SUBSTANCE MISUSE

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SUBSTANCE MISUSE

• Dr Mufaza Rashid

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(No Transcript)
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Topics

• NICE Guidelines
• Relevance to General Practice
• Assessment
• Testing
• Psychosocial interventions
• Pharmacological intervention

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General points

• Which drugs
• Cannabis
• Cocaine
• Opioids not as common but significant i.e
  heroin
• Polydrug misuse
• Alcohol

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Epidemiology

• In the UK the prevalence of problem drug use is
  9.35 per 1000 of the population aged 15-64 years
  (360,811 people).
• 3.2 per 1000 (123,498 people) inject drugs.
• The National Drug Treatment Monitoring System
  (NDTMS) estimates that in 2004-05 there were
  160,450 people in contact with drug treatment
  services in England.
• Most of the people in treatment were dependent
  on opioids.

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• Opioid misuse is a chronic relapsing remitting
  problem.
• Abstinence being the goal of treatment.
• Challenging to achieve.
• Pharmacological approach the primary treatment

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Initial Assessment

• To treat any emergency or acute problem.
• Keep drugs in mind in patients presenting with
  acute psycosis, mood /sleep disturbance, chest
  pain in young patient.
• Confirm patient is taking drugs (history,
  examination and urine analysis).
• Assess degree of dependence.
• Identify complications of drug misuse and assess
  risk behaviour.

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• Identify other medical, social and mental health
  problems.
• Give advice on minimising harm, including, access
  to sterile needles and syringes, testing for HIV,
  Hep B C , TB and Hep B immunisation.
• Determine the patient's expectations of treatment
  and the degree of motivation to change.
• Refer and liaise appropriately with local
  substance misuse services

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• Determine the need for substitute medication
• Notify the patient to the local Regional Drug
  Misuse Database using the appropriate local
  reporting form.
• Regional contact numbers are also given in the
  BNF

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History

• Reason for presentation.
• Past and current drug use.
• What, how much, how frequently.
• History of injecting and risk of HIV and
  hepatitis.
• Medical and psychiatric history.
• Past and present contact with the criminal
  justice system.

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• Assessment of social and family situation.
• Past contact with treatment services.
• Drug and alcohol misuse in partner, spouse and
  other family members.(think about domestic
  violence and child abuse)
• Impact of drug misuse on other aspects of the
  patient's life.(work education)

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Important points

• Involvement of families/partner
• To treat with respect and dignity.
• Important to be supportive
• Assess reasons of use- alternative coping
  strategies.
• goals in relation to his or her drug use
• treatment preferences if any.

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Investigations

• FBC, LFTs, UEs
• Urinalysis (details on handout)
• Hep B/C and HIV serology if indicated.

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Treatment options

• The type of treatment needed to tackle drug
  misuse depends on the individual needs of each
  drug-user.
• Informal advice and information, for example on
  giving-up drugs (brief interventions)
• Harm reduction services to prevent blood-borne
  diseases and drug-related death

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• Prescribing substitute drugs eg methadone
• Counselling and psychological support-formal,
  structured support provided by trained
  professionals
• Structured day programmes usually consist of a
  series of activities for a fixed period of time
  (for example 12 weeks) and often include group
  work, counselling, education and life skills, and
  creative activities.
• Detox regimes as in patient

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• Rehab - residential rehabilitation (rehab)
  usually involves staying in for weeks or months.
  have a mixture of group work, counselling and
  other practical and vocational activities.
• Aftercare - this is support for when clients
  leave treatment to help them return to normal
  life. Examples include help with housing,
  education, employment, general health care and
  relapse prevention

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Drug services

• www.addaction.org.uk
• http//talktofrank.com/
• http//www.nta.nhs.uk
• Drug Action Teams (DATs) There are 149 DATs in
  England covering all local authorities.
• DATs take strategic decisions on spending and the
  delivery of treatment to meet local needs.

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Drug treatment for opioid dependence

• categorised as maintenance (also known as
  (substitution or harm-reduction therapies),
  detoxification or abstinence
• aims of the maintenance approach are to provide
  stability by
• reducing craving
• preventing withdrawal,
• eliminating the hazards of injecting

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Treatment options

• Methadone
• Buprenorphine
• mainly prescribed in community and primary care
  prescribing programmes.
• DoH guidelines recommend
• maintenance opioid therapy should be supervised
  for atleast 3 months and should be relaxed only
  when their compliance is assured.

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Methadone

• BNF states that methadone to be used in opioid
  dependence at an initial dose of 10-40 mg daily.
• which is increased by up to 10 mg daily (with a
  maximum weekly increase of 30 mg) until no signs
  of withdrawal or intoxication are seen. The usual
  maintenance dose range is 60-120 mg daily.

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Continued

• Once only dose (long half life 24-37hrs)
• No serious side effects with chronic use
• No pronounced narcotic effects on maintenance
  therapy.
• Drugs like rifampicin, phenytoin may shorten half
  life. Fluoxetine may have an opposite effect.

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• Cautions early in treatment
• Potential risk of respiratory depression,
  specially if combined with Benzodiazepines,
  alcohol, TCAs.
• Also if higher doses used in people with
  impaired liver function eg ch hepatitis

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Buprenorphine

• Both partial opioid agonist antagonist activity
• Less euphoric
• Less sedating
• Sublingual tablets Inittial dose (0.8-4mg)/day
• Maintenance 12-24mg (max 32mg/day)

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Naltrexone

• To prevent relapse in detoxified former
  opioid-dependent patients.
• Should have remained opioid free for atleast 7-10
  days.
• If there is evidence that the person has been
  using the drugs again then the naltrexone
  treatment should be discontinued.
• Dose 25 mg initially then 50 mg/day.The weekly
  dose can be divided and given 3 days/week. 100mg
  mon and wed 150mg on Fri.

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Alcohol Abuse

• Identifying problem
• Approach/address
• Important that patient thinks its a problem
• CAGE questionairre

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Continued

• Have you ever felt you should cut down on your
  drinking?
• Have people annoyed you by criticising your
  drinking?
• Have you ever felt bad or guilty about your
  drinking?
• Have you ever had a drink first thing in the
  morning (eye-opener)?

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How much is too much?

• gt21 units/week if a man.
• Or gt14 units if a woman

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Dependent or non dependent?

• Dependent if
• Overwhelming desire for alcohol.
• Drinking out of control.
• Need for increasing amounts of alcohol.
• Withdrawal symptoms are experienced.
• Has little interest in other leisure activities.
• Continues drinking even when the harm being
  done is made clear.

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Management

• Non dependent drinking
• Brief intervention, advice, self help, health
  risks
• Finding out why they drink excessively-behaviour
  modification.
• Setting objectives.
• Reducing slowly 13-34 reduction a week
• (2.9-8.7 less mean drinks a week)

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Continued

• Detoxification
• Alcohol dependence normally needs controlled
  detoxification with help of an attenuation
  therapy e.g. benzodiazepines to avoid withdrawal
  symptoms/complications. Can be performed in the
  community but in-patient care recommended for
• Patients at risk of suicide.
• Those without social support
• Patients who have a history of severe withdrawal
  symptoms

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• Community detoxification requires
• Daily supervision to detect complications early
  (e.g. DTs, continuous vomiting, deterioration in
  mental state)
• Multivitamin preparations to prevent Wernicke's
  encephalopathy
• Benzodiazepines to prevent withdrawal symptoms
  (usually chlordiazepoxide)
• Continuing support - primary healthcare team,
  community alcohol team, residential
  rehabilitation programmes, voluntary
  organisations, referral to specialist mental
  health team, disulfiram

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Drugs used in acute withdrawal

• Benzodiazepines (chlordiazepoxide)
• Vitamin B complex (IV pabrinex initially then
  switch to oral thiamine and multivitamins.
• Treatments used in abstinence or prevention of
  relapse-Disulfiram (Antabuse)

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Disulfram

• Irreversibly and specifically blocks aldehyde
  dehydrogenase - a crucial enzyme
• involved in the metabolism of alcohol
• This leads to a build-up of acetaldehyde which
  results in an unpleasant reaction-the patient
  will be unkeen to take alcohol

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Continued

• The unpleasant reaction includes flushing,
  headaches, palpitations, nausea vomiting
• high dose of alcohol is taken then there is a
  risk of arrhythmias, MI, respiratory depression
  and hypotension and collapse - making its use
  less attractive.
• its use should be restricted in patients who are
  well motivated and can be supervised e.g.
  colleague or partner.