Transcript Addiction - Epsom VTS

Addiction
Dr Anna Barham
May 28th 2008
• Addiction
• Alcohol
• Drugs
• GP role
• Policies & Guidelines
• Case studies
• Ethics
ICD-10 criteria for
dependence
• A strong desire or sense of compulsion to take
the substance
• Difficulties in controlling substance-taking
behaviour (onset, termination, level of use)
• Physiological withdrawal state when substance
use has ceased or been reduced
• Evidence of tolerance
• Progressive neglect of alternative interests
• Persisting with substance use
Addictions
• Chemical substances
• Things to do with body – exercise, food,
weight loss, sex
• Material gain – work, shopping, money
• Risk – gambling, pornography, computer
games
• Less tangible – another person, religion,
perfectionism
• Newer addictions – contact, alter-ego
Discuss
“Addiction is a choice, a personality flaw not a disease. Addicts only have themselves
to blame. The NHS should not waste money
on treating people with drug and alcohol
related problems.”
Factors Contributing to
Substance Misuse
Personal
Environment
Environment
 Availability
 Socio-economic
status
 Peer pressure
(contacts)
Unemployment
Poor
housing/homelessness
Personality
Drug
Drug
 Individual effects of
drug
 Effects of drug may
be used to counter
feelings/depression
 Vulnerable personality
 Poor family
relationships/breakdown
& support
 Easily led
 Mental health
problems – Depression,
Schizophrenia, ADHD
 Family using
alcohol/drugs
(patterning/genetic)
 Poor achiever at
school
Know your limits
• How many units of alcohol in
a single measure (25mls) of vodka?
a bottle of standard strength beer (5%)?
a pint of superstrength cider (9%)?
a small 125ml glass of wine (10%)
a large 250ml glass of wine (14%)
a bottle of alcopop?
Know your limits
a single measure (25mls) of vodka? 1.0
a bottle of standard strength beer (5%)? 1.7
a pint of superstrength cider (9%)? 5.1
a small 125ml glass of wine (10%) 1.5
a large 250ml glass of wine (14%) 3.5
a bottle of alcopops? 1.4
The problem
• 8.2 million people consume more alcohol
than the recommended guidelines
– 16.3% of the population are hazardous drinkers
– 4.1% are harmful drinkers
• The harm associated with alcohol misuse
is estimated to be in excess of £15b a
year
• 10% of all psychiatric admissions are
alcohol related
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Models of care for alcohol misusers Consultation document 2005. Department of
health, National treatment agency for Substance Misuse
Complications of ETOH misuse
• 5% of dependent experience severe withdrawal
symptomatology including delirium tremens and grand
mal seizures
• Direct toxic effect on brain and liver
• Deficiency of protein and B vitamins
• Effects on cardiovascular system, lipids and glucose
• Damage to the fetus (fetal alc. syndrome, stillbirths)
• Risk of accidents
• Psychiatric disorders (intoxication, withdrawal, toxic or
nutritional disorders, associated mood and anxiety
disorders)
• Social problems
Alcohol Related Complications
Brief Intervention
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Ideal for primary care setting
Evidence based
Quick and cost effective (£20 per intervention)
GPs and practice nurses have skills
Evidence suggests that Brief Interventions are
effective in reducing alcohol intake by 20%
• Estimated that £10,000 invested in BI could save
£43,000 health care costs
Components of Brief
Intervention (5 to 10 mins)
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Assessment of alcohol intake
(Physical assessment)
Personalising of health effects
Information on hazardous/harmful
drinking – quantity & pattern
Clear advice with info booklet
Explore triggers for drinking
Negotiate realistic aims
Follow-up negotiated
Elements of Brief Intervention
(FRAMES)
• Feedback about risks of substance use and
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misuse
Responsibility placed on the patient for change
Advice to cut down/abstain etc.
Menu of options and choices
Empathic approach
Self-efficacy – using a non-confrontational
counselling style which encourages and
reinforces patient’s strengths
Home Detoxification Criteria
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No history of alcohol withdrawal seizures
Adequate home support
No inter-current serious mental health problem
No current suicidality
No multiple failed attempts at home
detoxification
• No poly-drug dependency
Home detoxification
• Daily visits with breathalyser test
• Reducing dose of benzodiazepine plus prn
doses.
• Consider instalment dispensing
• Oral vitamin supplements – thiamine and vitamin
B co strong
• 7-10 days usual
Drugs
Discuss your own professional and
personal experiences of drug
misusers
Problems Perceived by professionals:
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Difficult group of patients
Lack of training
Possibility of ‘swamping’
Doubtful value of intervention
Possibility of GP/pharmacist/psychiatrist
etc getting blamed
• Possibility of diversion of prescribed
drugs
Why should GPs get involved?
• Common chronic relapsing condition
• Patients prefer treatment in primary care
• Evidence that primary care treatment
works
• Government policy and NTA guidelines
promote GP involvement
• Good support and training now exists
Effects of dependent drug use
Physical:
Complications of injecting
(DVT, abscesses, overdose, SBE)
Blood-borne virus transmission
Side effects of opiates
(constipation, low salivary flow)
Side effects of cocaine
(vasoconstriction, local anaesthesia)
Social: Financial, employment, crime, relationships,
parenting, housing
Psychological: Depression, anxiety, psychosis,
craving, guilt
What can a GP offer a newly presenting drug
misuser?
• Harm reduction advice
• Health check, e.g. blood pressure
• Screening for blood borne viruses
• Contraception, smear
• Sexual health advice
• Check general immunisation status
• Signpost to additional help (counselling,
benefits, housing)
• Information on local drugs services including
needle exchange
How do I do a quick GP assessment?
Which drug ?
 Heroin/other opiates can be substituted by
Methadone or buprenorphine (subutex)
 Stimulants have no substitute available
Route of administration ?
 Oral
 Inhaled/smoked
 Injected
How long addicted ?
 Longer term addiction, quick detox less chance of
success
 Younger patient less suitable for long-term
maintenance as 1st option
Examination and Investigations
 Examination for injection sites etc
 Urine screen for opiates and other drugs
Opioid Treatment
• Pharmacological – detox or maintenance –
with methadone or buprenorphine - NICE
approved. Supervised consumption.
• Psychological interventions - key working,
brief interventions, self-help, contingency
management – NICE approved
• Social support – housing, employment,
parenting, finance
Contingency management
• Drug services should introduce these
programmes as part of phased implementation
• Programme should offer incentives e.g.
vouchers, privileges which are contingent on
each presentation of a drug-negative test
• For people at risk of physical health problems
from their drug misuse material incentives
should be considered to encourage harm
reduction. e.g one-off £10 voucher for
completion of hep B immunisation
Cycle of Change (Prochaska &
DiClemente 1986)
Case study
• Laura is a 26 year old woman who comes to see you for the first
time having recently joined your list. She tells you that for the last
five years she has been using heroin daily and that she now uses at
least three £10 bags a day, sometimes more and injects three or
four times a day. She smokes about thirty cigarettes a day but does
not drink alcohol. She uses occasional crack cocaine.
• Laura tells you that she does not have anywhere permanent to live
at present and is staying with her brother.
• Laura has never received treatment for her drugs problem in the
past and she tells you that she has come to see you “to get off all
drugs as soon as possible – I’ve had enough”
• On examination you find that Laura has old and new track marks on
both arms and is very thin, but otherwise appears healthy.
Questions
• 1. What are the issues raised by this
scenario?
• 2. What are the options?
• 3. What action do you take?
Case study
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You are on call on Saturday morning for the local co-op
and a call comes in from a patient. She is desperate
and wants help. She has just come to the area from
Liverpool and is staying with her mum. She is 7
months pregnant. She has left her methadone in
Liverpool and is ‘clucking real bad’
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What issues do you want to think about?
What are your options? And their consequences?
In ideal circumstances what can be done in these
cases?