Download Club drugs, legal highs or new psychoactive substances

Drugs, legal and illegal
Dr Tim M Williams
Clinical Director – Specialised Services AWP Mental Health NHS Trust
4th July 2014 – Wills Hall, Bristol.
Drug and alcohol harms
Alcohol
Alcohol affordability index, 1980-2010.
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing Group
Real spending on alcohol in UK, 1964-2010.
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing Group
Hospital admissions wholly attributable to alcohol in England, 2002 to 2010
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing Group
The Scots leads the world
Leon and McCambridge, Lancet 2006 (updated)
Leon and McCambridge, Lancet 2006 (updated)
Alcohol withdrawal
Time since last drink
tremor
nausea and vomiting
anxiety, irritability, depression
 BP,  pulse,  temp
insomnia
transient hallucinations/illusions
48 hours
seizures (7 - 48 hours)
72 hours
Delirium tremens (peak onset 48 - 72
hours after last drink or reduction).
Tremor, hallucinations, confusion, plus
delusions, insomnia and agitation,
autonomic hyperactivity
What to do when abstinent?
• Relapse Prevention essential
• Not usually offered by statutory/specialist
services
• 12 weeks treatment only in my service
• Medication???
▫ Disulfiram, acamprasate, naltrexone
▫ nalmefene currently hit the headlines
Alcohol harms
(is a downer)
Immediate Risks
Longer term
• Accidents
▫ Head injuries
▫ Driving
▫ Death (esp drowning / RTA)
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•
•
•
•
•
•
•
• Vulnerability
▫ to exploitation / date rape
• Heart
▫ Seen more in Russia
Liver
Pancreas
Brain / neurons
Heart
Vessels / kidney’s
GI tract
Sexual dysfunction
Addictive potential
▫ Minority: 3-5% dependence
• Mental health
▫ Massive co-morbidity
“Drugs”
UK drug use
Opioids
Benzodiazepines and opioids
• Benzodiazepines plus methadone or
buprenorphine
- higher opioid toxicity symptoms (Nielsen et al, 2007
Addiction)
- greater peak effects on performance measures
(Lintzeris et al, 2006 J. Clin. Psychopharmacology)
- higher mortality among patients co-prescribed
methadone and benzodiazepines (McCowan et al,
2009 BMJ)
Gabapentin misuse
 Smith et al Br J Gen Pract. 2012 Aug;62(601):406-7.
• “In primary care, an increasing number and urgency of
prescription requests cannot necessarily be explained by
the increased number of cases of neuropathic pain”
 5.2% of people in SM services using gabapentin
 Mean daily dose 1343mg
 Of 1400 post-mortems
 48 had gabapentin
 36 of whom also had morphine/ methadone
▫ Is fatal in overdose and unlike opioids or benzo’s
is irreversible
Opioid harms
(are downers)
Immediate Risks
Longer term
• Respiratory arrest
▫ Esp when mixed with
alcohol and other downers
• Crime and poverty
▫ Big overlap
• Accidents
• Vulnerability
▫ to exploitation
• Addictive potential
▫ Yes
• Mental health?
• IV use
▫ BBV’s
• Smoked
▫ COPD
Cocaine
Cocaine (crack) and other stimulants
• Difficult to engage
• Difficult to treat
• High mental health co-morbidity
Cochrane
Database
Syst Rev.
2010 Feb
17;(2):CD0
07380
Psychostimulants did not improve cocaine
use, craving, or treatment retention in
comparision to placebo
Cocaine harms
(is an upper)
Immediate risks
Longer term
• CVS risks
• Addictive potential – very
potent
▫ Could trigger a CVS event
• Psychosis
▫ Could trigger an event
• Specific Risks
▫ Nothing acute
• Long-term risks
▫ prominent CVS risks MI,
stroke
▫ COPD (crack)
▫ Nasal septum (snorted
cocaine)
NPS
…….or novel psychoactive substances (NPS)
…….or “club drugs”
…….or “legal highs”
Source- NTA ‘Club drugs: emerging risks and trends’ Dec 2012
3,4 Methylenedioxmethamphetamine (MDMA)
•The recreational drug Ecstasy
•Onset 20 minutes
•Effects last 2-5 hours
•Particular empathogenic /
entactogenic qualities
•Physiologically safe in therapeutic
applications
How dangerous is MDMA
when used recreationally?
• Between 1997 and 2000 in the UK:
• 81 deaths were attributed in part to ecstasy(Schifano F. 2003)
But....
•
•
•
•
•
59% also included opiates
60% included alcohol
Only 7% involved MDMA alone;
That is six deaths in three years
After some 300 million ecstasy tablets were consumed by
over a million people.
• And remember: this is NOT clinical use. This is the uncontrolled
recreational use of ‘ecstasy’.
4.8% of British soldiers returning from
combat in Iraq met the criteria for PTSD
(Iversen et al 2009)
US soldiers returning from service in Iraq
and/or Afghanistan, the incidence of
PTSD is as high as 18%. (Hoge et al 2004)
More returning soldiers from Iraq and
Afghanistan have committed suicide
from untreated PTSD than ever died
in the conflict out there.
2009 - MAPS / Mithoefer
MDMA for PTSD Study:
Michael and Annie
Mithoefer,
Hypotheses:
1. MDMA subjects will show improved rates of PTSD.
2. MDMA will not be associated with neurotoxicity.
Baseline
measurements
Introductory
Sessions
First MDMA /
Placebo
Session
Four non-drug
sessions
Measurements
Measurements
Second MDMA /
placebo session
Four nondrug
sessions
Measurement
THREEYEAR
FOLLOWUP:
Two Month
Follow-up
Results for Hypothesis One:
% meeting PTSD diagnosis – pre/post
100
90
80
% with PTSD
70
Baseline
60
50
final
40
30
20
10
0
Placebo
MDMA
Mithoefer ©
2009
3
4
MDMA harms
(is an upper)
Immediate risks
Longer term
• CVS risks
• Addictive potential – very
unlikely due to high tolerance
▫ Could trigger a CVS event
• Psychosis
▫ Could trigger an event
• Specific Risks
▫ Hyperthermia
▫ ?water intoxication
• Very little data on long-term
risks
▫ no CVS risks recorded
▫ No consistent evidence of
long-term memory deficits.
Short term reversible
deficits recognised.
MDMA/Ecstasy adulterants
• An emerging problem
▫ Need to develop new harm minimisation messages.
▫ Specific advise for coroners essential
• PMA (para-Methoxyamphetamine or 4-MA)
▫ 1 hour onset
• PMMA (para-Methoxy-N-methylamphetamine)
▫ Linked to deaths, ?less toxic than PMA
PMA / PMMA (is an upper)
Immediate risks
Longer term
• CVS risks
• Addictive potential ?
▫ ?Could trigger a CVS event
• Psychosis
▫ ?Could trigger an event
• Specific Risks
▫ Hyperthermia (greater than
MDMA)
• No data on long-term risks
Mephedrone
4-MMC, MMCat, Miaow, Meow Meow, Bubble,
• 4-Methylmethcathinone
(4-MMC)
• Stimulant, appeared in or
around 2007 (Sweden)
• Sold as powder, crystals
or sometimes capsules
• Made illegal from
16/04/10 (Class B). Price
nearly doubled
• Had bypassed regulations
as ‘plant food’, ‘not for
human consumption’
The Scunthorpe two: Louis
Wainwright and Nicholas
Smith
Died from taking
methadone not
mephedrone with
significant quantities of
alcohol
• Professor Sheila Bird, of the Medical Research Council's Biostatistics Unit in
Cambridge “deaths from cocaine fell in the first six months of 2009 to 66, a
statistically significant drop from 95 in the same period of 2008”
Mephedrone harms
(is an upper)
Immediate risks
Longer term
• CVS risks
• Addictive potential
▫ Could trigger a CVS event
• Psychosis
▫ Could trigger an event
• ?Specific risk of
vasoconstriction
• Specific come down risk
and suicide
• Very little data on long-term
risks
▫ Likely CVS risks
▫ ?mental health
K, ketamine
• and
methoxetamine?
The Observer Sunday 17 April 2011
Every parent's worst nightmare: how
ketamine killed our daughter
Bright, popular, rebellious and creative, 21-year-old Louise Cattell had everything to
live for. Then she made a fatal mistake. She took the party drug ketamine and was
found dead in the bath by her flatmate.
Ketamine harms
(is a downer)
Immediate Risks
Longer term
• Accidents
▫ especially drowning
▫ and hypothermia
▫ driving
• Bladder problems
▫ Thickening
▫ Urgency
▫ ‘K-cramps’
▫ Eventually dysfunctional
bladder
• Vulnerability
▫ to exploitation
• However is generally a very
safe drug used in a medical
context
• Stimulant at low doses
• Addictive potential
▫ Users 1-12g a day
• Mental health?
GHB, GBL and 1,4-BD
Confusingly sometimes referred to as “liquid
ecstasy”
GHB/GBL harms
(is a downer)
immediate
Longer term
• Respiratory depressant
▫ Very dangerous with alcohol
▫ Narrow therapeutic window
• Addictive
• Accidents
▫ Much like alcohol
▫ Disinhibits and poor
perception of risks
• Withdrawal syndrome
▫ Like alcohol but worse
▫ Severe seizures
▫ ?baclofen to treat
Khat
Main active
ingredients are
cathine and
cathinone
Khat harms
(is an upper)
Immediate risks
Longer term
• CVS risks
▫ Precipitate event
• CVS risks
▫ Early MI
▫ Early stroke
• Psychosis
▫ Minor risk
▫ But mixed with PTSD
increased
• Dependence
▫ Small minority
• GI cancers??
▫ Oral
▫ oesophageal
M-Cat, madcat and now M2 ie
3,4,DMMC (are stimulants)
See what the are doing here:
• cathinone (in khat)
• methcathinone (m-cat)
•4-methylmethcathinone (mephedrone)
•3,4-dimethylmethcathinone (“M2”)
Harms??
Immediate
Longer term
• CVS
• CVS
• Mental health
• Mental health
• Specific risks?
▫ Anaphylaxis
▫ Respiratory??
• Dependence
Can include 6-APB in this category (unhelpfully often called “benzofury”)
6-(2-aminopropyl)benzofuran
2-CB
(MDMA like)
The Sun 24/1/13
“Krokodil”
• CNN -“flesh-eating zombie drug”
• USA Today -“Flesh-Rotting ‘Krokodil’ Drug
Emerges in USA,”
• GQ – “flesh-eating
heroin substitute that
has found favour with
Russia's homeless,
and now "krokodil"
has come to Britain.”
“Krockadil” (desomorphine)
Immediate
Longer term
• CVS
▫ Resp depression + death
• CVS
• Mental health
• Mental health
• Specific risks?
▫ “flesh eating”??
• Dependence
▫ absolutely
Reports in Russia of homemade ‘krokodil’ by mixing codeine with
chemicals such as gasoline, red phosphorus, and hydrochloric acid.
Extremely unlikely to be found in Europe and US due to easy availability
of opioids
Other drugs
(not uppers or downers)
Cannabinoids
hallucinogens
• Respiratory if smoked
• Mushrooms (psilocybin), Acid
(LSD)
▫ Low risk
• Psychosis
▫ Precipitated - yes
▫ Cause - probably no
• Anxiety
• Amotivational
▫ Definitely
• Salvia divinorum
▫ Slightly different but still
low risk
• MDA
▫ A bit more of a stimulant
(MDMA like)
End