2008
NICE Definition
substance misuse is defined as intoxication by – or
regular excessive consumption of and/or dependence on – psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs (including alcohol when used in combination with other substances).
Comonest
Legal Alcohol Nicotine Glue
Illegal Cannabis Stimulants – ecstasy, cocaine,
amphetamines, khat. Benzodiazepaines Heroin
Young people at risk
those whose family members misuse
substances • those with behavioural, mental
health or social problems • those excluded from school and
truants • young offenders
Young people at risk
• looked after children • those who are homeless • those involved in commercial
sex work • those from some black and
minority ethnic groups.
NICE Interventions for those at risk
Offer a family-based programme of structured support over 2 or more years, drawn up with the parents or carers of the child or young person and led by staff competent in this area.
NICE Interventions for those at risk
The programme should: – include at least three brief motivational
interviews1 each year aimed at the parents/carers
– assess family interaction – offer parental skills training – encourage parents to monitor their
children’s behaviour and academic performance
NICE Interventions for those at risk
– include feedback – continue even if the child or young
person moves schools. • Offer more intensive support (for
example, family therapy) to families who need it.
Management
Management options for misusers Brief interventions Counselling Replacement therapy Referral to specialist clinics
Cannabis
Harms Damages lungs more than tobacco Impairs concentration Impairs motivation Impairs memory Heavy use in teenagers may predispose
to schizophrenia
Cannabis
Selective breeding of plants much higher concentration of active chemical THC = tetrahydro cannabinol
Cannabis induced psychosis more common
Dependency in 5 – 10% of users
Cannabis
Medication little role in treatment
GP role Identification of problem Brief intervention with
motivational technique Encourage patient to tackle
problem
Stimulants
Amphetamines Cocaine
Snorted as powder Injected Used in combination with heroin
= speedballing
Stimulants
Crack cocaine prepared by heating cocaine in
microwave with bicarb of soda. Makes a cracking noise when smoked
Can be injected Produces more intense and immediate
effect than powder cocaine Wears off in 5-10 mins triggering desire
to use it again
Stimulants
Crack cocaine Chronic high dose usage leads to
marked psychological dependence Physical complications include
Heart failure or MI Crack lung – a hypersensitivity reaction
causing dyspnoea and wheeze Blood borne virus transmission through
shared injection equipment Liver damage
Stimulants
Cocaine Cocaine and alcohol combine together to
produce cocaethylene which is more damaging to the liver than either substance
Mental health problems Lethargy Depression Full blown psychosis tactile hallucinations
are common the cocaine bug
Stimulants
Ecstasy Stimulant and hallucinogenic effects Risks
Overheating dehydration Fluid overload due to increased ADH
levels Advise users to take regular breaks from
exercise and sip maximum 1pint water per hour
Stimulants
Khat Green leaves of a shrub
commonly grown in Horn of Africa Effects similar to amphetamine Legally sold in those areas Drug induced psychotic episodes Common in Somali communities
Stimulants
Management Stop usage Treat individual symptoms
Insomnia hypnotics - short term only Depression – SSRI’s Psychological interventions most useful Local treatment services found Helpfinder
section of Drugscope website www.drugscope.org.uk
Benzodiazepines
Often used with other illicit drugs Increases risk of death from
overdose when combined with alcohol or opiates
No evidence that long term substitute prescribing reduces harm
Only licensed for reducing regimes and not for maintenance prescribing
Benzodiazepines
Be more reluctant to initiate prescription for benzo’s than opiates
Reduction regimes for users of street benzo’s is problematic only do when urine evidence of use and clear evidence of dependence and an agreed reduction plan
Benzodiazepines
Reduction regimes BNF has useful equivalent dose tables Convert to diazepam If high doses required refer for specialist
assessment For 30mg/day or less reduce by 2mg
every 2 weeks Can be prescribed for daily dispensing if
concerned about diversion or compliance
Heroin
Smoked by burning powder on tinfoil Heated with citric acid and injected Long term opiate dependency is
chronic relapsing condition Causes harm to users and there
families Typical user will spend £30- 100/day
on drug
Heroin
Typical user will spend £30- 100/day on drug
Result into drift into poverty 300,000 children of problem drug
users in UK Effective treatment can have
significant benefits for child and improved quality of family life.
Heroin
• Mortality risk 12x greater than general population
• Injecting users 22x more likely to die than non-injecting peers
• Drug related over doses commonly due to injected heroin in combination with alcohol, benzo’s or other depressants
• Significant number occur in users who have just left prison and under estimate their loss of opiate tolerance
Heroin
Good evidence that drug treatment reduces crime
Led to expansion of drug treatmetn services
Substance misuse management What every GP should provide for a
misuser Same responsibility to provide general
medical services to drug misusers as any other patient on their list
Advise on risks of injecting Increased risk of overdose when using
drugs alone Loss of tolerance after periods of
abstinence
Substance misuse management Prevention against blood borne
viruses Not sharing needles or other drug
paraphernalia filters, spoons. Safe sex - use of condoms Screening for blood borne viruses Opportunistic vaccination – accelerated
schedules increases uptake 0, 7, 21 days with booster at 12 months
Substance misuse management Consider any children- are they at risk
if so use local child protection framework - parents using drugs does not necessarily mean child is at risk or neglected.
No legal requirement to report to authorities except in Northern Ireland
Prescribers should report to their regional drug misuse database – details found in BNF
Treatment approaches
Aims To decrease level of drug use Decrease offending Decrease overdose risk Prevent spread of blood borne viruses Improve health of individual Improve health of family
Drug service providers
Key features To avoid prescribing in isolation
Harm minimisation
Drug service providers
Criminal justice services Specialist drug teams Shared care programs GP led services
Essential elements of treatment provision
Assessment of needs to include drug and alcohol misuse, health and social functioning and criminal involvement.
Risks to dependent children should be assessed for drug using parents
All patients entering treatment should have a care or treatment plan that is regularly reviewed
Essential elements of treatment provision Drug misuse treatment involves a
range of interventions not just prescribing
A named individual should manage and deliver aspects of the patients care or treatment plan
Drug testing can be a useful too in assessment and in monitoring compliance and outcome of treatment
Maintenance prescribing
Licensed treatments for maintenance Methadone 1mg/ml Buprenorphine – subutex
Never start at first contact Perform full physical and psychiatric
assessment Test urine to confirm opiate use
Maintenance prescribing
Prescribe for daily consumption for at least first 3 months
Liaise with chosen a pharmacy Pharmacies must
Have undergone training Developed protocols for communication
between patient, pharmacist and prescriber
Maintenance prescribing
Dose titration requires Experience Repeated assessment of patient Usual starting dose 10-30mg methadone
but deaths have occurred with doses as low as 20mg
Safer to start 10-20mg and build up
Maintenance prescribing
Doses are gradually increased by no more than 5-10mg
Max weekly total increase of 30mg above starting dose
Most patients need 60-120mg methadone
May take several weeks to achieve dose at which patient feels comfortable and is no longer needing illicit heroin
Maintenance prescribing
Methadone tablets can be ground up and injected don’t prescribe
Methadone ampoules should only be prescribed by a specialist
Maintenance prescribing
Buprenorphine Used in patients with lower opiate use Taken sublingually Starting dose 4-8mg/day Increased by 4-8mg daily to max dose of
32mg/day
Maintenance prescribing
Buprenorphine Inhibits other opiates blocking effect of
heroin used on top of the buprenorphine Can precipitate opiate withdrawal
symptoms if taken while there is still circulating opiate in body
First dose should be taken when patient is showing withdrawal symptoms
Maintenance prescribing
Buprenorphine Can be abused by injecting or snorting
Suboxone = buprenorphin-naloxone New substance recently launched to
address above problem. The naloxone has minimal effect if taken sublingually but if injected or taken intranasally it is likely to precipitate withdrawal effects – has lower street value