Substance misuse -awareness and interventions - Simone Black and Sean Wood Plus Service Users.

substance misuse-awareness and interventions -

Simone Black and Sean Wood Plus Service Users

drug definitions

A heavy smoker?A heavy smoker? Just the one?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

•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

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!]

“…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

trends - young people

experimentalrecreationalproblematicdependent

most of us

long term problems

health, social etc

very high risk, social exclusion, homelessness etc

chaotic

spectrum of use

more than just the drug….

setting – when? where? who with? culture?

set –substance-

e.g. what? how used? what mixed with?

e.g. why using? feelings?

knowledge? the risks and the rewards

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

use, craving, tolerance, d

ependencyenergy up

concentration

social confidence

‘alive’ & ‘alert’

stimulants

pos. psychosis

big crashes - physical & mental

paranoia

over agitation

depressants

life management

‘warm blanket’

euphoria

relaxationuse, craving, to

lerance, dependency

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 effectwhere 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

Speed Cocaine

Tobacco

LSD Magic

M’rooms

BenzosAlcohol

Methadone

Heroin

Caffeine

Cannabis

Crack

Glue/Solvents

Ecstasy

Ketamine

STIMULANTS

HALLUCINOGENS

DEPRESSANTS

cycle of dependence - depressantsuse to

manage or suppress feelings

mood changes/ feelings hidden

dependency patternreinforced

tolerance increases

drug effectiveness

decreases

feelings return

OUT?

stimulants - crash and craving

1. USE[Highs & Lows

]

3. LATE CRASH

[regret]

2. EARLY CRASH[big comedown]4. FEELING

OK[‘normal’]

5.The ‘MISSION’[anticipation]

Users m

ay ‘bounce’

between 1 and 2

all inter-related…

HEROIN BENZOS

CRACK 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

COCAINE CRACK

N

TIME

crack/cocaine

what goes up ….

dopamine depletion – thereafter adrenaline buzz only

amphetamine

benzodiazepines

cannabis

cannabis paraphernalia

cocaine and crack

crack paraphernalia

ecstasy

heroin

heroin paraphernalia

ketamine

LSD

magic mushrooms

methadone

HEROINMETHADONE

0 hr Duration 24 hr

Inte

nsi

ty

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 type service examples

1 non-specific GPs, housing, probation

2 open accessadvice and info, needle

exchange, drop–in

3structured specialist -

communitycommunity detox, CDTs, care planned structured

psycho-social interventions, SDP

4structured specialist -

residentialin-patient detox, residential

rehab

SERVICE PROVIDERSSERVICE PROVIDERS

•CDTs

•Counselling Services

•Street Agencies

etc. etc.

The Drug and Alcohol Action Team ‘A Framework for Partnership’

STATUTORY BODIES

•Education

•Health

•Police

•Prisons/Probation

•Social Services

•Community safety etc.

CENTRAL GOVERNMENT

•Home Office

•Nat. Treatment Agency [NTA]

•GODT [regional]

SHARED INFO – SPECIAL PROJECT GROUPS

JOINT INITIATIVES – POOLED BUDGETS

Strategy and Implementation Team

DAAT

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 serviceswe’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]

• drug - to have effect this must be close fit to neurotransmitter in order to cause [agonist] or prevent response [antagonist]

neurotransmitter

brain cell

receptor site‘firing’

response

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

receptorpartial 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 practicemost 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 (1)

• injecting

• previous non-fatal o/d experiences

• using at high levels

• low tolerance

• feeling low or depressed

I/V opiates – low tolerance

lines move up as tolerances increases

lethal dose

unconscious level of heroin in blood

time

highly intoxicated

OD – risk factors (2)

MIXING IT! [before OR at the same time]

• alcohol

• methadone

• benzos

• other sedatives

• stimulants [coke, speed etc]

14x more likely to OD

mixing it + high tolerance

lethal doseunconscious

level of heroin in blood

time [c.12 hrs]

TEMAZEPAM – used on perceived comedown

HEROINALCOHOL

intoxicated

•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

Amphetamine (benzedrine) Caffeine

spiders cont …

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!