Substance misuse
Download
1 / 92

Substance misuse - PowerPoint PPT Presentation


  • 98 Views
  • Updated On :

substance misuse. awareness and interventions - Simone Black and Sean Wood Plus Service Users. drug definitions. A heavy smoker?. Just the one?. definitions. drug physical vs. psychological dependence dependency vs. addiction alcoholic vs. problem drinker

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Substance misuse' - vernon


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Substance misuse l.jpg

substance misuse

awareness and interventions -

Simone Black and Sean Wood

Plus Service Users


Drug definitions l.jpg
drug definitions

A heavy smoker?

Just the one?


Slide3 l.jpg

definitions

  • drug

  • physical vs. psychological dependence

  • dependency vs. addiction

  • alcoholic vs. problem drinker

  • harm reduction vs. abstinence


Definitions l.jpg
definitions

Drug – any substance taken into the body for the purposes of creating a psychoactive effect in the user

Tolerance – to require more of the substance to produce the same or original effect

Withdrawal – physical and psychological effects user experiences when they stop using for whatever reason

Addiction– an absolute

Dependency– a continuum

Physical dependency – when asubstance effects the body in such a way that when it is removed the body undergoes physical withdrawal symptoms (sweats, shakes etc)


Definitions5 l.jpg
definitions

Psychological dependency – mental compulsion to use a drug. Most important factor when trying to understand use

Abstinence – not using any of the substance. Tolerance subsides after period of abstinence

Harm Reduction –reduce harm to the user, their family/friends and society at large

Alcoholic/Addict– an identity (big change). Suggests dependence reached level causing serious detrimental effects.

Problem Drinker/User – a behaviour (easier to change). Not blindly implying dependence


Slide6 l.jpg

drug related deaths p.a.estimated figures for England and Wales

Tobacco c. 114 000

Alcohol c. 36 000 – 60 000

All illicit drugs c. 1500 - 2500


Slide8 l.jpg

drug related deaths

  • opiate/opioid/GHB overdose [mostly with alcohol]

  • solvent related deaths – esp. young people

  • ‘ecstasy’ related deaths [heatstroke, too much water]

  • stimulant induced heart failure/seizure -

  • cannabis, LSD , magic mushrooms – no known overdoses


Slide9 l.jpg

national trends

  • 4% - 8% adults are ‘alcohol dependent’

  • 11 -15 year olds - drinking doubled in 10 years

  • illicit drugs - more choice + more affordable = moreuse

  • consistent across race, class, gender and geographical area


National trends l.jpg
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


The local hit parade illicit drugs l.jpg
the local hit parade [illicit drugs]

1. Cannabis

[over 40 years at number one!]

2. Cocaine

3. Ecstasy

4. Amphetamine

5. Heroin

[on the way up!]


Slide12 l.jpg

trends - young people

“…we urgently need to acknowledge that for many young people drug taking has become the norm ...… their motives appear to be less concerned with peer group status and more with rational consumption as part of their approach to their leisure time.”

Howard Parker, University of Manchester

18 – 24 year old males are the biggest risk takers


Slide13 l.jpg

spectrum of use

very high risk, social exclusion, homelessness etc

chaotic

long term problems

health, social etc

dependent

problematic

most of us

recreational

experimental


Slide14 l.jpg

more than just the drug….

set –

e.g. why using?

feelings?

knowledge?

substance-

e.g. what? how used? what mixed with?

the risks and the rewards

setting –when? where? who with? culture?


Slide15 l.jpg

drug sources - 3 of them

  • plants/herbs/fungi

    e.g. cannabis, magic mushrooms

  • illicitly produced chemicals

    e.g. mdma, cocaine hydrochloride, amphetamine sulphate

  • pharmaceuticals

    e.g. benzodiazepines, codeine, OTC medications

    2 exceptions = reindeer urine and toad-licking!


How do we classify them l.jpg
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 effecton our bodies - the most helpful

    DRUGS DO NOT EASILY FIT INTO PIGEON HOLES…


Slide17 l.jpg

types of effect – 3 broad categories

  • stimulant

  • depressant

  • hallucinogenic


Stimulants l.jpg
stimulants

energy up

concentration

social confidence

‘alive’ & ‘alert’

use, craving, tolerance, dependency

pos. psychosis

big crashes - physical & mental

paranoia

over agitation


Depressants l.jpg
depressants

life management

‘warm blanket’

euphoria

relaxation

use, craving, tolerance, dependency

treadmill of dependency

criminalisation?

self neglect/isolation?

[fear of] withdrawal


Slide20 l.jpg

hallucinogenics

  • change ‘reality’ by distorting perception

  • induce hallucinations – sight, sound, touch

  • tend to ‘amplify’ mood state

  • v. unpredictable, ‘bad trips’ etc

  • often long acting


Slide21 l.jpg

hallucinogen

stimulant

?

depressant

?

?

the scale of effectwhere do they fit?

?


Slide22 l.jpg

4 main ways of taking drugs

  • injection [very quick, very economical]

  • smoking [quick, not so economical]

  • snorting[fairly quick]

  • orally [slower]

    many drugs can be takenat least 2of these ways


Slide23 l.jpg

the scale of effect

STIMULANTS

Crack

Cocaine

Speed

Tobacco

Ecstasy

Caffeine

Magic M’rooms

LSD

Cannabis

HALLUCINOGENS

Glue/Solvents

Alcohol

Ketamine

Benzos

Methadone

Heroin

DEPRESSANTS


Cycle of dependence depressants l.jpg
cycle of dependence - depressants

use to manage or

suppress feelings

feelings return

mood changes/ feelings hidden

OUT?

drug effectiveness decreases

dependency pattern

reinforced

tolerance increases


Stimulants crash and craving l.jpg
stimulants - crash and craving

1. USE

[Highs & Lows ]

5.The ‘MISSION’

[anticipation]

Users may ‘bounce’ between 1 and 2

2. EARLY CRASH

[big comedown]

4. FEELING OK

[‘normal’]

3. LATE CRASH

[regret]


All inter related l.jpg
all inter-related…

HEROIN

BENZOS

CRACK

METHADONE


Cannabis things to know l.jpg
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


Cannabis as a treatment l.jpg
cannabis as a treatment?

  • MS

  • acute pain?

  • crohn’s and IBS (Irritable bowel syndrome)?

  • glaucoma

  • mental health and general stress

  • asthma

  • epilepsy

  • AIDS/cancer



Ecstasy things to know l.jpg
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?]



Slide32 l.jpg

crack/cocaine

what goes up ….

N

dopamine depletion – thereafter adrenaline buzz only

TIME

COCAINE

CRACK














Methadone l.jpg

HEROIN

METHADONE

methadone

Intensity

0 hr Duration 24 hr



Benzodiazepines47 l.jpg
benzodiazepines

  • widely available prescription drugs [class C]

  • many varieties, short & long-acting [3 – 9 hours]

  • NOT anti-depressants

  • tolerance develops quickly [symptoms return]

  • high levels of dependency

  • withdrawal = protracted and potentially fatal


Benzos common symptoms l.jpg
benzos – common symptoms

  • fearand phobias

  • sleepdisturbancese.g. insomnia, nightmares etc

  • mooddisorders – e.g. anger, anxiety, depression

  • sensoryeffects – e.g. tinnitus, giddiness, blurred vision

  • physical – e.g. exhaustion, twitching, aches and pains

  • extreme – e.g.delirium, convulsion and even death!


Street leakage l.jpg
street leakage

  • benzos! – especially diazepam and nitrazepam

  • methadone and subutex!

  • dihydrocodeine, MST, diconal

  • coproxamoland 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


Otc drugs of misuse l.jpg
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


On the horizon l.jpg
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


The political landscape l.jpg
the political landscape

  • crime and social disorder

  • providers v. NTA v. DAATs v. PCTs v. CDRPs

  • ££ in drugs not alcohol

  • MOC and MoCAM – where do GPs fit?



The drug and alcohol action team a framework for partnership l.jpg
The Drug and Alcohol Action Team‘A Framework for Partnership’

  • STATUTORY BODIES

  • Education

  • Health

  • Police

  • Prisons/Probation

  • Social Services

  • Community safety etc.

  • CENTRAL GOVERNMENT

  • Home Office

  • Nat. Treatment Agency [NTA]

  • GODT [regional]

  • SERVICE PROVIDERS

  • CDTs

  • Counselling Services

  • Street Agencies

  • etc. etc.

DAAT

Strategy and Implementation Team

SHARED INFO – SPECIAL PROJECT GROUPS

JOINT INITIATIVES – POOLED BUDGETS


Models of care treatment modalities l.jpg
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


Types of service 1 l.jpg
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


Types of service 2 l.jpg
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


Issues for services we re only a part of the solution l.jpg
issues for serviceswe’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


Scenarios which service l.jpg
scenarios – which service?

  • Billyis 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

  • Leanneis 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.


Scenarios which service60 l.jpg
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.


Methadone properties l.jpg
methadone properties

  • white crystalline powder

  • synthetic opioid

  • drunk, swallowed or injected (physeptone)

  • tolerance builds up slowly

  • long acting


Properties cont l.jpg
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


Methadone effects l.jpg
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)


Effects cont l.jpg
effects cont …

  • on the nerves

    - small pupils

    - constipation

    perhaps

    - dryness of eyes, nose + mouth

    - reduced blood pressure

    - difficulty passing urine


Effects cont65 l.jpg
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


Effects not l.jpg
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


How it works l.jpg
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


Very basic neurology l.jpg
[very] basic neurology

  • drug - to have effect this must be close fit to neurotransmitter in order to cause [agonist] or prevent response [antagonist]

  • neurotransmitter- specific chemical that fits receptor site and causes nerve impulse [effect]

neurotransmitter

drug [agonist]

brain cell

receptor site

‘firing’

response

brain cell

receptor site

‘firing’

response


Slide69 l.jpg

OPIATE AGONIST e.g. heroin, methadone, codeine

PARTIAL OPIATE AGONIST e.g. Subutex

opiate

receptor

opiate

receptor

‘firing’

response

partial firing – site blocked

OPIATE ANTAGONIST e.g. Naloxone, Naltrexone

knocks other opiates off site and blocks completely

opiate

receptor


Slide70 l.jpg
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…


Against l.jpg
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


Advisory council on misuse of drugs l.jpg
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.”


Good practice l.jpg
good practice

most successful programmes include

- high doses

- maintenance (rather than reduction)

- intensive counselling

- medical services

- good relationships between staff and patients


Dose assessment titration l.jpg
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


Alternatives l.jpg
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


Slide76 l.jpg

Drugs work by stimulating receptors in the brain.

These pictures show how Subutex 'sticks' to the opiate receptors stopping heroin having any effect and, at the same time, stimulating them enough to take away, or reduce, the desire to take heroin.


Alternatives77 l.jpg
alternatives

detox

  • Lofexidine

  • Dihydrocodeine

  • Naltrexone

  • Benzodiazepines


Naltrexone hydrochloride naloxone revia vivitrol nalorex l.jpg
Naltrexone hydrochlorideNaloxone 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 (!)


Slide79 l.jpg
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


Naloxone hydrochloride narcan l.jpg
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


Bbv transmission l.jpg
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


Bbv transmission82 l.jpg
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)


Bbv prevention l.jpg
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


Od the signs l.jpg
OD - the signs

  • deep snoring

  • unwakeable

  • getting cold

  • turning blue [esp. lips]

  • not breathing


Od risk factors 1 l.jpg
OD – risk factors (1)

  • injecting

  • previous non-fatal o/d experiences

  • using at high levels

  • low tolerance

  • feeling low or depressed


I v opiates low tolerance l.jpg

lethal dose

unconscious

level of heroin in blood

time

I/V opiates – low tolerance

highly intoxicated

lines move up as tolerances increases


Od risk factors 2 l.jpg
OD – risk factors (2)

MIXING IT!

[before OR at the same time]

  • alcohol

  • methadone

  • benzos

  • other sedatives

  • stimulants [coke, speed etc]

14xmore likely to OD


Mixing it high tolerance l.jpg
mixing it + high tolerance

TEMAZEPAM – used on perceived comedown

lethal dose

unconscious

intoxicated

level of heroin in blood

ALCOHOL

HEROIN

time [c.12 hrs]

  • all day drinking pushes up baseline of sedatives in system

  • o/d occurs about 3 hours after heroin use


A complex relationship drugs and mental health l.jpg
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 psychiatricsymptoms


Spiders l.jpg
spiders …

No chemical

Cannabis


Slide91 l.jpg

spiders cont …

Amphetamine (benzedrine)

Caffeine


Boundaries l.jpg
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!


ad