T3 SYMPOSIUM. Illicit Substance Misuse (SF).pptx

Illicit Drugs Symposium 9am Welcome and Introductions Lecture Theatre 9.10am Introduction to Addictions Psychiatry Lecture Theatre 9.45am 10.35am Group A Breakout rooms – Expert by Experience shares Breakout Rooms Group B Everything you wanted to know about illicit drugs? Lecture Theatre...

Illicit Drugs Symposium 9am Welcome and Introductions Lecture Theatre 9.10am Introduction to Addictions Psychiatry Lecture Theatre 9.45am 10.35am Group A Breakout rooms – Expert by Experience shares Breakout Rooms Group B Everything you wanted to know about illicit drugs? Lecture Theatre 10.35am 10.45am 11.25am Break Group A Everything you wanted to know about illicit drugs? Lecture Theatre Group B Breakout rooms – Expert by Experience shares Breakout Rooms Wrap up and final Q&A Lecture Theatre Introduction to Addiction Psychiatry and Opiate Dependence Dr James Fallon Clinical Senior Lecturer and Honorary Consultant Psychiatrist Courts / prison Forensic Psychiatr y Primary Care Self referral Primary care level psychological services Substance Misuse Service Children and Young Peoples Learning disability General communi ty Early Intervention in Psychosis Inpatient Eating disorders General Hospital Secondary Care Psychiatry Liaison Psychiatry Function al Working age Older peoples Dementi a General Communit y Teams Assertive Outreach Team Specialist Services Rehabilitati on Crisis Team Perinatal psychiatry Inpatient Neurodevelopme ntal Addictions Psychiatry • How to become an Addictions Psychiatrist in 5 easy steps: • • • • • Graduate Complete Foundation Year Core Training in Psychiatry – include some SMS (Substance Misuse Service experience) Higher Training in Psychiatry – one year formal training in Addictions Psychiatry Find a consultant job in Drug and Alcohol Services! • N.B. Substance Misuse Services are generally not NHS run • • • 3rd sector providers Locally – Change, Grow, Live Fewer student placements.... • But... • You will need to know about this whatever specialty you are in.... What do we do in Drug and Alcohol Services? Clinical services: Substitute prescribing, specialist nurse input, mental assessment, A&E liaison​ health Harm Reduction: needle exchange, advice & information, brief interventions, steroid clinic​ Medicated Detoxification: Community & referral for in-patient treatment – alcohol, opiates, benzodiazepines etc Rehab & detox support: Residential rehab & move-on support with round the clock support​ Health checks: sexual vaccinations​ ​ health screening, blood borne virus screening, Hep A/B Plus… • Women only service: Oasis Project has a crèche, sex workers outreach project, Young Oasis (14-25)​ • Psycho/social: practical support, one to one care-coordination ​ • Group work: structured strength based & recovery orientated group work & peer led support​ • Family & Carers Team: support family, friends & carers: group work, counselling & 121 support​ • LGBTQ specific events and support • Education, training & volunteering service: for clients currently in treatment or in recovery ​ Depressant sBenzodiazepi Alcohol nes Opiate s And Opioid s GBL / GHB PCP Nicotine Caffeine Cocaine and crack cocaine Amphetamine Mephadrone Methamphetami ne Stimulants Ketamine Cannabinoi ds and Synthetic cannabinoid s MDMA Psilocybin DMT Mescaline LSD Hallucinoge Thinking generally about use of substances… Level of use Use Description Psychoactive substance use that is not problematic Hazardous Use Psychoactive substance use that risks harm to health Harmful Use A pattern of psychoactive substance use that actually causes physical or mental harm Dependent Use Where a person needs to take a psychoactive substance to feel normal and So let’s think about this in practice…. • Scott, 24 years old has been using heroin daily for the past 3 years • Started smoking heroin on weekends at 19 • Moved to injecting at 20 • Now uses 4 times a day, £10 a time • From waking thinking about his next use • Doesn’t think he could go without this • Initially funded through pay, lost job and now shoplifting • Arrested for this 3 times, cautioned What in his history • Lost weight, poor diet indicates he is Scott – features of dependence • Scott, 24 years old has been using heroin daily for the past 3 years Toleranc • Started smoking heroin on weekends at 19 e • Moved to injecting at 20 Compulsion • Now uses 4 times a day, £10 a time • From waking thinking about his next use • Doesn’t think he could go without this • Initially funded through pay, lost job and now Persistenc shoplifting e despite • Arrested for this 3 times, cautioned • Lost weight, poor diet Salience evidence of harm So how can we define Dependence? W ithdrawal Physiological response to not having used the substance e.g. nausea after not using heroin for 8 hours C ompulsion S alience The strong desire to use the substance Placing the substance as more important than other areas of life e.g. buying heroin over buying food P ersistence despite Mental, physical, occupational, social, financial evidence of harm I mpaired control T olerance Once use has started find it hard to stop using Over time more of the substance is required to get the same effect Simon’s Body Map – Intoxication • After initial ‘nod’ can suddenly become v talkative or interested in something on radio or TV • Absolute contentment • Taste and smell of H (heroin) (if good quality) • Enjoyment of cuddling and touch • Hungry • Straight away post heroin – itchiness, can be too much but it is v quick and indicates a true hit (to me) (can be related to Citric acid that is mixed with heroin – comes with the clean needle kit) • Next stage – very warm, content, have an hour ‘nod’ • Final stage – if late sleep, if early carry on with day Signs of Opiate Intoxication • Euphoria / relaxation • Feeling of well being • Constricted pupils • Drowsiness • Slurred speech • Poor attention and concentration Simon’s body map – withdrawal • Very prone to emotional thought (too much emotion, anxiety, where, how, who to score) • Getting sicker • Feeling of disembodiment, kind of trippy, difficulty relating to people • Senses really heightened, smell, vision, etc. • Sweating • Hot and cold • Cannot handle being touched • Cannot eat even if starving • Fight or flight Opiate Withdrawal Physical health complications •Relate to:​ •Specific drug effects​ •Contaminants​ •Method of use​ •Lifestyle​ Deaths from opiates • Mortality 1-2%/year​ • 2020 – 2,236 drug poisoning deaths involving opiates Medical complicati ons Suicide Overdo se Accidental • Or trauma Purity and contaminants Table 6.3: Weighted mean purity/potencya of small quantityb drug seizures of certain illicit drugs in England and Wales, 2004 to 2018 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Amphetamine 9 10 11 11 8 8 8 10 5 7 12 10 10 9.5 11 Powder cocaine 42 43 35 33 29 20 24 26 37 38 36 44 54 60 63 Crack cocaine 64 65 50 52 43 27 31 26 30 36 37 48 71 76 77 Ecstasy/MDMA (powder/crysta l) - - - - - - - 81 - 69 72 75 74 76 Heroin 47 44 50 43 44 35 18 20 29 36 44 43 37.5 46 40 *Purity as a percentage unless otherwise specified b Data taken from seizures of ≤1g of powder drugs, except for heroin, where data is for seizures of ≤0.25g N.B. Drug dealers rely on repeat custom! Health consequences Some examples of adulterants Adulterant Legal Use Reason for illicit Public health use risk Sucrose, Lactose, Dextrose , Mannitol Sugars To dilute/add bulk. Inactive Legally and adulterants. readily available Caffeine Psychoactive stimulant drug Heroin Vaporizes heroin at lower temperature when smoked slightly increases efficiency. Stimulants Stimulant properties of caffeine can create similar, although usually milder, effects to Cut: A guide to adulterants Caffeine is legal, cheap and more readily available than illicit drugs. In small doses there are few serious health repercussi ons. Moderate to large doses can cause considerabl e harms Minimal risk of adverse health effects. Can cause nasal irritation • Mood disturbances • Induce anxiety • Addictive • Sleep disturbance • Increases risk of a range of health problems Thinking about Scott – what physical health complications might he present with? • Reminder: • Scott, 24 years old has been using heroin daily for the past 3 years • Started smoking heroin on weekends at 19 • Moved to injecting at 20 • Now uses 4 times a day, £10 a time • From waking thinking about his next use • Doesn’t think he could go without this • Initially funded through pay, lost job and now shoplifting • Arrested for this 3 times, cautioned • Lost weight, poor diet Physical Health Complications from Opiates o Infection: o Cellulitis, abscess, sepsis o o o o o o Blood borne viruses (e.g. HIV, Hep B/C) o Other infection related to lifestyle – screen sex working Chronic venous insufficiency and leg ulcers DVTs (damaged valves slow venous return) PEs or gangrene (from DVTs or emboli) Infective endocarditis Overdose (higher risk if IVDU than smoking) o Multiple sedative combinations most risky So… Opportunistically screen for complications • History and examination • Screening bloods When might we see Scott to do this? Opiate Overdose • Triad of symptoms pointing to OD • Unconsciousness • Respiratory depression • Pin point pupils • Treatment? • Establish airway • Ventilate (100% O2) • Naloxone IV/IM • Repeat 2-3 mins Naloxone kit: https://www.youtube.com/watch?v=bNRZRYHJmEs Scott and overdose risk – what risk factors does he have? • • • • • • • • • Young 21 years old Male Cis male White White Broke up with girlfriend 6 monthsSingle ago Does not live Lives with 2 other users alone Works as a laborer 3 days a week Working PMH – nil No hx chronic pain PPH – nil No psychiatric history Uses heroin IV and occasional crack use (smoked) Polydrug use – but not multiple respiratory depressants Risks for Overdose • white • single or divorced • unemployed • male • living alone Two-thirds of cases - there was a mention of a mental health condition • But many never saw mental health services (42%) A significant minority had a chronic pain condition (29%) Role of polydrug use and alcohol + opiates a factor Psychiatric Complications • Drug misuse (intoxication / withdrawal) can mimic most psychiatric syndromes. • Drug misusers increase rate psychiatric illness • • • • anxiety (28%) depression (26%) PD (18%) schizophrenia (7%) • Suicide risk x 15 Social Complications • Social • family, children, society • How many of those receiving treatment for a drug problem were parents or lived with children? • Just over 50% • 105,780 people • 40,852 lived with own children • 25,341 lived with children not their own • 39,587 were parents but did not live with their children • Occupational • Number “mostly unemployed” (NTORs) • Over 75% • Financial • street heroin currently cost £40-60 gram. • Legal: • in a UK study (NTORs) 60% of 1100 users committed over 70,000 separate crimes in the preceding 3 months. How can we reduce harms in drug use? Preventing Infection • Psychoeducation re: sharing needles and safe injecting • Needle Exchange Schemes Preventing / Management of Overdose • Psychoeducation - Don't use alone, Tell others what you are using, Do not mix with other sedatives • Naloxone pens • Public health messaging - high strength / adulterant alerts Reducing Illicit Drug Use • Opiate Substitution Therapies • Reduction over stopping Early Identification of Health Problems • Blood Bourne Virus Testing • Opportunistic Physical Health Reviews Safer injecting Needle Exchange: https://youtu.be/DQWXDxvMWl4 Safer Heroin Injecting: https://www.youtube.com/watch? v=Miv8i-slK2w • Treating Scott – Opiate Substitution Therapies (OST) What options do we have? Medication na me​ Mechanism of action​ Methadone​ (PO liquid)​ Opiate agonist​ Notes​ Allows use on top which some patients may want allowing harm reduction reduction in illicit use if not full cessation​ Due to long half-life stabilisation can take 4-5 days​ Buprenorphine​ Partial agonist at At high doses blocks the action of opiates like (S/L)​ opiate receptors​ heroin so encourages patients not to use on (Subutex)​ top as precipitates withdrawal (not suitable for those who prefer to use on top)​ Quicker to stabilise on than methadone​