ILLICIT DRUGS
Soap Box
Kate Rees
Swindon/Bath GP Registrar DRC
12/05/05
Why?
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Previous experience at Rockhall
Shared-care practice
Diploma in Substance Misuse part 1
We can save lives – scary stats to follow…
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.
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
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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
What’s out there and what can you
get for your money?
• 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
• Ectasy
– E, pills, brownies, burgers, disco biscuits, hug
drug, 'Mitsubishi's', 'Rolex's', 'Dolphin's', XTC
– Pills, liquid form (GBH)
• 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
• Benzodiazepines
– Jellies, benzos, eggs,
norries, rugby balls,
vallies, moggies,
mazzies, roofies,
downers.
– 10mg diazepam = £1
• 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
• 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
• Heroin
– Brown, skag, H, horse,
gear, smack
– smoked, snorted or
injected
– Purity 20-60%
– £10 bag= roughly 0.20.3g
– Addicts habit 0.5g- 2g
(or teenth) /day
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.
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
How we assess - History
1. Why have they presented today.
2. Past and current drug use.
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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
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
3. History of injecting (risk of infection)
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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
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
Examination
1. Physical
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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
2. Mental health
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Psycosis (cannabis, speed, cocaine)
Anxiety/Depression
Investigations
• Bloods
– HepB, HepC, HIV
• Urine
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on the premises (5-10mls)
Non-punitive
Confirm diagnosis
Helps with treatment plan
Covers you medico-legally
Protects patient from inappropriate px
↓street diversion
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
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)
Harm Prevention
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.
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