substance misuse awareness and interventions Simone Black and

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 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 the rewards setting – substancee. g. what? how used? what mixed with? 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 cy n e nd concentration e p e , d social confidence ‘alive’ & ‘alert’ , t g n i , use v cra o ce n a ler pos. psychosis big crashes - physical & mental paranoia over agitation

depressants life management ‘warm blanket’ e euphoria relaxation , c e s u r g, n i av nc a r tole p e d e, cy n e nd 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 Cocaine Tobacco Caffeine Crack Speed Ecstasy Cannabis Magic M’rooms LSD Glue/Solvents Alcohol STIMULANTS HALLUCINOGENS Ketamine Benzos Methadone Heroin DEPRESSANTS

cycle of dependence - depressants feelings return drug effectiveness decreases use to manage or suppress feelings OUT? mood changes/ feelings hidden dependency pattern reinforced tolerance increases

stimulants - crash and craving 5. The ‘MISSION’ [Highs & Lows ] [anticipation] ’ ce un 2 ‘bo nd ay 1 a sm n er ee Us etw b 1. USE 2. EARLY CRASH 4. FEELING OK [big comedown] [‘normal’] 3. LATE CRASH [regret]

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

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 Intensity 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 Mo. CAM – 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 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’ CENTRAL GOVERNMENT STATUTORY BODIES • Education • Home Office • Health • Prisons/Probation • CDTs • Counselling Services • Nat. Treatment Agency [NTA] • Police SERVICE PROVIDERS • GODT [regional] • Street Agencies etc. • Social Services • Community etc. safety SHARED INFO JOINT INITIATIVES DAAT Strategy and Implementation Team – 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 1 mg/1 ml (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 1 st • 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 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 9 mm by 19 mm - 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 400 mg 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 14 x more likely to OD • other sedatives • stimulants [coke, speed etc]

mixing it + high tolerance TEMAZEPAM – used on perceived comedown lethal dose unconscious level of heroin in blood intoxicated HEROIN ALCOHOL 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!