Drugs of Dependency

1. Drugs of Dependency Dr Linda Harris Wakefield Integrated Substance Misuse Services WISMS

2. OBJECTIVES • Substances of abuse and their physical and psychological effects • Dependency syndrome • An overview of treatment models

3. Major Drug Groups All drugs fall into one of three groups: Depressants: – slow you down, produce feelings of euphoria Stimulants – speed you up, boost your energy and confidence Hallucinogens – alter perception of the world

4. Opiates • Main drugs of abuse in UK • Derivative of OPIUM found in poppy plant • The euphoric and analgesic effects thought to lead to abuse • Side effects - nausea, constipation, respiratory depression

5. How are opiates taken • Injecting through a vein • Swallowing in tablet form • Smoking in cigarette form • Smoking by inhaling the fumes produced by burning powder in a foil – “chasing the dragon” • Sold in “bags” – 1 bag = 0.2gms = £10

6. Cocaine • Stimulant drug extracted from the leaves of the coca plant • Made into a crystalline salt form by adding sulphuric acid and finally ends up as cocaine hydrochloride powder • To make crack the powder is heated up in a microwave with bicarbonate of soda and water • Crack is easily melted and vapourised so it can be smoked • Crack may also be injected by mixing it with water and weak acid such as citric or ascorbic

7. Cocaine Effects: feelings of increased energy with consequent increased activity and improved social confidence. users feel more alert and energetic, confident, physically strong with a higher mental capacity Physical effects – dry mouth, sweating, loss of appetite, increased heart and pulse rate Side Effects: - irritability, paranoia, restlessness, psychosis

8. Cocaine - How is it used • Dabbing – rubbed on the gums • Snorting – most commonly in its hydrochloride powder form • Piping – smoked through a pipe • Injecting - • Chasing – chased on tin foil like heroin • Smoking/chipping – flaking bits of cocaine or crack into the top of a cigarette “joint” • “Speedballing”

9. Powder cocaine –“champagne image” • Crack – smokeable “rocks” • More likely to be associated with mental and physical health problems • Poly drug users • Links with criminality and violence • Costs – powder upwards of £40 per gram - £5 - £10 per rock

10. Harms associated with street drugs (notably heroin) • Psychological • Physical • Social

11. Harm (Psych) • Anxiety and depression • Drug related psychotic illnesses • Aggravation of pre existing psychological or psychiatric illness (“Dual Diagnosis”) • Practically any mental disorder you can think of

12. Harm (physical) • STD, unplanned pregnancy, Cx cancer • Asthma • Ear wax • DVT, vascular damage • Bacterial abscesses, metastatic sepsis • Cl. novyii, botulinum, tetani • HCV, HBV, HIV • Overdose, death

13. Harm (Social) • Unemployment, poverty • Crime: theft, dealing, physical violence, prostitution, murder • Imprisonment • Separation, divorce, children in care, loneliness and isolation • Loss of dignity and self respect

14. Amphetamines • Synthetic stimulants • Most commonly produced in tablet or powder form and can be swallowed snorted injected or smoked • Mimic the effects of adrenalin in the body and therefore produce: - Increased energy, talkativeness, reduced appetite, restlessness, agitation

15. Amphetamine abuse Side effects occur after prolonged use and when the effects of the drug wears off. • Depression • Irritability • Hunger • Fatigue • Vein damage in injectors • Sexually transmitted diseases • Acts of violence

16. Benzodiazepines • Depressant, synthetic drugs • Highly dependent with tolerance to their effects building up rapidly . Symptoms of withdrawal include: - ·         Anxiety and insomnia Nausea and vomiting ·         Phobias ·         Loss of confidence and paranoia ·         Headaches and dizziness ·         Palpitations

17. Cannabis This is a naturally occurring hallucinogenic drug most commonly seen in a variety of herbal forms or as a resin. It produces the following effects: ·         Euphoria ·         Increased confidence ·         Altered sensory perceptions ·         Feeling of well being ·         Relaxation

18. Cannabis - the health risks There is now established evidence that it produces dependence Studies suggest the risk of dependency equates with that of alcohol Cannabis is an intoxicant – impairs short term memory, judgement and co ordination – RTAs Psychotic episodes have been reported (recent papers suggests increased risk particularly in patients with premorbid mental health issues) Increased risk of chromic bronchitis and squamous metaplasia - ? Links with lung cancer

19. Cannabis – the health benefits • Used as a medicament for over 5,000 years • Clinical trials underway exploring its use as treatment for nausea and vomiting, combating muscle spasm in multiple sclerosis, treating loss of appetite and weight loss in AIDS • Drug companies looking at synthetic cannabinoids with therapeutic effects minus the psychoactive effects

20. Cannabis - the policy options Relaxation on prohibition: - Potential reduction in crime and therefore police and criminal justice expenditure Reduction in prison overcrowding Potential increase in use leading to as yet unknown health implications Society’s covert message – leading to massive increases in use

21. Solvent use • Young people • Effects similar to alcohol • ?Use is decreasing • Beware of the solitary user

22. Risk factors for substance misuse • Male • Young • Early childhood conduct disorder • Childhood neglect • Homeless • Poor academic achievement

24. Estimated 600,000 class A drug users in the UK = 1% of the population ( ie 18 per GP) • Est 300,000 Hepatitis C positive • Est 3 billion derived from prostitution • Massive implications, chldcare, criminal justice, social services acute care

25. Models of Care Medical Model Vs Social model Vs Criminal justice model Vs Community model

26. Government Targets • Reduce the proportion of people under 25 using heroin and cocaine by 25% by 2005 and by 50% by 2008 • Reduce the levels of repeat offending amongst drug misusing offenders by 25% by 2005 and 50% by 2008 • Increase the participation of problem drug misusers including prisoners in drug treatment programmes by 66% by 2005 and 100% by 2008

27. National Government Policy • 1998 – “Tackling Drugs to Build a Better Britain” • Ten year plan • 4 key objectives: - • Young people • Improve quality and access to treatment • Breaking the drugs crime link • Stifling availability of drugs on the streets

28. Emphasis on Breaking the Link Between Drugs and Crime UK Crime and Disorder Act • Drug Treatment and Testing Orders • Arrest Referral schemes • Prison throughcare and aftercare - Drugs Intervention Programme

29. Key messages • £1 spent on treatment saves £9.50 in terms of crime • Treatment works • The longer in treatment the better the outcome • Complications kill • Harm reduction saves lives

30. Graph showing deaths, comparing untreated patients with those in Methadone maintenance treatment in the Swedish study (15). (Reproduced from Gronbladh et al)

31. Attract Assess Retain Appropriate Care Substitution Treatment Harm reduction Hepatitis B immunisation Address homelessness Address skills deficits “Safer stronger communities” Treatment

32. Treating 10 heroin users with methadone for 1 year can save 2 lives Treating 100 hypertensives for 10 years might save 2 strokes

33. Text 4b Text 4a Text 3 Text 2 Tier 1 Models of Care Treatment Tiers • Tier 1 – Non Substance misuse specialist services e.g. GP surgeries, Walk in centre A and E • Tier 2 – Open access substance misuse services – light touch services or services to encourage more engagement with specialist services • Tier 3 – Structured Community Services providing only within a structured and planned treatment setting • Tier 4a – Residential substance misuse • Tier 4b – Highly specialist non substance misuse services – e.g. forensic services liver units eating disorder units etc

34. Options for levels of involvement • Generalist care • Shared care • GP wSi • Addictions psychiatrist

35. Good Medical Practice in managing dependency • Recognise the problem? • Identify the complications of drug misuse and assess risk taking behaviour • Reduce harm e.g. hepatitis screening and vaccination • Work with the patient to identify their needs and identify a way of meeting those needs • Work as part of a multidisciplinary team • Think of social and psychological needs as well as medical needs

36. Treatment – The evidence • Successful medical treatments aim to provide a safe substitute for the opiate heroin. • By prescribing an alternative or substitute one can alleviate withdrawal symptoms and the addict is released from the compulsion to carry out risk taking behaviour as part of their addiction. • Methadone remains the gold standard

37. Methadone The evidence • most widely used form of opioid replacement therapy in the US, Europe and Australia • Most evidence of impact on illicit drug use,and criminal acts • Most positive evidence of containment of HIV transmission • Most positive evidence of improvement in health, employment status and social well being goals

38. Substitution

39. Harm Reduction Basic care. Benefits, housing, child care issues, social services. Signposting to needle exchange, CDT Information Sexual health: Cx smear, contraception, HBV/HAV inoculations (grab and stab) Open door Who can’t do any of this?