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Drug and Alcohol Misuse
Dr Mick McKernan
Harm Reduction
Philosophy to lessen the dangers drug
abuse cause to Individual/society
We will never stop drug misuse 15K BC
cannabis. Opiates 5K B C. Alcohol 10k
BC
Holistic care. Crime/criminal
behaviour/employment/mental health
/physical health/family therapy/alternate
medicine/ 3rd sector /housing/finance
Maintenance
Detoxification
Abstinence
Client agenda – detoxification
Service agenda -maintenance
Political Pressure to push for
detoxification and abstinence
Families and
Communities
Hidden Harm report gave estimate of
300.000 children living with problem
drug users
More proactive on children's issues-not
waiting until risk
Children ending up cared for-very high50%
Attracting women into treatment
Blood Borne Viruses
Current levels of morbidity and mortality are of
concern. Future outcome and costing to NHS is
unknown but expected to rise. ?400,000 Hep C
positive. 50,000 known cases. 7,000 treated.
44% Hepatitis C prevalence amongst IDU
represent 90% of total cases in UK (HPA)
World prevalence of Hepatitis C is x4 times that
of HIV
2% HIV prevalence- level rising
Dry spot testing
Socioeconomic Cost
£13 billion on crime annual
£1 million per life time of each user= 1
billion in Salford alone for current users
drug treatment s are cost effective-£3
saved for every £1 spent-mainly through
less crime costs
£40k average crime per annum
Tobacco
> 95% smoking prevalence of those in
treatment
50% all smokers will die as a result of their
addiction > 100k per annum
NRT/Oral agents
Evidence suggests tackling nicotine
dependence improves drug treatment
outcomes
Smoking cessation therapy/advice most cost
effective NHS intervention
Alcohol
NTORS report at yr 1 and 5-no fall in level of alcohol
misuse
Annual deaths: alcohol 30,000 v 2500 drugs
Integration of drug and alcohol teams
Treatment Outcome Profiles- alcohol recording and
as primary drug from 2007
Drug trends
- polydrug v polydrug and alcohol at present
Alcohol
1million dependent drinkers- 60,000
have had formal help
Lack of resources/funding
Government push to help in this area
Home/residential detox
Screening –FAST/CAGE
Brief interventions
Opiates-Methadone
A potent opiate 1 cocodamol = 0.5ml
methadone 1mg/1ml
Usual max start 40mg
Golden rule start low go slow
Therapeutic range 60-120ml
Usual max increase 20ml per week
Caution with alcohol /benzodiazepeines
Opiates-Buprenorphine
Very safe
Partial agonist/full antagonist
4-8mg start then 12-24mg daily
Misuse/diversion
Cost
Not for everyone
Opiates- Injectables
• Little evidence base- need UK research
• Injecting behaviour strongly linked to BBV
transmission
• Linked to Overdose
• Use is variable by drug teams
• Attracting hard to reach users?
• Only 3% of clients are given injectables
• Expensive 10k per annum per user
Stimulants
Services often dominated by opiates
and script based philosophy
Lack of evidence for replacement
therapies
Psychosocial interventions
Stigma of attending an opiate based
service
Role for Contingency management
Benzodiazepines and Z
Drugs
All work the same way-hypnotics,
anxiolytics, anticonvulsants, muscle
relaxants and amnesics
All are addictive
Licensed for 2-4 weeks only
1993 10million scripts- 2007 10million
scripts issued > Z use
Drug Users & Benzos
90% in 1 year period
linked to higher BBV risk, greater polydrug use, psychopathology and social
dysfunction
Prefer diazepam 10mg (blues)
Usually orally rarely injected
Drug Users & Benzos
Used for anxiety, insomnia, Iatrogenic
dependence, enjoy effects, enhance
opiate effect, help mood, coping skills,
and/or reduce voices
To help come down from
amphetamines, ecstacy, crack and
cocaine
Benzo Detoxification
Fits are very rare at doses below 30mg
Convert all benzos/z drugs to diazepam
e.g. Temazepam 20mg = diazepam
10mg
Prescribe in 2mg tablets & weekly at
most
Reduce by 2mg every 2 weeks e.g.
Diazepam 10mg=a 10 week detox