helpline services • needle exchange types of service 2 • outreach [community support, homeless, youth] • peer support [e.g. AA] • residential rehab • structured day programmes ALSO – • help through the criminal justice system [DIP, DRRs, arrest referral, prison schemes etc.] • some GPs issues for services we’re only a PART of the solution • • • • • • • • • criminal justice vs. health fear and ignorance vs. pragmatism full capacity/waiting lists skills shortage unfashionable work unrealistic expectations [clients, others] short term planning/competitive tendering social/primary care partnerships must improve NTA - Px practice changing scenarios – which service? • Billy is a long term heroin user who has been in and out of prison for drug related crimes. He is on a conditional discharge but has just been arrested for shoplifting. He is sick of his lifestyle and swears he wants to change things • Leanne is a young professional woman who uses lots of E and speed at weekends when she goes out with her mates. She does not see her drug use as a problem but her family are worried about her and ask you for help. scenarios – which service? • Fred has been drinking at least half a bottle of spirits a day since his partner was killed in a car crash 3 months ago. He wakes up one morning feeling and looking very ill and presents to you desperate for help. • Eileen is an ex heroin user who wants to steer clear of it all together. She admits she smokes a bit of dope but her main problem is that she feels bored and de-motivated. methadone properties • white crystalline powder • synthetic opioid • drunk, swallowed or injected (physeptone) • tolerance builds up slowly • long acting properties cont… • mixture contains – methadone hydrochloride - green S +tartrazine - glucose syrup - chloroform water • methadone mixture DTF 1mg/1ml (green, clear, blue, brown or yellow) • Class A drug methadone effects • on the brain - levelling of emotions - drowsiness - slower shallower breathing - reduced cough reflex - reduction of physical pain - feeling sick - mood change (less intense than heroin) effects cont … • on the nerves - small pupils - constipation perhaps - dryness of eyes, nose + mouth - reduced blood pressure - difficulty passing urine effects cont … • release of histamine causing - sweating - itching - flushing of the skin - narrowing of air passages in lungs • perhaps - menstrual disruption - reduced sexual desire - reduced energy - heavy arms + legs effects … not! • unless drowsy it will not affect - coordination - speech - touch - vision - hearing • long term use does not affect – – – – – – heart liver brain bones reproductive system immune system how it works • similar to heroin therefore reduces withdrawal • fills tissue reservoirs in liver/lungs/fat 1st • after 3 days blood conc. stable • 30 mins to be absorbed 4 hrs to reach peak levels • binds to several of the opiate receptors • has long half life (approx 25 hours) • NOT a detox medication [very] basic neurology • neurotransmitter - specific chemical that fits receptor site and causes nerve impulse [effect] neurotransmitter brain cell receptor site ‘firing’ response • drug - to have effect this must be close fit to neurotransmitter in order to cause [agonist] or prevent response [antagonist] drug [agonist] brain cell receptor site ‘firing’ response OPIATE AGONIST e.g. heroin, methadone, codeine opiate receptor ‘firing’ response PARTIAL OPIATE AGONIST e.g. Subutex opiate receptor partial firing – site blocked OPIATE ANTAGONIST e.g. Naloxone, Naltrexone opiate receptor knocks other opiates off site and blocks completely for • just for starters … - regular - long acting - free - legal - clean - accompanied by other interventions - generally drunk not injected - attracts users into service + retains them and many more… against • inappropriate prescribing can - cause fatal overdose - increase drug consumption - supply illicit market - increase drug related chaos - demoralise users and staff - reduce respect for prescribing agency - reduce client motivation advisory council on misuse of drugs The 1993 ACMD Update report concluded that; “The benefit to be gained from oral methadone maintenance programmes both in terms of individual and public health and cost effectiveness has now been clearly demonstrated and we conclude that the development of structured programmes in the UK would represent a major improvement in this area of service delivery.” good practice most successful programmes include - high doses - maintenance (rather than reduction) - intensive counselling - medical services - good relationships between staff and patients dose assessment/titration • need to decide - amount of opiates client using - treatment aims • start on safe, low dose, work up • can’t directly convert illicit dose to methadone dose • dose should be titrated against prevention of withdrawal + in craving NOT observable intoxication alternatives Subutex (buprenorphine hydrochloride) • safer in o/d • partial blocker • fewer side effects? • anecdotally more popular • can be used for detox • sub-lingual difficult to monitor? • transference sometimes awkward Drugs work by stimulating receptors in the brain. These pictures show how Subutex 'sticks' to the opiate receptors stopping heroin having any effect and, at the same time, stimulating them enough to take away, or reduce, the desire to take heroin. alternatives detox • Lofexidine • Dihydrocodeine • Naltrexone • Benzodiazepines Naltrexone hydrochloride Naloxone Revia Vivitrol Nalorex how does it work • antagonist - blocks the opioid receptors • money wasted if try to use on top • may reduce or prevent cravings in some people • in America it is approved for the treatment of alcohol dependence (!) use • implants can be used to ensure regular dosage • available through private clinics • approx 9mm by 19mm - inserted through a 1 inch incision in the lower abdomen or at the back of the upper arm • also as part of a rapid detox programme Naloxone Hydrochloride [Narcan] • • • • • strong opiate antagonist used to reverse opiate overdose 400mg per 1 ml amp paramedic only very short half life – [O/D therefore still possible after administration] • I/V and/or I/M • I/V … – revival almost immediate – titration possible - practitioner discretion BBV transmission • Sharing any blood contaminated injecting equipment, paraphernalia and works • Occupational injuries – needle stick injury, infection from medical & dental procedures • Household contact - sharing razors, toothbrushes, nail scissors etc • Unsterile ear & body piercing, tattooing, electrolysis, acupuncture etc BBV transmission • Blood transfusion prior to 1991 • Blood products before 1987 • Unprotected sexual intercourse (for HCV considered low risk = 6% transmission risk in regular partners of infected people) • Vertically (mother to baby) (for HCV considered low risk = 6%, breastfeeding also low risk) BBV prevention • Immunisation (Only for HBV and HAV) • Safer sex (using condoms etc) • Safer drug use (ie using new/own/sterile equipment) • Using new/own/sterile equipment for acupuncture, tattooing + ear/body piercing • Infection control measures OD - the signs • deep snoring • unwakeable • getting cold • turning blue [esp. lips] • not breathing OD – risk factors • injecting • previous non-fatal o/d experiences • using at high levels • low tolerance • feeling low or depressed (1) I/V opiates – low tolerance lethal dose unconscious level of heroin in blood highly intoxicated time lines move up as tolerances increases OD – risk factors (2) MIXING IT! [before OR at the same time] • alcohol • methadone • benzos 14x more likely to OD • other sedatives • stimulants [coke, speed etc] mixing it + high tolerance TEMAZEPAM – used on perceived comedown lethal dose unconscious intoxicated level of heroin in blood ALCOHOL HEROIN time [c.12 hrs] •all day drinking pushes up baseline of sedatives in system •o/d occurs about 3 hours after heroin use a complex relationship: drugs and mental health: • primary psychiatric illness precipitating or leading to drug [mis]use • drug [mis]use worsening or altering the course of a psychiatric illness • drug use and/or withdrawal leading to psychiatric symptoms or illnesses • concurrent drug use and psychiatric symptoms spiders … No chemical Cannabis spiders cont … Amphetamine (benzedrine) Caffeine boundaries remember: • you don’t HAVE to prescribe • safety first – you and them • better Px nothing than Px wrong • make good links [e.g. spec. nurse/pharmacy] • you can always do something • watch the guilt trip – it’s NOT YOUR FAULT!