James Bell February 2014 Alcohol, drugs, and hospitals
Dec 28, 2015
James BellFebruary 2014
Alcohol, drugs, and hospitals
Why do people use drugs?
Why do people use drugs?
Drug use is normal behaviour
Who develops drug problems?
Who develops drug problems
0
5
10
15
20
25
Pre
va
len
ce
18-24 25-34 35-44 45-54 55-64 65+
Age
Males (9.0)
Females (3.2)
Neurobiology of drug use
• Drugs of abuse have in common that they act on the “reward pathway”
• The reinforcing effect of drugs is reduction in anxiety and creation of a sense of well-being
• Repeated exposure leads to lasting brain changes, including protracted withdrawal
Drug DependenceA maladaptive pattern of substance use leading to impairment or distress
Tolerance and Withdrawal
Salience
Craving
Reinstatement after abstinence
Persisting use despite harm
Communities vulnerable to drug dependence
Those without taboos or rewards
Especially: - indigenous communities - marginalised communities- deregulated communities
Responding to drug problems
Distinct area of medicine:• Serious morbidity and mortality• Involves values and choices
Simply telling people to stop is of limited value
Components of behavioural medicine
• Exchange of information• Structure• Support• Relief of symptoms
Alcohol and hospitals
Alcoholics need not apply
Admissions with alcohol problems KCH 2009
CARE_GROUP Elective Emergency Non-Elective TotalCardiac 44 25 16 85
Child Health 1 14 1 16CSDS 4 4Dental 7 26 3 36Liver 465 191 109 765
Medical 8 1716 8 1732Neurosciences 26 38 49 113
Renal 15 25 7 47
Specialist Medicine 3 23 26Surgical 67 231 13 311
Women's Health 3 3 6Grand Total 643 2292 206 3,141
Questions
Hospitalised drug user
A heroin user was admitted for hand surgery after a fight
- Post-operatively, complaining of pain
- When told his next scheduled dose of analgesia was not for several hours, he swore at the nurse and threatened vilence
Progress
Addiction nurse assessed patient- Opioid withdrawal- Recommended methadone be given, plus
analgesia as needed
Once withdrawal relieved, addictions nurse suggested apology
Patient agreed, situation resolved
Why do heroin addicts receive methadone?
Opioid Substitution Treatment of Addiction
1. Controlled Supply
2. Stabilization (abolish withdrawal)
3. Diminish reinforcing effects of street heroin
4. Structure – attendance and monitoring
5. Support
Prescribing Methadone for admitted patients not on OST
FIRST 24 HOURS
Prescribe methadone liquid 1mg/mlDose 1-10mg every 4 hours PRN according to signs of
withdrawalMaximum dose 40mg in first 24 hours
Always refer these patients to the Substance Misuse Nurse on pager KH3227.
Person on methadone (or buprenorphine) admitted
1. Continue medication
2. In addition, usual analgesia, may need titration
3. If head injury / hepatic encephalopathy, may need dose reduction
4. Note drug interactions (anticonvulsants, rifampicin, other CYP inducers)
Caution
F40 morbidly obese, admitted leg ulcer Mx
Methadone 100mg/day, not supervised as she had limited mobility.
Methadone prescribed in hospital, administered day1
Day 2 – noted to be drowsy, snoring cyanosed, with pin-point pupils
Party Drugs
GBL
GABA b agonist, precursor of GHB
• Produces confidence, charm, relaxation (“charisma”), sexual disinhibition
• In higher doses produces prompt sleep
• Narrow therapeutic index – risk of OD
• Usage mainly in gay males
Why do people use GBL?
1. Socialising
2. Sex
3. Sleep
GBL - dependence
• Uncommon?
• Involves dosing every 1-2 hours
• Can develop rapidly (eg after a “long weekend” of partying)
• Often occurs when drug is used for sleep
• Associated with social withdrawal, emotional blunting, compromised social role
GBL withdrawal
Onset rapid – 3-4 hoursCan occur after awaking from ODMay be severe (delirium, agitated psychosis,
severe anxiety and insomnia)Several cases required ICU management
UK experience – people admitted for elective detox have required ICU transfer (delirium, rhabdomyolysis)
GBL withdrawal management
• Initiate high dose diazepam (20mg 2nd hourly) early. “Usual” dose 70-90 mg day 1
• Baclofen 10mg tds• Transfer to AAU (more appropriate setting)
Further Reading
• Bell J & Collins R (2011) Gamma-butyrolactone (GBL) dependence and withdrawal Addiction 106(2); 442-447
• McDonough M, Kennedy N, Glasper A, Bearn J (2004) Clinical features and management of gamma-hydroxybutyrate (GHB) withdrawal: a review Drug and Alcohol Dependence 75; 3–9
• Le Tourneau J, Hagg D, Smith S (2008) Baclofen and gamma-hydroxybutyrate withdrawal Neurocritical Care 8(3):430-3
Questions