Harm Reduction 2024 PDF

7 OSPAP Programme Substance Misuse and Harm Reduction Rebecca Waton [email protected] OSPAP MPHM15 Pharmacy Law, Ethics Slide 1 of 44 and Practice WEE Learning K...

7 OSPAP Programme Substance Misuse and Harm Reduction Rebecca Waton [email protected] OSPAP MPHM15 Pharmacy Law, Ethics Slide 1 of 44 and Practice WEE Learning K 1 7 Outcomes Be able to describe the harm (both individual and societal) of substance misuse Know the types of substances which are misused The role of pharmacies in contributing to harm reduction strategies To understand some of the issues associated with providing harm Slide 2 of 44 reduction services WEE K The Scale of the Problem (ONS, 1 Dec 2023) 7 In 2022/23 9.5% ( ~ 3.1 mill) of 16‐59-year-olds admitted to using an illicit drug in the past year Cannabis is the most used drug. The next most common is powdered cocaine. Nitrous oxide use has halved since 2020. Highest amongst those aged 16 -24 years old (17.6%), this has decreased since 2020 seeing a reduction in cannabis use in this age group Those from lower income households are more likely to misuse drugs than those from higher income households, but this could also be connected to age as younger people are more likely to have a lower income OSPAP MPHM15 Pharmacy Law, Ethics Slide 3 of 44 and Practice  The Scale of the Problem (NHS Digital) 2022/23 hospital admission data 13,427 hospital admissions for poisoning by narcotics and hallucinogens Increase on the previous year at 12,226 cases Admissions were more likely in the most deprived areas, compared to the less deprived areas Hospital Admitted Patient Care Activity, 2022-23 - NHS England Digital Statistics on Public Health, England 2021 - NHS England Digital WEE K 1 7 What sorts of substances are misused? OSPAP MPHM15 Pharmacy Law, Ethics Slide 6 of 44 and Practice WEE Substances which K 1 7 can be misused OTC medicines Plant Prescripti material on – Cannabis medicine – Opioids s – Mushroom Volatile s substanc Alcohol es Cocaine Caffeine OSPAP MPHM15 Pharmacy Law, Ethics Slide 7 of 44 and Practice WEE K OTC 1 7 medicines OSPAP MPHM15 Pharmacy Law, Ethics Slide 8 of 44 and Practice  Crystal meth (methamphetamine) Legal restrictions on the amount of pseudoephedrine that can be sold (see law lecture) Professional requirement that sales should only be made by the pharmacist or by staff who have received training If there is any suspicion of misuse then the sale should be refused See MEP and RPS quick reference guide for further information WEE ‘Meth K 1 7 Labs’ OSPAP MPHM15 Pharmacy Law, Ethics Slide 10 of 44 and Practice WEE Prescription K 1 7 Medicines Amphetamines Analgesics including opioids, pregabalin Benzodiazepines Hypnotics Antidepressants Antimuscarinic drugs e.g. procyclidine Drugs in sport e.g. anabolic steroids OSPAP MPHM15 Pharmacy Law, Ethics and Practice Slide 11 of 44 WEE K 1 7 Amfetamines Schedule 2 (CD POM) Often used in medicine to treat narcolepsy or ADHD Atomoxetine; Dexamfetamine; Methylphenidate. Otherwise, they have very few indications; and in particular, should not be used to treat depression, obesity, or for the relief of fatigue. OSPAP MPHM15 Pharmacy Law, Ethics Slide 12 of 44 and Practice WEE K 1 7 Amfetamines Act as sympathomimetics Methamphetamine [ice, crystal meth]; Smoked Snorted Taken orally Injected 3,4‐Methylenedioxymethamphetamine [MDMA] or ‘ecstasy’; Taken orally All have similar effects to cocaine; OSPAP MPHM15 Pharmacy Law, Ethics Slide 13 of 44 and Practice  Benzodiazepi WEE K 1 7 nes Schedule 4, part 1 [CD Benz] except temazepam [CD No Reg] Benzodiazepines are often used in medicine as either hypnotics (nitrazepam) or anxiolytics (lorazepam) Have problems associated with dependence and tolerance Committee in Safety of Medicines has recommended that: Benzodiazepines are indicated for the short term relief (two to four weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable stress Benzodiazepines should OSPAP bePharmacy MPHM15 used toLaw, treat insomnia only Ethics Slide 14 of 44 and Practice  Benzodiazepine WEE K 1 7 s When taken in high doses and particularly when injected, benzodiazepines can provide a ‘high‘ The abuse of temazepam is particularly common (hence the reclassification) Gel‐filled soft capsule formulation withdrawn in 1996 (‘Wobbly eggs’) Benzodiazepines are widely available on the street and are cheap Benzodiazepines alleviate withdrawal effects, including anxiety and insomnia, when supplies of other drugs are limited OSPAP MPHM15 Pharmacy Law, Ethics Slide 15 of 44 and Practice  Volatile WEE K 1 7 Substances Methylated spirit ‘denatured ethanol’ Methanol All products containing solvents e.g. glues, nail varnish, butane gas refills In 2009, solvent abuse killed 46 people 34 out of the 46 people were killed by butane inhalation Die by cardiac arrhythmia Moth Balls p‐DCB Naphthalene Caffeine containing products Pro‐plus OSPAP MPHM15 Pharmacy Law, Ethics Slide 16 of 44 and Practice WEE K 1 7 Cocaine Used as a local anaesthetic Hydrochloride (coke, snow or blow) usually inhaled nasally through short tube – “snorting” Alkaloid base is “crack” more stable & often smoked or heated & vapour inhaled “crack” said to be more addictive Works by causing massive release of catecholamine transmitters and repeated use depletes these OSPAP MPHM15 Pharmacy Law, Ethics Slide 17 of 44 and Practice WEE K 1 7 Cocaine Continued use causes damage to nasal mucosa and eventually destruction of nasal tissue Has largely been superseded by newer local anaesthetics OSPAP MPHM15 Pharmacy Law, Ethics Slide 18 of 44 and Practice  Misuse of natural WEE K 1 7 Cannabis products Schedule 1 controlled drug (CD Lic) Contains cannabinoids (THC is the most common) Magic Mushrooms Produce similar hallucinogenic‐type effects to LSD when you eat them No known therapeutic use OSPAP MPHM15 Pharmacy Law, Ethics Slide 19 of 44 and Practice WEE K Drugs of 1 7 Abuse: Opioids Derived from the opium poppy [Papaver somniferum] Opium contains many alkaloids: Morphine; Codeine; Papaverine; Noscapine. OSPAP MPHM15 Pharmacy Law, Ethics Slide 20 of 44 and Practice WEE K 1 7 Heroin Also known as diamorphine (or diacetylmorphine) Not found in the opium poppy (is a semi‐synthetic derivative) Used in palliative care as it has excellent analgesic properties Twice as potent as morphine Schedule 2 (CD POM) Tolerance, psychological and physical dependence can develop OSPAP MPHM15 Pharmacy Law, Ethics Slide 21 of 44 and Practice WEE K 1 7 Heroin Most made for illegal supply Often “cut” with various powders Oral route has slow onset Smoking heroin takes between 2 and 5 minutes to feel effect Injecting heroin takes about 2 ‐ 5 seconds to feel effect Many dangers from injecting “cut” powder or OSPAP MPHM15 Pharmacy Law, Ethics Slide 22 of 44 ground tablets and Practice WEE K 1 7 Heroin Heroin often contains insoluble impurities Users use citric acid/ascorbic acid powder to help dissolve heroin in water and then draw up solution through a cigarette filter/cotton wool Repeated injection of unsterile drug damages veins, leading to eventual collapse After easily accessible veins are damaged, users attempt to access deeper veins in areas such as the groin This requires larger needles and ‘fishing’ for a vein, leading to increased local OSPAP MPHM15 Pharmacy Law, Ethics and Practice Slide 23 of 44 Taxonomy WEE K 1 of Drug‐Related 7 Harm Drug users Other – Premature death (around 1%) – Drug‐related crime individuals – Loss of quality of life (mental and – Transmissions of infections physical) from drug misusers to others – Contracting HIV and other diseases Wider community – Impact on educational attainment – Drug litter effects – Unemployment and lifetime loss of – Fear of crime Families/ earnings – Reduced property values near drug – Increased Impact carers on vulnerability foetuses markets Indust – Impaired parenting ry– Sickness absence – Domestic violence – Theft in the workplace – Victims of crime – Security expenditure to prevent – Reduced performance at school drug‐related crime – Transmission of infections – Productivity losses – Intergenerational impact of drug use – Impact of illicit markets on – Financial problems Public legitimate markets – Concern/ worry for users – Health care Sector – Increased health service needs expenditure for family members – Criminal justice – Caring for drug misusers or their expenditure dependants – Social services – Victims of drug‐driving – Social security – Drug‐related violence benefits OSPAP MPHM15 Pharmacy Law, Ethics Slide 24 of 44 and Practice WEE K 1 7 Drug‐related Crime (House of Commons Committee Report 23-24) The sale and use of illegal drugs costs the UK society around £20 billion per year It is also estimated that between one third and one half of all acquisitive crimes are committed by those who are addicted to heroin or cocaine A drug addict not in a treatment programme costs society on average £26,074 per year By investing in a harm reduction strategy, it is estimated that 19.5m crimes would be prevented and estimated £3.6bn saving to society over a 3‐year period The relationship between drug use and crime is complex but the main impact comes from the economic‐compulsive element (average of £1,296 spent on illicit substances in the 4 weeks prior to entering treatment) OSPAP MPHM15 Pharmacy Law, Ethics Slide 25 of 44 and Practice WEE K 1 Harm In an ideal reduction 7 world people would stop misusing drugs This is difficult for many reasons: – Physical dependence – Psychological dependence – Social reasons Therefore, ‘harm reduction’ was developed: – intended to reduce adverse effects of drug misuse as far as possible until misuser has decided, or is able, to stop misusing the drug Three principles: – Misuse of drugs accepted but not approved of – User should be treated as a normal human being – Harm reduction need not necessarily lead to the longer term goal of ridding the world of drug misuse Around 200,000 people in England are being treated for substance dependence OSPAP MPHM15 Pharmacy Law, Ethics Slide 26 of 44 and Practice WEE Substitution Therapy K 1 7 (CKS, 2024) Methadone or buprenorphine are used Best used in conjunction with psychosocial support Programmes can be maintenance or detoxification A complete history is needed on entering a treatment programme to assess current drug use (usually used alongside toxicology screening) Prescribing is then tailored to the individual Therapy is usually initially supervised daily for at least 3 months, most important in first 3-6 months OSPAP MPHM15 Pharmacy Law, Ethics and Practice Slide 27 of 44 WEE Methadone (CKS, K 1 7 2024) Long-acting synthetic opioid acting as a full mu-receptor agonist removes the need to use drugs by blocking withdrawal for 24 hours Long half‐life produces stable plasma concentrations (mean ~ 15 hrs) Effective at treating withdrawal symptoms and also blocking additional opioid binding Clinically effective at treating opioid dependence supported by clinical OSPAP MPHM15 Pharmacy Law, Ethics research and Practice Slide 28 of 44 WEE Buprenorphine (CKS, K 1 7 2022) Semi synthetic opioid that acts as a partial mu-receptor agonist Less likely to cause respiratory depression and sedation than full agonists At doses of more than 8mg it blocks the effect of additional opioid use as it prevents occupation at the opioid receptors Clinically effective at treating opioid dependence, newer drug than methadone Sublingual tablet available in various OSPAP MPHM15 Pharmacy Law, Ethics strengths (also available and Practice in Slide 29 of 44 WEE Needle Exchange K 1 7 Schemes Injecting increases the risk of bacterial and fungal infections of soft tissues as well as septicaemia Sharing injection equipment can lead to transmission of blood borne viruses such as HIV and Hepatitis C Lack of absorption barrier also increases risk of overdose Needle exchange schemes provide access to sterile injecting equipment to actual or potential injecting substance misusers with OSPAP MPHM15 Pharmacy Law, Ethics Slide 30 of 44 anonymity, dignity and and Practice  Needle exchange WEE K 1 7 packs OSPAP MPHM15 Pharmacy Law, Ethics Slide 31 of 44 and Practice WEE K 1 Supply of paraphernalia to 7 drug misusers The following people may legally supply drug paraphernalia to drug misusers: Practitioners, Pharmacists, Lawful drug treatment centres, SPs acting under a clinical management plan. Pharmacists may supply the following: Swabs, Citric acid, Ascorbic acid (vitamin C), Filters Cookers Water for injection Needle bin OSPAP MPHM15 Pharmacy Law, Ethics Slide 32 of 44 and Practice WEE K 1 7 Harm reduction: What are the advantages and disadvantages? OSPAP MPHM15 Pharmacy Law, Ethics Slide 33 of 44 and Practice WEE Harm K 1 7 Reduction Advantages Disadvantages – Reduction in – High cost drug related – Do clients crime misuse the – Reduction in drug treatment? related harm – Does not both at individual achieve and societal level abstinence – Optimised – Potential for opportunities for diversion health promotion – Risks to staff – Reduces risks of – Non‐return of litter needles OSPAP MPHM15 Pharmacy Law, Ethics Slide 34 of 44 and Practice WEE K 1 7 From Harm to Help: A 10-year drugs plan to cut crime and save Produced lives (April 2022) under a Johnson Conservative government A 10-year plan to cut off the supply of drugs Provide drug addicts with a route to a productive drug-free life £780 million invested in the next 3 years Treat addiction as a chronic condition Rebuild local authority commissioned substance misuse services Ensure better integration of services – physical and mental health OSPAP MPHM15 Pharmacy Law, Ethics Slide 35 of 44 and Practice WEE Hopefully K 1 7 prevents this…. OSPAP MPHM15 Pharmacy Law, Ethics Slide 36 of 44 and Practice WEE K 1 7 Talk to FRANK OSPAP MPHM15 Pharmacy Law, Ethics Slide 37 of 44 and Practice WEE Pharmacy K 1 7 Services Supervised administration (Community Pharmacy England) Needle Exchange Schemes (Community Pharmacy England) HIV and Syphilis Point of Care Testing (Community Pharmacy England) All commissioned by Local Authorities Health promotion (Essential Service) leaflets provided on safer sex, injection techniques, immunisation, STIs etc Pharmacy to provide support and advice and onward referral (Essential Service) where necessary to other health and social care professionals and specialist drug and alcohol treatment services as necessary For all need to consider: – Staff training around client group – ConfidentialityOSPAP MPHM15 Pharmacy Law, Ethics Slide 38 of 44 and Practice WEE Referen K 1 7 ces FRANK Available at: http://www.talktofrank.com/ (Accessed 8 November 2024) Community Pharmacy England (2022) Enhanced Service – Supervised Administration (Consumption of prescribed medicines) Available from: Microsoft Word - EN1 Supervised Administration Service.doc (cpe.org.uk) (Accessed 8 November 2024) Community Pharmacy England (2022) Enhanced Service – Needle & Syringe Exchange Available from: Microsoft Word - EN2 Needle & syringe exchange.doc (cpe.org.uk) (Accessed 8 November 2024) Office for National Statistics (2023) Drug misuse in England and Wales: year ending March 2023 Available from: Drug misuse in England and Wales - Office for National Statistics (Accessed 08 November 2024) CKS (2024) Scenario Management: Management: Opioid Dependence Scenario: Management | Management | Opioid dependence | CKS | NICE (Accessed 8 November 2024) Gov.uk (2022) From Harm to Hope: A 10-year drugs plan to cut crime and save lives From harm to hope: A 10-year drugs plan to cut crime and save lives - GOV.U K (accessed 8 November 2024) OSPAP MPHM15 Pharmacy Law, Ethics Slide 39 of 44 and Practice