A Pharmacological challenge

Question 1

What is a drug?

Answer 1

A drug is a substance which alters the body/s function either physically and/or psychologically

Question 2

Which drugs are most commonly misused?

Answer 2

Sedatives and anti-anxiety meds e.g. benzodiazepines, ‘z’ drugs zopiclone and zolpidem
Painkillers e.g. opioids, pregabalin, gabapentin (become addicted and tolerant to the effects)
Antidepressants – not addictive but patients may find it difficult to stop taking them

Question 3

Which illegal drugs are most commonly misused?

Answer 3

Cannabis – most common illegal drug in UK; long term use leading to bronchitis and possible cancers of lung
Cocaine – 2nd most commonly used drug in UK; strong CNS stimulant; induces a powerful euphoric effect whilst decreasing want to eat or sleep
Heroin – CNS depressant usually injected or smoked; euphoric effect or ‘rush’ (rapid feeling of intense pleasure and includes state of mental detachment and extreme well-being)

Question 4

What are the medical consequences of misusing drugs?

Answer 4

Opioids – low BP, slowed breathing rate, potential for breathing to stop or coma; OD can lead to death
Anti-anxiety meds and sedatives – low BP, slowed breathing and memory problems; OD can cause coma or death; abruptly stopping can lead to withdrawal symptoms e.g. nervous system hyperactivity and seizures
Stimulants – dangerously high body temperatures, heart problems, high BP, seizures or tremors, hallucinations, aggressiveness and paranoia

Question 5

Why are alcohol and tobacco commonly misused?

Answer 5

Alcohol is a CNS depressant = calming and sedative effects; in large amounts has similar effects to opioids
Tobacco – cigarettes contain nicotine which alters the balance of dopamine and noradrenaline; this imbalance means mood and concentration levels change

Question 6

What are the short-term risks of alcohol misuse?

Answer 6

Injuries e.g. motor vehicle crashes, falls, drownings, burns
Violence e.g. homicide, suicide, sexual assault, intimate partner violence
Alcohol poisoning
Risky sexual behaviours e.g. unprotected sex, sex with multiple partners leading to unwanted pregnancy or STDs including HIV
Pregnant women - miscarriage and stillbirth or fetal alcohol spectrum disorders

Question 7

What are the long term risks of alcohol misuse?

Answer 7

High BP, heart disease, stroke, liver disease and digestive problems
Cancer of breath, mouth, throat, oesophagus, liver and colon
Learning and memory problems including dementia and poor school performance
Mental health problems e.g. depression, anxiety
Social problems e.g. lost productivity, family problems, unemployment
Alcohol dependence or alcoholism

Question 8

What are the risks of smoking?

Answer 8

70% of lung cancers attributed to smoking
Causes cancer in other parts e.g. mouth, throat, larynx, oesophagus, stomach, pancreas, liver, kidney, bladder, bowel, cervix
Damages heart and blood circulation increasing risk of: coronary heart disease, heart attack, stroke, peripheral vascular disease, cerebrovascular disease
Damages lungs leading to COPD and pneumonia
Impotence in men (limits blood supply to penis)

Question 9

What is substance misuse?

Answer 9

Harmful use of substances such as drugs and alcohol for non-medical purposes.

Question 10

What is addiction?

Answer 10

Physical or psychological need for substance due to regular, continued use.

Question 11

How can you treat substance misuse?

Answer 11

Behavioural counselling
Medication
Medical devices and applications used to treat withdrawal symptoms or deliver skills training
Evaluation and treatment for co-occurring mental health issues such as depression and anxiety
Long term follow up to prevent relapse

Question 12

What programmes are available for drug misuse?

Answer 12

Brief interventions – group based psycho educational interventions for health interventions i.e. safe sex
Contingency management – techniques to focus on changing specified behaviours
Behavioural couples therapy – for drug users of stimulant or opioid misuse and their partners
Behavioural family interventions – non drug misusing families, carers and partners to get support on how to cope and aid with support of drug misusers
Cognitive behavioural therapy and psychodynamic treatment – focuses on addiction of patients; can be offered comorbid depression and anxiety disorders treatment which are associated with drug users

Question 13

What are the physiological effects of substance misuse?

Answer 13

Sleeping disturbances
Dental decay
Sinus issues or watery eyes
Skin rashes or breakouts
Chronic fatigue 
Digestive concerns
Unintended weight gain/loss
Heart and/or circulation problems
Organ damage or failure

Question 14

What are the psychological effects of substance misuse?

Answer 14

Poor decision making abilities
Inability to concentrate or focus
Memory loss
Confusion and disorientation
Powerful cravings for substance of choice

Question 15

What is the link between suicide and substance misuse?

Answer 15

Addiction leads to feelings of hopelessness, despair and guilt associated with depression
People committing suicide have suffered from depression, substance abuse disorder or both
High risk in young men
Opiates e.g. heroin and morphine are the most frequently mentioned drug
Prescription drug suicides have also increased by more than 60%

Question 16

What is non-compliance?

Answer 16

Failure or refusal to comply; a patient who does not take a prescribed medication or follow a prescribed course of treatment

Question 17

Why might a patient be non-compliant?

Answer 17

May be due to cost, forgetfulness (in elderly), inability to obtain filled prescriptions
Due to poor doctor patient relationship and lack of communication
Adverse events caused by medication can be more uncomfortable than actual disease symptoms; complicated drug regimes

Question 18

How to improve patient compliance?

Answer 18

Good communication is needed for involvement of patients in decisions about medicines and supporting adherence
Increasing patient involvement requires healthcare professionals to acknowledge patient’s views about their condition and its treatment
Supervised consumption – a patient should not be converted to fully supervised dose immediately as it places them at risk of OD if they have been non-compliant
Understanding the patient’s knowledge, beliefs and concerns about medicines

Question 19

How to deal with difficult patients?

Answer 19

Remain calm when dealing with difficult patients
Engage in conversation – try to draw out their feelings
Be empathetic
Avoid arguing
Set boundaries
Shake it off

Question 20

What healthcare is available for offenders?

Answer 20

Primary care: Prisoners should also have access to a doctor, nurse, optician and dentist, although this may not be the case for every establishment. Most frequently deal with mental health issues and musculoskeletal pain.
Secondary care: If a specialist care is needed, there is often an ‘in-reach’ team made up of a psychiatrist, psychologist, social worker, or specialist nurse that may come into the prison. Or if this is not available or another specialist is needed, the prisoner will be taken to hospital with a prison escort.

Question 21

What are the challenges for offender healthcare?

Answer 21

Vulnerable backgrounds: older people, learning difficulties, poor diets, dental hygiene, and undiagnosed health conditions, commodities
Unhealthy environment: Overcrowded, diets in prison are often poor and sparse; often not following healthy eating guidelines; very little exercise and fresh air. Very little mental stimulation.
Mental health issues: Overcrowding, violence, forced solitude, lack of support networks and inadequate health services mean prisoners are at far greater risk of developing anxiety, depression, schizophrenia, personality disorders or attempt self-harm or suicide, poor mental health services.
Poor access to services: long waiting times for appointments and medications, restraints and lack of patient confidentiality
Poor integration after release: difficult referral arrangements, lack of registered GP, lack of links to community mental health services

Question 22

What is the timeline for alcohol withdrawal?

Answer 22

6-12 hours: Headaches, anxiety, shaking, nausea, irritability.
12 - 24 hours: More severe, additionalsymptoms may involve disorientation,handtremors and seizures.​
Day 2: Hallucinations and panicattacksare common.
Day 3-7: Symptoms come and go
After 1 week: Many symptoms begin to subside. Some may persist for a few weeks, managed with medication. Anxiety, lower energy, troubled, sleeping, delayed reflex, may last for up to one year.

Question 23

What services are available for alcohol detoxification?

Answer 23

First point of contact – GP - offer structured brief advice for mild alcohol misuse​
Potential extended brief interventions
Referral to specialist services for severe – counselling, local alcohol services, mental health services - therapy​

Question 24

How would you encourage alcohol detoxifcation in a patient with mild alcohol misuse?

Answer 24

Detox at home without needing medication as symptoms mild, may attend support groups and havetherapeutic intervention.​

Question 25

How would you encourage alcohol detoxifcation in a patient with higher alcohol consumption (>20 units per day) ?

Answer 25

May still be able to detox at home but likely given medication tomanagewithdrawal symptoms.
These individuals may also have a 24 hours short stay support to ensure withdrawal.
Common medication: Chlordiazepoxide and Benzodiazepine

Question 26

What is Intensive rehabilitation and recovery support for alcohol detoxification?

Answer 26

Residential rehabilitation -Individuals with high level ofalcohol dependence(alcohol addiction). Orthose for who other options have been unsuccessful. Private or possible funding from localauthorities.
Structured programme, 4 – 12 weeks
Safe environment – no temptations or access to alcohol anddrugs, focuson recovery. Includes counselling, CBT, group therapy, motivational interviewing.

Question 27

What self-help organisations are available for alcohol detoxification?

Answer 27

Alcoholics Anonymous (AA)​- 12 weeks, desire to stop drinking
SMART recovery— self management and recovery training
Sheffield - Drink wise, age well: Free confidential advice and support, including one to one support, home visits​. Raise awareness of impact of alcohol use, can deliver sessions in work place​

Question 28

What therapeutic interventions are available for alcohol detoxification?

Answer 28

Cognitive behavourial therapy— To change a persons behaviour must change their thoughts. Identify negative thought patterns that contribute to addiction.
Social network and environment and based therapies—examine social behaviours
Behavioural couples therapy—focus on alcohol related problems and their effect on the persons relationships.
Family therapy - Support family members of alcohol misusers. Help family members learn how to support an individual.

Question 29

What medications can be used for alcohol detoxification?

Answer 29

Acamprosate - reducing craving, affect GABA levels
Naltrexone - help prevent relapse or limit amount of alcohol can drink, inhibits opioids receptors, prevents effects of alcohol
Disulfiram - Deters drinking as causes physical reactions when drink alcohol— chest pain, vomiting, dizziness
Nalmefene - helps reduce alcohol consumption, blocks opioid receptors in brain, prevents effects of alcohol. Can be used in patients without physical withdrawal symptoms who don’t need immediate detoxification

Question 30

What are the dangers of alcohol consumption?

Answer 30

Alcohol misuse—biggest risk factor for death, ill-health and disability among 15-49 year olds in UK

Alcohol is a causal factor in more than 60 medical conditions, including: mouth, throat, stomach, liver, breast cancers, high blood pressure, cirrhosis of liver, depression