Substance Misuse: Awareness, Treatment Guidelines & Support

1. ILLICIT DRUGS Soap Box Kate Rees Swindon/Bath GP Registrar DRC 12/05/05

2. Why? • Previous experience at Rockhall • Shared-care practice • Diploma in Substance Misuse part 1 • We can save lives – scary stats to follow…

3. What and How? • What’s out there, what guise it takes • What should we be doing about substance misuse and misusers • And how can we achieve this.

4. Facts • 6-9/1000 adults (15-64) drug problem • IVDU • On long term opiates, cocaine, amphetamine • That’s 25 patients in 1,800 average list • 3:1 male/female (girls under-detected) • 14 X MORTALITY general population • 34 X MORTALITY in prison leavers • 30-80% IVDU Hep C positive • 1-3% HIV positive

5. What’s out there and what can you get for your money?

6. Cannabis • Bhang, black, blast, blow, blunts. Bob Hope, bush, dope, draw, ganja, grass, hash, hashish, hemp, herb, marijuana, pot, puff, Northern Lights, resin, sensi, sensemilla, shit, skunk, smoke, soap, spliff, wacky backy, weed, zero. • Hash (blacky-brown lump)= resin of the plant. • Grass or weed =dried leaves • Price varies • Smoked, eaten, drunk, bong, bucket

7. Ectasy • E, pills, brownies, burgers, disco biscuits, hug drug, 'Mitsubishi's', 'Rolex's', 'Dolphin's', XTC • Pills, liquid form (GBH)

8. LSD • Acid, blotter, cheer, dots, drop, flash, hawk, L, lightening flash, liquid acid, Lucy, micro dot, paper mushrooms, rainbows, smilies, stars, tab, trips, tripper, window. • Tiny squares of paper, liquid or pellets • Cost £1 - £5 a tab

9. Benzodiazepines • Jellies, benzos, eggs, norries, rugby balls, vallies, moggies, mazzies, roofies, downers. • 10mg diazepam = £1

10. Speed • Amphetamine Sulphate, Phet, Billy, Whizz, Sulph, Paste, Base Ice, Meth, Dexies, Yaba • usually sold as powder wraps like cocaine. • Base speed is purer = putty. • Crystal meth, or methamphetamine = rocks or crystals. • Prescription dexamphetamine = pills. • Dabbed, sniffed, swallowed, injected or smoked

11. Cocaine • coke, charlie, C, white, Percy, snow, toot. • Crack • rocks, wash, stones, pebbles, base, freebase. • smokeable form (lumps) • cocaine, baking soda and water. • A rock = £12 and £20 • Speedball • Injection mixture cocaine and heroin

12. Heroin • Brown, skag, H, horse, gear, smack • smoked, snorted or injected • Purity 20-60% • £10 bag= roughly 0.2-0.3g • Addicts habit 0.5g- 2g (or teenth) /day

13. What should we be doing? DoH Drug Misuse Guidelines  Diagnosis of drug misuse  Brief assessment  Harm reduction  Safer sex advice  Hepatitis A, B, C and HIV testing  Hepatitis B immunisation (and A if appropriate)  Referral to appropriate services • for drugs treatment • sexual health • infectious diseases  General health care, including nutrition.

14. How we begin…. • Confidentiality • Notification to NDTMS (National drug treatment Monitoring scheme) anonymous • Don’t rush into planning substitute medication or withdrawal programme – it may be more dangerous • DVLA considerations

15. How we assess - History • Why have they presented today. • Past and current drug use. • Types and quantities used; +/- alcohol • Routes • Experiences of overdose • Periods of abstinence and triggers for relapse • Cost of drug misuse • Symptoms of Withdrawal ‘clucking’ • Dependence

16. Dependence Syndrome • ICD 10 criteria • 3+ in last year: • Compulsion • Difficulty controlling use • Physiological withdrawal • Tolerance • Neglect other interests • Persist in use despite harmful effects

17. 3. History of injecting (risk of infection) • Supply of needles • Sharing habits • How to inject safely • How do they dispose of used equipment • Knowledge of HIV/HepB/C • Use of condoms 4. Medical History • Hep B/C and HIV status • Last cervical smear • LMP

18. 5. Psychiatric history 6. Forensic history 7. Social history • Do they have kids • Do they have a place to live • Do they have a job/money 8. Past contact with Rx services

19. Examination • Physical • Opiate withdrawal (restless, yawning, sweating, retching, dilated pupils, ↑BP) • Opiate toxicity (pyrexia, ataxia) • Cocaine (vasoconstrictor, local anesthetic) BP, peak flow • Injecting complications – cellulitis/abcess, dvt/pe, liver disease • Mental health • Psycosis (cannabis, speed, cocaine) • Anxiety/Depression

20. Investigations • Bloods • HepB, HepC, HIV • Urine • on the premises (5-10mls) • Non-punitive • Confirm diagnosis • Helps with treatment plan • Covers you medico-legally • Protects patient from inappropriate px • ↓street diversion

21. Immunisations • Hep B • Offer immediate vaccination if not already infected/immune • Incubation period 6/52 - 6/12. • 70% asymptomatic • If result positive can discontinue • Vaccine recommended for IVDU and contacts esp. partners and children • Hep A now also recommended

22. Hep C • 92% IVDU related – sharing any equipment/ paraphernalia • Only 5% STI • 80% long term infection/ 20% clearance • Routine antibody test detects past or present infection • PCR/referral to gastro for treatment (if no iv use or alcohol dependence)

23. Harm Prevention

24. Harm Reduction • Route • Safe injecting • sites, equipment, precipitation, company • Avoiding cocktails – O/D risk • GUM if prostitution • Pregnancy – often amenorrhoea. High risk pregnancy when entering treament.

25. The End • RCGP certificate Part 1 • www.doctorsnet.uk • www.smmgp.org.uk • mark@smmgp2.demon.co.uk • NEXT course next wed 19th Oct in Yate • Neil.Kerfoot@GP-L81063.nhs.uk • 01179 611774