1. 2008

2. NICE Definition  substance misuse is defined as intoxication by – or  regular excessive consumption of and/or  dependence on – psychoactive substances,  leading to social, psychological, physical or  legal problems. It includes problematic use  of both legal and illegal drugs (including  alcohol when used in combination with  other substances).

3. Comonest  Legal  Alcohol  Nicotine  Glue  Illegal  Cannabis  Stimulants – ecstasy, cocaine, amphetamines, khat.  Benzodiazepaines  Heroin

4. Young people at risk  those whose family members misuse  substances  those with behavioural, mental health or  social problems  those excluded from school and truants  young offenders

5. Young people at risk  looked after children  those who are homeless  those involved in commercial sex work  those from some black and minority  ethnic groups.

6. NICE Interventions for those at risk  Offer a family-based programme of structured support over 2 or more years, drawn up with the parents or carers of the child or young person and led by staff competent in this area.

7. NICE Interventions for those at risk  The programme should: – include  at least three brief motivational interviews1 each year aimed at the parents/carers  – assess family interaction  – offer parental skills training  – encourage parents to monitor their children’s behaviour and academic performance

8. NICE Interventions for those at risk  – include feedback  – continue even if the child or young person  moves schools.  Offer more intensive support (for example, family therapy) to families who need it.

9. Management  Management options for misusers  Brief interventions  Counselling  Replacement therapy  Referral to specialist clinics

10. Cannabis  Harms  Damages lungs more than tobacco  Impairs concentration  Impairs motivation  Impairs memory  Heavy use in teenagers may predispose to schizophrenia

11. Cannabis  Selective breeding of plants much higher concentration of active chemical THC = tetrahydro cannabinol  Cannabis induced psychosis more common  Dependency in 5 – 10% of users

12. Cannabis  Medication little role in treatment  GP role  Identification of problem  Brief intervention with motivational technique  Encourage patient to tackle problem

13. Stimulants  Amphetamines  Cocaine  Snorted as powder  Injected  Used in combination with heroin = speedballing

14. Stimulants  Crack cocaine  prepared by heating cocaine in microwave with bicarb of soda. Makes a cracking noise when smoked  Can be injected  Produces more intense and immediate effect than powder cocaine  Wears off in 5-10 mins triggering desire to use it again

15. Stimulants  Crack cocaine  Chronic high dose usage leads to marked psychological dependence  Physical complications include  Heart failure or MI  Crack lung – a hypersensitivity reaction causing dyspnoea and wheeze  Blood borne virus transmission through shared injection equipment  Liver damage

16. Stimulants  Cocaine  Cocaine and alcohol combine together to produce cocaethylene which is more damaging to the liver than either substance  Mental health problems  Lethargy  Depression  Full blown psychosis tactile hallucinations are common the cocaine bug

17. Stimulants  Ecstasy  Stimulant and hallucinogenic effects  Risks  Overheating dehydration  Fluid overload due to increased ADH levels  Advise users to take regular breaks from exercise and sip maximum 1pint water per hour

18. Stimulants  Khat  Green leaves of a shrub commonly grown in Horn of Africa  Effects similar to amphetamine  Legally sold in those areas  Drug induced psychotic episodes  Common in Somali communities

19. Stimulants  Management  Stop usage  Treat individual symptoms  Insomnia hypnotics - short term only  Depression – SSRI’s  Psychological interventions most useful  Local treatment services found Helpfinder section of Drugscope website www.drugscope.org.uk

20. Benzodiazepines  Often used with other illicit drugs  Increases risk of death from overdose when combined with alcohol or opiates  No evidence that long term substitute prescribing reduces harm  Only licensed for reducing regimes and not for maintenance prescribing

21. Benzodiazepines  Be more reluctant to initiate prescription for benzo’s than opiates  Reduction regimes for users of street benzo’s is problematic only do when urine evidence of use and clear evidence of dependence and an agreed reduction plan

22. Benzodiazepines  Reduction regimes  BNF has useful equivalent dose tables  Convert to diazepam  If high doses required refer for specialist assessment  For 30mg/day or less reduce by 2mg every 2 weeks  Can be prescribed for daily dispensing if concerned about diversion or compliance

23. Heroin  Smoked by burning powder on tinfoil  Heated with citric acid and injected  Long term opiate dependency is chronic relapsing condition  Causes harm to users and there families  Typical user will spend £30- 100/day on drug

24. Heroin  Typical user will spend £30- 100/day on drug  Result into drift into poverty  300,000 children of problem drug users in UK  Effective treatment can have significant benefits for child and improved quality of family life.

25. Heroin Mortality risk 12x greater than general population Injecting users 22x more likely to die than non- injecting peers Drug related over doses commonly due to injected heroin in combination with alcohol, benzo’s or other depressants Significant number occur in users who have just left prison and under estimate their loss of opiate tolerance

26. Heroin  Good evidence that drug treatment reduces crime  Led to expansion of drug treatmetn services

27. Substance misuse management  What every GP should provide for a misuser  Same responsibility to provide general medical services to drug misusers as any other patient on their list  Advise on risks of injecting  Increased risk of overdose when using drugs alone  Loss of tolerance after periods of abstinence

28. Substance misuse management  Prevention against blood borne viruses  Not sharing needles or other drug paraphernalia filters, spoons.  Safe sex - use of condoms  Screening for blood borne viruses  Opportunistic vaccination – accelerated schedules increases uptake 0, 7, 21 days with booster at 12 months

29. Substance misuse management  Consider any children- are they at risk if so use local child protection framework - parents using drugs does not necessarily mean child is at risk or neglected.  No legal requirement to report to authorities except in Northern Ireland  Prescribers should report to their regional drug misuse database – details found in BNF

30. Treatment approaches  Aims  To decrease level of drug use  Decrease offending  Decrease overdose risk  Prevent spread of blood borne viruses  Improve health of individual  Improve health of family

31. Drug service providers  Key features  To avoid prescribing in isolation  Harm minimisation

32. Drug service providers  Criminal justice services  Specialist drug teams  Shared care programs  GP led services

33. Essential elements of treatment provision  Assessment of needs to include drug and alcohol misuse, health and social functioning and criminal involvement.  Risks to dependent children should be assessed for drug using parents  All patients entering treatment should have a care or treatment plan that is regularly reviewed

34. Essential elements of treatment provision  Drug misuse treatment involves a range of interventions not just prescribing  A named individual should manage and deliver aspects of the patients care or treatment plan  Drug testing can be a useful too in assessment and in monitoring compliance and outcome of treatment

35. Maintenance prescribing  Licensed treatments for maintenance  Methadone 1mg/ml  Buprenorphine – subutex  Never start at first contact  Perform full physical and psychiatric assessment  Test urine to confirm opiate use

36. Maintenance prescribing  Prescribe for daily consumption for at least first 3 months  Liaise with chosen a pharmacy  Pharmacies must  Have undergone training  Developed protocols for communication between patient, pharmacist and prescriber

37. Maintenance prescribing  Dose titration requires  Experience  Repeated assessment of patient  Usual starting dose 10-30mg methadone but deaths have occurred with doses as low as 20mg  Safer to start 10-20mg and build up

38. Maintenance prescribing  Doses are gradually increased by no more than 5-10mg  Max weekly total increase of 30mg above starting dose  Most patients need 60-120mg methadone  May take several weeks to achieve dose at which patient feels comfortable and is no longer needing illicit heroin

39. Maintenance prescribing  Methadone tablets can be ground up and injected don’t prescribe  Methadone ampoules should only be prescribed by a specialist

40. Maintenance prescribing  Buprenorphine  Used in patients with lower opiate use  Taken sublingually  Starting dose 4-8mg/day  Increased by 4-8mg daily to max dose of 32mg/day

41. Maintenance prescribing  Buprenorphine  Inhibits other opiates blocking effect of heroin used on top of the buprenorphine  Can precipitate opiate withdrawal symptoms if taken while there is still circulating opiate in body  First dose should be taken when patient is showing withdrawal symptoms

42. Maintenance prescribing  Buprenorphine  Can be abused by injecting or snorting  Suboxone = buprenorphin-naloxone  New substance recently launched to address above problem. The naloxone has minimal effect if taken sublingually but if injected or taken intranasally it is likely to precipitate withdrawal effects – has lower street value