Transcript The Role of the GP in the Treatment of Drug Dependency

Drugs of Dependency
Dr Linda Harris
Wakefield Integrated
Substance Misuse Services
WISMS
OBJECTIVES
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Substances of abuse and their physical and psychological
effects
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Dependency syndrome
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An overview of treatment models
Major Drug Groups
All drugs fall into one of three groups:
Depressants: – slow you down, produce
feelings of euphoria
Stimulants – speed you up, boost your energy
and confidence
Hallucinogens – alter perception of the world
Opiates
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Main drugs of abuse in UK
Derivative of OPIUM found in poppy plant
The euphoric and analgesic effects
thought to lead to abuse
Side effects - nausea, constipation,
respiratory depression
How are opiates taken
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Injecting through a vein
Swallowing in tablet form
Smoking in cigarette form
Smoking by inhaling the fumes produced
by burning powder in a foil – “chasing the
dragon”
Sold in “bags” – 1 bag = 0.2gms = £10
Cocaine
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Stimulant drug extracted from the leaves of the
coca plant
Made into a crystalline salt form by adding
sulphuric acid and finally ends up as cocaine
hydrochloride powder
To make crack the powder is heated up in a
microwave with bicarbonate of soda and water
Crack is easily melted and vapourised so it can be
smoked
Crack may also be injected by mixing it with water
and weak acid such as citric or ascorbic
Cocaine
Effects: feelings of increased energy with
consequent increased activity and improved social
confidence. users feel more alert and energetic,
confident, physically strong with a higher mental
capacity
Physical effects – dry mouth, sweating, loss of
appetite, increased heart and pulse rate
Side Effects: - irritability, paranoia, restlessness,
psychosis
Cocaine - How is it used
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Dabbing – rubbed on the gums
Snorting – most commonly in its hydrochloride powder
form
Piping – smoked through a pipe
Injecting Chasing – chased on tin foil like heroin
Smoking/chipping – flaking bits of cocaine or crack
into the top of a cigarette “joint”
“Speedballing”
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Powder cocaine –“champagne image”
Crack – smokeable “rocks”
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More likely to be associated with mental and physical health
problems
Poly drug users
Links with criminality and violence
Costs
– powder upwards of £40 per gram
- £5 - £10 per rock
Harms associated with street
drugs (notably heroin)
 Psychological
 Physical
 Social
Harm (Psych)
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Anxiety and depression
Drug related psychotic illnesses
Aggravation of pre existing psychological or
psychiatric illness (“Dual Diagnosis”)
Practically any mental disorder you can think
of
Harm (physical)
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STD, unplanned pregnancy, Cx cancer
Asthma
Ear wax
DVT, vascular damage
Bacterial abscesses, metastatic sepsis
Cl. novyii, botulinum, tetani
HCV, HBV, HIV
Overdose, death
Harm (Social)
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Unemployment, poverty
Crime: theft, dealing, physical violence,
prostitution, murder
Imprisonment
Separation, divorce, children in care,
loneliness and isolation
Loss of dignity and self respect
Amphetamines
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Synthetic stimulants
Most commonly produced in tablet or powder
form and can be swallowed snorted injected or
smoked
Mimic the effects of adrenalin in the body and
therefore produce: - Increased energy,
talkativeness, reduced appetite, restlessness,
agitation
Amphetamine abuse
Side effects occur after prolonged use and when
the effects of the drug wears off.
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Depression
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Irritability
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Hunger
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Fatigue
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Vein damage in injectors
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Sexually transmitted diseases
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Acts of violence
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Benzodiazepines
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Depressant, synthetic drugs
Highly dependent with tolerance to their
effects building up rapidly
. Symptoms of withdrawal include: ·
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Anxiety and insomnia
Nausea and vomiting
Phobias
Loss of confidence and paranoia
Headaches and dizziness
Palpitations
Cannabis
This is a naturally occurring hallucinogenic drug
most commonly seen in a variety of herbal forms
or as a resin.
It produces the following effects:
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Euphoria
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Increased confidence
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Altered sensory perceptions
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Feeling of well being
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Relaxation
Cannabis - the health risks
There is now established evidence that it produces
dependence
Studies suggest the risk of dependency equates
with that of alcohol
Cannabis is an intoxicant – impairs short term
memory, judgement and co ordination – RTAs
Psychotic episodes have been reported (recent papers
suggests increased risk particularly in patients with premorbid
mental health issues)
Increased risk of chromic bronchitis and squamous
metaplasia - ? Links with lung cancer
Cannabis – the health benefits
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Used as a medicament for over 5,000 years
Clinical trials underway exploring its use as
treatment for nausea and vomiting, combating
muscle spasm in multiple sclerosis, treating loss of
appetite and weight loss in AIDS
Drug companies looking at synthetic cannabinoids
with therapeutic effects minus the psychoactive
effects
Cannabis - the policy options
Relaxation on prohibition: Potential reduction in crime and therefore police
and criminal justice expenditure
Reduction in prison overcrowding
Potential increase in use leading to as yet
unknown health implications
Society’s covert message – leading to massive
increases in use
Solvent use
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Young people
Effects similar to alcohol
?Use is decreasing
Beware of the solitary user
Risk factors for substance misuse
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Male
Young
Early childhood conduct disorder
Childhood neglect
Homeless
Poor academic achievement
New Notifications for
Heroin Addiction U.K. (1980-1996)
16000
14000
12000
10000
Heroin
Methadone
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Estimated 600,000 class A drug users in the
UK = 1% of the population ( ie 18 per GP)
Est 300,000 Hepatitis C positive
Est 3 billion derived from prostitution
Massive implications, chldcare, criminal
justice, social services acute care
Models of Care
Medical Model
Vs
Social model
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Criminal justice model
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Community model
Government Targets
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Reduce the proportion of people under 25 using
heroin and cocaine by 25% by 2005 and by 50%
by 2008
Reduce the levels of repeat offending amongst
drug misusing offenders by 25% by 2005 and 50%
by 2008
Increase the participation of problem drug
misusers including prisoners in drug treatment
programmes by 66% by 2005 and 100% by 2008
National Government Policy
1998 – “Tackling Drugs to Build a Better
Britain”
 Ten year plan
 4 key objectives: 
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Young people
Improve quality and access to treatment
Breaking the drugs crime link
Stifling availability of drugs on the streets
Emphasis on Breaking the Link
Between Drugs and Crime
UK Crime and Disorder Act
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Drug Treatment and Testing Orders
Arrest Referral schemes
Prison throughcare and aftercare Drugs Intervention Programme
Key messages
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£1 spent on treatment saves £9.50 in terms
of crime
Treatment works
The longer in treatment the better the
outcome
Complications kill
Harm reduction saves lives
Graph showing deaths, comparing untreated patients with those in Methadone
maintenance treatment in the Swedish study (15).
(Reproduced from Gronbladh et al)
Treatment
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Attract
Assess
Retain
Appropriate Care
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Substitution Treatment
Harm reduction
Hepatitis B
immunisation
Address homelessness
Address skills deficits
“Safer stronger
communities”
Treating 10 heroin users with
methadone for 1 year can save 2
lives
Treating 100 hypertensives for 10
years might save 2 strokes
Models of Care Treatment Tiers
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Tier 1 – Non Substance misuse
specialist services e.g. GP surgeries,
Walk in centre A and E
Tier 2 – Open access substance misuse
services – light touch services or
services to encourage more engagement
with specialist services
Tier 3 – Structured Community
Services providing only within a
structured and planned treatment setting
Tier 4a – Residential substance misuse
Tier 4b – Highly specialist non
substance misuse services – e.g.
forensic services liver units eating
disorder units etc
Text 4b
Text 4a
Text 3
Text 2
Tier 1
Options for levels of involvement
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Generalist care
Shared care
GP wSi
Addictions psychiatrist
Good Medical Practice in
managing dependency
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Recognise the problem?
Identify the complications of drug misuse and assess
risk taking behaviour
Reduce harm e.g. hepatitis screening and
vaccination
Work with the patient to identify their needs and
identify a way of meeting those needs
Work as part of a multidisciplinary team
Think of social and psychological needs as well as
medical needs
Treatment – The evidence
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Successful medical treatments aim to provide a safe
substitute for the opiate heroin.
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By prescribing an alternative or substitute one can
alleviate withdrawal symptoms and the addict is
released from the compulsion to carry out risk taking
behaviour as part of their addiction.
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Methadone remains the gold standard
Methadone
The evidence
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most widely used form of opioid replacement therapy
in the US, Europe and Australia
Most evidence of impact on illicit drug use,and
criminal acts
Most positive evidence of containment of HIV
transmission
Most positive evidence of improvement in health,
employment status and social well being goals
Substitution
Substitution
Detoxificaiton
Can use opiates or non opiates
Need to be well motivated
Tends not to be effective
Longer term Maintentance
Need to build in regular reviews
Beware of drug diversion
Short term maintenacene
Methadone
Buprenorphine
Harm Reduction
Basic care. Benefits, housing, child care
issues, social services.
Signposting to needle exchange, CDT
Information
Sexual health: Cx smear, contraception,
HBV/HAV inoculations (grab and stab)
Open door
Who can’t do any of this?