Outline
Biography
Introduction
• Intoxicating substances, old and new
• Dependence and withdrawal
• Comprehensive SM history
• Conventional approaches to SM treatment
Integration
• Drugs and alcohol in the sexual health setting
• Advice for screening and intervention
• Services local to C&W
Medical and psychiatric training
• Chelsea & Westminster Hospital: Liaison / HIV
• Central & North West London: Addictions
• Special interests: Club Drug Clinic
• WLMHT Integrated care for patients with LTCs
Now
• WLMHT / Ealing : Consultant Liaison Psychiatrist
• Home ward Ealing – Intermediate Care Service
• Imperial College: Honorary Senior Clinical Lecturer
• Medical Council on Alcohol: Executive Committee
Acknowledgements
• Dr Owen Bowden-Jones
• David Stuart, Antidote
• Mark Dunn
• Stacey Hemmings
•
•
•
•
Dr Pepe Catalan
Flick Thorley
Dr Amrit Sachar
Prof Anne Lingford-Hughes
Declarations
CH has in the past received honoraria for travel /
lecturing (not related to this work) from: Bayer, Lilly,
Pfizer and Janssen
Categories of intoxicating substances
Depressants
Opioids, benzodiazepines, alcohol
Stimulants
Cocaine, amphetamines, MDMA, caffeine
Hallucinogens
LSD, PCP, ketamine
Cannabis, nicotine
Highs and harms
Desirable effects
• Pleasure
• Relaxation, anxiety reduction, disinhibition
• Increased energy, enjoyment, confidence
• Fatigue reduction, pain reduction
• Curiosity, new experiences, ‘psychonaut’
Highs and harms
Undesirable effects
• Mode of administration
• Physical and systemic effects
• Psychiatric effects
• Dependence potential and withdrawal
• Behavioural consequences
• Indirect harms / harms to others
• Crime
• Synergistic effects
The most harmful drug overall?
Nutt et al Lancet 2010; 376:1558
The most harmful drug overall?
Nutt et al Lancet 2007; 369:1047
Novel psychoactive substances
• Club drugs recreational drugs used in
nightclubs, festivals, gigs, bars, circuit and house
parties
• Eg: amphetamine, methamphetamine, MDMA, cocaine
• NPS designed to mimic controlled drugs but
synthesised to evade prohibitions
• Many now banned after period as legal highs
• Eg: mephedrone, methoxetamine, GHB/GBL
• Easily available online, head shops, dealers
Novel psychoactive substances
Categories of drugs
Depressants
Opioids, benzodiazepines, alcohol, GBL/GHB,
Phenibut,
Stimulants
Cocaine, amphetamines, MDMA, caffeine m-cat,
NRG-1, BZP, MDAI, Synthacaine, 5/6-APB
Hallucinogens
LSD, PCP, ketamine, AMT, methoxetamine
Cannabis, nicotine
Spice
Novel Psychoactive Substances - Key points
• It is impossible for clinicians to remain abreast
of all NPS on the market (1 new drug per week)
• NPS are synthesised to mimic existing drugs /
use the same neurotransmitter mechanisms
• Most NPS are not detected by routine urinary
drug testing – false negatives
• Ask, and have degree of suspicion based on
clinical assessment
Scale of drug use in England & Wales
• Adults 16-59:
• Prevalence of having taken illicit drugs:
– 36.4% ever
– 8.6% in last year
– 3% Class A
• Young adults 16-24:
– 48.6% ever
– 20.4% in last year
– 6.6% Class A
NHS IC 2011
Scale of NPS use
EMCDDA 2005-111
• 164 NPS were formally notified (now ~1 per week)
• UK - 23% European NPS users
Crime Survey E&W 2011-122
• 1.1% respondents had used mephedrone in the last
year, 3.3% in 16-24 age group
Global drugs survey 20132 (clubbing last month):
• 36.1% reported lifetime use of mephedrone
1
EMCDDA-Europol 2011 Annual Report on the Implementation of Councel Decision 2005/387/JHA. EMCDDA/Europol, 2012. | 2
Home Office. Drug misuse declared: findings from the 2011 to 2012 Crime Survey for England and Wales. Home Office, 2012. | 3
Winstock, A. "Global Drug Survey." Mixmag, May 2013.
A whirlwind tour of addiction
• Chronic relapsing brain disorder characterised by
neurobiological changes that lead to compulsion to
take a drug (or activity) with loss of control over the
activity.
• Transition from recreational to obsessive use
• From positive to negative reinforcement
• Psychological factors drive the behaviour
Koob GF and Le Moal M, Science, 1997
But what drives the psychological factors?
Inside the
brain of a
recreational
user of drugs
Boileau et al Synapse 2003
Inside the
brain of a
dependent
user of drugs
1. Volkow
2. Koob
Outline
Biography
Introduction
• Intoxicating substances, old and new
• Dependence and withdrawal
• Comprehensive SM history
• Conventional approaches to SM treatment
Integration
• Drugs and alcohol in the sexual health setting
• Advice for screening and intervention
• Services local to C&W
ICD-10 diagnosis of dependence
• Three or more at once in the last year:
•
•
•
•
•
•
Withdrawal symptoms
Tolerance to the effects of the drug
Strong desire or compulsion to use the substance
Persistent use despite adverse consequences
Difficulty controlling use / amount / recidivism
Neglect of other activities / primacy
• (Narrowing of repertoire)
Comprehensive SM history
• Who? (everyone)
• What substances? (Avoid ‘illegal’)
– Quantity
– Frequency
– Route
– Circumstances
– History of use (first, regular, heaviest, cumulative)
• Negative effects (teachable moment)
• Features of dependence and withdrawal
2L Cider (£3)
7.5%
15 units
1 pint Peroni
5.1%
2.95 units
440mL Special
Brew (£1.32)
9%
70cL whisky
4 units
40%
28 units
250mL wine
13%
3.25 units
75cL wine
13%
9.75 units
Clinical treatment strategies
•
•
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Education & brief intervention
Harm minimisation
Stabilisation / maintenance
Detoxification
Rehabilitation
Abstinence
• NHS Drug Clinics
• PHE commissioned (via LAs)
Outline
Biography
Introduction
• Intoxicating substances, old and new
• Dependence and withdrawal
• Comprehensive SM history
• Conventional approaches to SM treatment
Integration
• Drugs and alcohol in the sexual health setting
• Advice for screening and intervention
• Services local to C&W
Alcohol and sexual health
Family Planning Association Survey 2009
1000 18-30 year olds, Online survey by Mori
• 37% had unprotected sex with a new partner
• Of these: 40% said alcohol was a factor
• 38% reported sex which they regretted later
• Of these: 70% said alcohol was a factor
• 28% reported having sex with someone they wouldn’t
normally find attractive
• Of these: 78% said alcohol was a factor
Alcohol and sexual health
Binge drinking, sexual behaviour and sexually
transmitted infection in the UK
Int J STD & AIDS 2007; 18; 810-13
•
•
•
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86% GU attendees are binge drinkers
32% felt alcohol played a role in their attendance
77% drunk before sex with a new partner
Binge drinking assoc with bacterial STI diagnosis and
unwanted pregnancy
Recreational drugs and GUM: meth
Scale of methamphetamine use (UK)
• CSEW 2011-121: 0.1% used in last yr
• GMSS 20072: 4.7% used in last yr
• HIV testing cohort3: (2002-3): 8.3% in last yr
• HIV treatment cohort3 (2002-3): 12.6% in last yr
• Gym cohort (2004)3 21% in last yr
1Home
Office. Drug misuse declared: findings from the 2011 to 2012 Crime Survey for England and Wales. Home Office, 2012. | 2Keogh
P et al. Wasted opportunities: Problematic alcohol and drug use among gay men and bisexual men. Sigma Research 2009 | 3Bolding G
et al. Addiction 2006; 101, 1622–1630
• CNWL (NHS)
• Antidote (Charity)
• National / open access
• Opened: Jan 2011
• First 18 months:
• 291 patients seen
CDC - Presenting drug use (n=291)
GBL/GHB
Crystal methamphetamine
Mephedrone
Cocaine
Ketamine
Alcohol
MDMA
Cannabis
Other NPS
Benzodiazepines
Opioids
Amyl Nitrate
CDC - Presenting drug use (n=52 heterosexual)
Ketamine
Cocaine
Alcohol
Mephedrone
GBL/GHB
Crystal methamphetamine
MDMA
Cannabis
Benzodiazepines
Other NPS
Opioids
Crystal methamphetamine and HIV
• Users of crystal methamphetamine in the
clinic (n=120) were two times more likely to
be HIV positive than non users (n=170).
68% vs 33% (p <0.05)
• Users of crystal methamphetamine in the
clinic were four times more likely to be HCV
positive than non users.
12% vs 3% (p <0.05)
Crystal methamphetamine and HIV
Do you attribute your HIV status to
your drug use?
30% of HIV positive patients
responded YES
Crystal methamphetamine and HIV
Does your drug use get in the way
of taking your prescribed
medications regularly?
39% patients on antiretrovirals
responded YES
Injecting drug use
Crystal methamphetamine users:
• 53% reported having injected the drug
• 47% never
Non crystal users:
• 6% reported currently injecting (meph, cocaine, G, K)
• 19% reported previously injecting
• 75% never
MSM and substance use – why?
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Helps to relax and be more sociable
Mitigating social unease (general, sexuality, scene)
Alleviating loneliness / unhappiness
Enabling sexual encounters
(sexuality, HIV, ‘raucous’ – integral to sex)
• Gay norms of alcohol and substance use
(integral to socialising)
Keogh P et al. Wasted opportunities: Problematic alcohol and drug use among gay men and
bisexual men. Sigma Research 2009
Associations between substance use and HIV related
risk indicators
• Systematic review of 23 studies
(2012)1 looked at studies into
various substances: only
methamphetamine and binge
alcohol drinking associated with
sexual risk (see plot)
• Systematic review of 61 studies
(2012)2 highlighted HIV+ MSM
who use meth more likely to
report high-risk sexual behaviour,
incident STI, serodiscordant UAI
compared with HIV+ MSM who
do not use methamphetamine
1 Vosburgh, HW et al. A Review of the Literature on Event-Level Substance Use
and Sexual Risk Behavior Among Men Who Have Sex with Men. AIDS Behav 2012: 16:1394–1410
2 Rajasingham R et al. A Systematic Review of Behavioral and Treatment Outcome Studies Among HIV-Infected Men Who Have Sex with Men Who Abuse
Crystal Methamphetamine. AIDS PATIENT CARE and STDs 2012: 26; 36-51
High risk sexual behaviours
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Increased frequency of sex
Prolongation of sex (‘marathon’)
Increased number of partners
Reduced condom use / UAI
Increased condom failure
Disinhibiting effects
Mucosal trauma
Co-infection with other STI
Colfax G, Guzman R. Club Drugs and HIV Infection: A Review. CID 2006: 42:1463–9
High risk sexual behaviours
Clinical experience
• Online apps / websites
• ‘Party and play’ / parTy
• Multiple partners
• Higher risk sexual practices
• Intravenous use in sexualised contexts
• ‘Slamming’ / re-injecting
Kirkby T, Thornber-Dunwell M. High-risk drug practices tighten grip on London gay scene.
Lancet 2013: 381; 101-2
Interventions
Patient
• 37 year old HIV+ gay man, working full time in City
• Recent acquisition of HCV following casual UPSI at
party arranged online
• Binges on drugs 3-4x per month including ‘tina’
smoked or ‘slammed’ and ‘meph’
• Reports feeling depressed and being ‘monitored’
online at times
• Would like to abstain from drugs, but doesn’t see self
as a ‘junkie’ so won’t visit mainstream services
• Multiple lapses related to sex: ‘haven’t had drug free
sex for years’, ‘can’t manage sex without drugs’
Substance misuse in sexual health
• Investigate the link
between substance
misuse and sexual health
• Design interventions to
minimise harm from both
Social care
Disintegrated services
Relationships
Sex
Social life
Family / children
Employment
Habits
Spirituality &c
Justice System
Addiction services
• NHS
• Third Sector
Mental health
Physical health
• HIV
• Sexual health
• Other medical
problems
Primary
care
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Wellbeing
Self esteem
Depression, anxiety
Cognitive function
Psychosis
Self harm
Substance misuse in sexual health
• Clinicians should
– be aware of the commonly used recreational drugs
and their potential short term complications and risks
– consider screening individuals at risk
– give simple safety advice and information
– have agreed referral pathways into local services
AK Sullivan, O Bowden Jones, Y Azad (2014)
Drug Screening Qs
1.
Did you use drugs before/during sex in the last 3m
Yes / No / Yes but not during sex
2.
Which drugs did you use?
Crystal methamphetamine - 
Mephedrone - 
GHB/GBL- 
Ketamine- 
Cocaine- 
Other (specify)- 
3.
Did you inject?
Yes / No / Yes but not in the last 3m
Identification and Brief Advice
• “The teachable moment”
Change in
awareness
Change in
attitude
Change in
behaviour
Prochaska & DiClemente
Identification and Brief Advice
• “The teachable moment”
• Reflect back to the patient any identified harms
• Offer advice on making changes
• Offer further advice/support/referral
• Cochrane review supports effectiveness of IBA1
• To reduce drinking to lower-risk levels, NNT = 8 2
1 Kaner
2007, 2 Moyer 2002
Referral pathways
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•
•
•
Access to integrated SMHW
Mental Health referral pathways
Integrated health and social care services
Addictions services:
– PHE/LA commissioned
– Increasingly partnerships between 3rd sector and NHS
– Concern about reduced capacity to deal with
complexity including physical / MH comorbidity
– Culturally competent? Eg MSM specific
Clinical treatment strategies
PS - Mental health in sexual health
Psychological Wellbeing Agenda
• Support at time of diagnosis
• Screening for psychological needs:
depression, anxiety, SM, stress, self
harm, cognitive impairment
• Initial management interventions
• Referral pathways - evidence based,
HIV-specific, timely, competent,
access to psychological care
Resources
Specialist services:
CODE
ChemClinic
ReShapeNow.org
• THT www.drugfucked.tht.org.uk
• talktofrank.com
• erowid.com