Substance Misuse 11117 MRT Middlesbrough Recovering Together Medical

Substance Misuse 1/11/17

MRT Middlesbrough Recovering Together Medical service – GP and OST at foundations Recovery Connections, helping with detox and beyond Treatment services at CGL, psychosocial input and help with non-opiate addictions

Drug Misuse & Dependence Misuse Dependence (ICD 10) 3 or more: The use of a substance for a purpose not consistent with legal or medical guidelines Craving Tolerance Compulsive drug-seeking behaviour Difficulties controlling drug taking Physiological withdrawal state Progressive neglect of alternative interests World Health Orgnization (WHO) 2006 Lexicon of Alcohol and Drug Terms Persistence of drug use despite evidence of harmful consequences

Drug Misuse UK has amongst the highest rates of illegal drugs misuse in western world Approx 306, 000 problem heroin/cocaine users in the UK Drug-related death rate is …Why?

Substance Misuse Which substance are being misused?

The neurology of addiction You. Tube Brain Reward: understanding how the brain responds to natural rewards and drugs of abuse https: //www. youtube. com/watch? v=7 VUl. KP 4 LDy. Q

Effects of dependence Injection site infections Respiratory problems DVT Impaired nutrition/immunity BBV SBE, osteomyelitis, discitis Hypogonadism Chronic pain Risk of OD bone density Vulnerability, risk of abuse and STIs Constipation Poor mental health Poor dentition

Effects of dependence Poverty, social exclusion, homelessness, stigma, unemployment, crime Poor outcomes in pregnancy, family breakdown

Polydrug misuse Cocaine - tissue damage (vasoconstriction/LA effect) IHD, arrhythmia Respiratory problems (crack lung) Increased risk taking behaviour Additive effects of substances = increased likelihood of OD & misadventure

Heroin Poppies are dried- sticky opium is extracted. This is crushed/boiled and morphine is extracted, which is then treated diamorphine (aka heroin) Heroin- a white or brown powder Smoked on foil (‘chasing the dragon’) Snorted Dissolved in a heated solution of citric acid (vitamin C) prior to injecting https: //www. youtube. com/watch? v =Miv 8 i-sl. K 2 w 00: 00 - 2: 58

Heroin Gives a feeling of warmth, relaxation and detachment with a lessening of anxiety “It is probably one of the most pleasurable experiences I’ve had. All the pain goes. All the anger is gone. I was lying on the sofa floating happily. It makes you feel safe and warm like being wrapped up in a blanket. ”

Heroin withdrawal symptoms Early symptoms <24 hrs Later symptoms >24 hrs muscle aches diarrhoea restlessness abdominal cramping anxiety goose bumps on the skin lacrimation nausea and vomiting runny nose dilated pupils and possibly blurry vision excessive sweating inability to sleep yawning very often rapid heartbeat high blood pressure

Heroin withdrawal “You can get addicted pretty quickly and start feeling you have to have it all the time. It’s cut with all sorts of rubbish but you don’t really care. The only goal in life became getting more. It kind of took all my feelings away”.

Cocaine & Crack Cocaine is generally found in white powder form Usually snorted Effect from snorting occurs within 1 -5 minutes, peaks within 20 -30 minutes, dissipates within 1 -2 hours If cocaine is injected, the effects begin, peak, and endure about the same time as crack Crack is found in a rock form (white, cream, tan, or light brown) Cocaine + water + baking soda (boiled) = a solid (crack) Usually smoked through a pipe (or made soluble by adding acid, then injected) Effects of crack occur < one minute, peak in 3 -5 minutes, and last 30 -60 minutes. Crack is more concentrated, so offers a more intense, faster, cheaper ‘high’

Cocaine Stimulant- makes user feel euphoric, alert, energised, confident, strong…disinhibited Short acting, prompting repeat doses After effects- fatigue, despair, paranoia, depersonalisation (may use heroin to offset this) Long term effects include symptoms of agitation, depression, anxiety, nausea, extreme fatigue, myalgia, suicidal thoughts and intense cravings

Cannabisis The most widely-used illegal drug in Britain, although the numbers of people using it are falling. Cannabis is naturally occurring it is made from the cannabis plant. Main effect is relaxation, happiness Unwanted effects – anxiety, paranoia, hallucinations, poor concentration/memory Smoked- with usual complications

Novel Psychoactive Substances Novel psychoactive substances: types, mechanisms of action, and effects BMJ 2017; 356: 127 -168 No 8090 (Published 25 January 2017) https: //www. youtube. com/watch? v=q. SVJusx. L 96 Y You. Tube ‘watch before you take spice, black mamba 1: 38’ Individuals will be prosecuted for trading, but not possession NPS are not safer/less harmful than established recreational drugs There is considerable variation in risks between individual NPS and between doses of the same NPS If using a NPS…start low and go slow, as with any drug! Risks if combined with other substances If an individual becomes unwell, advise A&E (taking a sample of NPS)

Amphetamines aka Speed Stimulant, gives a feeling of energy, excitement, alertness, represses hunger Can cause hyperactivity, agitation, psychosis The high is generally followed by a long slow comedown, associated with irritability and depressed mood Can result in cardiac fatalities

Ketamine and Ecstacy Ketamine Ecstasy (aka MDMA) Gives a floating or detached feeling as if the mind and body have been separated, can also lead to distortions of reality, hallucinations Makes people feel ‘in tune’ with their surroundings, and can make music and colours more intense BP and HR Feel ‘loved up’ Cause also cause confusion, agitation, panic attacks, and memory impairment Adverse effects include panic attacks, confusion, paranoia, psychosis Loss of feelings, muscle paralysis and loss of touch with reality potential harm form self or others Dilated pupils, paraesthesia, tightening of the jaw muscles, temperature, HR May lead to depression and bladder problems You. Tube Too High on MDMA 1: 44 (0: 14 -0: 56 https: //www. youtube. com/watch? v=4 l. VFu. JRz Yv. Y

Benzodiazapines Significant problem amongst poly-drug users Approx 90% of drug users report benzo use at some point Frequently used with heroin, potentiating OD Usually taken orally, but can be crushed/injected Rapidly addictive, significant withdrawal symptoms ‘please prescribe diazepam for me so that I can stop my illicit use’

Prescription Medication Opiates Regular med reviews Benzodiazepines Time-limit trial periods Zopiclone ‘lost’ prescriptions Ritalin Wanting increased doses Mirtazapine Avoid dispersibles & rapid acting formulations Sildenafil Gabapentin PREGABALIN Requesting early… the naughty list

https: //www. youtube. com/watch? v=5 Kr. UL 8 t. Oa. Qs

Pregabalin & gabapentin The drugs have a similar mechanism of action, both have propensity for misuse Both are associated with significant euphoric effects –mis-users describe improved sociability, euphoria, relaxation and a sense of calm Both can cause depression of the CNS, resulting in drowsiness, sedation, respiratory depression and death They have additive effects when used with other centrally acting drugs, particularly opioids The pharmacokinetic properties of pregabalin make the drug relatively more dangerous than gabapentin in high doses Pregabalin misusers take large quantities, up to 5 g as a single dose Street value of £ 1 -2 per capsule

Pregabalin & gabapentine. PACT data 2011 -2013 In 2013 the total use in England of both these medicines was 8. 2 million prescriptions. This represents a 46% rise in prescribing of gabapentin and 53% rise in pregabalin prescribing since 2011 
 There is a wide variation in prescribing across the four NHS regions North of England GPs prescribe 3 x more than London GPs Opiates can increase the bioavailablity of gabapentinoids https: //www. youtube. com/watch? v=8 fc 8 s. XWop. Bs 00: 00 -04: 26

Pregabalin & gabapentin Public health England –Advice for prescribers on the risk of the misuse of pregabalin and gabapentin Prescribing for patients with a known or suspected propensity to misuse, divert or become dependent on these drugs may place these people at greater risks from their use While no patient should normally be excluded from access to medications that may help them simply because of a current or past problem with misuse or dependence (or because of concern about propensity to such risk), that concern is a proper and relevant consideration in how, and even whether to prescribe these drugs

Pregablin & gabapentin Agree a management plan – if newly initiated, set a time-limited trial (on acute px), set target dates for decreasing. If currently on repeat, consider if it is appropriate to taper, stop, consider alternatives or continue with strict boundaries/regular reviews If dependence, misuse or diversion is suspected, then this should be discussed sensitively and documented clearly Consider a random urine screen (white top bottle, select ‘toxicity’ on ICE and specify the drugs to be tested) If completely inappropriate use is confirmed (eg, unequivocal objective evidence that the drugs are simply being diverted) the drugs should be stopped Tapering: pregabalin - by a max of 50 -100 mg/week gabapentin - by a max of 300 mg every 4 days If dependence is suspected then consider a more gradual taper that allows assessment of emergent symptoms that may have been controlled by the drug

Substance misuse- how do we affect change? Treating drug addiction as a chronic condition mortality OST crime Harm minimisation risk taking behaviour Holistic care spread of BBV Continuity of care Public health issues morbidity

New presentation of drug problems to GP – drug history Which drug/s? (including prescribed & OTC) Ask specifically about alcohol, cannabis and ‘prescribed’ tablets How much are they using? How often? Trigger for use (‘need’ or ‘choice’) Which route/s? Duration of use/dependence? Current or previous contact with drugs misuse services?

New presentation of drug problems It isn’t all about prescribing!!! Health check –BP, HR & rhythm, chest Screening & imms–BBV Sexual health, contraception Injection sites Signposting: Talking therapies, benefits, housing, local drugs services, women’s refuge, SECOS, Breaking the boundaries, CAB

New presentation of drug problems - Harm minimisation Injecting –avoid (especially groins/neck)!! Smoke instead, do not inject alone, avoid polydrug use, use clean needles/paraphenalia NALOXONE – how to save a life (yours and others) Avoiding BBVs- signpost to needle exchange, safer sex, avoid sharing toothbrushes/pipes/razors, screening & imms Beware times of reduced tolerance- eg prison release, hospital stay, poor £, as tolerance = risk of OD

Which is the most harmful substance of misuse?

Alcohol

Alcohol related hospital admission rates In 2014/15 – 1. 1 million estimated admissions due to alcoholrelated disease or injury, a rise of 3% from 2013/14 The highest number of admissions 511, 260 (48 per cent of all admissions) were due to CVD, a rise of 7% compared to 2012/13 This is an admission rate of 1970 admissions per year per 100 000 population There is considerable regional variation

Standardised Hospital Admission Ratio for England Source: North West Public Health Observatory, 2012

Alcohol dependence Physical signs & symptoms Other harms recurrent intoxication, nausea, sweating, tachycardia, hypertension Mood swings, depression, anxiety, suicide dyspepsia, diarrhoea, bloating, hematemesis, jaundice poor nutrition, poor immunity and personal neglect anxiety, insomnia, chronic fatigue, amnesic episodes paraesthesia, neuropathy, tremor, unsteady gait, memory loss, erectile dysfunction seizures, hallucinations, delirium tremens, Accidents Drink driving Poor pregnancy outcomes Domestic violence Crime: 60% of homicides 75% of stabbings 70% of beatings 50% of fights/domestic disturbances Loss of employment

Increased risks of ALD MEN WOMEN HTN X 4 X 2 Stroke X 2 X 4 CHD X 1. 7 X 1. 3 Pancreatitis 3 2 Liver disease 13 13

Alcohol How much is a unit? volume (ml) x ABV% (alcohol by volume) divided by 1000 E. g. one pint (568 ml) of strong lager (ABV 5. 2%): 568 (ml) x 5. 2 (%) ÷ 1, 000 = 2. 95 units

Alcohol Misuse Hazardous drinking Drinking at an excessive level likely to cause harm Harmful drinking Consider using assessment tools if presentation/bloods indicate alc excess Assessment tools AUDIT C excessive drinking that is already causing physical, mental or social harm, or aggravating pre-existing disease AUDIT Excessive drinking SADQ causing harm and the person is unable to control or stop their drinking (dependent drinking) … or refer to GP alcohol teams/CGL Modified SASQ

Top tips regarding alcohol misuse ID/discuss harms Record intake: photos, ring-pulls, bottles Smaller glasses, reduced strength alcohol, alternating with soft drinks, defer the first drink Even alcohol-dependent patients should be safe with a reduction of 10% per week Behavioural change Motivational Interviewing Refer …do NOT initiate a stand-alone detox (kindling effect)

Medications used as part of a psychosocial alcohol reduction plan Nalmefene Post- detox used for high risk, nondependent drinkers. Opiod antagonist, taken 1 -2 hrs before drinking Disulfiram (antabuse) – taken daily. If alc is consumed →unpleasant /violent sideeffects Detox Acamprosate- (campral) – taken daily, ↓ craving for alcohol approx 2/3 of those who complete a detox will relapse within 3/12 Naltrexone (adepend) – opiod antagonist, ↓ craving for alcohol and may ↓ alcohol intake in those who continue to drink

Tricky scenarios… As always, start with ICE… ‘if you don’t prescribe for me now, then you are forcing me to go and use heroin’ ‘I am addicted to x…please prescribe it for me so that I can come off it’ ‘I’ve tried every medication. The only thing that works is dihydrocodeine/gabapentin/oramorph…’ ‘I’ve got a neuropathic pain/sciatica/the pain clinic says I need pregabalin’

Tricky scenarios… ‘I need a detox NOW’ Alcohol reductions- how? MED 3 s Don’t forget comorbidities: -check for BBV -consider prescribing thiamine/vit B -contraception/sexual health screen -social situation -driving … and document!

SAFEGUARDING Communicate and document!