Download street drugs and alcohol

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 and 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
substancee.g. what? how used? what
mixed with?
the rewards
setting –
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
concentration
social confidence
pos. psychosis
‘alive’ & ‘alert’
big crashes - physical
& mental
paranoia
over agitation
depressants
life management
‘warm blanket’
euphoria
relaxation
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
STIMULANTS
Crack
Cocaine
Tobacco
Caffeine
Speed
Ecstasy
Cannabis
Magic
M’rooms LSD
HALLUCINOGENS
Glue/Solvents
Alcohol
Ketamine
Benzos
Methadone
Heroin
DEPRESSANTS
cycle of dependence - depressants
use to
manage or
suppress
feelings
feelings return
drug
effectiveness
decreases
OUT?
mood changes/
feelings hidden
dependency pattern
reinforced
tolerance
increases
stimulants - crash and craving
1. USE
5.The ‘MISSION’
[Highs & Lows ]
[anticipation]
2. EARLY CRASH
4. FEELING OK
[big comedown]
[‘normal’]
3. LATE
CRASH
[regret]
all inter-related…
HEROIN
CRACK
BENZOS
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
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 MoCAM – 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
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’
STATUTORY BODIES
CENTRAL
GOVERNMENT
•Education
•Home Office
•Health
•Nat. Treatment
Agency [NTA]
•Police
•Prisons/Probation
•GODT [regional]
•Social Services
•Community
safety etc.
SHARED INFO
SERVICE PROVIDERS
•CDTs
•Counselling Services
•Street Agencies
etc. etc.
DAAT
Strategy and
Implementation
Team
–
JOINT INITIATIVES
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 1mg/1ml (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 1st
• 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
how 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 9mm by 19mm - 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
400mg 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
14x more likely to OD
• other sedatives
• stimulants [coke, speed etc]
mixing it + high tolerance
TEMAZEPAM – used on perceived comedown
lethal dose
unconscious
intoxicated
level of
heroin in
blood
ALCOHOL
HEROIN
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!