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