Substance misuse

1. 2008 Substance misuse

2. NICE Definition • substance misuse is defined as intoxication by – or • regular excessive consumption of and/or • dependence on – psychoactive substances, • leading to social, psychological, physical or • legal problems. It includes problematic use • of both legal and illegal drugs (including • alcohol when used in combination with • other substances).

3. Comonest • Legal • Alcohol • Nicotine • Glue • Illegal • Cannabis • Stimulants – ecstasy, cocaine, amphetamines, khat. • Benzodiazepaines • Heroin

4. Young people at risk • those whose family members misuse • substances • • those with behavioural, mental health or • social problems • • those excluded from school and truants • • young offenders

5. Young people at risk • • looked after children • • those who are homeless • • those involved in commercial sex work • • those from some black and minority • ethnic groups.

6. NICE Interventions for those at risk • Offer a family-based programme of structured support over 2 or more years, drawn up with the parents or carers of the child or young person and led by staff competent in this area.

7. NICE Interventions for those at risk • The programme should: – include • at least three brief motivational interviews1 each year aimed at the parents/carers • – assess family interaction • – offer parental skills training • – encourage parents to monitor their children’s behaviour and academic performance

8. NICE Interventions for those at risk • – include feedback • – continue even if the child or young person • moves schools. • • Offer more intensive support (for example, family therapy) to families who need it.

9. Management • Management options for misusers • Brief interventions • Counselling • Replacement therapy • Referral to specialist clinics

10. Cannabis • Harms • Damages lungs more than tobacco • Impairs concentration • Impairs motivation • Impairs memory • Heavy use in teenagers may predispose to schizophrenia

11. Cannabis • Selective breeding of plants much higher concentration of active chemical THC = tetrahydro cannabinol • Cannabis induced psychosis more common • Dependency in 5 – 10% of users

12. Cannabis • Medication little role in treatment • GP role • Identification of problem • Brief intervention with motivational technique • Encourage patient to tackle problem

13. Stimulants • Amphetamines • Cocaine • Snorted as powder • Injected • Used in combination with heroin = speedballing

14. Stimulants • Crack cocaine • prepared by heating cocaine in microwave with bicarb of soda. Makes a cracking noise when smoked • Can be injected • Produces more intense and immediate effect than powder cocaine • Wears off in 5-10 mins triggering desire to use it again

15. Stimulants • Crack cocaine • Chronic high dose usage leads to marked psychological dependence • Physical complications include • Heart failure or MI • Crack lung – a hypersensitivity reaction causing dyspnoea and wheeze • Blood borne virus transmission through shared injection equipment • Liver damage

16. Stimulants • Cocaine • Cocaine and alcohol combine together to produce cocaethylene which is more damaging to the liver than either substance • Mental health problems • Lethargy • Depression • Full blown psychosis tactile hallucinations are common the cocaine bug

17. Stimulants • Ecstasy • Stimulant and hallucinogenic effects • Risks • Overheating dehydration • Fluid overload due to increased ADH levels • Advise users to take regular breaks from exercise and sip maximum 1pint water per hour

18. Stimulants • Khat • Green leaves of a shrub commonly grown in Horn of Africa • Effects similar to amphetamine • Legally sold in those areas • Drug induced psychotic episodes • Common in Somali communities

19. Stimulants • Management • Stop usage • Treat individual symptoms • Insomnia hypnotics - short term only • Depression – SSRI’s • Psychological interventions most useful • Local treatment services found Helpfinder section of Drugscope website www.drugscope.org.uk

20. Benzodiazepines • Often used with other illicit drugs • Increases risk of death from overdose when combined with alcohol or opiates • No evidence that long term substitute prescribing reduces harm • Only licensed for reducing regimes and not for maintenance prescribing

21. Benzodiazepines • Be more reluctant to initiate prescription for benzo’s than opiates • Reduction regimes for users of street benzo’s is problematic only do when urine evidence of use and clear evidence of dependence and an agreed reduction plan

22. Benzodiazepines • Reduction regimes • BNF has useful equivalent dose tables • Convert to diazepam • If high doses required refer for specialist assessment • For 30mg/day or less reduce by 2mg every 2 weeks • Can be prescribed for daily dispensing if concerned about diversion or compliance

23. Heroin • Smoked by burning powder on tinfoil • Heated with citric acid and injected • Long term opiate dependency is chronic relapsing condition • Causes harm to users and there families • Typical user will spend £30- 100/day on drug

24. Heroin • Typical user will spend £30- 100/day on drug • Result into drift into poverty • 300,000 children of problem drug users in UK • Effective treatment can have significant benefits for child and improved quality of family life.

25. Heroin • Mortality risk 12x greater than general population • Injecting users 22x more likely to die than non-injecting peers • Drug related over doses commonly due to injected heroin in combination with alcohol, benzo’s or other depressants • Significant number occur in users who have just left prison and under estimate their loss of opiate tolerance

26. Heroin • Good evidence that drug treatment reduces crime • Led to expansion of drug treatmetn services

27. Substance misuse management • What every GP should provide for a misuser • Same responsibility to provide general medical services to drug misusers as any other patient on their list • Advise on risks of injecting • Increased risk of overdose when using drugs alone • Loss of tolerance after periods of abstinence

28. Substance misuse management • Prevention against blood borne viruses • Not sharing needles or other drug paraphernalia filters, spoons. • Safe sex - use of condoms • Screening for blood borne viruses • Opportunistic vaccination – accelerated schedules increases uptake 0, 7, 21 days with booster at 12 months

29. Substance misuse management • Consider any children- are they at risk if so use local child protection framework - parents using drugs does not necessarily mean child is at risk or neglected. • No legal requirement to report to authorities except in Northern Ireland • Prescribers should report to their regional drug misuse database – details found in BNF

30. Treatment approaches • Aims • To decrease level of drug use • Decrease offending • Decrease overdose risk • Prevent spread of blood borne viruses • Improve health of individual • Improve health of family

31. Drug service providers • Key features • To avoid prescribing in isolation • Harm minimisation

32. Drug service providers • Criminal justice services • Specialist drug teams • Shared care programs • GP led services

33. Essential elements of treatment provision • Assessment of needs to include drug and alcohol misuse, health and social functioning and criminal involvement. • Risks to dependent children should be assessed for drug using parents • All patients entering treatment should have a care or treatment plan that is regularly reviewed

34. Essential elements of treatment provision • Drug misuse treatment involves a range of interventions not just prescribing • A named individual should manage and deliver aspects of the patients care or treatment plan • Drug testing can be a useful too in assessment and in monitoring compliance and outcome of treatment

35. Maintenance prescribing • Licensed treatments for maintenance • Methadone 1mg/ml • Buprenorphine – subutex • Never start at first contact • Perform full physical and psychiatric assessment • Test urine to confirm opiate use

36. Maintenance prescribing • Prescribe for daily consumption for at least first 3 months • Liaise with chosen a pharmacy • Pharmacies must • Have undergone training • Developed protocols for communication between patient, pharmacist and prescriber

37. Maintenance prescribing • Dose titration requires • Experience • Repeated assessment of patient • Usual starting dose 10-30mg methadone but deaths have occurred with doses as low as 20mg • Safer to start 10-20mg and build up

38. Maintenance prescribing • Doses are gradually increased by no more than 5-10mg • Max weekly total increase of 30mg above starting dose • Most patients need 60-120mg methadone • May take several weeks to achieve dose at which patient feels comfortable and is no longer needing illicit heroin

39. Maintenance prescribing • Methadone tablets can be ground up and injected don’t prescribe • Methadone ampoules should only be prescribed by a specialist

40. Maintenance prescribing • Buprenorphine • Used in patients with lower opiate use • Taken sublingually • Starting dose 4-8mg/day • Increased by 4-8mg daily to max dose of 32mg/day

41. Maintenance prescribing • Buprenorphine • Inhibits other opiates blocking effect of heroin used on top of the buprenorphine • Can precipitate opiate withdrawal symptoms if taken while there is still circulating opiate in body • First dose should be taken when patient is showing withdrawal symptoms

42. Maintenance prescribing • Buprenorphine • Can be abused by injecting or snorting • Suboxone = buprenorphin-naloxone • New substance recently launched to address above problem. The naloxone has minimal effect if taken sublingually but if injected or taken intranasally it is likely to precipitate withdrawal effects – has lower street value