1. Drugs, dependence and medicine D B Double

2. Outcome To discuss the importance of promoting independence, empowering patients and allowing them to take control of their lives, particularly in long-term conditions To appreciate that people can become dependent on substances, both physically and psychologically

3. The problem of long-term conditions Seventeen and a half million people in this country report a long term condition (such as diabetes, asthma or arthritis).

4. The problem of long-term conditions Seventeen and a half million people in this country report a long term condition (such as diabetes, asthma or arthritis). For some people, especially older people and those with more than one condition, discomfort and stress is an everyday reality.

5. The problem of long-term conditions The impact on the NHS and social care for supporting people with long term conditions is significant.

6. The problem of long-term conditions The impact on the NHS and social care for supporting people with long term conditions is significant. Care for many people with long term conditions has traditionally been reactive, unplanned and episodic. This has resulted in heavy use of secondary care services

7. The problem of long-term conditions The impact on the NHS and social care for supporting people with long term conditions is significant. Care for many people with long term conditions has traditionally been reactive, unplanned and episodic. This has resulted in heavy use of secondary care services Just 5% of inpatients, many with long term conditions, account for 42% of all acute bed days.

8. Long-term Medical Conditions Alliance Umbrella body in the UK for over 100 national voluntary organisations

9. Long-term Medical Conditions Alliance Umbrella body in the UK for over 100 national voluntary organisations Mission to ensure people affected by long-term conditions have access to the services and support they need and can be active participants in determining their care.

10. Long-term Medical Conditions Alliance Patients working in partnership with healthcare professionals

11. Long-term Medical Conditions Alliance Patients working in partnership with healthcare professionals Persons with a particular condition can play an important, and sometimes leading part in their own care and in the management of their disease

12. Persons with a particular condition can play an important, and sometimes leading part in their own care and in the management of their disease Most patients' organisations believe that this ideal has not yet been generally accepted. Why not?

13. Patient autonomy Adversely curbed or restrained within contemporary healthcare

14. Patient autonomy Adversely curbed or restrained within contemporary healthcare Patients are often envisaged as more or less passive recipients rather than active contributors

15. Patient autonomy Adversely curbed or restrained within contemporary healthcare Patients are often envisaged as more or less passive recipients rather than active contributors Powerful position of many doctors

16. Patient autonomy Patriarchal attitudes continue to exist among healthcare professionals

17. Patient autonomy Patriarchal attitudes continue to exist among healthcare professionals Lack of appropriate training in how to work in partnership with patients still prevents the appropriate use of patients' expertise and wisdom

18. Patient autonomy Lack of political commitment? - in practice, involvement of users has been confused with public participation

19. Patient autonomy Lack of political commitment? - in practice, involvement of users has been confused with public participation - health professionals have been given the authority to define users' needs for them

20. Patient autonomy Lack of political commitment? - in practice, involvement of users has been confused with public participation - health professionals have been given the authority to define users' needs for them Lack of time available to clinicians to invest in forming partnerships with patients?

21. New Hippocratic Oath? Hippocratic oath, which granted physicians the right to practice in the patient's best interest, may conflict with modern trend toward patient rights

22. Do doctors promote the independence of patients? What is dependence?

23. Living with drugs Legal vs illicit drugs

24. Living with drugs Legal vs illicit drugs Individual freedom vs. state control

25. Living with drugs Legal vs illicit drugs Individual freedom vs. state control Cultural factors eg alcohol

26. Units of alcohol Unit of alcohol is 10mls of pure ethanol

27. Units of alcohol Unit of alcohol is 10mls of pure ethanol One pint (568mls) of 3.7% ABV beer is therefore 568 x 3.7 / 1000 = 2.1 units

28. Units of alcohol Unit of alcohol is 10mls of pure ethanol One pint (568mls) of 3.7% ABV beer is therefore 568 x 3.7 / 1000 = 2.1 units Small pub measure (25ml) of spirits (40% ABV) = 1 unit

29. Units of alcohol Unit of alcohol is 10mls of pure ethanol One pint (568mls) of 3.7% ABV beer is therefore 568 x 3.7 / 1000 = 2.1 units Small pub measure (25ml) of spirits (40% ABV) = 1 unit 750ml bottle of wine (12% ABV) = 9 units

30. Alcohol safety Sensible drinking (DoH 1995)

31. Alcohol safety Sensible drinking (DoH 1995) No significant risk to health - men 3-4, women 2-3 units/day

32. Alcohol safety Sensible drinking (DoH 1995) No significant risk to health - men 3-4, women 2-3 units/day Increasing risk to health - men > 4, women >3 units/day regularly

33. Alcohol safety Royal College of Physicians

34. Alcohol safety Royal College of Physicians Low risk: men <21, women <14 units per week

35. Alcohol safety Royal College of Physicians Low risk: men <21, women <14 units per week Increasing risk: men 22- 50, women 15-35 units per week

36. Alcohol safety Royal College of Physicians Low risk: men <21, women <14 units per week Increasing risk: men 22- 50, women 15-35 units per week Harmful: men >50, women >35 units per week

37. Prevalence of alcohol use In 2002, average weekly alcohol consumption in England was 17.0 units for men and 7.6 units for women

38. Prevalence of alcohol use In 2002, average weekly alcohol consumption in England was 17.0 units for men and 7.6 units for women Increasing slightly for men and much more markedly for women, especially 16-24 year olds

39. Syndromal concept of dependence (i) a narrowing in the repertoire of drug use behaviour

40. Syndromal concept of dependence (i) a narrowing in the repertoire of drug use behaviour (ii) increased salience in drug-seeking behaviour

41. Syndromal concept of dependence (i) a narrowing in the repertoire of drug use behaviour (ii) increased salience in drug-seeking behaviour (iii) increased tolerance to the drug

42. Syndromal concept of dependence (i) a narrowing in the repertoire of drug use behaviour (ii) increased salience in drug-seeking behaviour (iii) increased tolerance to the drug (iv) repeated withdrawal symptoms

43. Syndromal concept of dependence (v) repeated relief or avoidance of withdrawal symptoms by further drug use

44. Syndromal concept of dependence (v) repeated relief or avoidance of withdrawal symptoms by further drug use (vi) subjective awareness of a compulsion to use the drug

45. Syndromal concept of dependence (v) repeated relief or avoidance of withdrawal symptoms by further drug use (vi) subjective awareness of a compulsion to use the drug (vii) rapid reinstatement of the syndrome after relapse.

46. Psychological dependence Reliance on medication

47. Psychological dependence Reliance on medication Negative affect experienced in absence of drug

48. Psychological dependence Reliance on medication Negative affect experienced in absence of drug People may form attachments to their medication more because of what they mean to them than what they do

49. Conclusions Promoting independence and empowering patients is important Dependence can be psychological as well as physical