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Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS
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Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Dec 18, 2015

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Page 1: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Drugs of Dependency

Dr Linda HarrisWakefield Integrated

Substance Misuse ServicesWISMS

Page 2: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

OBJECTIVES

  Substances of abuse and their physical and

psychological effects

Dependency syndrome  An overview of treatment models

 

Page 3: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Major Drug Groups

All drugs fall into one of three groups:

Depressants: – slow you down, produce feelings of euphoria

Stimulants – speed you up, boost your energy and confidence

Hallucinogens – alter perception of the world

Page 4: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Opiates

Main drugs of abuse in UK Derivative of OPIUM found in poppy

plant The euphoric and analgesic effects

thought to lead to abuse Side effects - nausea, constipation,

respiratory depression

Page 5: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

How are opiates taken

1. Injecting through a vein2. Swallowing in tablet form3. Smoking in cigarette form4. Smoking by inhaling the fumes

produced by burning powder in a foil – “chasing the dragon”

5. Sold in “bags” – 1 bag = 0.2gms = £10

Page 6: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Cocaine

Stimulant drug extracted from the leaves of the coca plant

Made into a crystalline salt form by adding sulphuric acid and finally ends up as cocaine hydrochloride powder

To make crack the powder is heated up in a microwave with bicarbonate of soda and water

Crack is easily melted and vapourised so it can be smoked

Crack may also be injected by mixing it with water and weak acid such as citric or ascorbic

Page 7: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Cocaine

Effects: feelings of increased energy with consequent increased activity and improved social confidence. users feel more alert and energetic, confident, physically strong with a higher mental capacity

Physical effects – dry mouth, sweating, loss of appetite, increased heart and pulse rate

Side Effects: - irritability, paranoia, restlessness, psychosis

Page 8: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Cocaine - How is it used

Dabbing – rubbed on the gums Snorting – most commonly in its hydrochloride

powder form Piping – smoked through a pipe Injecting - Chasing – chased on tin foil like heroin Smoking/chipping – flaking bits of cocaine or crack

into the top of a cigarette “joint” “Speedballing”

Page 9: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Powder cocaine –“champagne image” Crack – smokeable “rocks”

– More likely to be associated with mental and physical health problems

– Poly drug users– Links with criminality and violence

Costs – powder upwards of £40 per gram

- £5 - £10 per rock

Page 10: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Harms associated with street drugs (notably heroin)

PsychologicalPhysicalSocial

Page 11: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Harm (Psych)

Anxiety and depression Drug related psychotic illnesses Aggravation of pre existing psychological or

psychiatric illness (“Dual Diagnosis”) Practically any mental disorder you can think

of

Page 12: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Harm (physical)

STD, unplanned pregnancy, Cx cancer Asthma Ear wax DVT, vascular damage Bacterial abscesses, metastatic sepsis Cl. novyii, botulinum, tetani HCV, HBV, HIV Overdose, death

Page 13: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Harm (Social)

Unemployment, poverty Crime: theft, dealing, physical violence,

prostitution, murder Imprisonment Separation, divorce, children in care,

loneliness and isolation Loss of dignity and self respect

Page 14: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Amphetamines

Synthetic stimulants

Most commonly produced in tablet or powder form and can be swallowed snorted injected or smoked

Mimic the effects of adrenalin in the body and therefore produce: - Increased energy, talkativeness, reduced appetite, restlessness, agitation

Page 15: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Amphetamine abuse

Side effects occur after prolonged use and when the effects of the drug wears off.

Depression Irritability Hunger Fatigue Vein damage in injectors Sexually transmitted diseases Acts of violence

1.           

Page 16: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Benzodiazepines

Depressant, synthetic drugs Highly dependent with tolerance to their effects

building up rapidly

. Symptoms of withdrawal include: -·         Anxiety and insomnia

Nausea and vomiting·         Phobias·         Loss of confidence and paranoia·         Headaches and dizziness·         Palpitations

Page 17: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Cannabis

This is a naturally occurring hallucinogenic drug most commonly seen in a variety of herbal forms or as a resin.

It produces the following effects: ·         Euphoria·         Increased confidence·         Altered sensory perceptions·         Feeling of well being·         Relaxation

Page 18: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Cannabis - the health risks

There is now established evidence that it produces dependence

Studies suggest the risk of dependency equates with that of alcohol

Cannabis is an intoxicant – impairs short term memory, judgement and co ordination – RTAs

Psychotic episodes have been reported (recent papers suggests increased risk particularly in patients with premorbid mental health issues)

Increased risk of chromic bronchitis and squamous metaplasia - ? Links with lung cancer

Page 19: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Cannabis – the health benefits

Used as a medicament for over 5,000 years Clinical trials underway exploring its use as

treatment for nausea and vomiting, combating muscle spasm in multiple sclerosis, treating loss of appetite and weight loss in AIDS

Drug companies looking at synthetic cannabinoids with therapeutic effects minus the psychoactive effects

Page 20: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Cannabis - the policy options

Relaxation on prohibition: -Potential reduction in crime and therefore

police and criminal justice expenditureReduction in prison overcrowdingPotential increase in use leading to as yet

unknown health implicationsSociety’s covert message – leading to

massive increases in use

Page 21: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Solvent use

Young people Effects similar to alcohol ?Use is decreasing Beware of the solitary user

Page 22: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Risk factors for substance misuse

Male Young Early childhood conduct disorder Childhood neglect Homeless Poor academic achievement

Page 23: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

0

2000

4000

6000

8000

10000

12000

14000

1600080 82 84 86 88 90 92 94 96

Heroin

Methadone

New Notifi cations f orHeroin Addiction U.K. (1980-1996)

Page 24: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Estimated 600,000 class A drug users in the UK = 1% of the population ( ie 18 per GP)

Est 300,000 Hepatitis C positive Est 3 billion derived from prostitution Massive implications, chldcare, criminal

justice, social services acute care

Page 25: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Models of Care

Medical Model

Vs

Social model

Vs

Criminal justice model

Vs

Community model

Page 26: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Government Targets

Reduce the proportion of people under 25 using heroin and cocaine by 25% by 2005 and by 50% by 2008

Reduce the levels of repeat offending amongst drug misusing offenders by 25% by 2005 and 50% by 2008

Increase the participation of problem drug misusers including prisoners in drug treatment programmes by 66% by 2005 and 100% by 2008

Page 27: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

National Government Policy

1998 – “Tackling Drugs to Build a Better Britain”

Ten year plan 4 key objectives: -

– Young people– Improve quality and access to treatment– Breaking the drugs crime link– Stifling availability of drugs on the streets

Page 28: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Emphasis on Breaking the Link Between Drugs and Crime

UK Crime and Disorder Act – Drug Treatment and Testing Orders– Arrest Referral schemes– Prison throughcare and aftercare -

Drugs Intervention Programme

Page 29: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Key messages

£1 spent on treatment saves £9.50 in terms of crime

Treatment works The longer in treatment the better the

outcome Complications kill Harm reduction saves lives

Page 30: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Graph showing deaths, comparing untreated patients with those in Methadone maintenance treatment in the Swedish study (15).

(Reproduced from Gronbladh et al)

Page 31: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Treatment

Attract Assess Retain Appropriate Care

Substitution Treatment Harm reduction Hepatitis B

immunisation Address homelessness Address skills deficits “Safer stronger

communities”

Page 32: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Treating 10 heroin users with methadone for 1 year

can save 2 lives

Treating 100 hypertensives for 10 years might save 2 strokes

Page 33: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Models of Care Treatment Tiers

Tier 1 – Non Substance misuse specialist Tier 1 – Non Substance misuse specialist services e.g. GP surgeries, Walk in centre services e.g. GP surgeries, Walk in centre A and EA and E

Tier 2 – Open access substance misuse Tier 2 – Open access substance misuse services – light touch services or services services – light touch services or services to encourage more engagement with to encourage more engagement with specialist servicesspecialist services

Tier 3 – Structured Community Services Tier 3 – Structured Community Services providing only within a structured and providing only within a structured and planned treatment settingplanned treatment setting

Tier 4a – Residential substance misuse Tier 4a – Residential substance misuse Tier 4b – Highly specialist non substance Tier 4b – Highly specialist non substance

misuse services – e.g. forensic services misuse services – e.g. forensic services liver units eating disorder units etcliver units eating disorder units etc Tier 1

Text 2

Text 3

Text 4a

Text 4b

Page 34: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Options for levels of involvement

Generalist care Shared care GP wSi Addictions psychiatrist

Page 35: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Good Medical Practice in managing dependency

Recognise the problem? Identify the complications of drug misuse and assess

risk taking behaviour Reduce harm e.g. hepatitis screening and vaccination Work with the patient to identify their needs and

identify a way of meeting those needs Work as part of a multidisciplinary team Think of social and psychological needs as well as

medical needs

Page 36: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Treatment – The evidence

Successful medical treatments aim to provide a safe substitute for the opiate heroin.

By prescribing an alternative or substitute one can alleviate withdrawal symptoms and the addict is released from the compulsion to carry out risk taking behaviour as part of their addiction.

Methadone remains the gold standard

Page 37: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Methadone

The evidence- most widely used form of opioid replacement therapy

in the US, Europe and Australia- Most evidence of impact on illicit drug use,and

criminal acts- Most positive evidence of containment of HIV

transmission- Most positive evidence of improvement in health,

employment status and social well being goals

Page 38: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Substitution

D etoxifica itonC an u se op ia tes o r n on op ia tes

N eed to b e w e ll m o tiva tedTen d s n o t to b e e ffec tive

L on g er te rm M a in ten tan ceN eed to b u ild in reg u la r review s

B ew are o f d ru g d ive rs ion

S h ort te rm m a in ten acen eM eth ad on e

B u p ren orp h in e

S u b s titu t ion

Page 39: Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS.

Harm Reduction

Basic care. Benefits, housing, child care issues, social services.

Signposting to needle exchange, CDTInformation

Sexual health: Cx smear, contraception, HBV/HAV inoculations (grab and stab)

Open doorWho can’t do any of this?