james bell february 2014 alcohol, drugs, and hospitals

James BellFebruary 2014

Alcohol, drugs, and hospitals

Why do people use drugs?

Why do people use drugs?

Drug use is normal behaviour

Who develops drug problems?

Who develops drug problems

0

5

10

15

20

25

Pre

va

len

ce

18-24 25-34 35-44 45-54 55-64 65+

Age

Males (9.0)

Females (3.2)

Neurobiology of drug use

• Drugs of abuse have in common that they act on the “reward pathway”

• The reinforcing effect of drugs is reduction in anxiety and creation of a sense of well-being

• Repeated exposure leads to lasting brain changes, including protracted withdrawal

Drug DependenceA maladaptive pattern of substance use leading to impairment or distress

Tolerance and Withdrawal

Salience

Craving

Reinstatement after abstinence

Persisting use despite harm

Communities vulnerable to drug dependence

Those without taboos or rewards

Especially: - indigenous communities - marginalised communities- deregulated communities

Responding to drug problems

Distinct area of medicine:• Serious morbidity and mortality• Involves values and choices

Simply telling people to stop is of limited value

Components of behavioural medicine

• Exchange of information• Structure• Support• Relief of symptoms

Alcohol and hospitals

Alcoholics need not apply

Admissions with alcohol problems KCH 2009

CARE_GROUP Elective Emergency Non-Elective TotalCardiac 44 25 16 85

Child Health 1 14 1 16CSDS 4 4Dental 7 26 3 36Liver 465 191 109 765

Medical 8 1716 8 1732Neurosciences 26 38 49 113

Renal 15 25 7 47

Specialist Medicine 3 23 26Surgical 67 231 13 311

Women's Health 3 3 6Grand Total 643 2292 206 3,141

Questions

Hospitalised drug user

A heroin user was admitted for hand surgery after a fight

- Post-operatively, complaining of pain

- When told his next scheduled dose of analgesia was not for several hours, he swore at the nurse and threatened vilence

Progress

Addiction nurse assessed patient- Opioid withdrawal- Recommended methadone be given, plus

analgesia as needed

Once withdrawal relieved, addictions nurse suggested apology

Patient agreed, situation resolved

Why do heroin addicts receive methadone?

Opioid Substitution Treatment of Addiction

1. Controlled Supply

2. Stabilization (abolish withdrawal)

3. Diminish reinforcing effects of street heroin

4. Structure – attendance and monitoring

5. Support

Prescribing Methadone for admitted patients not on OST

FIRST 24 HOURS

Prescribe methadone liquid 1mg/mlDose 1-10mg every 4 hours PRN according to signs of

withdrawalMaximum dose 40mg in first 24 hours

Always refer these patients to the Substance Misuse Nurse on pager KH3227.

Person on methadone (or buprenorphine) admitted

1. Continue medication

2. In addition, usual analgesia, may need titration

3. If head injury / hepatic encephalopathy, may need dose reduction

4. Note drug interactions (anticonvulsants, rifampicin, other CYP inducers)

Caution

F40 morbidly obese, admitted leg ulcer Mx

Methadone 100mg/day, not supervised as she had limited mobility.

Methadone prescribed in hospital, administered day1

Day 2 – noted to be drowsy, snoring cyanosed, with pin-point pupils

Party Drugs

GBL

GABA b agonist, precursor of GHB

• Produces confidence, charm, relaxation (“charisma”), sexual disinhibition

• In higher doses produces prompt sleep

• Narrow therapeutic index – risk of OD

• Usage mainly in gay males

Why do people use GBL?

1. Socialising

2. Sex

3. Sleep

GBL - dependence

• Uncommon?

• Involves dosing every 1-2 hours

• Can develop rapidly (eg after a “long weekend” of partying)

• Often occurs when drug is used for sleep

• Associated with social withdrawal, emotional blunting, compromised social role

GBL withdrawal

Onset rapid – 3-4 hoursCan occur after awaking from ODMay be severe (delirium, agitated psychosis,

severe anxiety and insomnia)Several cases required ICU management

UK experience – people admitted for elective detox have required ICU transfer (delirium, rhabdomyolysis)

GBL withdrawal management

• Initiate high dose diazepam (20mg 2nd hourly) early. “Usual” dose 70-90 mg day 1

• Baclofen 10mg tds• Transfer to AAU (more appropriate setting)

Further Reading

• Bell J & Collins R (2011) Gamma-butyrolactone (GBL) dependence and withdrawal Addiction 106(2); 442-447

• McDonough M, Kennedy N, Glasper A, Bearn J (2004) Clinical features and management of gamma-hydroxybutyrate (GHB) withdrawal: a review Drug and Alcohol Dependence 75; 3–9

• Le Tourneau J, Hagg D, Smith S (2008) Baclofen and gamma-hydroxybutyrate withdrawal Neurocritical Care 8(3):430-3

Questions

james.bell@slam.nhs.uk