Substance misuse

Question 1

A definition of substance misuse

Answer 1

• Substance abuse or misuse is formally defined as the continued minuse of any mind-altering substance that severely affects a person’s physical and mental health, social situation and responsibilities

Question 2

A definition of drug dependence

Answer 2

• A state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, characterised by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience psychic effects, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present

Question 3

Classification os psychoactive drugs

Answer 3

• Stimulants: speed up CNS to increase neural activity in the brain. Effects = more alert
  
  • Examples: Amphetamine, cocaine, crack, ecstasy, crystal meth
• Depressants: slow down CNS to suppress neural activity in the brain. Effects= drowzy, calm
  
  • Examples: Alcohol, Opiates and BZs
• Halucinogens: Alters the perception of the world by distorting what is seen or heard. Effects: Vivid images, colours, sounds
  
  • Examples: Psilocybin (Magic mushrooms), LSD

Question 4

The facts and figures

Answer 4

• The current cost of drug-related crime is estimated to be £13.4 billion per year
• 50% of all acquisitive crime may be committed by someone using heorin, crack or cocaine powder
• The estimate is there are approx. 250,000 regular heorin/crack users
• Overall drug use is decreasing in the UK, but an older generation is now presenting for treatment
• Between 2-3 million people in the UK are smoking cannabis on a regular basis

Question 5

Facts and figures

Answer 5

• The current cost of alcohol misuse in the UK is estimated to be £18 - £25 Billion
• For the NHS alone, the financial burden for harmful alcohol use is 2.7 billion alone (and rising)
• Estimated there are 1.6 million people in the UK with mild, moderate or severe alcohol dependence
• In 2018, there were 4359 deaths registered with the cause being drug poisoning, which included both legal and illegal drugs. The largest number since records began in 1993
• The ratio of deaths male:female was 3:1 and over 2/3rds were attributed to illicit drug use
• Approximately 30% of all drug-related deaths had an element of alcohol abuse as an attached cause in addition to the drug recorded

Question 6

what is recovery

Answer 6

• A process through which an individual can move on from their problem drug use to a drug-free life as an active and contributing member of society
• Each individual will have a different recovery journey with different goals and challenges along the way
• The service user’s needs and aspirations are placed at the centre of their care and treatment

Question 7

Supervised consumption

Answer 7

• Supervision of consumption, by an appropriate professional provides the best guarantee that a medication has been taken as directed. This has advantages to both the patient and the service providing the prescription. It’s a three way contact. User, service and pharmacy
  *

Question 8

What are the disadvantages of supervised consumption

Answer 8

• Patient feel that they are not trustworth
• Time consuming i.e. subtex/buprenorphine 3-5 minutes
• Patient may feel that they are being, judged depending on the way they are spoken too
• Unconfortable about asking patient to open mouth to show tablet has been dissolved or medication has been swallowed
• Confronting patient if you believe they have concealed medication
• Judging not to give medication if patient is intoxicated

Question 9

Methadone initiation and maintenance treatment

Answer 9

• Starting dose between 10-40mg depending on prescriber’s assessment
• Dose increase of no more than 10mg in one day and 30mg in one week
• Allow a few days between dose increases for assessment (time to reach steady state 3-10 days)
• Titrate dose until patient is stable and doesn’t experience withdrawal or intoxicating effects
• Daily doses vary from 30-120mg
• May take several weeks to get dose right
• ECG monitoring for doses over 100mg

Question 10

Methadone side effects

Answer 10

• Constipation
• N+V
• Dry mouth, eyes and nose
• Constricted pupils
• Rashes
• Sweating
• QT prolongation ECG monitoring for dose 100mg + RD

Question 11

Buprenorphine initiation and maintenance treatment

Answer 11

• Patient must be withdrawing before administration first dose at least 6 hours after last use of opioid
• Starting dose 4-8mg
• Half-life is 32-35 hours
• Daily incremental doses between 2-8mg
• Usual daily doses between 12-16mg
• Tablet strengths 0.4, 2, 8mg for tailored dosing
• Max daily dose 32mg for buprenorphine and 24mg for Suboxone
• Longer half-life, SL tablet acts as a partial opioid antagonist
• SE profile- Similar to methadone,
• Switching from methadone to Buprenorphine. Reduce to max dose of 30mg, methadone daily then allow at least 24 hours before initiating buprenorphine therapy

Question 12

Espranor 2mg and 8mg oral lyophilisate

Answer 12

• Espranor are slightly different to the generic buprenorphine tablet
• Service user to drink water before placing wafer on top of tounge (rather than under it)
• They are in the form of a wafer, which means they will dissolve quicker
• It usually dissolves in about 15(s) food and drink should also not be consumed for 5 minutes after the wafer has dissolved
• Dosage range is 2mg-18mg (outside this range is unlicensed)

Question 13

Espranor Advantages and disadvantages

Answer 13

• Dissolves rapidly
• Difficult to palm
• Pleasent tasting
  
  • Brands go out of stock
  • No dosage equivalent below 2mg and above 18mg

Question 14

Buvidal S/C injection- the future is now

Answer 14

• Weekly or monthly Fluid Crystal injection depot technology
• Administration of buvidal is restricted to healthcare professionals and there is no take home dose or self-adminstration allowed
• Weekly- 8, 16, 24, 32mg
• Monthly- 64, 96, 128mg

Question 15

Initiation of treatment in patients not already receiving buprenorphine

Answer 15

• Patients who have not previously been exposed to buprenorphine should receive a sublingual buprenorphine 4mg dose and be observed for an hour before the first administration of weekly Buvidal to confirm tolerability to buprenorphine
• To avoid precipitating an opioid withdrawal syndrome, the first dose of buprenorphine should be started only when objective signs of mild to moderate withdrawal are evident

Question 16

Missed doses

Answer 16

• To avoid missed doses
  
  • Weekly Buvidal doses may be adminstered upto 2 days before or after weekly scheduled appointment
  • Monthly Buvidal doses may be administered upto one week before or after the monthly schedule appointment

Question 17

Supervised consumption tips

Answer 17

Question 18

Patient information the pharmacist can provide

Answer 18

• Risk of overdose, poly drug use (BZs and Alcohol)
• Prevention and management of overdose
• Safe storage of medication at home
• Advice on dental care, diet, medications, alcohol consumption
• Safe injecting (harm reduction) BBV’s
• Pharmacy first (Minor Ailment scheme) if applicable
• Referral into treatment (sign posting)
• Smoking Cessation clinics
• Sexual health clinics
• EHC + Free condoms

Question 19

Needle and syringe programmes NICE guidance

Answer 19

• Encourage people who inject drugs to use the services on offer
• Provide as many needles and syringes and other injecting equipment as someone needs. A variety of needle lengths and gauges should be made available
• Provide sharps bin and advice on how to dispose of used equipment safely
• Provide advice on safer injecting and ways to get help to stop using drugs or switch to non-injecting methods
• Advice and services to help them stop injecting
• Treat people requesting needle exchange with respect, confidentiality and treated them in a non-stigmatising way

Question 20

Needle and syringe programmes in pharmacies

Answer 20

1. NICE guidance states that pharmacies should be used to gain geographic and demographic coverage of users of needle and syringe programmes
2. In community pharmacies providing level 2&3 services (involving the distribution of more specialist, bespoke equipment plus health promotion advice), staff should be willing and able to offer advice on the full range of drugs that clients may be using and how to prevent and manage an overdose
3. Pharmacy staff need to be trained in the safe disposal of returned used equipment and what to do in the event of a needle stick injury
4. Commissioners of Needle and Syringe Programmes should provide services to meet the needs of people who inject image and performance enhancing drugs
5. Commissioners and providers should ensure level two and three programmes used by a high proportion of people who inject image and performance enhancing drugs, provide specialist services for this group
6. Community pharmacies providing a level three service should offer people who use image and performance enhancing drugs access to appropriate injecting equipment
7. Providers should ensure that their policy includes the provision of the service for those aged under 18 years. Service users should be assessed by providers for their consensual age, seriousness of misuse, whether their harm or risk is increasing, and the general context in which they are using drugs and encourage young users to contact specialist services

Question 21

Drug alerts, harm reduction campaigns and significant incidents

Answer 21

• Drug Alerts will be communicated through PharmOutcomes, so make sure you are logging on a regular basis
• Harm Reduction Campaigns will also be communicated to you through PharmOutcomes
• The five Rs of drug administration
  
  • Right drug
  • Right dose
  • Right route
  • Right time
  • Right patient
• When Reporting Significant Incidents be open and honest. Check patient is okay. Report to AO, Prescriber, Own Organisation and do a Root Cause Analysis and share the learning

Question 22

Preventing and treatment of illicit or prescribed orpiate drug overdose

Answer 22

• Advice to give to substance misusers Smoke the heroin instead of injecting it as potency of injecting can be two and a half to five times stronger than smoking it. There are more overdoses caused by injecting than smoking heroin
• Test the potency first by only using a small amount to prevent overdosing
• If injecting rotate injecting sites as using the same vein and site may lead to vein collapse known as “blown veins” and abscesses and blood infections
• If injecting use clean equipment and do not share paraphernalia
• Do not smoke or inject illicit drugs alone as if someone overdoses, the person with them can raise the alarm and get help

Question 23

Preventing and treatment of illicit or prescribed opiate drug overdose

Answer 23

• Known substance misusers should be given a Naloxone Injection Pack and trained on how to use it along with family, friends and associates, as this will save a life of someone who has overdosed on opiates as it is an opioid antagonist and reverses the effects of the opiate
• Do not mix Heroin with drugs which cause respiratory depression such as alcohol, other opiates, benzodiazepines and tricyclic antidepressants, as they can all potentiate the effect of respiratory depression
• If patient is on a Opiate Substitution Therapy, they must store their medication safely if taking home as a 5ml dose of methadone 1mg/ml can kill a child
• Do not use illicit drugs on top of normal ‘holding’ dose of methadone
• Do not buy ‘Street’ Methadone as the strength may differ from dilution so the potency can not be assumed to be 1mg/ml

Question 24

Signs and symptoms of opiate/opioid overdose

Answer 24

• Pinpoint pupils
• Acting drowsy/having staying awake
• Sudden mood shifts
• Experiencing nausea
• Not knowing where
• Uncontrolled vomitting
• Acting confused
• RR <12/min
• Moving slowly if at all
• Asking just ot be allowed to go to sleep
• Acting as if nothing mattered anymore

Question 25

Naloxone -

Answer 25

• Call ambulance and, if trained, administer Naloxone 0.4ml of a 1mg/ml injection to outer thigh muscle or arm deltoid muscle
• Administer every 3 minutes until ambulance arrives.
• Observe the patient, particularly respiratoryrate (i.e. number of breaths per minute). Normal respirationratefor an adult at rest = 12 to 20 breaths per minute. Under 12 or over 25 breaths per minute while resting = abnormal
• Keep patient awake and prevent them from going to sleep by gently tapping on their shoulders and talking to them until ambulance arrives
• Remember: tell the ambulance crew exactly what has happened and how much Naloxone you administered (if you were trained to do so) as well as the suspected drug which has caused the overdose, if known

Question 26

What to do in a case of opioid/opiate overdose

Answer 26

• Patient should be placed in the recovery position (lying on their side, mouth open pointing towards the ground).
• Call ambulance and, if trained, administer Naloxone 0.4ml of a 1mg/ml injection to outer thigh muscle or arm deltoid muscle
• Administer every 3 minutes until ambulance arrives
• Observe the patient, particularly respiratoryrate (i.e. number of breaths per minute). Normal respirationratefor an adult at rest = 12 to 20 breaths per minute. Under 12 or over 25 breaths per minute while resting = abnormal
• Remember: tell the ambulance crew exactly what has happened and how much Naloxone you administered (if you were trained to do so) as well as the suspected drug which has caused the overdose, if know