Drug misuse, its complications and management Dr Susi Harris Clinical Lead, City and South Community Drug and Alcohol team Summary of talk • Drug misuse – – – – Diagnosing substance dependence Types of substance and prevalence Individual drugs and their harms Administration routes • Brief history of Drug Misuse management • Where we are today – typical patients • Management of concomitant pain – Particular problems – Common pitfalls What is substance dependence? ICD-10 defines dependence as: • a cluster of physiological, behavioural, and cognitive phenomena in which • the use of a substance takes on a much higher priority for a given individual than other behaviours that once had greater value. • The desire to take the psychoactive drugs, alcohol, or tobacco is strong or overpowering and • relapse after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals. Making a diagnosis A diagnosis of dependence would be made if three or more of the following criteria have been present together at some time during the previous year: 1. A strong desire or sense of compulsion to take the substance; 2. Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use; 3. A physiological withdrawal state when substance use has ceased or has been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms; 4. Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses. 5. Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects; 6. Persisting with substance use despite clear evidence of overtly harmful consequences, such as liver damage through excessive drinking, drug-related impairment of cognitive functioning, and damage to relationships. What drugs are we talking about? • • • • • • • • Heroin Cocaine/crack Amphetamines Benzodiazepines Cannabis Alcohol ‘Club drugs’ OTC/prescribed drugs Drug misuse prevalence – Class A Prevalence – non-class A Treatment population is getting older…. http://www.nta.nhs.uk/uploads/statisticsfromndtms201112vol1thenumbersfinal.pdf Heroin “Brown” “B” • Brownish powder, about 30% pure • Smoked on foil using a tube to inhale • Dissolved in water with citric acid • Drawn up through a filter • Injected – often using femoral vein in groin Harms: • Heroin itself not very harmful • Main harms due to injecting and lifestyle Cocaine Cocaine: • White powder –purity much less and now much cheaper • Usually snorted via tube Harms • Paranoid psychosis • Hypertension • Cardiac: 25% MI’s in under 45’s • Liver damage if mixed with alcohol due formation of hepatotoxic cocaethylene Crack “White” “W” • • • • Pale waxy crystals Smoked via pipe – many home made Injected, often with heroin – “speedballing” Strong compulsion to continue – users can spend many £100’s in a binge • Lasts 25 mins – 1 hour • Unpleasant withdrawals within 3 hours • Associated with alcohol/bz use to ameliorate ‘comedown’ Harms • Crack lung – allergic alveolitis, (plastic/aluminium fumes) • Emphysema/COPD • Associated with higher risk DVT in groin injectors Benzodiazepines Pattern of use varies • Bingeing common – eg 3-10 x 10mg diazepam • To ameliorate crack withdrawals • As a hypnotic • Inadvertent use – common adulterant of H Harms • Risk taking behaviour • Retrograde amnesia • Withdrawal fits • Associated high proportion fatal overdoses Cannabis “Weed” “Puff” • Smoked rolled with tobacco: “spliff” • Smoked alone with a pipe Harms • Apathy • Depression • Psychosis • Withdrawal insomnia Amphetamine “Speed” “Whizz” • • • • • • White/off white powder Traditionally highly impure Ingested wrapped in cigarette paper Rubbed into gums Snorted injected Club Drugs • Numbers small but steady increase (in contrast to other drug prevalence in UK) • Different cohort – young, gay scene • Usually oral, some injecting – – – – Ecstasy/MDMA – hyperthermia, rarely death Ketamine – interstitial cystitis, psychosis Mephedrone (M-CAT, Miaowmiaow) GHB/GBL (‘G’) – overdose, physiological withdrawals • New club drug clinics – treatment: – Detox for ‘G’ – v high dose bzs needed – Psychological support - all get low mood – Outcomes good OTC/prescribed drugs • • • • • Codeine/dihydrocodeine Tramadol MST/oramorph/fentanyl Benzodiazepines/z’s Gabapentin/pregabalin Prescribed medication abuse Primary prescription opioid addiction • Escape from reality • US - oxycodone now commonest drug prescribed • Legal, available OTC Secondary to illicit drug use • Opioid withdrawal • Enhance effects of illicit drugs • Saves money in a tight corner Particular circumstances in prisons: • Boredom • Currency • Status EFFECTS OF DEPENDENT DRUG USE [1] Physical: ►Dependence ► Effects of poverty ► Poor pregnancy outcomes ► Side effects of Opioids (constipation, low salivary flow affects dentition) ► Side effects of Cocaine (vasoconstriction, local anaesthesia) ►Complications of injecting • • • • • • DVT and post-phlebitic syndrome Leg ulcers abscesses overdose SBE Blood borne virus transmission – up to 50% prevalence Hep C in IVDUs (HIV and Hep B much rarer “Shooting up” - HPA • One in six people who inject drugs had ever been infected with the hepatitis B virus in 2011. • Hepatitis B infection among people who inject drugs has declined over the last decade. • This decline most probably reflects the marked increase in the uptake of the hepatitis B vaccine among people who inject drugs. Among people who inject drugs in the UK: • Around half have been infected with hepatitis C • Around one in every 100 has HIV. • Almost one-third report a symptom of a bacterial infection (such as a sore or abscess) at an injecting site in the past year. • Around one-sixth of people who inject drugs continue to share needles and syringes. (Far < 10 yrs ago) EFFECTS OF DEPENDENT DRUG USE [2] Social: ► Effects on families ► Drive to criminality ► Imprisonment ► Social exclusion Psychological: ► Fear of withdrawal ► Craving ► Guilt (all temporarily alleviated by drug use) Mental Health ► ‘Self Medication’ ► Depression, Psychosis, Dual Diagnosis AIMS OF TREATMENT To reduce harm to user, family, community and society To improve health and prevent death To stabilise physically and psychologically To improve quality of life and social functioning To address all issues and reduce harm associated with substance misuse To reduce crime Substitute prescribing by doctors and non-medical prescribers is only one part of treatment and can only succeed in conjunction with adequate key worker and psychosocial support during and after an individual being on substitute medication HOW DO I DO A QUICK ASSESSMENT? Which drugs ? ► Which ones? ► How much? ► Don’t forget – Alcohol, Cannabis, Tobacco Route of administration ? ► Oral ► Inhaled/smoked ► Injected How long had a problem with drugs? ► Any previous treatment episode/s? Examination and Investigations ► Examination for injection sites etc ► Urine screen for Opioids and other drugs Harm Reduction Advice ► Essential – polydrug (use of more than one drug +/- Alcohol) use now normal BASIC HARM REDUCTION National Guidelines state all practitioners should be able to provide the following: Retaining patients in high quality treatment is protective against overdose ► not injecting, injecting more safely, not using drugs alone ► reducing amount taken after intervals where tolerance is lost ► training drug users and their families in risks of overdose and how to respond in an emergency Action to prevent blood borne virus transmission ► not sharing needles etc ► safer sex (condoms) ► provision of Hepatitis A and B vaccination ► blood borne virus screening including Hepatitis C Referral where appropriate ► specialist drug services ► voluntary sector services ► infectious diseases services The ‘British System’ • 1920’s heroin prescribed; sanctioned in UK (1) as addiction treatment (in contrast to USA) • 1956 USA banned all medicinal use of heroin • 1959 only 4 countries still prescribing H, ban had spread worldwide • 1950s -60s – ‘the British system’: compassion and clinical freedom - some Drs prescribing heroin privately to addicts (2) • 1967s – mandatory licensing for heroin prescribing only awarded to doctors in specialist clinics (3) • 1980s -massive waiting lists in clinics • 1988 - AIDS - ACMD recommends expansion of methadone prescribing as harm minimisation (4) 1990s typical patient • Largely male (5/6), mid to late 20’s • Waiting many months for treatment • Usually injecting and sharing, mostly heroin, some crack • Committing daily acquisitive crimes, around £100/day • Lottery of treatment philosophy & availability • Poor engagement in treatment – very unstable • Frequent diversion of substitute medication Impact on on Crime CRIME NTORS 10 year drugs strategy AIDS Harm minimisation agenda Increase numbers in treatment Money Pooled Treatment Budget Targets Coercive treatment Policy National Treatment Agency Crime and disorder Act 2000’s – The NTA • ‘Models of Care’ – Consistency of treatment policy – Ending postcode lottery • • • • Emphasis on harm minimisation Recruitment of GPs Supervised consumption in pharmacies Detox and rehab out of favour Harm minimisation gains • Targets achieved – Treatment number doubled early – Waiting times dramatically reduced – DRDs almost halved • NICE and DH 2007 – evidence is for high dose maintenance, minimum 12 weeks • New targets to Retain in Treatment • Monitoring of doses 2007 – typical patient • • • • • • • • Mostly male (4/5) mid to late 30’s Alcohol rare, usually problematic if drinking Methadone 60 -120mg (4/5) Buprenorphine 8 -16mg (1/5) Stopped injecting Some still using C+H smoked Never tried detox or rehab Stable pattern for 2-7 years 2010 – The Recovery Agenda • • • • • • • • Patient and advocate complaints Conspiracy theories Opposition perceives lack of progress 2010 – new party in power New targets on treatment EXIT Emphasis on dose reduction and detox Increased support for detox, rehab facilities Promotion of recovery groups/networks Current themes • Alcohol is cheap, widely available • Fewer young people starting to use heroin • Recession – Less housing – Fewer jobs – Benefits about to be cut • Health and Social Care Bill: – NTA disappears into Public Health – Drug Treatment budget disappears into LAs 2013 – typical patient • • • • • • • • • Predominantly male (3/5) early to mid 40’s Using alcohol, often problematically Methadone 40 - 80mg (4/5) and reducing Buprenorphine 4 - 8 mg (1/5), reducing Stopped injecting Some still using C + H smoked (but fewer) Associated Benzo use is common Had a go at detox/rehab/recovery group Chronic diseases starting to manifest – eg: Hep C, venous ulcers, COPD, cancers Treatment journey: Drugs services in Leeds Untreated drug use Social exclusion Community treatment Criminal Justice City And Sh care South Recovery and reintegration Sh care IDTS (HMPArmley) Needle exchange DRR Recovery Groups Sh care Sh care Leeds Community Drugs Partnership Sh care Multiple Choice Aftercare WNW Sh care Detox Sh care Harm reduction York Street (homeless) Rapid Access/ Arrest referral Platform Young people ENE Sh care Rehab Sh care Leeds Addiction Unit Preganacy Dual diagnosis Highly complex physical The Space Single Point of Access • In all but name! Citywide Harm Reduction Service 0113 242 1161 Pain – Technical problems of treating in opioid misuse – Opioid tolerance – Lowered pain threshold – Most analgesics CNS depressants> risk OD – Buprenorphine blockade Pain – difficulties with rationale of treating in opioid misuse – No tests to diagnose pain or its extent – Pain is common, and often long term – Most analgesics are abusable – Risk of diversion (selling on black market) Further information Information on individual drugs: http://www.drugscope.org.uk/resources/drugsearch/drugsearch Prevalence data: • British Crime Survey • National Treatment Agency Club drugs: http://www.nta.nhs.uk/uploads/clubdrugsreport2012[0].pdf Blood borne viruses: http://www.hpa.org.uk/Publications/InfectiousDiseases/BloodBorneInfecti ons/ShootingUp/1211Shootingup2012/ Thank you! susi.harris@nhs.net