Substance misuse

Substance misuse PowerPoint PPT Presentation


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drug definitions. A heavy smoker?. Just the one?. definitions. drugphysical vs. psychological dependencedependency vs. addictionalcoholic vs. problem drinker harm reduction vs. abstinence. definitions. Drug

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Substance misuse

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1. substance misuse awareness and interventions - Simone Black and Sean Wood Plus Service Users

2. drug definitions Drug definitions – use pictures to illustrate how important it is to have definitions that can be agreed on Drug definitions – use pictures to illustrate how important it is to have definitions that can be agreed on

4. definitions

5. definitions

10. national trends over 90% of people have been in ‘drug offer’ situations by age of 17. cannabis = most widely used illicit drug followed by, ecstasy, amphetamine and cocaine crack cocaine more and more prevalent

11. the local hit parade [illicit drugs]

16. how do we classify them? legally by class A, B or C and schedules [1 to 5] outlined in The Misuse of Drugs Act 1971 – of limited use socially ‘hard’, ‘soft’, ‘medicinal’, ‘recreational’, ‘dance’ etc. – of almost no use by their effect on our bodies - the most helpful DRUGS DO NOT EASILY FIT INTO PIGEON HOLES…

18. stimulants

19. depressants

24. cycle of dependence - depressants

25. stimulants - crash and craving Use – Bingeing etc – bounce between 1 and 2 EC – depressant drugs? Anxiety, Not Sleeping/Eating, Depression LC - remorse - Hunger etc, ‘Never again’. OK - More in control, some physical recovery Mi - High craving, JustificationUse – Bingeing etc – bounce between 1 and 2 EC – depressant drugs? Anxiety, Not Sleeping/Eating, Depression LC - remorse - Hunger etc, ‘Never again’. OK - More in control, some physical recovery Mi - High craving, Justification

26. all inter-related…

27. cannabis – things to know more home grown, less resin smoked/eaten use in young people rising paranoia = v. common increases likelihood of psychotic episode linked to schizophrenic illness affects memory, learning and co-ordination long term carcinogenic? [lungs, head, neck] detectable in urine for up to 28 days

28. cannabis as a treatment? MS acute pain? crohn’s and IBS (Irritable bowel syndrome)? glaucoma mental health and general stress asthma epilepsy AIDS/cancer

30. ecstasy – things to know neurotoxicity – research inconclusive long term use - memory impairment? depression? harm reduction advice = key to preventing deaths ‘ecstasy’ = MDMA and other things [LSD, speed etc] poly drug patterns [10:1 smokers] comedowns can be crashes [heroin?, benzos?]

33. amphetamine

34. benzodiazepines

35. cannabis

36. cannabis paraphernalia

37. cocaine and crack

38. crack paraphernalia

39. ecstasy

40. heroin

41. heroin paraphernalia

42. ketamine

43. LSD

44. magic mushrooms

45. methadone

46. volatile substances

47. benzodiazepines

48. benzos – common symptoms fear and phobias sleep disturbances e.g. insomnia, nightmares etc mood disorders – e.g. anger, anxiety, depression sensory effects – e.g. tinnitus, giddiness, blurred vision physical – e.g. exhaustion, twitching, aches and pains extreme – e.g. delirium, convulsion and even death!

49. street leakage benzos! – especially diazepam and nitrazepam methadone and subutex! dihydrocodeine, MST, diconal coproxamol and some codeine based painkillers cyclizine - potentiates heroin, users report more cerebral or ‘trippy’ effect some tricyclics – esp. amitriptyline and dothiepin procyclidine [rare] – apparently psycho-active

50. OTC drugs of misuse codeine based medications [e.g. Nurofen Plus - Solpadeine] decongestants [e.g. Sudafed, Dodo] sleep aids [e.g. Nytol] cough/cold cures [e.g. Collis Browne, Benylin] antihistamines [e.g. Piriton] – esp. with alcohol Ephedrine, Caffeine – stimulants Codeine, Dextromethorphan- depressants Diphneydramine/Promethazine Hydrochloride - sedatives

51. on the horizon? HEPATITIS B and C [already here] more alcohol related disease – esp. in young women? more psychoses in young people? ecstasy/hallucinogenic related mood disorders methamphetamine? more use of hallucinogens – mushrooms, salvia, 2-CT-7 etc Ketamine use drug trends are changing all the time

52. the political landscape crime and social disorder providers v. NTA v. DAATs v. PCTs v. CDRPs ŁŁ in drugs not alcohol MOC and MoCAM – where do GPs fit?

53. Models of Care - treatment tiers

54. The Drug and Alcohol Action Team ‘A Framework for Partnership’

55. Models of Care treatment modalities advice and info needle exchange care planned structured psycho-social interventions structured day programmes community prescribing inpatient treatment residential rehab

56. types of service 1 community drug and/or alcohol teams [clinical] day services [e.g. drop-in, wet house] drug/drink counselling education/prevention/helpline services needle exchange

57. types of service 2 outreach [community support, homeless, youth] peer support [e.g. AA] residential rehab structured day programmes ALSO – help through the criminal justice system [DIP, DRRs, arrest referral, prison schemes etc.] some GPs

58. issues for services we’re only a PART of the solution criminal justice vs. health fear and ignorance vs. pragmatism full capacity/waiting lists skills shortage unfashionable work unrealistic expectations [clients, others] short term planning/competitive tendering social/primary care partnerships must improve NTA - Px practice changing

59. scenarios – which service? Billy is a long term heroin user who has been in and out of prison for drug related crimes. He is on a conditional discharge but has just been arrested for shoplifting. He is sick of his lifestyle and swears he wants to change things Leanne is a young professional woman who uses lots of E and speed at weekends when she goes out with her mates. She does not see her drug use as a problem but her family are worried about her and ask you for help.

60. scenarios – which service? Fred has been drinking at least half a bottle of spirits a day since his partner was killed in a car crash 3 months ago. He wakes up one morning feeling and looking very ill and presents to you desperate for help. Eileen is an ex heroin user who wants to steer clear of it all together. She admits she smokes a bit of dope but her main problem is that she feels bored and de-motivated.

61. methadone properties white crystalline powder synthetic opioid drunk, swallowed or injected (physeptone) tolerance builds up slowly long acting

62. properties cont… mixture contains – methadone hydrochloride - green S +tartrazine - glucose syrup - chloroform water methadone mixture DTF 1mg/1ml (green, clear, blue, brown or yellow) Class A drug

63. methadone effects on the brain - levelling of emotions - drowsiness - slower shallower breathing - reduced cough reflex - reduction of physical pain - feeling sick - mood change (less intense than heroin)

64. effects cont … on the nerves - small pupils - constipation perhaps - dryness of eyes, nose + mouth - reduced blood pressure - difficulty passing urine

65. effects cont … release of histamine causing - sweating - itching - flushing of the skin - narrowing of air passages in lungs perhaps - menstrual disruption - reduced sexual desire - reduced energy - heavy arms + legs

66. effects … not! unless drowsy it will not affect - coordination - speech - touch - vision - hearing long term use does not affect heart liver brain bones reproductive system immune system

67. how it works similar to heroin therefore reduces withdrawal fills tissue reservoirs in liver/lungs/fat 1st after 3 days blood conc. stable 30 mins to be absorbed 4 hrs to reach peak levels binds to several of the opiate receptors has long half life (approx 25 hours) NOT a detox medication

68. [very] basic neurology neurotransmitter - specific chemical that fits receptor site and causes nerve impulse [effect]

70. for just for starters … - regular - long acting - free - legal - clean - accompanied by other interventions - generally drunk not injected - attracts users into service + retains them and many more…

71. against inappropriate prescribing can - cause fatal overdose - increase drug consumption - supply illicit market - increase drug related chaos - demoralise users and staff - reduce respect for prescribing agency - reduce client motivation

72. advisory council on misuse of drugs The 1993 ACMD Update report concluded that; “The benefit to be gained from oral methadone maintenance programmes both in terms of individual and public health and cost effectiveness has now been clearly demonstrated and we conclude that the development of structured programmes in the UK would represent a major improvement in this area of service delivery.”

73. good practice most successful programmes include - high doses - maintenance (rather than reduction) - intensive counselling - medical services - good relationships between staff and patients

74. dose assessment/titration need to decide - amount of opiates client using - treatment aims start on safe, low dose, work up can’t directly convert illicit dose to methadone dose dose should be titrated against prevention of withdrawal + in craving NOT observable intoxication

75. alternatives Subutex (buprenorphine hydrochloride) safer in o/d partial blocker fewer side effects? anecdotally more popular can be used for detox sub-lingual difficult to monitor? transference sometimes awkward

76. Subutex Also known as: Buprenorphine hydrochloride. Subutex and the law As long as it is prescribed Subutex is legal to possess. What is subutex? Subutex belongs to a group of pain killing drugs called opioids and is a form of buprenorphine hydrochloride, others of which include methadone, morphine and heroin. Subutex is used to be a substitute for other opioids as it contains a higher dose of buprenorphine and can be prescribed as a maintenance dose or part of a detoxification regime. What does it look like? Subutex is supplied as an oval white tablet which comes in two dosage strengths of 2mg and 8mg. The tablet has a sword logo embossed on one side and either B2 or B8 on the reverse depending upon the dosage. How is it used? The tablets are placed under the users tongue to dissolve. Tablets should not be chewed or swallowed or they will not work properly and may cause withdrawal symptoms. What are the effects? Subutex works as a substitute opiate to relieve cravings and withdrawal symptoms. Although it is a substitute for heroin the effects such as pain relief, feelings of euphoria, drowsiness and nausea are far less pronounced. When do the effects start and how long do they last? What are the risks? If other opiates are taken whilst the user is on subutex they will suffer withdrawal symptoms. It works by stopping opioids having an effect on the brainbrain, effects are not felt even though the opioid is present in the body. This increases the risk of overdose when the effect of subutex wears off. Overdoses may also occur if it is taken with other medication or alcohol. Subutex may cause the blood pressure to drop which may result in light-headedness and fainting. Is it addictive? While buprenorphine's primary purpose is to treat opiate addiction, it can still cause drug dependence. Some evidence suggests that subutex can be habitual and addictive and be a problem for users. Subutex Also known as: Buprenorphine hydrochloride. Subutex and the law As long as it is prescribed Subutex is legal to possess. What is subutex? Subutex belongs to a group of pain killing drugs called opioids and is a form of buprenorphine hydrochloride, others of which include methadone, morphine and heroin. Subutex is used to be a substitute for other opioids as it contains a higher dose of buprenorphine and can be prescribed as a maintenance dose or part of a detoxification regime. What does it look like? Subutex is supplied as an oval white tablet which comes in two dosage strengths of 2mg and 8mg. The tablet has a sword logo embossed on one side and either B2 or B8 on the reverse depending upon the dosage. How is it used? The tablets are placed under the users tongue to dissolve. Tablets should not be chewed or swallowed or they will not work properly and may cause withdrawal symptoms. What are the effects? Subutex works as a substitute opiate to relieve cravings and withdrawal symptoms. Although it is a substitute for heroin the effects such as pain relief, feelings of euphoria, drowsiness and nausea are far less pronounced. When do the effects start and how long do they last? What are the risks? If other opiates are taken whilst the user is on subutex they will suffer withdrawal symptoms. It works by stopping opioids having an effect on the brainbrain, effects are not felt even though the opioid is present in the body. This increases the risk of overdose when the effect of subutex wears off. Overdoses may also occur if it is taken with other medication or alcohol. Subutex may cause the blood pressure to drop which may result in light-headedness and fainting. Is it addictive? While buprenorphine's primary purpose is to treat opiate addiction, it can still cause drug dependence. Some evidence suggests that subutex can be habitual and addictive and be a problem for users.

77. alternatives detox Lofexidine Dihydrocodeine Naltrexone Benzodiazepines

78. Naltrexone hydrochloride Naloxone Revia Vivitrol Nalorex how does it work antagonist - blocks the opioid receptors money wasted if try to use on top may reduce or prevent cravings in some people in America it is approved for the treatment of alcohol dependence (!) Those who take it know that they cannot achieve a 'high' from using heroin and that any money therefore spent on heroin will be wasted.Those who take it know that they cannot achieve a 'high' from using heroin and that any money therefore spent on heroin will be wasted.

79. use implants can be used to ensure regular dosage available through private clinics approx 9mm by 19mm - inserted through a 1 inch incision in the lower abdomen or at the back of the upper arm also as part of a rapid detox programme Implants are usually effective for six week periods. Implants are usually effective for six week periods.

80. Naloxone Hydrochloride [Narcan] strong opiate antagonist used to reverse opiate overdose 400mg per 1 ml amp paramedic only very short half life – [O/D therefore still possible after administration] I/V and/or I/M I/V … revival almost immediate titration possible - practitioner discretion

81. BBV transmission Sharing any blood contaminated injecting equipment, paraphernalia and works Occupational injuries – needle stick injury, infection from medical & dental procedures Household contact - sharing razors, toothbrushes, nail scissors etc Unsterile ear & body piercing, tattooing, electrolysis, acupuncture etc

82. BBV transmission Blood transfusion prior to 1991 Blood products before 1987 Unprotected sexual intercourse (for HCV considered low risk = 6% transmission risk in regular partners of infected people) Vertically (mother to baby) (for HCV considered low risk = 6%, breastfeeding also low risk)

83. BBV prevention Immunisation (Only for HBV and HAV) Safer sex (using condoms etc) Safer drug use (ie using new/own/sterile equipment) Using new/own/sterile equipment for acupuncture, tattooing + ear/body piercing Infection control measures

84. OD - the signs deep snoring unwakeable getting cold turning blue [esp. lips] not breathing Sleep - Unconsciousness If on their back – blocked airway [tongue, saliva, vomit] St. John = expert – later! Sleep - Unconsciousness If on their back – blocked airway [tongue, saliva, vomit] St. John = expert – later!

85. OD – risk factors (1) injecting previous non-fatal o/d experiences using at high levels low tolerance feeling low or depressed Points [in order] 14X more likely to od Over confidence Intoxication etc Prison, finishing treatment etc More abandon Points [in order] 14X more likely to od Over confidence Intoxication etc Prison, finishing treatment etc More abandon

86. I/V opiates – low tolerance

87. OD – risk factors (2) MIXING IT! [before OR at the same time] alcohol methadone benzos other sedatives stimulants [coke, speed etc] 1 drug = statistically unlikely Depressants increase each other [potentiate] Earlier intake [‘normal’ amounts = enough] Purity rarely a factor Coke etc = over-confidence/recklessness 1 drug = statistically unlikely Depressants increase each other [potentiate] Earlier intake [‘normal’ amounts = enough] Purity rarely a factor Coke etc = over-confidence/recklessness

88. mixing it + high tolerance

89. a complex relationship: drugs and mental health: primary psychiatric illness precipitating or leading to drug [mis]use drug [mis]use worsening or altering the course of a psychiatric illness drug use and/or withdrawal leading to psychiatric symptoms or illnesses concurrent drug use and psychiatric symptoms

90. spiders …

92. boundaries remember: you don’t HAVE to prescribe safety first – you and them better Px nothing than Px wrong make good links [e.g. spec. nurse/pharmacy] you can always do something watch the guilt trip – it’s NOT YOUR FAULT!

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