Download Substance misuse

2008
SUBSTANCE MISUSE
NICE Definition
 substance misuse is defined as intoxication
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by – or
regular excessive consumption of and/or
dependence on – psychoactive substances,
leading to social, psychological, physical or
legal problems. It includes problematic use
of both legal and illegal drugs (including
alcohol when used in combination with
other substances).
Comonest
 Legal
 Alcohol
 Nicotine
 Glue
 Illegal
 Cannabis
 Stimulants – ecstasy, cocaine, amphetamines,
khat.
 Benzodiazepaines
 Heroin
Young people at risk
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those whose family members misuse
substances
• those with behavioural, mental health or
social problems
• those excluded from school and truants
• young offenders
Young people at risk
 • looked after children
 • those who are homeless
 • those involved in commercial sex
work
 • those from some black and minority
 ethnic groups.
NICE Interventions for those
at risk
 Offer a family-based programme of
structured support over 2 or more
years, drawn up with the parents or
carers of the child or young person
and led by staff competent in this
area.
NICE Interventions for those
at risk
 The programme should: – include
 at least three brief motivational interviews1
each year aimed at the parents/carers
 – assess family interaction
 – offer parental skills training
 – encourage parents to monitor their
children’s behaviour and academic
performance
NICE Interventions for those
at risk
 – include feedback
 – continue even if the child or young person
 moves schools.
 • Offer more intensive support (for example,
family therapy) to families who need it.
Management
 Management options for misusers
 Brief interventions
 Counselling
 Replacement therapy
 Referral to specialist clinics
Cannabis
 Harms
 Damages lungs more than tobacco
 Impairs concentration
 Impairs motivation
 Impairs memory
 Heavy use in teenagers may predispose to
schizophrenia
Cannabis
 Selective breeding of plants much
higher concentration of active
chemical THC = tetrahydro
cannabinol
 Cannabis induced psychosis more
common
 Dependency in 5 – 10% of users
Cannabis
 Medication little role in treatment
 GP role
 Identification of problem
 Brief intervention with motivational
technique
 Encourage patient to tackle problem
Stimulants
 Amphetamines
 Cocaine
 Snorted as powder
 Injected
 Used in combination with heroin =
speedballing
Stimulants
 Crack cocaine
 prepared by heating cocaine in microwave with
bicarb of soda. Makes a cracking noise when
smoked
 Can be injected
 Produces more intense and immediate effect than
powder cocaine
 Wears off in 5-10 mins triggering desire to use it
again
Stimulants
 Crack cocaine
 Chronic high dose usage leads to marked
psychological dependence
 Physical complications include
 Heart failure or MI
 Crack lung – a hypersensitivity reaction causing
dyspnoea and wheeze
 Blood borne virus transmission through shared
injection equipment
 Liver damage
Stimulants
 Cocaine
 Cocaine and alcohol combine together to produce
cocaethylene which is more damaging to the liver
than either substance
 Mental health problems
 Lethargy
 Depression
 Full blown psychosis tactile hallucinations are
common the cocaine bug
Stimulants
 Ecstasy
 Stimulant and hallucinogenic effects
 Risks
 Overheating dehydration
 Fluid overload due to increased ADH levels
 Advise users to take regular breaks from
exercise and sip maximum 1pint water per
hour
Stimulants
 Khat
 Green leaves of a shrub commonly
grown in Horn of Africa
 Effects similar to amphetamine
 Legally sold in those areas
 Drug induced psychotic episodes
 Common in Somali communities
Stimulants
 Management
 Stop usage
 Treat individual symptoms
 Insomnia hypnotics - short term only
 Depression – SSRI’s
 Psychological interventions most useful
 Local treatment services found Helpfinder section of
Drugscope website www.drugscope.org.uk
Benzodiazepines
 Often used with other illicit drugs
 Increases risk of death from overdose when
combined with alcohol or opiates
 No evidence that long term substitute
prescribing reduces harm
 Only licensed for reducing regimes and not
for maintenance prescribing
Benzodiazepines
 Be more reluctant to initiate
prescription for benzo’s than opiates
 Reduction regimes for users of street
benzo’s is problematic only do when
urine evidence of use and clear
evidence of dependence and an
agreed reduction plan
Benzodiazepines
 Reduction regimes
 BNF has useful equivalent dose tables
 Convert to diazepam
 If high doses required refer for specialist
assessment
 For 30mg/day or less reduce by 2mg every 2
weeks
 Can be prescribed for daily dispensing if
concerned about diversion or compliance
Heroin
 Smoked by burning powder on tinfoil
 Heated with citric acid and injected
 Long term opiate dependency is chronic
relapsing condition
 Causes harm to users and there families
 Typical user will spend £30- 100/day on drug
Heroin
 Typical user will spend £30- 100/day on drug
 Result into drift into poverty
 300,000 children of problem drug users in UK
 Effective treatment can have significant
benefits for child and improved quality of
family life.
Heroin
• Mortality risk 12x greater than general
population
• Injecting users 22x more likely to die than non-
injecting peers
• Drug related over doses commonly due to
injected heroin in combination with alcohol,
benzo’s or other depressants
• Significant number occur in users who have just
left prison and under estimate their loss of opiate
tolerance
Heroin
 Good evidence that drug treatment reduces
crime
 Led to expansion of drug treatmetn services
Substance misuse management
 What every GP should provide for a misuser
 Same responsibility to provide general medical
services to drug misusers as any other patient on
their list
 Advise on risks of injecting
 Increased risk of overdose when using drugs alone
 Loss of tolerance after periods of abstinence
Substance misuse management
 Prevention against blood borne viruses
 Not sharing needles or other drug paraphernalia
filters, spoons.
 Safe sex - use of condoms
 Screening for blood borne viruses
 Opportunistic vaccination – accelerated schedules
increases uptake 0, 7, 21 days with booster at 12
months
Substance misuse management
 Consider any children- are they at risk if so
use local child protection framework - parents
using drugs does not necessarily mean child is
at risk or neglected.
 No legal requirement to report to authorities
except in Northern Ireland
 Prescribers should report to their regional
drug misuse database – details found in BNF
Treatment approaches
 Aims
 To decrease level of drug use
 Decrease offending
 Decrease overdose risk
 Prevent spread of blood borne viruses
 Improve health of individual
 Improve health of family
Drug service providers
 Key features
 To avoid prescribing in
isolation
 Harm minimisation
Drug service providers
 Criminal justice services
 Specialist drug teams
 Shared care programs
 GP led services
Essential elements of
treatment provision
 Assessment of needs to include drug and
alcohol misuse, health and social functioning
and criminal involvement.
 Risks to dependent children should be
assessed for drug using parents
 All patients entering treatment should have a
care or treatment plan that is regularly
reviewed
Essential elements of
treatment provision
 Drug misuse treatment involves a range of
interventions not just prescribing
 A named individual should manage and
deliver aspects of the patients care or
treatment plan
 Drug testing can be a useful too in
assessment and in monitoring compliance
and outcome of treatment
Maintenance prescribing
 Licensed treatments for maintenance
 Methadone 1mg/ml
 Buprenorphine – subutex
 Never start at first contact
 Perform full physical and psychiatric
assessment
 Test urine to confirm opiate use
Maintenance prescribing
 Prescribe for daily consumption for at least
first 3 months
 Liaise with chosen a pharmacy
 Pharmacies must
 Have undergone training
 Developed protocols for communication between
patient, pharmacist and prescriber
Maintenance prescribing
 Dose titration requires
 Experience
 Repeated assessment of patient
 Usual starting dose 10-30mg methadone but
deaths have occurred with doses as low as 20mg
 Safer to start 10-20mg and build up
Maintenance prescribing
 Doses are gradually increased by no more
than 5-10mg
 Max weekly total increase of 30mg above
starting dose
 Most patients need 60-120mg methadone
 May take several weeks to achieve dose at
which patient feels comfortable and is no
longer needing illicit heroin
Maintenance prescribing
 Methadone tablets can be ground up
and injected don’t prescribe
 Methadone ampoules should only be
prescribed by a specialist
Maintenance prescribing
 Buprenorphine
 Used in patients with lower opiate use
 Taken sublingually
 Starting dose 4-8mg/day
 Increased by 4-8mg daily to max dose of
32mg/day
Maintenance prescribing
 Buprenorphine
 Inhibits other opiates blocking effect of heroin
used on top of the buprenorphine
 Can precipitate opiate withdrawal symptoms if
taken while there is still circulating opiate in body
 First dose should be taken when patient is
showing withdrawal symptoms
Maintenance prescribing
 Buprenorphine
 Can be abused by injecting or snorting
 Suboxone = buprenorphin-naloxone
 New substance recently launched to address
above problem. The naloxone has minimal effect if
taken sublingually but if injected or taken
intranasally it is likely to precipitate withdrawal
effects – has lower street value