Dr Mike D’Souza MD FRCGP FFPHM FRSA GP Canbury Medical Centre

1. Managing Substance Abuse by Lowering Stress - Current Progress- Spring 2009 Dr Mike D’Souza MD FRCGP FFPHM FRSA GP Canbury Medical Centre

2. People suffering from addiction are a big burden on our taxes • There are now about 327,000 problem drug users in the UK. (over 15.3 million worldwide) • It was estimated in 2008 that illegal drug abuse had cost Britain £110 billion over the past decade. (ref. Addaction) • The figures are rising with costs now running at £18 billion p.a.. • Currently each problem drug user is estimated to cost the state around £44,000 a year • ‘Recreational’ users costs are estimated to be under £20 a year because they commit little crime and do not overburden the health service. • Yet as against prison only 3% of all spending is spent on helping people with addiction recover.

3. Addiction also causes severe medical problems e.g. • Depression • Post Traumatic Stress Disorder • Anxiety and panic • Infections HIV/AIDS, Hepatitis, VD • Deep Vein Thrombosis • Ulcers -Necrotising fasciitis • Accidental death • Suicide • Murder

4. Addicted people have severe Social Problems as well • Social exclusion • Semi-literacy • Homelessness/|Poor housing • Rough sleeping • Police harassment • Poor access to medical/social service care • Their children are often taken away from them • Imprisonment and poor care in prison • Uncoordinated impersonal care - if they can get any

5. Our punitive approach is not only costly it may be actually worsening the problem • 50% of those in trouble start using heroin at the age of 14yrs • The average cost of a 12 month DTTO (drug treatment and testing order) is £10,000 • Each new prison sentence in 2008 cost us £119,000 • 70% of male prison inmates are drug users. • 50% of female prison inmates are drug users • It is much easier to get brown heroin in prison than cannabis. • More than 5% get introduced to drug use while in prison

6. As a consequence of addiction people become… • Rootless • Homeless • Friendless • Loveless • Lacking in Self-respect • Vulnerable and at risk

7. Could we be missing the point? • Why are drug abusers such a nuisance to themselves and society? • Why would any healthy intelligent person choose to lead such a dreadful lifestyle? • Are we missing a scientific explanation for why they start, why they go on and indeed why some manage to stop? • Can we understand the problem instead of just judging it’s symptoms?

8. Recent research has at last begun to produce evidence that a clinical stress-reduction approach might be more effective

9. f MRI -Functional magnetic resonance imaging

10. f MRI Findings 1 • There are different centres in the oldest parts of the brain which control memory, moods, sleep, appetite, sweating, libido, empathy etc. • These seem to become temporarily or chronically damaged by the hormones we produce when stressed

11. f MRI Findings 2 • The damage to our control centres is revealed by shrinkage of their size seen on f MRI pictures • Exercise antidepressants and stress reduction increases a repair hormone called BDNF which is seen to reverse the clinical situation and f MRI pictures *Hippocampal Neurogenesis, Depressive Disorders, and Antidepressant Therapy Eleni Paizanis,1, 2 Michel Hamon,1, 2 and Laurence Lanfumey1, 2 Neural PlasticityVolume 2007, Article ID 73754,7pages

12. Neglect of self and others • Mirror neuron centres in front of brain may enable us to empathize. • When these get damaged by stress we may lose our ability to care for others and ourselves • This may partially explain patients behaviour • Stress reduction fortunately also seems to repair this.

13. So what might be happening to people who get addicted? • Their mood control centres may be more easily damaged by stressful events • Also Bereavements, Sexual abuse etc may cause recurrent stressful memories • Stress damage causes depression anxiety and panic etc and so even more stress • Patients find alcohol , drugs etc help a bit • Then they get habituated and too frightened to risk stopping them. i.e. trapped into “taking problems to solve problems”

14. “Mankind cannot stand too much reality” T.S. Eliot • Some patients reduce their stress by unconsciously escaping into “personality disorder” • This shows up in recurrent immature and inappropriate social behavior • Over 30% of substance abusers have this psychological problem badly • They are rarely helped by antidepressants etc and can become dependent, manipulative and criminal. But they are also helped by stress reduction and tend to improve as they grow older.

15. Broken Stories • Stress can be defined as anything that generates high levels of stress hormones • The causes of stress are external events like accidents, illness etc • Or internal reactions like worrying • This is often about “Broken life stories” Remorse over lost dreams or anxiety about future loss. • Such worrying can be addressed by “talking therapies” like CBT or Mindfulness • And by supportive personal “Adult to Adult” care.

16. To test this theory we have been treating patients suffering from substance abuse with prolonged stress reduction i.e. 1 Long-term personalmedical care givinga non judgmental clinical explanations and encouraging future planning 2 Reliable non-embarrassing weekly* scripts 3 Better Psychoactive treatment e.g. CBT, Antidepressants and Mood stabilizers and for some Propranolol for “Loosening the grip of bad memories” 4 Prescriptions for Exercise * Following the the suggestion of GP Roger Weekes

17. Outcome Survey • 26 Males 5 Females • Mean Age 36.4yrs • Mean Age of starting abuse 19.7yrs • Most had failed with CDAT & Kaleidoscope • 2 removed from our list (one stole from the surgery the other punched a patient in the waiting room) • 4 not yet surveyed (one in prison) Demography at start in 2006

18. Their Mental Health Problems at start • 92.0% Clinical Depression • 36.0% Actively Self-harming • 92.0% Post Traumatic Stress Symptoms • 60.0 % Flashbacks • 76.0% Feelings of immaturity • 8 % Psychotic Episodes

19. Their Social situation at start • 52.0% Have children • 68.0% Get some support from family • 60.0% Have supportive partner • 68.0% Give support to a partner • 40.0% Have housing problems • 96.0% Are on benefit • 16.0% Rely on dealing for income • 72.0% Want to give up use now • 60.0% Have reading difficulties

20. Their Clinical and Social Care Costs at start Hospitalizations • Ever 78.2% • 47.8% were inpatients in last year • HIV 3 cases Hep B 2 cases Hep C 9 cases Imprisonment • Ever 75% • 25% in the last year • Average times in prison 99/24 = 4.1 per case ( N.B.Each single new prison sentence costs £119,000 nearly twice the cost of a Borough wide ECBC scheme)

21. Addiction Problems admitted at start • 10.0% Needle craving • 12.5% using I.V. street opiates • 43.5 % Inhaling street opiates • 5.0% use Methamphetamine • 25.0% Crack/ Cocaine • 30.1% Pot 8/21 • 81.0% Benzodiazepines • 33.3% have Alcoholism • 77.3% Smoke tobacco • 8.3% Have Food • 5.0 % Have Other habits • N.B No Gamblers!

22. They now have future plans and wishes • 100% wish to continue weekly scripts • 65.2% Now have plans • For getting back to work 75% • Giving their families more care 66.6% • Developing hobbies/interests 75% 83.3% Would now accept more help 100% Want to try our ECBC pilot

23. Our long-term social care was judged by the patients to be more helpful than other services • SOCIAL SERVICES 6.0% • The POLICE 23.0% • Local Drug Servive 36.65 • PRISON 39.3 • KALEIDOSCOPE 40.7% • Our GP Care 87.0% Scores as a rating out of ten per patient Patient approval is important if we want to keep them in care

24. How well is our treatment approach workingby Spring 2009 ? • Requested Home Detox 32% • Success of our Detox 75% • Stopped all opiates 24% • Reducing Methadone dose 36% • Maintaining Methadone dose 24% • Increasing Methadone dose 16.0% • Overall Satisfactory progress in 84.0% • Chaotic at entry 76.0% • Chaotic still 24.0% Anecdotally nearly all of these patients now cause practice staff much less nuisance. Police reported that Kingston was safest Borough in 2008; with a large drop in Crime; Burglary by 3% Criminal damage by 6% Theft & Violence by 10%. In the town centre near where our practice is situated Criminal damage dropped by 17% Violence against person by 22% and Theft by 24%

25. SUMMARY Stress reduction by continuing Personal GP medical care over three years using a non- judgmental explanatory clinical approach has helped over 80% of people suffering from long-term substance abuse. Despite the fact that most of these patients were previously chaotic and had failed to engage with local drug services. Factors that may have been helpful include: - Ensuring proper medical care Weekly scriptsMood stabilization. -Giving Weekly scripts of Methadone reducing embarrassment Weekly scripts contact with pushers. • Encouraging Exercise with scripts at local Gyms and Future life planning. • Delaying Detox until it was clinically agreed that it was likely to work.