Drug and Alcohol Misuse Dr Mick McKernan

Harm Reduction Philosophy to lessen the dangers drug abuse cause to Individual/society We will never stop drug misuse 15K BC cannabis. Opiates 5K B C. Alcohol 10k BC Holistic care. Crime/criminal behaviour/employment/mental health /physical health/family therapy/alternate medicine/ 3 rd sector /housing/finance

Maintenance Detoxification Abstinence Client agenda – detoxification Service agenda -maintenance Political Pressure to push for detoxification and abstinence

Families and Communities Hidden Harm report gave estimate of children living with problem drug users More proactive on children's issues-not waiting until risk Children ending up cared for-very high- 50% Attracting women into treatment

Blood Borne Viruses Current levels of morbidity and mortality are of concern. Future outcome and costing to NHS is unknown but expected to rise. ?400,000 Hep C positive. 50,000 known cases. 7,000 treated. 44% Hepatitis C prevalence amongst IDU represent 90% of total cases in UK (HPA) World prevalence of Hepatitis C is x4 times that of HIV 2% HIV prevalence- level rising Dry spot testing

Socioeconomic Cost £13 billion on crime annual £1 million per life time of each user= 1 billion in Salford alone for current users drug treatment s are cost effective-£3 saved for every £1 spent-mainly through less crime costs £40k average crime per annum

Tobacco > 95% smoking prevalence of those in treatment 50% all smokers will die as a result of their addiction > 100k per annum NRT/Oral agents Evidence suggests tackling nicotine dependence improves drug treatment outcomes Smoking cessation therapy/advice most cost effective NHS intervention

Alcohol NTORS report at yr 1 and 5-no fall in level of alcohol misuse Annual deaths: alcohol 30,000 v 2500 drugs Integration of drug and alcohol teams Treatment Outcome Profiles- alcohol recording and as primary drug from 2007 Drug trends - polydrug v polydrug and alcohol at present

Alcohol 1million dependent drinkers- 60,000 have had formal help Lack of resources/funding Government push to help in this area Home/residential detox Screening –FAST/CAGE Brief interventions

Opiates-Methadone A potent opiate 1 cocodamol = 0.5ml methadone 1mg/1ml Usual max start 40mg Golden rule start low go slow Therapeutic range ml Usual max increase 20ml per week Caution with alcohol /benzodiazepeines

Opiates-Buprenorphine Very safe Partial agonist/full antagonist 4-8mg start then 12-24mg daily Misuse/diversion Cost Not for everyone

Opiates- Injectables Little evidence base- need UK research Injecting behaviour strongly linked to BBV transmission Linked to Overdose Use is variable by drug teams Attracting hard to reach users? Only 3% of clients are given injectables Expensive 10k per annum per user

Stimulants Services often dominated by opiates and script based philosophy Lack of evidence for replacement therapies Psychosocial interventions Stigma of attending an opiate based service Role for Contingency management

Benzodiazepines and Z Drugs All work the same way-hypnotics, anxiolytics, anticonvulsants, muscle relaxants and amnesics All are addictive Licensed for 2-4 weeks only million scripts million scripts issued > Z use

Drug Users & Benzos 90% in 1 year period linked to higher BBV risk, greater poly- drug use, psychopathology and social dysfunction Prefer diazepam 10mg (blues) Usually orally rarely injected

Drug Users & Benzos Used for anxiety, insomnia, Iatrogenic dependence, enjoy effects, enhance opiate effect, help mood, coping skills, and/or reduce voices To help come down from amphetamines, ecstacy, crack and cocaine

Benzo Detoxification Fits are very rare at doses below 30mg Convert all benzos/z drugs to diazepam e.g. Temazepam 20mg = diazepam 10mg Prescribe in 2mg tablets & weekly at most Reduce by 2mg every 2 weeks e.g. Diazepam 10mg=a 10 week detox