* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Introduction to Substance Misuse Objectives 1. 2. Substance history taking and identification of dependency Increase awareness of the effects of commonly abused substances 3. Knowledge of withdrawal symptoms 4. Co-morbidity issues 5. Case scenarios to discuss possible management strategies Substance History Taking Ask all patients if they drink alcohol. Can use alcohol screening questionnaires: CAGE – 4 questions, Alcohol use disorder AUDIT or FAST alcohol screening test Ask about other substances Legal Prescribed Illegal Over the counter How much, how often, route of use, length of use Withdrawal symptoms? How does it affect life, work, family? Are they receiving support? Do they think they have a problem? Do they want help? Get history from informant if possible Check other records if available Be aware of how to refer top local services if dependent Consider joint working between CMHT and SMS Dependent Use Daily or almost daily use Tolerance to substance Craving and loss of control over use Withdrawal symptoms Major effect on functioning Rapid reinstatement after stopping Use ongoing despite harm to self and others Intoxication Definition A condition following use of a psychoactive substance which results in: Disturbances in level of consciousness Disturbed cognitive functioning Changes in affect or behaviour The disturbances are directly related to the pharmacological effects of the substance and resolve over time. Intoxication can lead on to overdose, which can be fatal. Poly-drug abuse is common in fatal overdoses in opiate addicts with alcohol and benzodiazepines often implicated. Individuals with a known substance misuse problem are at high risk of intoxication with a range of substances, not only the substance which is their primary problem. Alcohol 1 unit is 8g and is eliminated in approx. 1 hour 1 unit contained in: ½ pint of 3-4% beer 125ml average strength wine a single measure of 25ml spirits Recommended limits: Women – maximum 14 units per week Men – maximum 21 units per week Harmful drinking is: More than 35 units per week for women More than 50 units per week for men 40% of alcohol misusers develop acute withdrawal symptoms. These range from minor to severe. Delirium tremens is uncommon. This starts 48-72 hours after stopping and is a medical emergency. Other patients can mostly be managed as outpatients. Admission to inpatient psychiatric wards for detoxification is not recommended. But this may be necessary if psychiatric co-morbidity is present. A risk assessment is needed. Alcohol withdrawal Acute alcohol withdrawal syndrome following abrupt reduction or cessation of regular high alcohol intake appears as soon as the blood alcohol level decreases significantly. Symptoms usually peak at 12-30 hours and subside by 48 hours. Delirium tremens occurs in <5% of individuals and if untreated delirium tremens has a mortality of 15%. Basic management of alcohol withdrawal All patients with suspected alcohol misuse should be monitored for signs of withdrawal Using CIWA-AR scoring regularly (ie 2 hourly with physical obs for first 24 hours) CIWA-AR score should inform Chlodiazepoxide dosing. PRN choldiazepoxide should be prescribed for the first 2448hours if CIWA-AR score is >10. This dosing can be given up to hourly to a maximum of 200mg a day if the CIWA remains above 10. After 48hrs NO PRN should be given, but the daily TOTAL dose needed over the last 48 hrs divided into 4 doses and gradually reduced in a regimen over the following 5-7 days Only in EXCEPTIONAL circumstances will an individual need a detox longer than 7 days This approach reduces under and over prescribing of Chlodiazepoxide Betsi-wide guideline regarding alcohol detoxification prescribing should be ready within the next few months Basic Management of alcohol withdrawal All patients with alcohol withdrawal should be given thiamine orally Patients with signs/symptoms of wernickes/korsakoffs should be given Pabrinex Prophylactic Pabrinex should be given in those at high risk (i.e. malnourished individuals) Night sedation should NOT be prescribed routinely (NICE guidelines) Additional benzodiazepines should NOT be prescribed routinely (NICE guidelines) Psychoactive Substances Stimulants Depressants Hallucinogen Hallucinogens s Cannabinoids Cocaine Ecstasy Amphetamine Heroin Benzodiazepines Methadone LSD Magic Mushrooms Cannabis Benzo Fury Gogaine Mephedrone BZP Dextromethorphan GBL Etizolam Ketamine Methoxetamine Tryptamines Spice Black Mamba Clock Work Orange Ketamime Action blocks activation of non-completive N-methyl-D-aspartate receptors (NMDA) Abuse by snorting or injecting Hallucinogenic dose is 30 mg orally Reduces sensation and movement Feeling of detachment (K-hole) Hallucinations Toxic confusional state Bladder damage with regular use No physical withdrawal symptoms But ?clinically useful Low dose ketamine infusion for treatment resistant depression First UK study in Oxford reported in J. Psychopharmacology April 2014 Cocaine Cocaine is the psychoactive alkaloid of the coca plant Naturally occurring local anaesthetic Well absorbed, peak concentration 5-10 mins after IV use 5-10 mins after smoking 60 mins after snorting Shorter acting than amphetamines Enhances dopamine activity Blocks dopamine re uptake into nerve terminal Direct action on cell membranes blocking nerve impulses (local anaesthetic action) Also blocks re-uptake of 5HT and noradrenaline Acts on vertical tegmental area Effects of cocaine on user Euphoria and mood elevation Increased energy and self confidence Enhances talkativeness Enhances mental alertness Alleviates fatigue… BUT… At HIGH DOSES or when USE is CHRONIC, adverse effects are more common Restlessness and nervousness Excitability Aggression Suspicious and paranoid thoughts Loss of libido Hallucinations Delusional thoughts Not all patients develop withdrawal symptoms. Withdrawal symptoms are more likely in: Long term higher dose patients Patients with a history of drug and alcohol dependence Patients with dependent and avoidance type personality types Basic management of opiate withdrawal Symptomatic treatment is recommended (This can be monitored using the COWS scoring) Paracetamol and ibuprofen for muscle aches Loperamide for diarrhoea Mebeverine for abdominal pain Night sedation (low dose and short term) Lofexidine can also be used DO NOT commence on opiate replacement therapy such as methadone as this will need to be initiated and followed up by SMS services, instead manage symptomatically and refer to SMS ASAP Methadone Initiated by specialist services ONLY Its effects are longer acting than those of morphine, which may result in a cumulative effect – thus it should not be given more than twice a day, it is also less sedating Well absorbed orally and prescribed as liquid (green) 1mg in 1ml Doses of 50mg or less can be fatal in non tolerant patients It is an excellent analgesic When seeing an inpatient on methadone please ensure SMS services are aware of their admission DO NOT PROVIDE METHADONE TTOS (liaise with SMS and community pharmacy to facilitate methadone upon discharge) Methadone for opiate dependency Methadone is a synthetic compound with pharmacological action similar to that of morphine and heroin, almost equal in addiction liability “Methadone is a valuable drug in the treatment of opioid dependence. But it is two-edged in that if carelessly employed it can add to the toll of opioid-related deaths.” ….Reducing Drug Related Deaths,2000 Buprenorphine (Subutex) (Suboxone) Also known as temgesic (Subutex) – this is for you to be aware of if seeing individuals on this drug, again we would ask that SMS be informed if patient admitted and informed of discharge so medication can be arranged – DO NOT PROVIDE TTOS of suboxone/subutex for substance misuse clients Taken sublingually – first pass metabolism in liver Maintenance dose for opiate addicts, 2 mgs – 32 mgs – average maintenance dose around 12 mgs Negative on screening for opiates Long acting x 1/day Partial agonist µ Agonist Kappa Antagonist As effective as oral methadone on various trials Use of Suboxone as less abuse potential Dual Diagnosis – some findings Rates of substance misuse are much higher in people with psychosis than in the general population The main problem substances are cannabis and alcohol, if nicotine is excluded Misuse is more usual than dependency Between 30-50 % of patients known to drug services fulfil criteria for a psychiatric diagnosis, mostly anxiety/depression Relevant issues for Dual Diagnosis Patients Problems in diagnosis – often have more than 2 diagnoses Patients perceived to be difficult, with a poor prognosis and unpopular with service providers Demarcation disputes between drug services and general psychiatric services – many fall through the net of service provision Patients may conceal their substance use from professionals, fearing stigma and discrimination Possible Relationships between Substance Misuse and Psychotic Symptoms Intoxification e.g. amfetamines, LSD, cannabis Withdrawal states e.g. alcohol, benzodiazepines Hallucinosis e.g. alcohol Confusional states e.g. Crack/cocaine, LSD Exacerbation of underlying psychosis (often small quantities) e.g. cannabis, alcohol, amfetamines Drug induced psychosis (symptoms continue after no evidence of drug in body) e.g. amfetamines Clinical Scenarios 1. Patient is verbally threatening intoxified with alcohol and expressing suicidal ideation 2. Patient on oral Methadone has developed psychotic symptoms 3. Patient has lost Methadone and Diazepam prescription Substance Misuse and Prescribing Dr Sue Ruben August 2011 Alcohol Use Disorder Identification of alcohol problems Varied clinical presentation including: Depression Anxiety Fatigue, debility, memory problems Gastro-intestinal symptoms Liver disease Marital disharmony Onset of fits in adult life Frequent absences from work, particularly Monday mornings Alcohol abuse often complicates the picture in patients with psychiatric problems and leads to a worse prognosis Alcohol Use Disorder Alcohol use disorders involve drinking above recommended limits Recommended limits are based on daily or weekly total alcohol consumption in units 1 unit of alcohol = 10ml ethanol (but most drinkers do not think in terms of ethanol volume or alcohol units) Alcohol Units Alcohol Use Disorder The pattern of drinking and the total weekly consumption of alcohol are important determinants of alcohol related harm: Hazardous alcohol use Harmful alcohol use Alcohol dependence Binge Drinking Classification of Alcohol Use Disorder Hazardous Drinking Pattern of alcohol consumption that may eventually cause harm i.e. drinking above sensible or recommended limits: >14 units a week for women (3 units a day) >21 units a week for men (4 units a day) Classification of Alcohol Use Disorder Binge drinking – regularly drinking twice the daily recommended limit i.e. 8 or more units a day for men or 6 or more units a day for women Binge drinking may fall into hazardous or harmful categories Classification of Alcohol Use Disorder Harmful Drinking Pattern of alcohol consumption that is already causing damage to the person’s physical or mental health (50 units men or 35 units women) Damage may be acute (acute pancreatitis) or chronic (alcohol related brain damage) Despite evidence of alcohol related problems patients do not usually seek treatment Classification of Alcohol Use Disorder Alcohol Dependence Syndrome A strong desire or sense of compulsion to drink Difficulties in controlled alcohol intake A psychological withdrawal state, includes: Shaking and tremor Anxiety symptoms Insomnia Sweating Morning nausea and vomiting Tolerance Progressive neglect of alternative pleasures or interests Persistent drinking despite clear evidence of harmful consequences Blood Alcohol Values and Their Effects on Normal Drinkers BAC (mg/dl) 20 40 60 80 100 120 150 300-400 450 and above EFFECTs Light drinkers begin to feel some effects Begin to feel relaxed Judgement somewhat impaired, drivers TWICE as likely to have an accident Co-ordination and driving skilled impaired, beginnings of disinhibition Reaction time and self control impaired, accidents 7 TIMES more likely If drinking rate is fast vomiting can occur Slurred speech and staggering, accidents 25 TIMES more likely Loss of consciousness likely Death can occur Alcohol Misuse and Dependence Alcohol History Taking Consider alcohol as a possible cause of symptoms CAGE questionnaire Have you ever felt you should Cut down your drinking? Have people Annoyed you by criticising your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves and get rid of a hangover (Eye opener)? Carry out AUDIT score… Alcohol Use Disorder Identification Test (AUDIT) Please circle the answer that is correct for you: 1. How often do you have a drink containing alcohol? Never Monthly 2-4 times 2-3 times or less a month a week 4 or more times a week 2. How many standard drinks containing alcohol do you have on a typical day of drinking? 1-2 2-4 5-6 7-9 10 or more 3. How often do you have six or more drinks on one occasion? Never less than monthly monthly weekly daily 4. How often during the last year have you found that you were not able to stop drinking once you have started? Never less than monthly monthly weekly daily 5. How often during the last year have you failed to do what was normally expected from you because of drinking? Never less than monthly monthly weekly daily 6. How often during the last year have you need a drink in the morning to get yourself going after a heavy drinking session? Never less than monthly monthly weekly daily 7. How often during the last year have you had a feeling of guilt or remorse after drinking? Never less than monthly monthly weekly daily 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never less than monthly monthly weekly daily 9. Have you or someone else been injured as a result of your drinking? No yes, but not in the last year yes, during the last year 10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down? No yes, but not in the last year yes, during the last year (scoring 0-4 for each answer 0 – never, 4 – daily) A score of 8 or more is associated with harmful or hazardous drinking A score of 13 or more in women, and 15 or more in men is likely to indicate alcohol dependence Alcohol Misuse and Dependence Detoxification If a patient is physically dependent, they usually require medication to minimise withdrawal symptoms This may not require in-patient treatment unless: History of fits High risk of delirium tremens Very poor physical health/lack of social stability Co-morbidity For home detoxification, the patient needs to: Show good motivation to detoxify Agreed with Substance Misuse Team to oversee the withdrawal No history of abuse of prescribed medication Use Librium (Chlordiazepoxide) Starting dose between 10 – 20 mgs QDS – max 200mg/day Reduce to zero over 5 – 7 days – once controlled No routine night sedation Vitamin B supplements Rest and high fluid intake Alcohol Misuse and Dependence Post Detoxification Avoid prescribing: Benzodiazepines Chlormethiazole Routine night sedation (risk of dependency) (Never in a community setting) Assess mood: If depressive symptoms prominent or mixed depression/anxiety and panic after 2 – 3 weeks alcohol free, consider anti depressants Repeat LFT’s, FBC – Gamma GT should improve if alcohol free Disulfiram and Acamprosate can be used to assist staying alcohol free Consider AA, counselling or other support services available locally Monitor the patients’ progress on a regular basis If relapse occurs may require referral to specialist services Alcohol Misuse and Dependence Management Early intervention in primary care Advice about sensible drinking Useful for patients who are at early stage of alcohol problem Motivational interviewing techniques Helps patients to reach a decision to change Give feedback about risks Emphasis on personal responsibility Give direct advice about drinking Discuss a menu of options for changing drinking Remain empathic towards the patient Set and agree goals which are attainable short-term and have positive rewards for patients Involve the family, if possible Enhance self esteem and hope Use other agencies e.g. counselling, AA Be prepared to confront and challenge the patient of necessary Follow up support Delerium Tremens Occurs in severe alcohol withdrawal in approx 5% of patients It is a toxic confusional state and can be life threatening Is often associated with other medical conditions Requires treatment in a general medical setting Symptoms Clouding of consciousness and confusion Vivid hallucinations Agitation and tachycardia, hypertension, sweating and fever Marked tremor Paranoid ideation Symptoms peak 72-96 hours after last drink Wernicke’s Encephalopathy Caused by acute Thiamine deficiency Classic symptoms are Opthalmoplegia Ataxia Confusion Always consider during alcohol detoxification if patient has any of these signs Must have parenteral B complex (Pabrinex) not oral Thiamine for 3-5 days Benzodiazepines Substance Misusing Patients and Benzodiazepines Abuse of benzodiazepines is very common in patients with substance misuse problems (both drugs and alcohol) Many display a pattern of binge use with periods of abstinence and are not “dependent” on the medication Some injecting drug users will inject benzodiazepines Substance misusers often obtain supplies from patients who are not themselves substance misusers For heroin addicts, the use of benzodiazepines in association with heroin increases the risk of death in overdose Benzodiazepine prescribing should be avoided in this patient group Benzodiazepines Main therapeutic Uses 1. 2. 3. 4. Anxiolytic (not a first line treatment for anxiety disorders) Treatment of insomnia – short term Sedative e.g. pre-operative Management of agitation in psychosis Problems associated with benzodiazepines Sedation Cognitive impairment, poor concentration, poor short term memory Tolerance, dependence with dose escalation Withdrawal symptoms Abuse and diversion into the illicit market Good Prescribing Practice of Benzodiazepines Use non-drug therapies wherever possible for anxiety and insomnia Identify depression which is common and where appropriate prescribe anti depressants Only prescribe for a short time with regular reviews Discuss the “pros” and “cons” with the patient Do not prescribe more than one benzodiazepine at a time Always be aware of the risks of misuse of the medication and possibility of diversion to the illicit market Try and prescribe as low dose as possible Develop a Prescribing Policy within each therapeutic setting Benzodiazepines Managing Withdrawal from Benzodiazepines Identify suitable patients Transfer patient to a long acting benzodiazepine (usually diazepam) prior to withdrawal Agree a treatment plan with the patient with dose reductions at regular intervals Be prepared to be flexible Any overall dose reduction is positive Offer psychological support and non-drug therapies: Anxiety management Relaxation therapy Cognitive restructuring Exercise Acupuncture Symptoms of Benzodiazepine Withdrawal Anxiety Sweating Insomnia Headache Tremor Nausea (poor appetite) Feelings of unreality Hypersensitivity to stimuli Abnormal sensations within the body Withdrawal psychosis Epileptic seizures Not all patients develop withdrawal symptoms. Withdrawal symptoms are more likely in: Long term higher dose patients Patients with a history of drug and alcohol dependence Patients with dependent and avoidance type personality types Prescribing for Heroin Addicts 1. 2. 3. 4. 5. 6. Opiate withdrawal is not a life threatening condition opiate toxicity is Do not initiate opioid substitution treatment in general adult psychiatry without the support of substance misuse services for full assessment and plan If patient is on substitute medication before continuing it, check with prescriber and/or pharmacy to verify dose If uncertain about compliance consider dose reduction or split dose, ask patient what dose they take ECG if adding antipsychotics to methadone (QT interval) Risk of respiratory depression when co-prescribed sedative medication - increase levels of observation and do not prescribe if patient appears intoxified e.g. slurred speech, ataxia, confused Methadone Methadone is a synthetic compound with pharmacological action similar to that of morphine and heroin, almost equal in addiction liability “Methadone is a valuable drug in the treatment of opioid dependence. But it is two-edged in that if carelessly employed it can add to the toll of opioid-related deaths.” ….Reducing Drug Related Deaths,2000 Methadone Its effects are longer acting than those of morphine, which may result in a cumulative effect – thus it should not be given more than twice a day, it is also less sedating Well absorbed orally and prescribed as liquid (green) 1mg in 1ml Doses of 50mg or less can be fatal in non tolerant patients Methadone Expected Outcome Reducing drug use Reduced criminal activity Reduced mortality Improved physical and mental health Reduced risk behaviours for HIV, HCV and other blood-borne pathogens and reduced risk behaviours for HIV and STD’s Methadone Benefits of Methadone This occurs when methadone is given in adequate dosage, with good supervision and in the context of psychosocial support Often supervised in community at local pharmacy Start with low dose and titrate up Doses vary between 10 mgs – 120mgs/day Better outcomes with doses over 60 mgs/day Buprenorphine (Subutex) Also known as temgesic (subutex) Taken sublingually – first pass metabolism in liver Maintenance dose for opiate addicts, 2 mgs – 32 mgs – average maintenance dose around 12 mgs Negative on screening for opiates Long acting x 1/day Partial agonist µ Agonist Kappa Antagonist As effective as oral methadone on various trials Buprenorphine Advantages Safer in overdose Less euphoriant effects May be easier to detox from ?Some anti-craving action Rapid dose titration Good alternative for patients who do not want methadone Increasingly used as an alternative to methadone Disadvantages Hard to reverse with Naloxone Readily abused intravenously and snorted More expensive More difficult to supervise Have to be in moderate withdrawal prior to first dose Higher dropout rates early in treatment Side effects include hallucinations ?Caution in psychotic patients ?Hepatotoxicity – advise LFT’s prior to prescribing Crack Cocaine/Amfetamines Increase in all areas in particular urban/inner city Reduced price, often sold with heroin Often the gateway drug point prior to heroin Often used intravenously (speedballing with heroin) Abuse more common than dependency Cocaine mixed with alcohol makes cocethyelene No evidence based pharmacotherapy for cocaine or amfetamine dependency Some week evidence for acupuncture Treatment services mostly consist of psychosocial interventions Detoxification from opiates Choice of treatments: 1. 2. 3. 4. Methadone reduction Lofexidine Subutex (buprenorphine) “Cold turkey) Symptomatic relief: 1. 2. 3. 4. 5. 6. 7. Anti-nausea drug Anti-diarrhoea drugs Anti-spasmodic drugs Night sedation (but be aware of risks of dependence) Acupuncture and E.S.T Massage/reflexology Exercise Relapse Prevention Opiate dependence is a chronic relapsing condition and relapse is common especially in the first three months after detox To reduce risk of relapse: 1. Naltrexone 2. Psychological and social support 3. Residential rehabilitation This is to certify that: ......................................... Has reviewed/completed .......... Substance Misuse................. Date ........................................