james bell february 2014 alcohol, drugs, and hospitals
TRANSCRIPT
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James BellFebruary 2014
Alcohol, drugs, and hospitals
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Why do people use drugs?
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Why do people use drugs?
Drug use is normal behaviour
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Who develops drug problems?
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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)
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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
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Drug DependenceA maladaptive pattern of substance use leading to impairment or distress
Tolerance and Withdrawal
Salience
Craving
Reinstatement after abstinence
Persisting use despite harm
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Communities vulnerable to drug dependence
Those without taboos or rewards
Especially: - indigenous communities - marginalised communities- deregulated communities
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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
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Components of behavioural medicine
• Exchange of information• Structure• Support• Relief of symptoms
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Alcohol and hospitals
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Alcoholics need not apply
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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
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Questions
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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
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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
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Why do heroin addicts receive methadone?
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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
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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.
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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)
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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
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Party Drugs
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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
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Why do people use GBL?
1. Socialising
2. Sex
3. Sleep
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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
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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)
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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)
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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