Download IMPARTS 2014JB

Alcohol, drugs, and hospitals
James Bell
February 2014
Why do people use drugs?
Why do people use drugs?
Drug use is normal behaviour
Who develops drug problems?
Who develops drug problems
25
Prevalence
20
15
Males (9.0)
Females (3.2)
10
5
0
18-24
25-34
35-44
45-54
Age
55-64
65+
Neurobiology of drug use
• Drugs of abuse have in common that they
act on the “reward pathway”
• The reinforcing effect of drugs is reduction
in anxiety and creation of a sense of wellbeing
• Repeated exposure leads to lasting brain
changes, including protracted withdrawal
Drug Dependence
A maladaptive pattern of substance use
leading to impairment or distress
Tolerance and Withdrawal
Salience
Craving
Reinstatement after abstinence
Persisting use despite harm
Communities vulnerable to
drug dependence
Those without taboos or rewards
Especially:
- indigenous communities
- marginalised communities
- deregulated communities
Responding to drug
problems
Distinct area of medicine:
• Serious morbidity and mortality
• Involves values and choices
Simply telling people to stop is of limited
value
Components of
behavioural medicine
•
•
•
•
Exchange of information
Structure
Support
Relief of symptoms
Alcohol and hospitals
Alcoholics need not apply
Admissions with alcohol
problems KCH 2009
CARE_GROUP Elective Emergency Non-Elective
Cardiac
44
25
16
Child Health
1
14
1
CSDS
4
Dental
7
26
3
Liver
465
191
109
Medical
8
1716
8
Neurosciences
26
38
49
Renal
15
25
7
Specialist Medicine
3
23
Surgical
67
231
13
Women's Health
3
3
Grand Total
643
2292
206
Total
85
16
4
36
765
1732
113
47
26
311
6
3,141
Questions
Hospitalised drug user
A heroin user was admitted for hand surgery after a
fight
- Post-operatively, complaining of pain
- When told his next scheduled dose of analgesia was
not for several hours, he swore at the nurse and
threatened vilence
Progress
Addiction nurse assessed patient
- Opioid withdrawal
- Recommended methadone be given, plus
analgesia as needed
Once withdrawal relieved, addictions nurse
suggested apology
Patient agreed, situation resolved
Why do heroin addicts receive
methadone?
Opioid Substitution Treatment of
Addiction
1. Controlled Supply
2. Stabilization (abolish withdrawal)
3. Diminish reinforcing effects of street
heroin
4. Structure – attendance and
monitoring
5. Support
Prescribing Methadone for
admitted patients not on OST
FIRST 24 HOURS
Prescribe methadone liquid 1mg/ml
Dose 1-10mg every 4 hours PRN according to signs of
withdrawal
Maximum dose 40mg in first 24 hours
Always refer these patients to the Substance Misuse
Nurse on pager KH3227.
Person on methadone (or
buprenorphine) admitted
1. Continue medication
2. In addition, usual analgesia, may need
titration
3. If head injury / hepatic encephalopathy,
may need dose reduction
4. Note drug interactions (anticonvulsants,
rifampicin, other CYP inducers)
Caution
F40 morbidly obese, admitted leg ulcer Mx
Methadone 100mg/day, not supervised as she had
limited mobility.
Methadone prescribed in hospital, administered day1
Day 2 – noted to be drowsy, snoring cyanosed, with pinpoint pupils
Party Drugs
GBL
GABA b agonist, precursor of GHB
• Produces confidence, charm, relaxation
(“charisma”), sexual disinhibition
• In higher doses produces prompt sleep
• Narrow therapeutic index – risk of OD
• Usage mainly in gay males
Why do people use GBL?
1. Socialising
2. Sex
3. Sleep
GBL - dependence
• Uncommon?
• Involves dosing every 1-2 hours
• Can develop rapidly (eg after a “long
weekend” of partying)
• Often occurs when drug is used for sleep
• Associated with social withdrawal, emotional
blunting, compromised social role
GBL withdrawal
Onset rapid – 3-4 hours
Can occur after awaking from OD
May be severe (delirium, agitated psychosis,
severe anxiety and insomnia)
Several cases required ICU management
UK experience – people admitted for elective
detox have required ICU transfer (delirium,
rhabdomyolysis)
GBL withdrawal management
• Initiate high dose diazepam (20mg 2nd
hourly) early. “Usual” dose 70-90 mg day 1
• Baclofen 10mg tds
• Transfer to AAU (more appropriate setting)
Further Reading
•
Bell J & Collins R (2011) Gamma-butyrolactone (GBL)
dependence and withdrawal Addiction 106(2); 442-447
•
McDonough M, Kennedy N, Glasper A, Bearn J (2004) Clinical
features and management of gamma-hydroxybutyrate (GHB)
withdrawal: a review Drug and Alcohol Dependence 75; 3–9
•
Le Tourneau J, Hagg D, Smith S (2008) Baclofen and gammahydroxybutyrate withdrawal Neurocritical Care 8(3):430-3
Questions
[email protected]