CLINICAL FORUM: ADDICTIONS
WITHIN FORENSIC MENTAL
HEALTH SERVICES
15 March 2013,
SPS College, Polmont
Substance Misuse & Mental Health
Malcolm Bruce
Consultant Psychiatrist in Addiction
NHS Lothian
Structure of presentation
1. Some data relevant to Forensic Psychiatry
2. What's the background of Drugs Induced
Psychosis
3. What’s new in Drugs
4. What’s new in Psychosis
5. What’s new in co-morbidity
6. Summary with my view of MWC focus
A SERVICE EVALUATION OF THE
MANAGEMENT AND EDUCATION OF DRUG
DEPENDENT INPATIENTS IN SCOTTISH
FORENSIC PSYCHIATRY SETTINGS.
• AUTHORS:
Dr Michelle McGlen, ST4 Forensic
Psychiatry, South East Scotland Deanery.
• Dr Fionnbar Lenihan, Consultant Forensic Psychiatrist,
Orchard Clinic, Royal Edinburgh Hospital, Edinburgh
Issues from MWC & WHO
• Lack of access to specialist drug services
• Lack of education regarding loss of tolerance
and dangers of poly-substance misuse (ref: high
drug related mortality following release)
• Variable practice regarding approaches to
managing drug dependent patients on admission
to facilities (e.g., enforced abstinence)
Online Survey Forensic Settings
• Focussing on drug dependent patients
– Assessment
– Management
– Education
• Lead clinicians at all eight units – 100% reply
Results
Lack of access to
SM team
V
Agree*2
Agree*3
DK*2
Disagree*1
Identify DWS
H/E/I all
Scales*3
Urine*5
Oral*2
Ideal model
joint*7
only forensic*1
Access to SM team
yes*6
no*2
Use SM team
often*2
occ*3
rare*3
Management
Detox*4
ISQ*1
DK*1
Nothing*2
Education
1:1 *7
Group*6
MI*4
Naloxone*3
Background of Drug induced
psychosis…
• Hallucinogens – designed onset effect, LSD etc.,
• Stimulants – onset effect, dose related side effect,
cocaine etc.,
• Sedatives incl alcohol – offset effect, withdrawal states,
with long term neuro-cognitive damage.
• Cannabis – onset effect, dose effect, THC content
changes
• Drug subculture & overlap with disadvantaged groups
(Severe & Enduring Mental Illness)
Risks to human health
• Direct Cannabis effect (not a single drug)
– Cannabinoid receptors
• Immediate – desired effect / intoxication
• Intermediate – tolerance / dependence / withdrawal
– Other effects
• Delayed – carcinogenesis (what part of drug mix?)
• Induce psychotic illness? (what part of drug mix? Esp. cannabidiol :THC
ratio)
• Indirect
– E.g., choice of route and technique
– Established illness (schizophrenia) - dealing with cannabis use
(including dependence) is now a major element in the clinical
management of many young men with established psychotic
illnesses.
Some of the evidence...
• The number of patients admitted to hospital
with a diagnosis of acute cannabis intoxication
in England has remained stable (at between 107
and 140 per year) over the 5 years 1995–2003
• Newcombe RD. (2004) Does cannabis cause psychosis? A study
of trends in cannabis use and psychosis in England, 1995–2003.
Evidence to the Advisory Council on the Misuse of Drugs.
Advisory Council Misuse Drugs
2002
2005 –”increase in the potency of cannabis products currently
available....suggesting a causal link between cannabis use and the development
of mental health problems”
The Council does not advise the reclassification of cannabis products
2008 – “review the classification of cannabis in the light of real public concern
about the potential mental health effects of cannabis use and, in particular, the
use of stronger strains of the drug.”
The Council does not advise the reclassification of cannabis products
Mean THC content (%) of cannabis products
Median THC and CBD content (%)
in material seized in 2005
What’s new in Drugs …
• New substances (Early Warning Systems, European
Monitoring Centre for Drugs and Drug Addiction)
– 2009 – 24
– 2010 - 41
– 2011 – 49
– 2012 expected the total 60
• Online sites selling drugs
– 2010 – 314
– 2011 - 690
•
•
•
•
Annihilation (3g)
Availability: IN STOCK
£28.19
IN STOCK
• Designed for maximum effect, the improved blend burns a new
herbal incense atmosphere into the room. Out of the box
thought combined with elation. Annihilation is best shared, best
experienced as a singular calm with others. Nights in were never
meant to be like this. A pwoerful legal incense fixer upper to an
otherwise dull night, burn Annihilation and set a fire to your
night.
• They consume you. You don't consume
them.
“Legal High”
• Advertised as plant food or research chemicals,
and often labelled ‘not for human consumption’
• Synthetic cannabinoids sprayed onto a plant
based mix (that does not contain tobacco or
cannabis) for the purposes of achieving
intoxication from smoking.
• lack of regulation over their production,
distribution and use
ACMD 2009
• Experience in Germany that suggests that
should one of the cannabinoids be controlled,
manufacturers move to adding a chemically
different, yet functionally similar, synthetic
cannabinoid in the ‘Spice’ mix. Due to the
number of variations, it is highly likely that
specific legislation would always run some way
behind the availability of a legal mix on the
street.
Cannabidiol can directly activate 5-HT1A receptors…
…but only with rather low potency
OH
Cannabidiol
HO
Cannabidiol
• Cannabidiol (CBD) in animals, has been shown
to have effects similar to antipsychotic drugs
through an as yet undetermined mechanism
• A survey of ketamine users, who also used
cannabis, found that those who had both CBD and
THC present in hair samples exhibited a lower
rating of psychosis-like symptoms than those in
whom only THC was found
Morgan CJA, Curran HV (2008) Effects of cannabidiol on schizophrenialike symptoms in cannabis users. B J Psych 192: 306–307.
Cannabis & specific subtypes
• Cannabis produces its effects on the human brain
through interactions between THC and specific
proteins on the surface of cells known as
cannabinoid receptors. Other psychoactive
components of cannabis, especially cannabidiol,
interact with other receptors in the brain. Different
preparations of cannabis have different proportions
of THC and other psychoactive constituents; the
consequences of using cannabis may, therefore,
vary depending on the relative proportions of the
psychoactive substances that are present.
ACMD 2012
• For those drug groups which are controlled in the UK
by generic legislation, such as the synthetic
cannabinoids, gaps in the generic controls are being
exploited which permit “designer” versions (specifically
formulated to have certain effects and avoid legislation)
to be offered
• Home Office Forensic Early Warning System (FEWS)
in July 2012 included results from a test purchasing
exercise showing the presence of uncontrolled synthetic
cannabinoids, such as AM2201, RCS-4 and UR-144, in
substances on sale via the internet.
Modifications of chemical structure
noted since the 2009 report include:
• Substitution with halogen atoms on the side chain attached to
the indole nitrogen atom (for example AM 694, AM 2201). It
appears that such modifications can enhance potency. The onset
of psychoactive effects of AM2201 are cited as occurring rapidly
and may last for up to 3 hours (ReDNET, 2012).
• Modification of the indole nitrogen substitution into a
methylpiperidin-2-yl structure (AM 1220, AM 2233).
• Use of a benzoylindole core structure (AM-694, RCS-4). This
structure was not included in the 2009 generic controls.
• Replacement of the benzoyl/naphthoyl structure by an
adamantoyl group (AB-001, AM-1248).
• Replacement of the benzoyl/naphthoyl structure by a
tetramethylcyclopropylcarbonyl group (UR-144, AB-034).
Worst case scenario......?
• 1982 - Patients arrived at
San Francisco area
emergency rooms after
using a synthetic analogue
of heroin (to get around
the law)(MPPP
contaminated with MPTP
– made originally by a 23year-old chemistry
graduate student). Fully
conscious but unable to
move or speak, they were
soon diagnosed as having
advanced irreversible
Parkinson's disease.
Government Response
• November 2011, the UK government (as part of the
Police Reform and Social Responsibility Bill)
introduced an amendment to Schedule 17 of the Misuse
of Drugs Act 1971 that permits any substance not
already classified by the Act that is ‘being, or is likely to
be, misused’ and whose misuse ‘is having, or is capable
of having harmful effects’ to be placed in a temporary
class drug order for a 12 month period.
• At the end of this 12-month period, the Advisory
Council on the Misuse of Drugs (ACMD) is required to
produce a report recommending permanent
classification
Where are services responding..
• Addiction Services
– NHS, set up to deal with addiction to alcohol,
heroin, benzodiazepines and crack cocaine
– Crew 2000
• A&E • MHAS/IHTT • I/P Psychiatric Service -
Drugs: a medical matter
• A moral/spiritual judgemental
stand is not acceptable for a
health problem.
• Patient’s first
• Raising profile of detection
• Range of responses by all
doctors from harm reduction –
to referral to specialist services
• A challenge to nihilistic views
on interventions, but accepting
of an often chronic relapsing
condition.
What's new in Psychosis
• First Episode Psychosis
(FEP)
• Duration of Untreated
Psychosis (DUP)
• Good outcome at 3-5
years in FEP related to
short DUP
How should we approach the diagnosis
and assessment of FEP?
Online RCPsych CPD
• First-episode psychosis:
– Part 1 – assessment, diagnosis and rationale
– Part 2 – treatment approaches and service
delivery
Dr Andrew Thompson, Dr Rick Fraser and
Dr Richard Whale
Diagnostically, DSM-IV identifies psychoses
•
•
•
•
•
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•
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Schizophrenia
Schizoaffective disorder
Delusional disorder
Brief psychotic disorder
Shared psychotic disorder
Psychotic disorder due to a medical condition
Substance-induced psychotic disorder
Psychosis not otherwise specified (NOS).
• Such diagnoses, however, require clear symptom profiles and durations that
are difficult to elucidate in the first acute presentation.
What’s new in co-morbidity?
NICE guideline 2011
Raise profile of detection – ask…
• Substance(s) used
• Quantity, frequency and pattern
• Route of administration
• Duration of current level of use
• Evidence of Dependence
– Carving, Loss of control,
tolerance, withdrawal, use to avoid
withdrawal, harm
health/relationships etc.,
• Consent for corroborative
history
Respectful, trusting, non-judgemental
• Do not exclude from either
– Mental Health Services
– Drug Services
• Various models of delivery of care
– Joint working
• Parallel services with good communication (+/- CPA)
• Joint clinics
– Specialist Co-morbidity clinics
• Assessment of vulnerable adult & children
I/P Services
• Promoting a therapeutic environment free from
drugs and alcohol
–
–
–
–
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search procedures,
visiting arrangements,
planning and reviewing leave,
drug and alcohol testing,
disposal of legal and illicit substances
In patient Px options...
• Appropriate use of a brief medication-free
observation period when at all possible (24–48
hours)
• Use of benzodiazepines both during this period
and as an appropriate means of treating acute
agitation or disturbance
• Judicious use of short-acting rapid
tranquilisation if necessary.
DRUG TREATMENT of ACUTE BEHAVIOURAL
DISTURBANCE in GENERAL ADULT (18 – 65yrs)
PSYCHIATRIC IN-PATIENTS
• Preventative skilled management (e.g. de-escalation techniques)
is obviously preferable to the use of medication. Medication
prescribed in an emergency should be reviewed at least daily to
prevent subsequent inappropriate escalation of dose
• Rationale for Choice of Regimens for Algorithm
• Haloperidol and lorazepam is the treatment choice in acute
behavioural disturbance and must be considered first line for all
patients.
• This combination of haloperidol and a benzodiazepine is
desirable to avoid very high antipsychotic doses when the
immediate aim is sedation.
• Olanzapine is the second treatment choice and may only be
considered for:
– patients who have had severe dystonic reactions to haloperidol previously
– patients with less extreme agitation who are refusing oral therapy but who are
showing escalating levels of hostility
– IM Olanzapine must not be administered with a benzodiazepine.
Mental Welfare Commission (MWC) (1)
• Concerns regarding use/misuse MHA in comorbidity cases
• Support / promote NICE guide
– Respectful, trusting, non-judgemental relationship
– Routinely ask about drug/alcohol use, testing and
corroboration with consent
– Do not exclude/discharge from services solely due
to substance use
– Discharge with a Care Plan +/- CPA
MWC (2) - Using MHA
• Drug aetiology does not exclude use
• Symptoms may not completely subsided, and
even if they appear to have, a longer period of
assessment may be needed especially in novel
drugs
• Drug and alcohol services need to be more
assertive in helping people to engage
• To help patients make an informed choice about
lifestyle and drug use
MWC report Mr F 2009
Effective care and treatment in dual diagnosis
of mental illness and alcohol misuse
• Stigma
CSA/PTSD/PD/Addiction
(ADS)
– Delay in diagnosis of Psychotic
illness
• Poor engagement
– discharge v out reach
• Poor outcome
– Homicide 2ndry to command
hallucinations
• Service model strengths
– DDT v CMHT/SMS
– Change RMO I/P & O/P
• Required
– Shared Care Plans v CPA
– Involvement none NHS
– Risk assessment with
reviews built in
MWC report Ms Z 2010
Effective care and treatment in dual diagnosis
of mental illness and alcohol misuse
• Diagnostic uncertainty
– Schizophrenia,
schizoaffective disorder,
alcohol problems, ARBD,
personality factors and
social aetiology
• Crisis management with
no care plan
• Unplanned discharge
with no care plan
• Autonomy v control by
the use of MHA
• Ongoing responsibility
for psychiatric care –
leadership required
• No joint working CMHT
& Addiction service, no
outreach
• CPA again promoted
• Response to drinking as
I/P
Summary – Drug Induced Psychosis
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Address our stigma to substance use
Raise our detection of substance use
Challenge our nihilism to I/P substance use
Acknowledge uncertainty in management of
FEP in context of substance use, and the skills
inherent in Consultant Psychiatrist. Promote
Medical Leadership.
• In high risk cases – care plans, assertive outreach
and 2nd opinions +/- MHA CTO are required