CLINICAL FORUM: CLINICAL FORUM: ADDICTIONS WITHIN ADDICTIONS WITHIN

FORENSIC MENTAL HEALTH FORENSIC MENTAL HEALTH

SERVICESSERVICES 15 March 2013, 15 March 2013,

SPS College, PolmontSPS College, Polmont

Substance Misuse & Substance Misuse & Mental HealthMental Health

Malcolm BruceMalcolm Bruce Consultant Psychiatrist in Addiction Consultant Psychiatrist in Addiction

NHS Lothian NHS Lothian

Structure of presentation

1. Some data relevant to Forensic Psychiatry

2. What's the background of Drugs Induced Psychosis

3. What’s new in Drugs4. What’s new in Psychosis5. What’s new in co-morbidity6. Summary with my view of MWC focus

A SERVICE EVALUATION OF THE MANAGEMENT AND EDUCATION OF DRUG DEPENDENT INPATIENTS IN SCOTTISH FORENSIC PSYCHIATRY

SETTINGS.

• AUTHORS: Dr Michelle McGlen, ST4 Forensic Psychiatry, South East Scotland Deanery.

• Dr Fionnbar Lenihan, Consultant Forensic Psychiatrist, Orchard Clinic, Royal Edinburgh Hospital, Edinburgh

Issues from MWC & WHO

• Lack of access to specialist drug services• Lack of education regarding loss of

tolerance and dangers of poly-substance misuse (ref: high drug related mortality following release)

• Variable practice regarding approaches to managing drug dependent patients on admission to facilities (e.g., enforced abstinence)

Online Survey Forensic Settings

• Focussing on drug dependent patients– Assessment– Management – Education

• Lead clinicians at all eight units – 100% reply

Results

Lack of access to SM team

V Agree*2 Agree*3 DK*2 Disagree*1

Identify DWS H/E/I all Scales*3 Urine*5 Oral*2

Ideal model joint*7 only forensic*1

Access to SM team yes*6 no*2

Use SM team often*2 occ*3 rare*3

Management Detox*4 ISQ*1 DK*1 Nothing*2

Education 1:1 *7 Group*6 MI*4 Naloxone*3

Background of Drug Background of Drug induced psychosis…induced psychosis…

• Hallucinogens – designed onset effect, LSD Hallucinogens – designed onset effect, LSD etc., etc.,

• Stimulants – onset effect, dose related side Stimulants – onset effect, dose related side effect, cocaine etc.,effect, cocaine etc.,

• Sedatives incl alcohol – offset effect, Sedatives incl alcohol – offset effect, withdrawal states, with long term neuro-withdrawal states, with long term neuro-cognitive damage.cognitive damage.

• Cannabis – onset effect, dose effect, THC Cannabis – onset effect, dose effect, THC content changescontent changes

• Drug subculture & overlap with disadvantaged Drug subculture & overlap with disadvantaged groups (Severe & Enduring Mental Illness) groups (Severe & Enduring Mental Illness)

Risks to human healthRisks to human health• Direct Cannabis effect (not a single drug)Direct Cannabis effect (not a single drug)

– Cannabinoid receptorsCannabinoid receptors• Immediate – desired effect / intoxicationImmediate – desired effect / intoxication• Intermediate – tolerance / dependence / withdrawalIntermediate – tolerance / dependence / withdrawal

– Other effectsOther effects• Delayed – carcinogenesis (what part of drug mix?)Delayed – carcinogenesis (what part of drug mix?)• Induce psychotic illness? (what part of drug mix? Esp. Induce psychotic illness? (what part of drug mix? Esp.

cannabidiol :THC ratio)cannabidiol :THC ratio)• IndirectIndirect

– E.g., choice of route and techniqueE.g., choice of route and technique– Established illness (schizophrenia) - dealing with Established illness (schizophrenia) - dealing with

cannabis use (including dependence) is now a cannabis use (including dependence) is now a major element in the clinical management of many major element in the clinical management of many young men with established psychotic illnesses.young men with established psychotic illnesses.

Some of the evidence...Some of the evidence...

• The number of patients admitted to The number of patients admitted to hospital with a diagnosis of acute hospital with a diagnosis of acute cannabis intoxication in England has cannabis intoxication in England has remained stable (at between 107 and remained stable (at between 107 and 140 per year) over the 5 years 1995–140 per year) over the 5 years 1995–20032003

• Newcombe RD. (2004) Does cannabis cause Newcombe RD. (2004) Does cannabis cause psychosis? A study of trends in cannabis use and psychosis? A study of trends in cannabis use and psychosis in England, 1995–2003. Evidence to the psychosis in England, 1995–2003. Evidence to the Advisory Council on the Misuse of Drugs.Advisory Council on the Misuse of Drugs.

Advisory Council Misuse Advisory Council Misuse DrugsDrugs

2002

2005 –”increase in the potency of cannabis products currently available....suggesting a causal link between cannabis use and the development of mental health problems” The Council does not advise the reclassification of cannabis products2008 – “review the classification of cannabis in the light of real public concern about the potential mental health effects of cannabis use and, in particular, the use of stronger strains of the drug.” The Council does not advise the reclassification of cannabis products

Mean THC content (%) of cannabis Mean THC content (%) of cannabis productsproducts

Median THC and CBD Median THC and CBD content (%) in material content (%) in material

seized in 2005seized in 2005

What’s new in Drugs … …

• New substances New substances ((Early Warning Systems, European Monitoring Centre for Drugs and Drug Addiction) – 2009 – 242009 – 24– 2010 - 41 2010 - 41 – 2011 – 492011 – 49– 2012 expected the total 602012 expected the total 60

• Online sites selling drugs Online sites selling drugs – 2010 – 3142010 – 314– 2011 - 690 2011 - 690

• Annihilation (3g)Annihilation (3g)• Availability: Availability: IN STOCKIN STOCK• £28.19£28.19 • IN STOCK IN STOCK • Designed for maximum effect, the improved blend Designed for maximum effect, the improved blend

burns a new herbal incense atmosphere into the burns a new herbal incense atmosphere into the room. Out of the box thought combined with elation. room. Out of the box thought combined with elation. Annihilation is best shared, best experienced as a Annihilation is best shared, best experienced as a singular calm with others. Nights in were never singular calm with others. Nights in were never meant to be like this. A pwoerful legal incense fixer meant to be like this. A pwoerful legal incense fixer upper to an otherwise dull night, burn Annihilation upper to an otherwise dull night, burn Annihilation and set a fire to your night. and set a fire to your night.

• They consume you. You don't They consume you. You don't consume them.consume them.

““Legal High”Legal High”

• Advertised as plant food or research chemicals, and often labelled ‘not for human consumption’

• Synthetic cannabinoids sprayed onto a Synthetic cannabinoids sprayed onto a plant based mix (that does not contain plant based mix (that does not contain tobacco or cannabis) for the purposes tobacco or cannabis) for the purposes of achieving intoxication from smoking.of achieving intoxication from smoking.

• lack of regulation over their production, distribution and use

ACMD 2009ACMD 2009

• Experience in Germany that suggests Experience in Germany that suggests that should one of the cannabinoids be that should one of the cannabinoids be controlled, manufacturers move to controlled, manufacturers move to adding a chemically different, yet adding a chemically different, yet functionally similar, synthetic functionally similar, synthetic cannabinoid in the ‘Spice’ mix. Due to cannabinoid in the ‘Spice’ mix. Due to the number of variations, it is highly the number of variations, it is highly likely that specific legislation would likely that specific legislation would always run some way behind the always run some way behind the availability of a legal mix on the street.availability of a legal mix on the street.

Cannabidiol can directly activate 5-HT1A receptors……but only with rather low potency

OH

HO

Cannabidiol

CannabidiolCannabidiol

• Cannabidiol (CBD) in animals, has been Cannabidiol (CBD) in animals, has been shown to have effects similar to shown to have effects similar to antipsychotic drugs through an as yet antipsychotic drugs through an as yet undetermined mechanismundetermined mechanism

• A survey of ketamine users, who also used A survey of ketamine users, who also used cannabis, found that those who had both CBD cannabis, found that those who had both CBD and THC present in hair samples exhibited a and THC present in hair samples exhibited a lower rating of psychosis-like symptoms than lower rating of psychosis-like symptoms than those in whom only THC was foundthose in whom only THC was found

Morgan CJA, Curran HV (2008) Effects of cannabidiol on Morgan CJA, Curran HV (2008) Effects of cannabidiol on schizophrenia-like symptoms in cannabis users. schizophrenia-like symptoms in cannabis users. B J Psych 192: B J Psych 192:

306–307.306–307.

Cannabis & specific Cannabis & specific subtypessubtypes

• Cannabis produces its effects on the Cannabis produces its effects on the human brain through interactions between human brain through interactions between THC and specific proteins on the surface THC and specific proteins on the surface of cells known as cannabinoid receptors. of cells known as cannabinoid receptors. Other psychoactive components of Other psychoactive components of cannabis, especially cannabidiol, interact cannabis, especially cannabidiol, interact with other receptors in the brain. Different with other receptors in the brain. Different preparations of cannabis have different preparations of cannabis have different proportions of THC and other psychoactive proportions of THC and other psychoactive constituents; the constituents; the consequences of using consequences of using cannabis may, therefore, vary depending cannabis may, therefore, vary depending on the relative proportions of the on the relative proportions of the psychoactive substances that are presentpsychoactive substances that are present..

ACMD 2012ACMD 2012

• For those drug groups which are controlled in the For those drug groups which are controlled in the UK by generic legislation, such as the synthetic UK by generic legislation, such as the synthetic cannabinoids, gaps in the generic controls are cannabinoids, gaps in the generic controls are being exploited which permit “designer” versions being exploited which permit “designer” versions (specifically formulated to have certain effects and (specifically formulated to have certain effects and avoid legislation) to be offered avoid legislation) to be offered

• Home Office Forensic Early Warning System Home Office Forensic Early Warning System (FEWS) in July 2012 included results from a test (FEWS) in July 2012 included results from a test purchasing exercise showing the presence of purchasing exercise showing the presence of uncontrolled synthetic cannabinoids, such as uncontrolled synthetic cannabinoids, such as AM2201, RCS-4 and UR-144, in substances on AM2201, RCS-4 and UR-144, in substances on sale via the internet. sale via the internet.

Modifications of chemical Modifications of chemical structure noted since the 2009 structure noted since the 2009

report include: report include: • SubstitutionSubstitution with halogen atoms on the side chain attached with halogen atoms on the side chain attached

to the indole nitrogen atom (for example AM 694, AM 2201). to the indole nitrogen atom (for example AM 694, AM 2201). It appears that such modifications can enhance potency. The It appears that such modifications can enhance potency. The onset of psychoactive effects of AM2201 are cited as onset of psychoactive effects of AM2201 are cited as occurring rapidly and may last for up to 3 hours (ReDNET, occurring rapidly and may last for up to 3 hours (ReDNET, 2012). 2012).

• ModificationModification of the indole nitrogen substitution into a of the indole nitrogen substitution into a methylpiperidin-2-yl structure (AM 1220, AM 2233). methylpiperidin-2-yl structure (AM 1220, AM 2233).

• Use of a benzoylindole core structure (AM-694, RCS-4). This Use of a benzoylindole core structure (AM-694, RCS-4). This structure was not included in the 2009 generic controls. structure was not included in the 2009 generic controls.

• ReplacementReplacement of the benzoyl/naphthoyl structure by an of the benzoyl/naphthoyl structure by an adamantoyl group (AB-001, AM-1248). adamantoyl group (AB-001, AM-1248).

• ReplacementReplacement of the benzoyl/naphthoyl structure by a of the benzoyl/naphthoyl structure by a tetramethylcyclopropylcarbonyl group (UR-144, AB-034). tetramethylcyclopropylcarbonyl group (UR-144, AB-034).

Worst case scenario......?Worst case scenario......?• 1982 - Patients arrived 1982 - Patients arrived

at San Francisco area at San Francisco area emergency rooms after emergency rooms after using a synthetic using a synthetic analogue of heroin (to analogue of heroin (to get around the law)get around the law)(MPPP contaminated (MPPP contaminated with MPTP – made with MPTP – made originally by a 23-year-originally by a 23-year-old chemistry graduate old chemistry graduate student). Fully student). Fully conscious but unable conscious but unable to move or speak, they to move or speak, they were soon diagnosed were soon diagnosed as having advanced as having advanced irreversible irreversible Parkinson's disease.Parkinson's disease.

Government ResponseGovernment Response• November 2011, the UK government (as part

of the Police Reform and Social Responsibility Bill) introduced an amendment to Schedule 17 of the Misuse of Drugs Act 1971 that permits any substance not already classified by the Act that is ‘being, or is likely to be, misused’ and whose misuse ‘is having, or is capable of having harmful effects’ to be placed in a temporary class drug order for a 12 month period.

• At the end of this 12-month period, the Advisory Council on the Misuse of Drugs (ACMD) is required to produce a report recommending permanent classification

Where are services Where are services responding..responding..

• Addiction ServicesAddiction Services– NHS, set up to deal with addiction to NHS, set up to deal with addiction to

alcohol, heroin, benzodiazepines and alcohol, heroin, benzodiazepines and crack cocainecrack cocaine

– Crew 2000Crew 2000

• A&E - A&E - • MHAS/IHTT - MHAS/IHTT - • I/P Psychiatric Service - I/P Psychiatric Service -

Drugs: a medical matter

• A moral/spiritual judgemental stand is not acceptable for a health problem.

• Patient’s first• Raising profile of detection• Range of responses by all

doctors from harm reduction – to referral to specialist services

• A challenge to nihilistic views on interventions, but accepting of an often chronic relapsing condition.

What's new in PsychosisWhat's new in Psychosis

• First Episode First Episode Psychosis (FEP)Psychosis (FEP)

• Duration of Duration of Untreated Untreated Psychosis (DUP)Psychosis (DUP)

• Good outcome at Good outcome at 3-5 years in FEP 3-5 years in FEP related to short related to short DUPDUP

How should we approach the How should we approach the diagnosis and assessment of diagnosis and assessment of

FEP?FEP?Online RCPsych CPDOnline RCPsych CPD• First-episode psychosis: First-episode psychosis:

– Part 1 – assessment, diagnosis and Part 1 – assessment, diagnosis and rationalerationale

– Part 2 – treatment approaches and Part 2 – treatment approaches and service deliveryservice delivery

Dr Andrew Thompson, Dr Rick Fraser and Dr Richard Whale

Diagnostically, DSM-IV identifies Diagnostically, DSM-IV identifies psychoses psychoses

• SchizophreniaSchizophrenia• Schizoaffective disorderSchizoaffective disorder• Delusional disorderDelusional disorder• Brief psychotic disorderBrief psychotic disorder• Shared psychotic disorderShared psychotic disorder• Psychotic disorder due to a medical Psychotic disorder due to a medical

conditioncondition• Substance-induced psychotic disorderSubstance-induced psychotic disorder• Psychosis not otherwise specified (NOS). Psychosis not otherwise specified (NOS).

• Such diagnoses, however, require clear symptom profiles and Such diagnoses, however, require clear symptom profiles and durations that are difficult to elucidate in the first acute durations that are difficult to elucidate in the first acute presentation.presentation.

What’s new in co-morbidity?

NICE guideline 2011Raise profile of detection – ask…• Substance(s) used• Quantity, frequency and

pattern• Route of administration• Duration of current level of

use• Evidence of Dependence

– Carving, Loss of control, tolerance, withdrawal, use to avoid withdrawal, harm health/relationships etc.,

• Consent for corroborative history

Respectful, trusting, non-judgemental

• Do not exclude from either– Mental Health Services– Drug Services

• Various models of delivery of care– Joint working

• Parallel services with good communication (+/- CPA)

• Joint clinics

– Specialist Co-morbidity clinics• Assessment of vulnerable adult &

children

I/P Services

• Promoting a therapeutic environment free from drugs and alcohol– search procedures, – visiting arrangements, – planning and reviewing leave, – drug and alcohol testing,– disposal of legal and illicit substances

In patient Px options...In patient Px options...

• Appropriate use of a brief medication-Appropriate use of a brief medication-free observation period when at all free observation period when at all possible (24–48 hours)possible (24–48 hours)

• Use of benzodiazepines both during Use of benzodiazepines both during this period and as an appropriate this period and as an appropriate means of treating acute agitation or means of treating acute agitation or disturbancedisturbance

• Judicious use of short-acting rapid Judicious use of short-acting rapid tranquilisation if necessary.tranquilisation if necessary.

DRUG TREATMENT of ACUTE BEHAVIOURAL DRUG TREATMENT of ACUTE BEHAVIOURAL DISTURBANCE in GENERAL ADULT (18 – 65yrs) DISTURBANCE in GENERAL ADULT (18 – 65yrs)

PSYCHIATRIC IN-PATIENTSPSYCHIATRIC IN-PATIENTS

• Preventative skilled management (e.g. de-escalation Preventative skilled management (e.g. de-escalation techniques) is obviously preferable to the use of medication. techniques) is obviously preferable to the use of medication. Medication prescribed in an emergency should be reviewed Medication prescribed in an emergency should be reviewed at least daily to prevent subsequent inappropriate escalation at least daily to prevent subsequent inappropriate escalation of doseof dose

• Rationale for Choice of Regimens for AlgorithmRationale for Choice of Regimens for Algorithm• Haloperidol and lorazepam is the treatment choice in acute Haloperidol and lorazepam is the treatment choice in acute

behavioural disturbance and must be considered first line for behavioural disturbance and must be considered first line for all patients. all patients.

• This combination of haloperidol and a benzodiazepine is This combination of haloperidol and a benzodiazepine is desirable to avoid very high antipsychotic doses when the desirable to avoid very high antipsychotic doses when the immediate aim is sedation.immediate aim is sedation.

• Olanzapine is the second treatment choice and may only be Olanzapine is the second treatment choice and may only be considered for:considered for:– patients who have had severe dystonic reactions to haloperidol previouslypatients who have had severe dystonic reactions to haloperidol previously– patients with less extreme agitation who are refusing oral therapy but who are patients with less extreme agitation who are refusing oral therapy but who are

showing escalating levels of hostilityshowing escalating levels of hostility– IM Olanzapine IM Olanzapine must notmust not be administered with a benzodiazepine. be administered with a benzodiazepine.

Mental Welfare Commission (MWC) (1)

• Concerns regarding use/misuse MHA in co-morbidity cases

• Support / promote NICE guide– Respectful, trusting, non-judgemental

relationship– Routinely ask about drug/alcohol use,

testing and corroboration with consent– Do not exclude/discharge from services

solely due to substance use– Discharge with a Care Plan +/- CPA

MWC (2) - Using MHA

• Drug aetiology does not exclude use• Symptoms may not completely subsided,

and even if they appear to have, a longer period of assessment may be needed especially in novel drugs

• Drug and alcohol services need to be more assertive in helping people to engage

• To help patients make an informed choice about lifestyle and drug use

MWC report Mr F 2009Effective care and treatment in dual diagnosis of mental illness

and alcohol misuse

• Stigma CSA/PTSD/PD/Addiction (ADS)– Delay in diagnosis of

Psychotic illness

• Poor engagement – discharge v out reach

• Poor outcome– Homicide 2ndry to

command hallucinations

• Service model strengths– DDT v CMHT/SMS– Change RMO I/P &

O/P

• Required – Shared Care Plans v

CPA– Involvement none

NHS– Risk assessment with

reviews built in

MWC report Ms Z 2010 Effective care and treatment in dual diagnosis of mental illness

and alcohol misuse• Diagnostic uncertainty– Schizophrenia,

schizoaffective disorder, alcohol problems, ARBD, personality factors and social aetiology

• Crisis management with no care plan

• Unplanned discharge with no care plan

• Autonomy v control by the use of MHA

• Ongoing responsibility for psychiatric care – leadership required

• No joint working CMHT & Addiction service, no outreach

• CPA again promoted• Response to drinking

as I/P

Summary – Drug Induced Psychosis

• Address our stigma to substance use• Raise our detection of substance use• Challenge our nihilism to I/P substance

use• Acknowledge uncertainty in management

of FEP in context of substance use, and the skills inherent in Consultant Psychiatrist. Promote Medical Leadership.

• In high risk cases – care plans, assertive outreach and 2nd opinions +/- MHA CTO are required