substance misuse Flashcards
what are the impacts of substance misuse
Physical health
• Mental health and emotional well-being
• Relationship and social functioning
• Society as a whole
what does harmful drinking mean
pattern of alcohol consumption that causes health problems, including psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis
• Harmful drinkers can become alcohol dependent, which NICE defines as characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences
whats the limit uptake of alcohol per week
Men and women should limit their intake to no more than 14 units a week to keep the risk of illness like cancer and liver disease low
what cancers are associated with heavy alcohol consumption
Mouth • Bowel • Stomach • Liver • Breast
how does alcohol affect pregnancy
Alcohol in pregnancy - no level of alcohol is safe to drink in pregnancy
• Alcohol misuse is associated with mental health problems
• A number of large epidemiological surveys demonstrate the high prevalence of co- morbidity in those attending mental health services and both drug and alcohol treatment services
how does alcohol affect employment
Significant negative health impacts can arise as a result of unemployment, both for the individual and their families
• This impact worsens when it involves alcohol misuse.
• Studies from Europe and the US conclude that alcohol misuse is more likely to start or escalate after unemployment begins
• Harmful drinking and the associated increased risk of mental health problems can make it harder for people with alcohol dependence issues to find work again
what effects does drugs have on the body
Drugs can have immediate and long-lasting effects on your physical health and well-being
what physical effects does drugs have on the body
When you’re under the influence of drugs, you might do things that you wouldn’t normally do • This can increase your chances of getting hurt or having an accident
• Drug-related injuries can be from things like falling and car accidents
how does the use of drugs cause violence
Some drugs can increase the likelihood of violent behaviour
• Violence is never an acceptable way to react in a situation, and if you become violent when you use drugs, it’s a good idea to re-evaluate your drug use
• Drug-induced violence can lead to serious injury to you and to others
how does drugs cause internal damage
Use of some drugs can damage your internal organs, like your liver, brain, lungs, throat and stomach
• For example, ordinary household glue can be characterized as a drug if sniffed
• The chemicals in glue can cause hearing loss and kidney damage if they’re inhaled over a long period of time
how does drugs impact stress
you might think that using certain drugs will help you relax and forget about the issues that cause stress
• But long-term drug use can have a big impact on the way your brain works, and lead to increased anxiety and stress
how does drugs cause depression
- Feeling low after using some drugs-including alcohol-is common
- You might feel depressed because of the drug itself, or because of something that happened while you were using
- Sometimes people use drugs as a way to cope with their depression, but drug use can often worsen these feelings
how does drugs cause mental illness
Although scientists generally agree that there is a link between drug use and serious mental illnesses like schizophrenia.
what is meant by dual diagnosis
Dual diagnosis refers to people with a severe mental illness (including schizophrenia, schizotypal and delusional disorders, bipolar affective disorder and severe depressive episodes with or without psychotic episodes) combined with misuse of substances (the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage).
what is the impact on relationships and social functioning
school work
You might not immediately notice the impact that your drug taking is having on your school work, but habitual drug use can prevent you from focusing on your responsibilities, like homework or concentrating in class
Your grades will suffer as a result
your job
Drug use can also affect your ability to concentrate at work
The side effects of using drugs-like a hangover, or a “coming down” feeling-can reduce your ability to focus
Poor performance at your job could cause you to lose your job all together
financial pressures
Regular drug use can become expensive
homelessness
Spending most of your money on drugs might not leave much money to cover your living expenses, like rent, food, or utility bills
If you can’t pay these necessary costs, you could even get kicked out of your home
what is meant by controlled drugs
The Misuse of Drugs Act 1971 defines CDs as “dangerous or otherwise harmful drugs” and categorises them into three distinct classes – A, B & C
• The Misuse of Drugs Regulations 2001 – stipulates how CDs may be prescribed, handled, stored and supplied by pharmacists
• The main purpose of the Act is to prevent the misuse of controlled drugs and achieves
this by imposing a complete ban on the possession, supply, manufacture, import and export of controlled drugs except as allowed by regulations or by license from the Secretary of State
what are the different classes of controlled drugs
Class A those considered most harmful – ecstasy, LSD, diamorphine (Heroin)
• Class B includes cannabis, amphetemines, methylphenidate & pholcodeine
• Class C painkillers, GHB
• Offences under the act include possession, supply or offering to supply with Class A drugs incurring the highest penalities.
what does the 5 classifications say about controlled drugs
In the 2001 regulations, drugs are divided into five Schedules, each specifying
the requirements governing such activities as import, export, production, supply, possession, prescribing, and record keeping which apply to them
what is schedule 1 CD?
Schedule 1 (CD licensed only/prescription only medicine) (CD Lic POM) • Virtually no therapeutic use
• Social problems through misuse
• A licence is required from Home Secretary to produce, possess or supply
• Examples include LSD, ecstasy and cannabis. (Sativex is an exception to the rules and does not require a licence, it is a schedule 4 drug)
what is schedule 2 CD?
Schedule 2 (CD prescription only medicine) (CD POM)
• Strict control
• Drugs of great therapeutic value
• All sch 2s are subject to full prescription control, safe custody, witnessed destruction and record keeping
• Examples include opiates, major stimulants -amphetamines. Ketamine products for medicinal use, epidyolex (cannabis oil)
what is schedule 3 CD?
CD No registration needed/prescription only medicine (CD No Reg POM)
• Reduced control e.g. no record keeping
• Invoices, however, must be retained
• Witnessed destruction not legal requirement but good practice
• Most sch 3s require prescription requirements and safe custody (except midazolam, tramadol, pregabalin and gabapentin)
• Examples: temazepam, buprenorphine, midazolam, phenobarbitone
• Recent additions (October 2018): Pregabalin and gabapentin
what is schedule 4 CD
Schedule 4 (CD Benz POM (benzodiazepines)) and (CD Anab POM (anabolics)) • Few restrictions
• No safe custody, witnessed destruction or prescription requirements but validity of prescription is 28 days (true for schedules 2,3 & 4)
• Good practice – 30 days clinical need (true for schedules 2,3 & 4)
• Examples CD Benz- most benzodiazepines and sativex
• CD Anab – anabolic and androgenic steroids plus growth hormones Sativex (cannabis oil spray)
what is schedule 5 CD
CD Inv POM or CD Inv P) (invoice)
Only requirement is that invoices must be retained for 2 years • Dilute preparations of schedule 2 drugs
• Prescription validity 6 months
• Some available OTC
• Examples codeine, pholcoldine & low strength morphine
prescribing drugs to help with addiction
If someone is addicted to diamorphine (heroin), dipipanone, Cocaine
– Can only be prescribed in addiction by prescribers who have a special home office licence (BNF guidance on prescribing, controlled drugs and drug dependence)
• Substitute prescribing (Methadone, buprenorphine (BNF section 4.10.3)
what are the CD prescription requirements
CD prescription requirements Schedule 2 & 3 CDs
• Prescriptions for Controlled Drugs that are subject to prescription requirements must be indelible (permanent), and must be signed by the prescriber, be dated, and specify the prescriber’s address.
The prescription must always state:
• The name and address of the patient;
• In the case of a preparation, the form and where appropriate the strength of the preparation;
• The total quantity in words and figures
• For liquids, the total volume in millilitres (in both words and figures) of the preparation to be supplied; for dosage units, the number (in both words and figures) of dosage units to be supplied; in any other case, the total quantity (in both words and figures) of the Controlled Drug to be supplied;
• The dose; (‘as directed’/’when required’ not acceptable but ‘one as directed’/’one when required’ is) – be specific, specify how many!
• The words ‘for dental treatment only’ if issued by a dentist
what must a pharmacist check fro before dispensing a CD for schedule 2 and 3
The prescription complies with the requirements as set out above
• The pharmacist must know the prescriber’s signature and have no reason to suspect a forgery
• OR the pharmacist has taken reasonably sufficient steps to satisfy himself that it is genuine
• Check if its within 28 days of appropriate date (2,3 & 4) – this includes any owings
• Mark the prescription, at the time of supply, with the date on which the drug was supplied (2 & 3)
• Do not give over 30 days supply – recommended (2,3 & 4)
• The prescriber’s address must be in the UK
what are FP10SS used by
GP, nurse, IP, hospital unit
prescriptions must be annotated with the type of prescriber issuing it.
forms annotated with the initials RD are repeat dispensing forms. forms with RA are repeat authorisation forms
what are FP10NC used by
GP
prescriptions must be annotated with the type of prescription issuing it
forms annotated with the initials RD are repeat dispensing forms. forms with RA are repeat authorisation forms
what are FP10HNC forms used by
hospital unit
prescriptions must be annotated with the type of prescription issuing it
forms annotated with the initials RD are repeat dispensing forms. forms with RA are repeat authorisation forms
why do you need to keep a register of control drugs
With most private prescriptions you don’t actually have to send them to the NHS business services agency at the end of each month, along with the NHS prescriptions
• However with private controlled drug prescriptions for schedules 2 & 3 you do have to send them in – this is to keep a register to see what prescribers are actually prescribing
under what conditions can a prescription be allowed to be dispensed
Prescriptions must be dispensed exactly as directed by the prescriber EXCEPT:
Technical errors on schedules 2 & 3 drugs
• A pharmacist can supply a prescription if:
• The drug is spelt wrongly
• Either the words or figures (but not both) of the total quantity is missing
PROVIDED:
• Prescription is genuine & supply is made according to prescriber’s intention • Amendments are made in ink and pharmacist dates and signs prescription
what are the conditions of collection of dispensed sched 2 CDS
Need to establish if it is the patient, the patient’s representative or a health care professional collecting.
• Proof of identity not always required
• If proof not established, the pharmacist decides whether to supply a controlled drug
• Where the person collecting is a health care professional, the pharmacist must also obtain their name and address.
→
Signing the back of the prescription
-
• Good practice for person collecting Sch2 & Sch3 CD to sign space on reverse of prescription form
• Can still supply if not signed subject to professional judgement of pharmacist
• Representative can sign (can ask for ID)
what must control CD registers contain
CD registers must
• Be chronological
• Be made on the day of the transaction or the next day
• NOT be cancelled, obliterated or altered but corrected by dated marginal notes or footnotes on the page
• Corrections must be in ink or indelible, signed and named
• Can be electronic
• Have a running balance – at any one time you should know exactly how much of a particular CD is present in the pharmacy in the CD cupboard
Form we have to fill out when we get CD from wholesaler & are dispensing
what is meant instalment prescribing
Instalment dispensing involves more than one dispensing from a single prescription
what is meant instalment prescribing
Instalment dispensing involves more than one dispensing from a single prescription
what is the reason of control of daily supply
Instalment prescriptions
• Allow daily supply of substitute
• Lives are already chaotic
• Avoids temptation to overdose on first day
• Supervised consumption
• Greater levels of control
• Should write a contract between the pharmacy and the service user
what are the conditions of dispensing a MDA prescription
Valid 28 days from date / start date
• Sign and ID on first visit – representative could collect with prior agreement and letter for each collection
• Dispensing fee for each collection (If patient pays it’s only one prescription charge)
what should ideally be the relationship between the prescriber
Most people on substitution programs will be under the care of a substance misuse clinic • Should have a good relationship with their ‘key worker’
how do you record a supply
Many pharmacies have a separate CD register for substitution therapy • Must be done on day of supply or the next day
what do you do if you missed a dose or multiple doses
Single missed doses
• Problem, particularly as it normally happens at weekends or bank holidays. • Best to have agreement beforehand
• Prescribers can put a specified form of words to help in this situation.
Multiple missed doses
• Missing a single dose quite frequently
– May be a good reason
– May indicate chaotic lifestyle – Contact key worker
• Missing multiple days at a time
– Danger that opiate tolerance will reduce, so when previous dose resumes it may be toxic – Contact key worker
what does whistle blowing mean
One who reveals wrong-doing within an organisation to the public or to those in positions of authority
• This wrong-doing relates to information about misconduct in their workplace that they feel violates the law or endangers the welfare of others
what are the two types of whistle blowing
nternal whistle-blowing: when an individual raises concerns within the organistion
• External whistle-blowing: when an individual raises concerns outside the organisation
why do people not want to whistle blow
Fear – repercussions from management and colleagues • Time – workload
• Not mandatory
• Thinking someone else will report it
• Lack of knowledge about whistle blowing
• Not promoted by organisation’s culture
• Feeling isolated and lacking support & advice
what does the public interest disclosure act say
Public Interest Disclosure Act 1998 (PIDA)
‘Protects whistle-blowers from detrimental treatment by their employer when making a disclosure in the public interest’
what are the qualifying disclosures for whistle blowers
Someone’s health and safety is in danger
ii. Damage to the environment
iii. A criminal offence
iv. The organisation is not obeying the law
v. Failure to comply with a legal obligation
vi. Miscarriages of justice – if you see someone being blamed wrongly vii. A deliberate attempt to cover up wrongdoing
what evens happened after the whistle blowing act came to light
Mid Staffs Hospital scandal between 2005-09 came to light
• Inquiry by Robert Francis QC (queens counsellor aka lawyer) begins in 2010
• PIDA was strengthened in 2013 by the Enterprise and Regulatory Reform Act which protects against bad treatment - unfair dismissal, victimisation
• Francis report published in 2013 with 290 recommendations
• Improved support for compassionate caring
• Openness, Transparency and Candour throughout the healthcare system
• Look up ‘The Francis Report’
ethics of whistle blowing
You must be prepared to challenge the judgement of your colleagues and other professionals if you have reason to believe that their decisions could affect the safety or care of others.
• Pharmacy professionals must speak up when they have concerns or when things go wrong
what must you do if you suspect malpractice
Record concerns, evidence • Get advice • Internal disclosure – Supervisor – Safeguarding teams • External disclosure • Regulators – CQC – GPhC • MPs and Councillors • Media
what is pharmacist support
Pharmacist Support is an independent charity for pharmacists and their families, preregistration trainees and pharmacy students in need.
• The Charity has provided a lifeline for pharmacists who, through circumstances often beyond their control – personal illness, disability or other life changing events - have required much needed help and assistance. This has been provided in many formats on a short or long-term basis and is specifically tailored to the individual’s circumstances and needs.
drugs-legal one buying on the internet
Consider
• Buying off the internet – what are you getting?
• Pharmacological effects – variable
• “We found that whilst most studies employing basic testing paradigms show that modafinil intake enhances executive function, only half show improvements in attention and learning and memory, and a few even report impairments in divergent creative thinking. In contrast, when more complex assessments are used, modafinil appears to consistently engender enhancement of attention, executive functions, and learning.”
Legally
• Buying modafinil for personal own use is NOT illegal
• Supplying modafinil is illegal
• Once the product is brought into the UK and exposed for onward sale or supply, UK medicines legislation will apply
Ethically Justifications for personal use • What’s the harm? • It’s the same as caffeine really • It’s not illegal • Everybody’s doing i
why deliver medicines via the nose
why nasal delivery? • Local effects • Systemic effects • Where oral route not available – Destroyed in GI fluids – Metabolized in gut wall – Extensive biotransformation by liver during first passage around circulation » Peptides, vaccines, hormones
describe the anatomy of the nasal cavity
Lateral view of nasal cavity
• Main nasal passage – turbinates and meatuses (air spaces 0.5 – 1.0 mm).
• Ciliated columnar epithelium. Convolutions increase surface area.
• Nasal mucosa highly vascularized. Important in modification of inspired air
- Particles deposited on turbinates IMMEDIATELY available for clearance – this is best area for absorption.
- Particles deposited anterior to turbinates not immediately available for clearance (dragged on mucus through cavity) but not best absorption site.
- Particles deposited in nasopharyngeal region cleared immediately by swallowing • Nasal cavity – 12 – 1 4 cm from nostrils to nasopharynx
- Divided in two by nasal septum
- Nasal vestibule – smallest X-sectional area ~ 0.3 cm2 on each side, guarded by vibrissae. Skin – squamous epithelium
- Main nasal passage – turbinates and meatuses (air spaces 0.5 – 1.0 mm). Ciliated columnar epithelium. Convolutions increase surface area.
- Olfactory region – non-ciliated neuro-epithelium
- Nasal mucosa highly vascularized. Important in modification of inspired air.
what is the main function of the human nose
- Air conditioning is MAIN function of human nose.
- Structure of nose allows for intimate contact between inspired air and mucosal surfaces.
- Warming from 23 oC to ~ 32 oC
- Increase humidity form 40 % to 98 %
what is the pericilary fluid
Periciliary fluid
Product of ion secretion from epithelium. e.g. Chloride channels. Helps in humidification
Depth important – too deep and cilia can’t interact, too shallow (e.g. CF) cilia can’t beat properly
what is the mucus made up of
Mucus
Gel-like substance – role in entrapping particulates and humidification ~ 1.5 – 2 litres secreted in nasal cavity daily
Viscoelastic gel resulting from entanglements of glycoprotein molecules
what is the cilia
Cilia
Effective stroke; Rest phase; recovery stroke Controlled by cAMP, intracellular calcium ions, NO
what are turbinates
Turbinates are small structures inside the nose that cleanse and humidify air that passes through the nostrils into the lungs.
what factors affects absorption
drug factors
- charge
MW
lipophilicity
formulation factors -ph osmocity viscosity concentration volume dosage form
patient factors
anatomical factors and physiological factors deposition mucocilary clearance permeability enzymic degregation
what are the advantages and disadvantages of anatomical and physiological factors that affect nasal absorption
advantages
large surface area
highly vascularised
disadvantages mucociliary clearnce metabolic activity -CP450 -peptidase - p- glycoprotein
immunological clearance
mucus barrier
epithelial barrier
describe how metabolic activity affects nasal absorption
Cytochrome P450 is present in nasal mucosa in quantities 2nd only to the liver (when expressed per gram of tissue). This can metabolise a wide range of lipophillic drugs including testosterone, progesterone and estradiol.
• Exopeptidases (mono and diamino peptidases – cleave at N- and C- terminii) and endopeptidases (serine, cysteine and aspartic proteinases – cleave internal peptide bonds) found in lumen and mucosa of nasal cavity. These can degrade peptide molecules e.g. desmopressin and decrease their bioavailability. Could include an enzyme inhibitor e.g. bestatin in formulation.
• MDR1 (the gene coding for a P- glycoprotein) has been found in nasal epithelium but apparently levels are ~250 fold lower than in liver. Affects many drugs with no obvious shared structural characteristics. MW can range from 250 Da to 1900 Da. Most drugs are basic or uncharged and all substrates discovered so far are amphipathic in nature. Role might be more important in olfactory epithelium
• Most drugs given are less than 1000 Da and are lipophilic. But hydrophillic/polar drugs are transported via paracellular route. • MW is an important determinant to rate and degree of transport drug
Cocaine – recreational drug • Commonly snorted
• Molecular mass: 303 g/mol • Log P: 2.3
• Onset of action: seconds to minute
what other drug factors affects the nasal absorption
molecular weight (hydrophilic, polar molecules)
- absorption decreases sharply when MW>1000pa
limited diffusion of molecule >3.6 angstroms
negligible diffusion if molecule >15 and
lipophilicty
absorption increases with increased lipopphilicty
charge
absorption best if molecule is uncharged
what is fentanyl
Fentanyl citrate • Mwt 336.5 • Log P 4.05 • Intranasal bioavailability 70 – 89 % • Instanyl (50, 100 and 200 mcg/spray) – Sodium dihydrogen phosphate dehydrate – Sodium phosphate dehydrate – Purified water • Tmax 12-15 minutes
what is Pecfent
• Fentanyl citrate (100 and 400 mcg/spray)
– Pectin (E440)
– Mannitol (E421)
– Phenylethyl alcohol
– Propyl parahydroxybenzoate (E216)
– Sucrose
– Hydrochloric acid (0.36%) or sodium hydroxide – Purified water
• Pectin – in situ gelling with calcium ions
• Tmax 15 – 21 minutes
what should you give in the event of an accidental overdose of an opioid
Drug overdose deaths, driven largely by prescription drug overdoses, are now the leading cause of injury death in the United States
• Treatment
– IV IM naloxone, also IN naloxone
what is naloxone
Naloxone
• M wt. 327.4
• Log P 2.09
• After intranasal (IN) administration, naloxone exhibits opiate antagonist effects almost as rapidly as the IV route with bioavailability approaching 100%.
Naloxone nasal spray (Narcan)
• Narcan approved by FDA 18th November 2015
• Drug overdose deaths, driven largely by prescription drug overdoses, are now the leading cause of injury death in the United States
• Many first responders and primary caregivers, however, feel a nasal spray formulation of naloxone is easier to deliver, and eliminates the risk of a contaminated needle stick.
Naloxone Nasal Spray (Nyxoid)
• MA issued by EMA 10th November 2017
• ‘Hybrid’ medicine
• Single dose container (1.8 mg/0.1 mL)
• 38 healthy volunteers 2 mg IN similar to 0.4 mg IM
which people are likely to be exposed to an opioid overdose
People at risk of an opioid overdose, their friends and families;
• People whose work brings them into contact with people who overdose (health-care workers, police, emergency service workers, people providing accommodation to people who use drugs, peer education and outreach workers).
what is Desmopressin, DDAVP
og P (-4.0 to -5.0) – very hydrophilic • Large • Molecular mass = 1,069 • Volume = 768 Angstroms3 • Oral bioavailability = 0.08 – 0.16% • Nasal bioavailability ~ 10%
what is Penetration enhancer – chitosan
Polysaccharide (deacetylation of chitin) • MW ~250,000 Da
• Cationic
• Increases absorption of polar molecules • Acts as bioadhesive
• Transiently opens tight junction
• Chitosan in a polysaccharide material produced by a process of deacetylation from the chitin found in crustacean shells
• Chitosan glutamate has a mean MW of ~250,000 Da and a degree of acetylation of ~ 80% • It is a positively charged polymer
• It is able to increase the absorption of polar molecules e.g. insulin and is non-toxic
• Novel nasal morphine product in phase 3 trails in US and phase 2 in Europe.
• RYLOMINE
• Morphine is a polar drug not readily absorbed by nose (bioavailability of ~10%), can be increased to 60 % with chitosan compared to IV injection
• Since been further optimised to give 80% bioavailability
• To be used for breakthrough pain.
• Chitosan believed to act as a bioadhesive and by transiently opening tight junctions to allow polar drugs through.
Therapeutic areas suitable for IN administration
ommon theme(s)
• Breakthrough cancer pain (fentanyl, morphine, alfentanil)
• Migraine and cluster headaches (sumatriptan, zolmitriptan)
• Anticholinesterase inhibitors for Alzheimer’s disease (galantamine) • Insulin for Alzheimer’s disease (autism) (nose to brain route)
• Apomorphine for erectile dysfunction
• Anti-nausea and motion sickness medicines (scopolamine)
• Emergency situation medicines
» Naloxone for opioid overdose
» Benzodiazepines for seizures
» Glucagon for insulin-induced hypoglycaemia
why do people take drugs
to feel good- novel sensation, experiences and to share them
to feel better, lessens anxiety,worries, fears,pain etc
what is meant by the nucleus accumbens
The nucleus accumbens is considered as the neural interface between motivation and action, playing a key role on feeding, sexual, reward, stress-related, drug self-administration behaviors, etc.
what sort of things does a person do that is considered addiction or substance misuse
taking more drugs than intended unsuccessful efforts to cut down strong urges/crave for the drug excessive time spent acquiring drug activities given up because of use
what is meant by addiction
individualts may choose initally to use drugs to experince their effects and is seen by many as a bad choice even for those with long term use
but we do not choose nor do we know how our brains will respond to the drug
brains of people who are addicted to drugs differ in structure and function to those who do not
how do peoples brains differ who are addicted to drugs
- Peoples brains (who become addicted to drugs) have different structures • D2 receptors shown in red
- As cocaine addiction increases, metabolic activity decreases
- The D2 receptors decrease in someone who is addicted to cocaine
what are the 3 pathways of the reward system
GABAergic, Glutamatergic and dopaminergic neurons
dopomine projections pathways acts on the D1 like (excitatory or D2 inhibitory receptors
what does D1 and D2 do
- D1 receptors – excitatory
- D2 receptors – inhibitory
- GABAergic neurons produce gamma-Aminobutyric acid (GABA), which is the main inhibitory neurotransmitter in the mammalian central nervous system (CNS)
- Glutamatergic neurons produce glutamate, which is one of the most common excitatory neurotransmitters in the central nervous system (CNS)
- Dopaminergic cell groups are collections of neurons in the central nervous system that synthesize the neurotransmitter dopamine
what is the mesolimbic pathway
Dopaminergic neurons project from the VTA to the nucleus accumbens and other structures in the limbic system
Regulates incentive salience (motivation for a reward)
- The mesolimbic pathway, sometimes referred to as the reward pathway, is a dopaminergic pathway in the brain
- The pathway connects the ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia in the forebrain
- The ventral striatum includes the nucleus accumbens and the olfactory tubercle
what is meant by the ventral tegmental area
Dopaminergic neurons project from the VTA to the nucleus accumbens and other structures in the limbic system
Regulates incentive salience (motivation for a reward)
The ventral tegmental area (VTA) is a group of neurons located close to the midline on the floor of the midbrain
• Dopamine-releasing neurons of the ventral tegmental area (VTA) have central roles in reward-related and goal-directed behaviors
• VTA dopamine-releasing neurons are heterogeneous in their afferent and efferent connectivity and, in some cases, release GABA or glutamate in addition to dopamine
what is meant by the nucleus accumbens
Significant role in the cognitive processing of motivation, aversion, reward (i.e., incentive salience), and reinforcement learning
Dopaminergic neurons project from the VTA to the nucleus accumbens and other structures in the limbic system
95% neurons GABAergic medium spiny neurons
D1 is excitatory and D2 is inhibitory
• There is a nucleus accumbens in each cerebral hemisphere; it is situated between
the caudate and putamen
• The nucleus accumbens is considered part of the basal ganglia and also is the main component of the ventral striatum
• The dopaminergic systems are generally divided into four major pathways: mesolimbic, mesocortical, nigrostriatal, and tuberoinfundibulnar
what is meant by the mesocortical pathway
Dopaminergic neurons project from the VTA to the prefrontal cortex
Dopaminergic neurons activate glutaminergic neurons in the PFC that project to multiple regions, including the NAc
Mediates incentive salience and conditioning behaviors
Cravings during abstinence is due to activation of glutamatergic projections to the NAc
Mesocortical neurons originate in the ventral tegmentum and project to the orbitofrontal and prefrontal cortex
• NAc: nucleus accumbens, PFC: prefrontal cortex
define addiction
Addictive behaviours come from remodeling of the previously mentioned system
• This all comes from the increase in dopamine that we experience when we take drugs
what is meant by synaptic plasticity
- Plasticity is when you reinforce some pathways and not others
- Long term potentiation: strengthening of synapses
- Drugs can also dictate the amount of neurotransmitter that is released e.g. increasing the amount of dopamine that is released
- Interneurons become drowned out in the nucleus accumbens
what are transcriptional changes
CREB activation increases the intrinisic excitability of MSN
contributes to synaptic plasticity in the nucleus accumbens in the D! and D2 type NAc MSNs
FosB increases AMPA receptor function in the D1 type MSNs but does the opposite in D2 type
CREB and FosB implicated in the epigenetic modifcations
- CREB-TF is a cellular transcription factor – it has a role in neuronal plasticity and long-term memory formation in the brain
- Medium spiny neurons (MSNs) are a special type of GABAergic inhibitory cell representing 95% of neurons within the human striatum
- Delta Fos B is the main player in addiction – only unregulated in neurons that have been changed by illicit substances
- Used as a biomarker to detect addiction
- AMPA receptors (AMPAR) are both glutamate receptors and cation channels that are integral to plasticity and synaptic transmission at many postsynaptic membranes
- Changes in brain structure will still be detected for a long time after use
give an example of neural mechanisms of drug seeking
Rat presses pedal that eventually releases cocaine
• Eventually, rat will start associating the environment with the drug
• It will start pressing the pedal more and more to recreate this
• Goal-directed behavior will turn into habitual drug seeking – the rat has now lost control, it is compulsively seeking the drug
what is meant by tolerance
a reduction in repsonse to a drug after repeated administration
withdrawal effects often accompanies tolerance
due ti reduced drug receptor binding or reduced postsynaptic action of drug
what is meant by sensitisation
left shift in the drug dose response
less drug to achive same effect
occurs after an acute dose
what are some of the effects of alcohol long term
- Pre-frontal cortex (decision-making, behaviour, inhibitory control)
- Temporal lobe (interpretation of sounds, language)
- Hippocampus (memory formation)
- Frontal lobe (speech, emotions, reasoning)
- Parietal lobe (senses)
- Cerebellum (movement, balance)
- Brain stem (body communication - can cause heart attacks or respiratory depression)
how does alcohol cause substance abuse
Primarily, alcohol works via GABA A receptors (ligand gated ion channels) – conduct chloride when a ligand binds to the receptor
• These receptors also have an additional binding site that alcohol can bind to – this increases the amount of chloride that passes through
• Alcohol abuse can increase in mRNA expression in the amygdala – an increase in GABA in the synaptic cleft reduces these emotions
how does cocaine cause substance abuse
Amphetamine, Cocaine & Nicotine induce Long-term potentiation (LTP) in the VTA and NA. They achieve this via D5 dopamine receptor-mediated activation of the cAMP-dependent protein kinase A (PKA) pathway and modulation of NMDA receptor subunit composition leading to increased activation. NMDA receptor activation and large influx of Ca2+ induces long-term potentiation (LTP) of synaptic neurotransmission. This causes increases in dendritic spines (synapses) and insertion of new AMPA-receptors (i.e. the same amount of glutamate next time causes a bigger response).
Cocaine crosses the blood brain carrier
• Normally, we have a dopaminergic neuron that instigates the release of dopamine into the synaptic cleft – which either binds to D1 or D2 receptors
• It then gets reabsorbed back into the presynaptic neuron
• Cocaine acts by binding to the dopamine transporter, blocking the removal of dopamine from the synapse
• Dopamine then accumulates in the synapse to produce an amplified signal to the receiving neurons
• This is what causes the euphoria commonly experienced immediately after taking the drug
- Even just taking cocaine once causes structural changes for months or even years
- More AMPA receptors = increases excitability
how does amphetamines cause substance abuse
- Central nervous system (CNS) stimulant (alcohol is a depressant)
- Attention Deficit Hyperactivity Disorder (ADHD), narcolepsy and obesity • Abused as a performance enhancing drug
- Recreationally used due to euphoric nature of its effects
- E.g. Adderall, Ritalin
how does dopomine cause addiction
Promote presynaptic dopamine release
• Increase vesicular release of dopamine
• Inhibit monoamine oxidases – reduce the reuptake of dopamine • Inhibit DAT1 – inhibit dopamine reuptake transporters
how does noradrenaline cause addiction
Release noradrenaline from stores in adrenergic neurons and block the reuptake of released noradrenaline into the neuron
Dopamine and noradrenaline are crucial neuromodulators controlling brain states, vigilance, action, reward, learning, and memory processes. Ventral tegmental area (VTA) and Locus Coeruleus (LC) are canonically described as the main sources of dopamine (DA) and noradrenaline (NA)
how does opioids cause substance abuse
- Long-term use = tolerance
- Physical dependence results in unpleasant withdrawal symptoms
- Respiratory depression – overdose with benzodiazepines = death
- Methadone replaces the opioid effect but limits the withdrawal symptoms
• In the normal communication process, dopamine is released by a neuron into the synapse (the small gap between two neurons), where it binds to specialized proteins
called dopamine receptors on the neighboring neuron.
• By this process, dopamine acts as a chemical messenger, carrying a signal from neuron to neuron.
• Enzymes in the brain convert heroin or prescription painkillers into morphine
• The morphine quickly binds to the brain’s opioid receptors (mu receptor)
• This binding action activates the receptors, flooding the brain with large amounts of dopamine
• This “rush” causes pain relief and euphoria at much more intense levels than can be naturally produced
• It has been proposed that the analgesic effect of opioids works by suppressing the inhibitory influence of the neurotransmitter GABA (gamma-aminobutyric acid) on neurons that form part of a descending antinociceptive pathway
what is menat by opioid addiction therapy
Opioid addiction therapy
• Opioid Replacement Therapy (ORT) replaces DoA with longer acting, but less euphoric opioid
• ORT reduces withdrawal & craving symptoms – thus, the patient can regain stability in life • 40-65% of ORT patients avoid opioid use entirely
• 70-90% of ORT patients significantly reduce opioid use
what is methadone
Methodone is a full miu opioid receptor agonist
• Methadone is used because it has a slow onset of action
• When taken orally, it has a long elimination half-life, which allows it to be used as an ORT or a detoxification agent
• The dosing range for Methadone can range between 80-150mg – typically start at 20-30mg
• After the patient shows improvement, you’ll start to reduce the dose of methadone (known as a dose reduction schedule)
• Usually, the longer the reduction period the less likely the patient is to relapse
• Methodone can cause a prolonged QT interval in some patients, suggesting that patients using methodone require close monitoring
• An isomer of methodone is Levomethadone (L-isomer)
• Levomethadone acetate is a longer acting derivative of methadone
• It is a full miu opioid receptor agonist
• Levomethadone is twice as potent, meaning
it can be dosed 3 times a week, compared to
methadone which has to be dose daily
• Given as 20mg doses every other day
what is naltrexone
Oral long acting opioid antagonist
• Has a high affinity for the miu opioid receptor
• Daily dose would be around 50mg (usually lasts for up to 24h) – this will block the pharmacological effects of 25mg heroin for up to 24h
• Increasing dose will increase its duration of action for 48h
• Very good at preventing the effects of heroin
• Dependence on Naltrexone doesn’t usually develop unlike methadone and levomethadone
• Associated with few side effects, usually quite a safe drug
• Despite these ideal properties, only weak evidence supports its effectiveness in clinical settings
• Primary problem is usually adherence to the medicine
what is buprenorphine and naloxone
Co-therapy for addiction
• Partial agonist of full miu opioid receptors
• Binds and activates opioid receptor but only has partial efficacy compared to a full agonist even if there is maximum receptor occupancy
• Recommended dose: 24-32mg (BUP only)
• Expected to produce fewer withdrawal symptoms due to it being a partial agonist, relative to things like methadone (not yet confirmed)
• Combined in a 4:1 ratio with naloxone
• Naloxone is a miu opioid antagonist, has a high affinity
• When taken orally, BUP effects at the opioid receptor will dominate the combination – this means the naloxone effects will be negligible
• This is due to the low bioavailability of naloxone when taken orally (it has a poor absorption rate)
• When you inject it, its bioavailability is much better
• Naloxone comes into play when someone is prescribed this co-therapy but they want to misuse it i.e. they inject it/inhale it
• Now, naloxone is the dominant compound and its antagonistic effect on the miu opioid receptor reduces the euphoria
what do you do for cocaine addiction therapy
ust don’t do it bro
• There’s actually no pharmacological intervention that’s been approved for cocaine addiction
• Researchers are exploring neurobiological targets, primarily focusing on dopamine (Dopamine D3 receptors)
• Cocaine actually induces changes in the brain related to neurotransmitters e.g. serotonin, dopamine etc.
• Dopamine is responsible for all the addictive behaviors
Cocaine Hydrolases (CocH3-Fc)
• Researchers found that synthetically produced hydrolases were capable of accelerating cocaine metabolism
• Main problem was that these enzymes had a very short half life of around 8 hours
• So they engineered an enzyme based on the observation of an antibody – they noticed it had a very long half life
• This was due to the Fc region (Fc domain)
• They created a long acting cocaine hydrolase that was combined with Fc region of an antibody
• This molecule had a half life of around 20 days
• They found that cocaine clearance was accelerated by the enzyme
Treatments for alcohol addiction
• Disulfiram (DF) – deterrent to maintain abstinence
o 200-500 mg OD
o Aldehyde-dehydrogenase enzyme inhibitor, causing an accumulation of acetaldehyde during ethanol intake
o May lead to “acetaldehyde syndrome” - characterized by heat in the face, purple rash in the neck and torso, tachycardia, hypertension, nausea, vomiting, diarrhoea, and headaches with breathing alterations. These will appear 5-15 mins after drinking alcohol, and last from 30 mins to a number of hours.
o DF is not indicated in the presence of severe liver disease, peripheral neuropathy, optic neuritis, or psychotic patients
• Naltrexone (NTX) – anti-craving in patients with reward cravings
o 380mg IM monthly
o NTX is a μ and κ-opioid receptor antagonist; effect relies on its ability to reduce dopamine release in the NA.
o Therefore, alcoholic patients who continue to drink during treatment with NTX report being less inclined to consume large amounts of alcohol (anti-reward therapy)
o High levels of craving, a positive family history of alcoholism and the presence of a specific polymorphism, Asn40Asp (A118G) single nucleotide polymorphism (SNP), in the μ-opioid receptor gene
• Acamprosate (ACM) - anti-craving in patients with relief craving
o For Adult 18–65 years (body-weight up to 60 kg): 666 mg once daily at breakfast and 333 mg twice daily at midday and at night; For Adult 18–65 years (body-weight 60 kg and above): 666 mg 3 times a day.
o NMDA receptor antagonist (Neuroprotective) which normalizes glutamate-induced hyperexcitability and prevents excessive neuronal calcium influx
o Causes a reduction in alcohol cravings by improving dysphoria
o Not recommended in patients with renal failure
o Side effects: diarrhoea, headaches, dizziness
• Nalmefene (aka Selincro) – alcohol reduction in patients with high drinking risk level
o 18 mg daily if required, taken on each day there is a risk of drinking alcohol, preferably taken 1–2 hours before the anticipated time of drinking, for 6 months.
o µ & δ-opioid antagonist and κ-opioid partial-agonist
o Recommended as a possible treatment for people with alcohol dependence who:
are still drinking more than 7.5 units per day (for men) and more than 5 units per day (for women) 2 weeks after an initial assessment, and
do not have physical withdrawal symptoms, and
do not need to either stop drinking straight away or stop drinking completely.
treatment for nicotine
• Nicotine replacement therapy (NRT)
o Skin patch, inhaler, nasal spray, gum
• Bupropion
o an antidepressant shown to reduce the severity of nicotine cravings. It blocks the dopamine transporter, so increases levels of dopamine in the Nucleus Accumbens.
what is acamprosate
This drug prevents alcohol withdrawal symptoms by reducing glutamine surges • Some suggest that acamprosate is a weak NMDA receptor antagonist
• The mechanism of action is still inconclusive
what are some future direction for addiction therapy
nti-drug vaccine that consists of a Hapten (a molecule that can elicit a production of antibodies)
• This is conjugated to a carrier & addition of adjuvant (an agent that improves the immune response to antibody production)
• Since psychoactive drugs lack immunogenicity, it is necessary to couple the Hapten with an immunogenic carrier protein via a linker to induce an immune response and further formulate the vaccine with an adjuvant to further improve the magnitude of response
• So essentially, patient gets vaccinated and will start generating polyclonal antibodies
• These will then start to sequester the psychoactive drug molecules in the periphery and prevent them from crossing the blood brain barrier
• The selection process provides you with more specific monoclonal antibodies – these are similar to polyclonal antibodies but can also prevent overdosing
what is meant by recreational drug
Recreation: The process or means of refreshing or entertaining oneself after a period of work by some pleasurable activity
Drug: A substance that acts on the nervous system e.g. a narcotic or stimulant, especially one causing addiction
how do you ensure quality
- PCQ = purity, consistency and quality the foundation of good and safe medicines’ production
- Is there any such thing as quality control when drug formulations are made up by layperson (responsibility free) with no interest in PCQ?
how are illegal drugs taken
- IV-intravenously by injection (“shoot-up”: heroin, temazepam) • Subcutaneous depot by injection (“popping”: heroin)
- Inhalation (smoking: heroin, crack-cocaine, marijuana)
- Insufflation (“snorting”: amphetamine, cocaine)
- Orally (pills: MDMA, barbiturates; micro-dots, bombs, POMs) • Rectally (“bombs”, “plugging”: heroin)
- Intra-vaginally (“bombs”: heroin)
When all their veins are “shot through” seasoned heroin addicts then are forced to look for easily viewed “last ditch” veins and so inject into their perineum and genitalia
what are some of the risk factors caused from addiction
Hygiene
• The following microbes are routinely found in recreational drugs but never in ‘sold’ commercial medicines
• Bacterial
– Bacillus cereus [soil]
– Clostridium botulinum (C. bot.) C. novyi, C. perfringens, C. sardellii [soil]
– Streptococcus spp. cause of necrotising faciitis [faeces]
– Staphylococcus spp. [poor hygiene]
– E. coli [poor hygiene, faecal bacterium]
– Bacillis anthracis (anthrax) [soil]
– Serratia liquifaciens [soil, rodent gut]
• Fungi
– Geotrichum spp. [soil, faeces]
– Trichosporon spp. [soil]
• Viruses
– Polioviruses, Coxsackie viruses and Echoviruses [soil; human, domestic animal and rodent gut]
whats the difference between a manufactured medicine and a illegal drug
The difference between the manufacturer of a drug [illicit] and a medicine is in terms of “intent.” A medicine is beneficial, bespoke or purposeful, a drug is hedonistic and purely for self-gratification. The former takes a lot of care, knowledge and altruism. The latter involves significant disregard for others, indifference or malice
what are the laws of driving under the influence
Driving Under the Influence” Laws
• The first drink driving law arrived in 1872 and another in 1925
• Road Traffic Act 1962, provided for the first time analytical tests on the presence of alcohol in bodily fluids
• Road Safety Act 1967 made it illegal to drive or be in charge of a vehicle after consuming so much alcohol that the proportion of it in the blood, breath, or urine exceeds the ‘prescribed limit’. The prescribed limits were set at:
– 35 mg of alcohol in 100 ml of breath
– 80 mg of alcohol in 100 ml of blood
– 107 mg of alcohol in 100 ml of urine
• The Crime and Courts Act 2013 created a new limits-based offence of drug-driving by inserting a new section 5A in the Road Traffic Act 1988. Under the Act, a driver can be convicted if the amount of drug proportion of the drug in their blood or urine exceeds the specified limit
it is illegal to drive if you
It is illegal to drive if you:
• Are either unfit to do so because you’re on legal or illegal drugs
• Have certain amounts of illegal drugs in your blood (even if they haven’t affected your driving)
• Legal drugs are prescription or over-the-counter (OTC) medicines. If you are not sure if you should drive, talk to any healthcare professional
• The police can stop you and make you do a ‘field impairment assessment’ (sobriety test) if they think you are on drugs. They can also use a roadside drug kit (roadside chemical test) to screen for cannabis and cocaine (and others)
• If they think you are unfit to drive because of taking drugs, you will be arrested and will have to take a blood or urine test at a police station
• You could be charged with a crime if the test shows you’ve taken drugs
what is drug driving
n 2012, the UK government announced a new offence in regard to driving with a specific controlled drug in the body above that drug’s accepted limit.
Following a report from a panel of experts and a consultation the government standpoint is:
• a zero tolerance approach to 8 illegal drugs
• a road safety risk based approach to 8 drugs for medical uses
• a separate approach to amphetamine that balances its legitimate use for medical purposes against its abuse
what are the drug driving guidelines
Table of drugs and limits
Amounts of dosage would equate to being over the specified limits are not indicated but healthcare professionals should be able to advise (There are too many variables, such as physical characteristics, where each person will metabolise the drug at different rates. Eating or drinking will also have an effect on the blood concentration)
Information for healthcare professionals
The Department for Transport published guidance and reference documents for healthcare professionals. Their purpose is to make sure people taking prescription and over-the-counter drugs understand the new offence and their responsibility not to drive whilst impaired
Sobriety Tests and RCT
Chemical tests are now very specific and accurate with a low LOD
• Since 2017 sobriety tests linked to quantifiable chemical tests (RCT) form the basis of legal action. Sobriety plus chemistry provides a strong argument
• Sobriety tests cover:
– Verbal incoherency
– Walk-the-line
– Touch-the-nose
– Stand still, stand on one leg
– Response to posed questions, simple calculations
– Breath test
– Gaze and pupil dilation
These form the basis of an inability the handle the vehicle
• Behaviour linked to precise chemical concentration
what are some of the penalties for drug driving
enalties for drug driving (or working)
If you’re convicted of drug driving you’ll get:
• A professional FTP ban
• a minimum 1 year driving ban
• an unlimited fine
• up to 6 months in prison
• a criminal record
• Your driving licence will also show you’ve been convicted for drug driving. This will last for 11 years.
• The penalty for causing death by dangerous driving under the influence of drugs is a prison sentence of up to 14 years
These have devastating consequences on employability
what to expect of a drug driving
he police will use a drug screening device (DSD) to establish the presence of drugs.
These can test up to 6 drugs in a single test of a person’s saliva.
• 2019: The DSDs are now ~100% accurate and therefore can be used as evidence in a court case. They have been constituted to avoid false readings both positive and negative and are unaffected by eating and drinking prior to the test
what tests are done to test for drug driving
SalivaConfirm4®: 4 Drug Screen – Saliva test
• Easy-to-read drug test kit that uses saliva for the sample.
• Evidence of the following illicit drugs at and above the stated levels: – AMP Amphetamines (>50 ng/ml)
– COC Cocaine (>20 ng/ml)
– MOR Heroin/Opiate/Morphine (>40 ng/ml)
– THC (Cannabis >10 ng/ml)
what is drug wipe
The detection limit of the active substance Δ9-THC in saliva is now 10 ng/ml.
• All results remain valid for 10 minutes after the test is completed.
• Easy, quick and hygienic handling with lowest sampling volume and colour indicator. • DrugWipe® S saliva test is robust. The test cassette is designed for a safe transport
how do drug kits work
You deposit some body fluid at the sample pad
- At the sample pad there are latex beads that are tagged with antibodies that detect specific drugs
- When the antibodies detect the drug, they bind to it, making them larger and heavier 4. As a result, they travel slower down the length of the test strip, and you end up with a positive line
- The empty latex beads travel the furthest because they are lighter (control)
how does spectrometry work for drug testing
Colour evolution based of chromatography (using antibody coated beads) or multiple redox reactions (similar to pregnancy or ovulation test kits)
– Use of specific enzymes to promote a response: colour, loss of colour or produce fluorescence/luminescence
• Electrochemical response
– Based on redox reactions that may involve an enzyme (similar to blood sugar kits) liberating electrons and producing a measurable current
what are the different pharmacy harm reduction approach
Needle Exchange
• Supervised Consumption
• Dispensing
• Health & Well being advice
what is meant by harm reduction
Harm reduction refers to policies and practices that try to reduce the harm that people do to themselves or others from their drug use.
• It can be contrasted with primary prevention which tries to prevent people using drugs in the first place, or to stop them using once they’ve started
why do we do harm reduction
Harm reduction focuses on ‘safer’ drug use and has also been developed as a way of educating young people about drug use, rather than telling them to ‘Just Say No’.
• There have been arguments over the morality of harm reduction. Some people say that it condones or promotes drug use, but people who support it say it is realistic, helps keep drug users safe and respects individual choices and freedoms
what harm reduction advise would you give for injections/shooting
- Injecting / Slamming / Shooting / Banging up
• Never share ANY injecting equipment
• Never re-use a needle
• Visit your local needle exchange
• Injecting any drug is an extremely high-risk practice – best avoided!
• Always dispose of equipment safely – in a sharps bin
• Use with other people that you know
Injection drug use
• Injection drug use and other high-risk behaviours are the cause of significant morbidity and mortality. Therefore, it has been the focus of many health promotion strategies
• Pharmacists are recognized as one of the most accessible health care professionals for the general population and are in an ideal position to reach injection drug users (IDUs)
• Community pharmacies are acknowledged as important, underutilized resources in preventing the spread of HIV and other blood-borne infections such as: Hepatitis B & hepatitis C and bacterial infections
what harm reduction advise would you give for snorting
Alternate nostrils
• Rinse nose with water before and after snorting
• If you get nosebleeds or headaches you’re using too much! • Use a clean straw & not a bank note: money carries lots of germs
• Don’t share rolled bank notes or straws: you risk getting a blood-borne viral infection (like Hepatitis C / BBV)
what harm reduction advise would you give for swollowing / dropping/ eating
Break pills into 1⁄2 or 1⁄4 & wait up to 3 hours before re- dosing.
• The drug has to pass through your digestive system so this method is less intense but more long-lasting than some others
• Eat a light meal a few hours before to reduce stomach aches, nausea or vomiting
• Regular use can give you stomach ulcers & other digestive problems
what harm reduction advise would you give for Smoking / Chuffing / Inhaling / Toking
Don’t hold your breath after inhaling, this causes more damage to the lungs
• Generally results in a shorter, more intense experience
• Regular smoking of any drug can cause respiratory problems like bronchitis and even cancer
• Choose a non-toxic pipe (e.g. a water bong) & avoid plastic or metal
what is the needle exchange programme
Needle Exchanges were set up in the 1980s
• This was in response to the sharp increase in the spread of Blood Bourne Viruses (BBVs) – Hepatitis B, Hepatitis C and HIV amongst injecting drug users
• Providing injecting equipment has proven to be one of the most effective ways in reducing the spread of BBVs’
Aim
To provide drug users with the appropriate help and support to remain healthy until they are ready and willing to stop injecting and achieve drug-free life
Objectives
• Promote safer injecting practices
• Reduce the risk of sharing and high risk injecting behaviour
• Provide sterile injecting equipment
• Ensure safe disposal of used equipment- prevent the spread of BBV’s
• Increase access to pharmacy-Provide and reinforce harm reduction messages including advice on overdose prevention (e.g. risks of poly-drug use and alcohol use) via relevant publications and materials.
• Signpost to services - support individual to engage in recovery from substance misuse
The groups of people likely to use a needle exchange
Needle exchange is not just for people who inject Heroin, Crack or Amphetamine
The service may also
• Performance or image enhancing drugs (PIEDs) such as anabolic steroids (to enhance physical appearance or strength)
• Psychoactive compounds, chemicals, plants or medicines
• Ketamine
what is the drug misuse act
Section 9a was drafted to enable prosecution of drug dealers who sell complete ‘kits’ of drug and implements to take them, and/or are raided and although not found to be in possession of drugs, do have all the paraphernalia needed to take them.
• 1998 – Pharmacist wrote a letter to the pharmaceutical journal questioning the legality of pharmacists selling citric acid to potential misusers
• Pharmacists stop supplying citric acid
• Misusers turned to lemon juice and vinegar for acid –with reports of eyesight issues and blindness from candida infection
2003: changes to section 9A MDA 1971 made it legal to supply • Swabs
• Utensils for preparation of control drugs
• Citric acid/ascorbic acid
• Filters
• Sterile Water ampules up to 2ml
NICE public health guidance 52
A pharmacist may supply specified drug paraphernalia to illicit drug users.
what does the pharmacy need to know
All staff need to be trained on the scheme • Need to be Hepatitis B vaccinated
• Specific SOP/Protocol in Place
• Area of the pharmacy for storage
• Record keeping
what does the client need to know
Need to know how to access the scheme
• Need privacy and confidentiality
• Need clean full packs to take quickly and easily • Needs to respect pharmacy environment
what do the drs need to know
SMS run training and authorise pharmacy
• Pharmacy orders stock from SMS
• PCO collects sharps bins
• Colleagues do not touch returned sharps
• Client comes in, places sharps in bin and picks up new pack. • Payment – Locally commissioned service
what is naloxone
Naloxone is an opioid antagonist; it antagonizes the effect of natural and synthetic opioids by completely or partially reversing the effects of CNS depression, mainly the respiratory depression
what does the opiate sub therapy entail
Enrolment & assessment
• Once they make an informed decision about treatment then
• Pharmacist will get them to fill the relevant referral forms to enrol them at drug treatment programme
• Receive an appointment for formal assessment covers:
• drug use ( past and present)
• health (mental & physical)
• employment
• social history
Treatment of addiction
• It is important that all aspects of patients life are addressed-rarely drug use is the only problem
• Identify their aims and expectation from the treatment- will help to take full part in their treatment
First aim of the treatment
To control drug use with substitute prescribing & support that will lead to a stable lifestyle, which enable other issues such as: mental health, childcare etc.
Methadone & Buprenorphine – Opioid replacement
Treatment choice depends largely on:
• Patient factors & their level of illicit drug use
• The dose is titrated until symptoms of withdrawal are prevented- SMS clinics • The overall outcome: abstinence from both illicit and prescribed medications
The Community Pharmacist – supervised consumption
• Patient is titrated at the SMS clinic
• Agreement is made with SMS, Client and Pharmacist for the supervised consumption • Supervision is taken over by community pharmacy
In order for community pharmacist to supervise consumption they: • Must have a private area
• Have sufficient capacity for new patient
• Ability to confirm Rx and prescriber genuine
• Understanding of SMS service and client needs-referral to other health and social care professionals when appropriate
• Undertake training
why community pharmacy
Can legally dispense CD2 medication
• Convenience for client – increases compliance • Long opening hours
• Healthcare Professional on the high street
• Cost effective
Disclosing confidential information – MEP
- Decisions about disclosing confidential information can be complex. In most situations you do not have to disclose information immediately
- However, there will be limited situations where to delay is not practical, for example if this may cause risk to another person
- You should take the necessary steps to satisfy yourself that any disclosure sought is appropriate and meets the legal requirements covering confidentiality
Shared care policy- between prescriber, patient and pharmacist
When patient misses scheduled pick-ups or supervision consumption for e.g. 3 consecutive days
• Concerns about a patient’s health or well-being
• Patient attends intoxicated-none adherent
