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

2. drug definitions A heavy smoker? Just the one?

3. definitions drug physical vs. psychological dependence dependency vs. addiction alcoholic vs. problem drinker harm reduction vs. abstinence

4. 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 a substance effects the body in such a way that when it is removed the body undergoes physical withdrawal symptoms (sweats, shakes etc)

5. 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

6. 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

8. 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

9. 4% - 8% adults are alcohol dependent 11 -15 year olds - drinking doubled in 10 years illicit drugs - more choice + more affordable = more use consistent across race, class, gender and geographical area national trends

10. 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] 1. Cannabis [over 40 years at number one!] 2. Cocaine 3. Ecstasy 4. Amphetamine 5. Heroin [on the way up!]

12. …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 trends - young people

13. experimental recreational problematic dependent most of us long term problems health, social etc very high risk, social exclusion, homelessness etc chaotic spectrum of use

14. more than just the drug…. setting – when? where? who with? culture? set – substance- e.g. what? how used? what mixed with? e.g. why using? feelings? knowledge? the risks and the rewards

15. 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!

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…

17. types of effect – 3 broad categories stimulant depressant hallucinogenic

18. use, craving, tolerance, dependency energy up concentration social confidence alive & alert stimulants pos. psychosis big crashes - physical & mental paranoia over agitation

19. depressants life management warm blanket euphoria relaxation use, craving, tolerance, dependency treadmill of dependency criminalisation? self neglect/isolation? [fear of] withdrawal

20. hallucinogenics change reality by distorting perception induce hallucinations – sight, sound, touch tend to amplify mood state v. unpredictable, bad trips etc often long acting

21. the scale of effect where do they fit? ? ? ? ? stimulant hallucinogen depressant

22. 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 taken at least 2 of these ways

23. the scale of effect Speed Cocaine Tobacco LSD Magic Mrooms Benzos Alcohol Methadone Heroin Caffeine Cannabis Crack Glue/Solvents Ecstasy Ketamine STIMULANTS HALLUCINOGENS DEPRESSANTS

24. cycle of dependence - depressants use to manage or suppress feelings mood changes/ feelings hidden dependency pattern reinforced tolerance increases drug effectiveness decreases feelings return OUT?

25. stimulants - crash and craving 1. USE [Highs & Lows ] 3. LATE CRASH [regret] 2. EARLY CRASH [big comedown] 4. FEELING OK [normal] 5.The MISSION [anticipation] Users may bounce between 1 and 2

26. all inter-related… HEROINBENZOS CRACKMETHADONE

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? crohns and IBS ( Irritable bowel syndrome) ? glaucoma mental health and general stress asthma epilepsy AIDS/cancer

29. the weed keeps me sane, man

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?]

31. crack/cocaine - dopamine flood

32. COCAINECRACK N TIME crack/cocaine what goes up …. dopamine depletion – thereafter adrenaline buzz only

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 HEROIN METHADONE 0 hr Duration 24 hr Intensity

46. volatile substances

47. 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

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 ££ in drugs not alcohol MOC and MoCAM – where do GPs fit?

53. Models of Care - treatment tiers tiertypeservice examples 1non-specific GPs, housing, probation 2open access advice and info, needle exchange, drop–in 3 structured specialist - communitycommunity detox, CDTs, care planned structured psycho-social interventions, SDP 4 structured specialist -residentialin-patient detox, residential rehab

54. SERVICE PROVIDERS CDTs Counselling Services Street Agencies etc. 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 ] SHARED INFO – SPECIAL PROJECT GROUPS JOINT INITIATIVES – POOLED BUDGETS Strategy and Implementation Team DAAT

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 were 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 1 st 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] drug - to have effect this must be close fit to neurotransmitter in order to cause [agonist] or prevent response [antagonist] neurotransmitter brain cell receptor site firing response drug [agonist] brain cell receptor site firing response

69. OPIATE AGONIST e.g. heroin, methadone, codeine opiate receptor firing response PARTIAL OPIATE AGONIST e.g. Subutex opiate receptor partial firing – site blocked OPIATE ANTAGONIST e.g. Naloxone, Naltrexone opiate receptor knocks other opiates off site and blocks completely

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 cant 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. 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.

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 (!)

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

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

85. OD – risk factors (1) injecting previous non-fatal o/d experiences using at high levels low tolerance feeling low or depressed

86. I/V opiates – low tolerance lines move up as tolerances increases lethal dose unconscious level of heroin in blood time highly intoxicated

87. OD – risk factors (2) MIXING IT! [before OR at the same time] alcohol methadone benzos other sedatives stimulants [coke, speed etc] 14x more likely to OD

88. mixing it + high tolerance lethal dose unconscious level of heroin in blood time [c.12 hrs] TEMAZEPAM – used on perceived comedown HEROIN ALCOHOL intoxicated all day drinking pushes up baseline of sedatives in system o/d occurs about 3 hours after heroin use

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 … No chemical Cannabis

91. Amphetamine (benzedrine) Caffeine spiders cont …

92. boundaries remember: you dont 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 – its NOT YOUR FAULT!