Substance Misuse. Myth or fact? Who develops a substance dependence problem? From abuse to dependence is a spectrum

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1 Myth or fact? Substance Misuse WHERE ARE WE NOW AND WHERE ARE WE GOING? Dr Alun George, Clinical Lead Deacon House CDTS 1. Methadone gets in your bones 2. Methadone rots your teeth 3. Buprenorphine is much better than methadone for getting people off heroin 4. Drug misusers are poor, commit crime and hang around dark alleys 5. Substance dependence can be cured 6. Substance dependence treatment depends on which substance is being abused 7. Novel Psychoactive Agents have flooded the country and are an immediate threat to our society 8. At LCDP If clients are using on top of their script we will ask them to leave treatment From abuse to dependence is a spectrum Who develops a substance dependence problem? Anyone can Same percentage of Drs have dependence problems compared to the population A combination of environmental and genetic factors Substance abuse is more prevalent in deprived areas; however substance dependence is probably not Peaches Geldoff, Dr Clive Froggatt The psychology of substance dependence It happens at the unconscious level - it is a compulsion like OCD there is no logic Do not got caught up in how people became dependant on substance misuse there is no why there just is The main question is What are you going to do next? People who regularly use drugs that affect their thinking will have disordered personalities (they do not have personality disorders) This means it is very important to have clear boundaries and share information treatment of substance misuse is very much a team effort Drug treatment in the Leeds area Partnership between St Martins Healthcare Services (SMHS) and DISC/BARCA/St Annes known as Leeds Community drugs Partnership (LCDP) We see clients with any substance problem for harm reduction and advice/sign posting. We can prescribe for opiate dependence and codependence on alcohol/benzodiazepines We ask that clients engage regularly with their prescribers and recovery co-ordinators, and respect our DNA/behaviour policies. We do not penalise our clients for using on top but we do place them on 6/7 DSC where necessary due to risks 1

2 Harm Reduction Safer injecting advice, provision of sterile needles/syringes Now can provide tin foil for smoking drugs Vaccinate against Hepatitis A and B Screen for Hepatitis B, C and HIV (this can now be done by Dried Bloodspot Testing for those with tricky veins!) Advise on how to minimise the spread of BBVs Sexual health advice, free condoms Liaise with other health carers re co-prescribing and advise on pain management reduce harm to the community if we suspect diversion or poly prescription drug use? Naloxone take homes?smoking cessation Impact of supervised consumption on methadone related deaths Impact of supervision of methadone consumption on deaths related to methadone overdose ( ): analyses using OD4 index in England and Scotland Strange et al, BMJ. 2010; 341 Alcohol and Cannabis Often ignored or over looked by those working in substance misuse Excessive alcohol consumption caused 1.4% of deaths in England and Wales in 2012 Cannabis often seen as a soft drug. It is as pernicious as alcohol With both of these we offer harm reduction for hazardous use If heavy/dependant use we use supervised consumption due to risks We ask clients to demonstrate they are not dependant on cannabis though abstaining and urine testing CUPIT similar to audit can be a useful screening tool Offer support to help them address these problems OTC Dependence Mainly codeine containing analgesics Sedatives (e.g. Nitol ) can be abused too As with alcohol some customers shop around different pharmacies Cyclizine very abusable Prescription drug abuse Deaths from tramadol have been increasing hence recently made schedule 2 recently Opiate prescribing by GPs increasing Gabanergic prescriptions increasing each year Benzodiazepine prescribing falling since late 80s BUT Z drug prescribing increasing The 2 trends cancelling each other out Long term use associated with increased risk of accidents, increased risk of dementia (non reversible), increased risk of mortality, exacerbate low mood and depression Zopiclone cannot be detected by urine testing (shhh!) Gabanergics Pregabalin commonly becoming part of our clients repertoire More popular than gabapentin as does not have a ceiling effect Very widely abused in the prison setting Clients often aware of the of symptoms to obtain it e.g. sciatica, shingles Often willing to go along the hierarchy of drugs e.g. amitriptyline, tramadol, gabapentin, pregabalin In Scotland 2013 implicated in 20% of overdose deaths If clients using illicits we ask GPs to reduce and stop these drugs regardless of who initiated them due to the risks 2

3 Novel Psychoactive Substances The Problems with NPSes.. AKA legal highs this is a press term The boom in these linked to explosion of the WWW although one of the first appeared in 1975 (Bromo-STP) Analogues of drugs already around e.g. methoxetamine/ketamine, alpha-pvp (cocaine), hallucinogens (2- CE, Bromo dragonfly), amphetamine/mdma stimulants (benzo-fury) Spice cannabinoid receptor agonists e.g. jwh-018 sprayed onto organic material. 30 times more likely to end up in emergency care after using these compared to cannabis 2011 study urine collected over 2 nights from MSM predominant London club found 72 parent drugs and their metabolites! Often sold on the dark web with no information about dosage Manufacturers don t always know what they re doing Cause memory problems and so dose stacking can be common and dangerous Cardiovascular effects due to catecholamine release Serotonin syndrome Serotonin is released from platelets on damage to the blood vessel walls. It acts as a potent vasoconstrictor. 25% of people buy and use mystery white powders Bromo dragonfly Ketamine On May 7, 2011, eight young people took bromo-dragonfly, thought to be 2C-E in USA, Denmark One, 35, suffered convulsions, liver and kidney failure, and lost several fingers and toes, while his unnamed friend died within hours of taking the substance He reported: "It was like being dragged to hell and back again. Many times. It is the most evil [thing] I've ever tried. It lasted an eternity Recommended dose of 2-CB (common) is mg Recommended dose of BDF (common) is μg Ketamine becoming more popular Norketamine cystotoxic some prolonged users have ended up with urostemies Worth asking about drug use in younger people with urinary symptoms Deaths have occurred when has been used prior to having a bath Regular use can lead to drug induced liver damage GHB and GBL The problem of the press reporting Gammabutyrlactone (GBL) is a pro drug of Gammahydroxybutyrate (GHB) Dangerous when mixed with alcohol as it can lead to vomiting in combination with unrouseable sleep, a potentially lethal combination Increasing reports of body builders using it as it enhances Stage 3 sleep and has been shown to increase levels of human growth hormone Abrupt withdrawal can result in delirium tremens treatment is with high doses of benzodiazepines and baclofen 3

4 You can research NPSs here: facts_researchchemicals.php Recovery model of drugs treatment Everyone is capable of recovery At LCDP we use a recovery roadmap so clients and treatment team can see where they are on the map and where they d like to be The map is not the terrain! The agenda embraces harm reduction, maintenance and recovery If clients are stable on their script (i.e. no using on top) we offer recovery we do not insist they take it. SMHS Recovery Road Map Maintaining Boundaries If you lay down boundaries you will always deal with anger It is a compassionate act to lay down boundaries Jung likened interpersonal relationships to bones they need tension to be healthy and grow Adopt a zero tolerance approach address any issues as soon as they come up, do not let them escalate Talk in terms of teams and not individuals e.g. your drugs service discussed with our pharmacy Remember your own state of mind! After a very difficult client allow yourself time out and discuss with colleagues This at the core of substance treatment Building Recovery in Communities If you always do what you ve always done you ll always get what you always got Mutual aid groups e.g. SMART ( Self Management and Recovery Training), Narcotics Anonymous (12 Step) strongly encouraged If someone has a substance dependence they cannot beat it alone it is bigger than them but they can in a group Social anxiety drives drug use and exacerbates it so most clients resistant to this we keep suggesting it We look at all aspects of a persons life relationships, employment, general physical and mental health 4

5 Towards the future Services currently being recommissioned Likely to be more of a hub and spoke model across the city Mutual aid groups growing exponentially Great work already being done with alcohol AUDITS and offering IBA Sharing data about our clients 5