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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

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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?

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  • drug

  • physical vs. psychological dependence

  • dependency vs. addiction

  • alcoholic vs. problem drinker

  • harm reduction vs. abstinence

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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

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

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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

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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

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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

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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

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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!]

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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

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spectrum of use

very high risk, social exclusion, homelessness etc


long term problems

health, social etc



most of us



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more than just the drug….

set –

e.g. why using?




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

the risks and the rewards

setting –when? where? who with? culture?

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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!

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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


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types of effect – 3 broad categories

  • stimulant

  • depressant

  • hallucinogenic

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energy up


social confidence

‘alive’ & ‘alert’

use, craving, tolerance, dependency

pos. psychosis

big crashes - physical & mental


over agitation

Depressants l.jpg

life management

‘warm blanket’



use, craving, tolerance, dependency

treadmill of dependency


self neglect/isolation?

[fear of] withdrawal

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  • change ‘reality’ by distorting perception

  • induce hallucinations – sight, sound, touch

  • tend to ‘amplify’ mood state

  • v. unpredictable, ‘bad trips’ etc

  • often long acting

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the scale of effectwhere do they fit?


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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

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the scale of effect








Magic M’rooms











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cycle of dependence - depressants

use to manage or

suppress feelings

feelings return

mood changes/ feelings hidden


drug effectiveness decreases

dependency pattern


tolerance increases

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stimulants - crash and craving

1. USE

[Highs & Lows ]



Users may ‘bounce’ between 1 and 2


[big comedown]





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all inter-related…





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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?]

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what goes up ….


dopamine depletion – thereafter adrenaline buzz only




Methadone l.jpg





0 hr Duration 24 hr

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  • 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

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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!

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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

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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

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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’


  • Education

  • Health

  • Police

  • Prisons/Probation

  • Social Services

  • Community safety etc.


  • Home Office

  • Nat. Treatment Agency [NTA]

  • GODT [regional]


  • CDTs

  • Counselling Services

  • Street Agencies

  • etc. etc.


Strategy and Implementation Team



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

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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

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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.

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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

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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


    - dryness of eyes, nose + mouth

    - reduced blood pressure

    - difficulty passing urine

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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

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[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]


drug [agonist]

brain cell

receptor site



brain cell

receptor site



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OPIATE AGONIST e.g. heroin, methadone, codeine








partial firing – site blocked

OPIATE ANTAGONIST e.g. Naloxone, Naltrexone

knocks other opiates off site and blocks completely



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  • 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

  • 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

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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.”

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good practice

most successful programmes include

- high doses

- maintenance (rather than reduction)

- intensive counselling

- medical services

- good relationships between staff and patients

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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

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

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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.

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  • 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 (!)

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  • 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

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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

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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

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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


level of heroin in blood


I/V opiates – low tolerance

highly intoxicated

lines move up as tolerances increases

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OD – risk factors (2)


[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



level of heroin in blood



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

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spiders …

No chemical


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spiders cont …

Amphetamine (benzedrine)


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  • 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!