W20 Substance Misuse Flashcards
What are the Tiers of Treatment in the Substance Misuse System? (4)
Tier 1: Non-drug treatment specific services
Tier: 2: Open access services and harm reduction services
Tier 3: Structured Community-Based Services – Specialist and GP
Tier 4: Rehab
The Misuse of Drugs Act 1971
What 3 classes are illegal drugs categorised into?
Illegal drugs are divided into classes according to the harm they cause and the criminal penalties attached:
Class A= Ecstasy, LSD, heroin, cocaine, crack, magic mushrooms, crystal meth
Class B= Cannabis, amphetamines, ketamine, barbiturates, codeine
Class C= tranquilisers, some painkillers, GHB, khat
What are stimulants, depressants and hallucinogens?
Examples?
Stimulants
* Speed up the way the body works
- Amphetamine, MDMA, Cocaine, Crack
Depressants
* Slow down the way the body works
- Benzodiazepines, Opioids, Alcohol, Cannabis
Hallucinogens
* Changes perception of reality
- LSD, Magic Mushrooms, PCP, Ketamine
What is the ICD 10 Definition of harmful use?
The diagnosis is made when an individual has a pattern of substance use that is causing damage to their health. The damage may be physical (eg liver damage or hepatitis) or mental (eg episodes of depression due to heavy consumption). This condition is diagnosed only when the individual does not fulfil the criteria for dependence.
What is the ICD 10 Definition of Dependence syndrome?
Dependence syndrome:
A physical syndrome which occurs after repetitive use of a psychoactive substance, typically for months or years.
The diagnosis of dependence should only be made if three or more of the following have been experienced at some time during the previous year:
* A strong desire to take the substance.
* Difficulties in controlling the use of the substance.
* A withdrawal syndrome when substance use has ceased or been reduced.
* Evidence of tolerance such that higher does are required to achieve the same effect.
* Neglect of interests and an increased amount of time taken to obtain the substance or recover from its effects.
* Persistence with the substance use despite evidence of its harmful consequences.
What makes up the Edwards and Gross criteria?
- Narrowing of the behavioural repertoire
- Salience of drinking and drug use
- Subjective awareness of compulsion2
- Increased tolerance
- Repeated withdrawal symptoms
- Relief from or avoidance of withdrawal symptoms
- Post abstinence re-instatement
Prochaska and Diclemente
Stages of Change
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Relapse
Assessment of substance misuse?
What are the steps?
- Confirm the patient is taking drugs (History, examination and drug testing).
- Assess the degree of dependence.
- Identify physical and mental health problems.
- Identify social problems – including housing, employment, domestic violence and offending.
- Assess risk behaviour.
- Determine the patient’s expectations of treatment and desire to change.
- Determine the need for substitute medication.
- Obtain information about dependent children.
How are drugs users assessed? What to ask?
Need to ask about:
* Type of drug/s used
* Pattern of use (duration, quantity, frequency of use, last 1–3 days, and last month, and whether continuous or binge)
* When last used
* Other drugs used (current, concurrent, and previous, reasons and patterns of use of other drugs)
* Route/s of administration
* History of use (age commenced, periods of abstinence)
* Circumstances and consequences of use
* Previous treatment (past withdrawal history, attempts to cut down/ stop)
What are the medical complications of drug misuse?
Hazards of drug?
Hazards of injecting?
Hazards of the drug
* Overdose
* Psychosis
* Withdrawal seizures
Hazards of injecting:
Viral infections: HIV, hepatitis B and C
Septicaemia, Pneumonia, Pulmonary abscess, Infective endocarditis Allergic reactions Skin abscess, Osteomyelitis, Thrombophlebitis,
Gangrene
Drug Testing
Biological samples used?
2 TYPES OF ANALYSIS?
- Urine
- Oral fluid
- Hair
a) Screening test.
b) Confirmation / classification test.
USES OF DRUG TESTING? (3)
- Initial assessment and confirmation of drug use.
- Confirming treatment compliance.
- Monitoring illicit drug use.
What are some psychosocial interventions? (tier 2 services)
- Drug related advice and information.
- Adviceandsupportforsocialproblems.
- Harm reduction.
- Motivational interviewing.
- Relapseprevention.
- Complementary and alternative therapies (eg acupuncture).
Mainly used in cocaine and other stimulant misuse. Also in cannabis use.
Harm minimisation strategies
Education:
* Hazards of injecting drugs (especially sharing injecting equipment)
* Safer sex
* How to obtain sterile injecting equipment and
condoms
* How to clean injecting equipment if it must be re-used
* Dangers of overdose
* First Aid for drug misusers who become
unconscious
Direct Action:
* Hepatitis B immunisation for non-immune individuals
* Provision of sterile injecting equipment (preferably in
exchange for used injecting equipment)
* Provisions of condoms
* Offer of BBV testing
* Naloxone and BLS training
* Prescription of substitute oral drugs
What is Opiate analgesia addiction?
Those individuals who are dealing with chronic pain are at particular risk of developing an addiction to opiate painkillers. Most people who use prescription opiates will never develop any problems because of it. Those who are most at risk for developing dependence will be long term users. It is also believed that anyone who has had previous substance abuse problems will be at an increased risk of addiction to prescription opiates.
What are some Pharmacological Interventions?
Substitute medication for heroin dependence
* Methadone.
* Buprenorphine.
* Suboxone/ Espranor/ Buvidal
Supervised consumption on commencement of treatment for at least 3 months or until stability is achieved.
After 3 days without their regular prescribed dose of opioid, patients may have lost their tolerance to the
drug and may be at risk of overdose, if the usual dose is then taken.
Other oral opioids sometimes used for maintenance -Dihydrocodeine (not licensed)
Injectable opioid treatment
- Less established and less accepted form of treatment.
- Should only be considered when optimised oral Methadone and Buprenorphine maintenance treatment are available and found not to be suitable.
- Specialist levels of clinical competence are required to prescribe injectable substitute drugs.
- Heroin (Diamorphine) prescribing also requires a Home Office licence.
Interventions for opiate withdrawal
- DO NOT start Methadone/ Buprenorphine without discussion with drug agencies.
- Give them a medication specific to their withdrawal symptoms
Symptomatic relief of withdrawal symptoms is the safest option for dealing with these symptoms in a non-prescribed individual:
* Muscular pains and headaches – Paracetamol, Aspirin and other NSAID
* Stomach cramps – Mebeverine, Buscopan®
* Agitation, anxiety, sleeplessness – Diazepam & Zopiclone (Assess for presence of agitation objectively. Avoid Diazepam if at all possible.)
* Nausea and vomiting – Metoclopramide
* Diarrhoea – Loperamide
What are some heroin withdrawal symptoms?
Stage 1 (up to 8hrs after last dose): Drug cravings, Moodiness
Stage 2 ( 8-24hrs after last dose): Stomach cramps, Upper body secretions (runny nose, eyes, tears, sweat), Restlessness
Stage 3 (Up to 3 days after last dose): Diarrhoea, Fever, Chills, Muscle spasms, Nausea/Vomiting, CVS problems (inc HR and BP)
Lofexidine
- Not a controlled drug.
- Alpha-2adrenergicagonistinhibiting noradrenaline release.
- Treatment course between 7 – 10 days.
- Side effects: dry mouth, drowsiness, hypotension, bradycardia.
- Mainly used in inpatient units.
Methadone
- Inexpensive – synthetic opioid
- Full agonist
- Long half-life (8 to 59 hrs)
- Wellabsorbedorally
- 85% bioavailability and metabolised by liver
- Cumulative effect – must be titrated
Buprenorphine
Synthetic opioid
* Partial agonist
* Halflife–24to36hrs
* Ensure the last dose of illicit opioids used (either injection/ inhaled/ oral) is 4 to 6 hrs before
If taking heroine- they must be in a withdrawal state prior to taking it
Naloxone
Opioid antagonist
Reverses opioid (heroin, methadone, prescription opioid) overdoses
Safe, cost effective
NALTREXONE FOR RELAPSE PREVENTION
- Opioid antagonist.
- When taken regularly, it blocks a former opiate user from experiencing the effects of the opiate. Can be helpful following detoxification in enabling a patient to maintainabstinence. Potentially hepatotoxic, LFT should be conducted before and during naltrexone treatment.
What is a UK unit?
Equal to 8g or 10ml of pure alcohol
UK alcohol consumption guidelines
- Women = 2-3 units
- Men= 3-4 units
No more than 14 units per week for both men and women with a couple alcohol-free days
What is FAS and FASD?
- Not a diagnostic but an umbrella term that encompasses all disabilities caused by prenatal exposure to alcohol
FAS – Fetal Alcohol Syndrome
- A group of symptoms seen in children who were exposed to alcohol before birth and characterised by : Growth deficiency, Facial characteristics and CNS damage
ARND – Alcohol Related Neurodevelopmental Disorders
- A diagnostic classification for individuals who were prenatally exposed to alcohol and do not have the facial characteristics of full FAS but have symptoms of CNS damage associated with FAS
ARBD – Alcohol Related Birth Defects
- A diagnostic classification for individuals who were prenatally exposed to alcohol and have physical defects such as malformation of the heart, bone, kidney, vision or hearing systems
Facial characteristics of FAS
FAS/ FASD At A Glance
- Alcoholiscapableofcausingbirthdefects.
- FAS involves brain damage, impaired growth and head and face abnormalities.
- FASDisoneoftheleadingknowncausesof mental retardation.
- FASDcancauseseriouslifelongsocialand beh avioural problems.
- No amount of alcohol has been proven safe during pregnancy.
- Women who are or may become pregnant are advised to avoid alcohol.
Excessive alcohol intake can lead to..? (3)
- physical morbidity
- psychiatric morbidity
- social morbidity
The neurobiology of alcohol dependence
- GABA – the main inhibitory neurotransmitter- slows you down
- Glutamate – the main excitatory neurotransmitter- speeds you up
- Normal balance
- Alcohol inc inhibitory transmitters
- Brain restores balance by inc excitatory transmitters
- Withdrawal- excitatory transmitters stay elevated when alcohol is removed
Non-pharmacological treatment of alcohol dependence
- Biological treatments – Detox
– Rehab - Psychological – MI
– CBT
– Family intervention - Social interventions
Acamprosate
- Reduces glutamate activity by “monitoring” the amount of glutamate that can react at the NMDA receptors
- Limits the amount of glutamate released by the neuron
- Enhance inhibitory effect of GABAA receptor
Naltrexone
- Blocks opioid receptors
- Diminishes dopamine release at nucleus accumbens when alcohol is consumed so reducing the pleasurable effects
- Reduces cravings during non-drinking periods
Baclofen
- Derivative of GABA (agonist for GABAB receptor) * Used for spasticity
- Newer use as anti-craving agent for alcohol
- Can cause withdrawal symptoms
Alcohol withdrawal Vs Opiate withdrawal
- Alcohol withdrawal can kill a patient. –Wernicke encephelopathy, Delirium Tremens – Withdrawal fits (Benzodiazepine dependence) – Aspiration, head injury etc….
- Opiate withdrawal will not
– Cold turkey
– Irritable and aggressive
