Addiction

Dr Anna Barham

May 28th 2008

• Addiction

• Alcohol

• Drugs

• GP role

• Policies & Guidelines

• Case studies

• Ethics

ICD-10 criteria for dependence

• A strong desire or sense of compulsion to take the substance

• Difficulties in controlling substance-taking behaviour (onset, termination, level of use)

• Physiological withdrawal state when substance use has ceased or been reduced

• Evidence of tolerance• Progressive neglect of alternative interests• Persisting with substance use

Addictions

• Chemical substances• Things to do with body – exercise, food,

weight loss, sex• Material gain – work, shopping, money• Risk – gambling, pornography, computer

games• Less tangible – another person, religion,

perfectionism• Newer addictions – contact, alter-ego

Discuss

“Addiction is a choice, a personality flaw - not a disease. Addicts only have themselves to blame. The NHS should not waste money on treating people with drug and alcohol related problems.”

Environment

Personality

Drug

Factors Contributing to Substance Misuse

Environment

Availability

Socio-economic status

Peer pressure (contacts)

Unemployment

Poor housing/homelessness

Personal

Vulnerable personality

Poor family relationships/breakdown & support

Easily led

Mental health problems – Depression, Schizophrenia, ADHD

Family using alcohol/drugs (patterning/genetic)

Poor achiever at school

Drug

Individual effects of drug

Effects of drug may be used to counter feelings/depression

Know your limits

• How many units of alcohol in

a single measure (25mls) of vodka? a bottle of standard strength beer (5%)? a pint of superstrength cider (9%)? a small 125ml glass of wine (10%) a large 250ml glass of wine (14%) a bottle of alcopop?

Know your limits

a single measure (25mls) of vodka? 1.0

a bottle of standard strength beer (5%)? 1.7

a pint of superstrength cider (9%)? 5.1

a small 125ml glass of wine (10%) 1.5

a large 250ml glass of wine (14%) 3.5

a bottle of alcopops? 1.4

The problem

• 8.2 million people consume more alcohol than the recommended guidelines– 16.3% of the population are hazardous drinkers

– 4.1% are harmful drinkers

• The harm associated with alcohol misuse is estimated to be in excess of £15b a year

• 10% of all psychiatric admissions are alcohol related

• Models of care for alcohol misusers Consultation document 2005. Department of health, National treatment agency for Substance Misuse

Complications of ETOH misuse• 5% of dependent experience severe withdrawal

symptomatology including delirium tremens and grand mal seizures

• Direct toxic effect on brain and liver • Deficiency of protein and B vitamins• Effects on cardiovascular system, lipids and glucose• Damage to the fetus (fetal alc. syndrome, stillbirths)• Risk of accidents• Psychiatric disorders (intoxication, withdrawal, toxic or

nutritional disorders, associated mood and anxiety disorders)

• Social problems

Alcohol Related Complications

Brief Intervention

• Ideal for primary care setting• Evidence based• Quick and cost effective (£20 per intervention)• GPs and practice nurses have skills• Evidence suggests that Brief Interventions are

effective in reducing alcohol intake by 20%• Estimated that £10,000 invested in BI could save

£43,000 health care costs

Components of Brief Intervention (5 to 10 mins)

• Assessment of alcohol intake• (Physical assessment)• Personalising of health effects• Information on hazardous/harmful

drinking – quantity & pattern• Clear advice with info booklet• Explore triggers for drinking• Negotiate realistic aims• Follow-up negotiated

Elements of Brief Intervention(FRAMES)

• Feedback about risks of substance use and misuse

• Responsibility placed on the patient for change• Advice to cut down/abstain etc.• Menu of options and choices• Empathic approach• Self-efficacy – using a non-confrontational

counselling style which encourages and reinforces patient’s strengths

Home Detoxification Criteria

• No history of alcohol withdrawal seizures• Adequate home support• No inter-current serious mental health problem• No current suicidality• No multiple failed attempts at home

detoxification• No poly-drug dependency

Home detoxification

• Daily visits with breathalyser test• Reducing dose of benzodiazepine plus prn

doses. • Consider instalment dispensing• Oral vitamin supplements – thiamine and vitamin

B co strong• 7-10 days usual

Drugs

Discuss your own professional and personal experiences of drug misusers

Problems Perceived by professionals:

• Difficult group of patients• Lack of training• Possibility of ‘swamping’• Doubtful value of intervention• Possibility of GP/pharmacist/psychiatrist

etc getting blamed• Possibility of diversion of prescribed

drugs

Why should GPs get involved?

• Common chronic relapsing condition • Patients prefer treatment in primary care• Evidence that primary care treatment works • Government policy and NTA guidelines

promote GP involvement• Good support and training now exists

Effects of dependent drug usePhysical: Complications of injecting

(DVT, abscesses, overdose, SBE)Blood-borne virus transmissionSide effects of opiates (constipation, low salivary flow)Side effects of cocaine

(vasoconstriction, local anaesthesia)

Social: Financial, employment, crime, relationships, parenting, housing

Psychological: Depression, anxiety, psychosis, craving, guilt

What can a GP offer a newly presenting drug misuser?

• Harm reduction advice

• Health check, e.g. blood pressure

• Screening for blood borne viruses

• Contraception, smear

• Sexual health advice

• Check general immunisation status

• Signpost to additional help (counselling, benefits, housing)

• Information on local drugs services including needle exchange

How do I do a quick GP assessment?

Which drug ? Heroin/other opiates can be substituted by Methadone or buprenorphine (subutex) Stimulants have no substitute available

Route of administration ? Oral Inhaled/smoked

InjectedHow long addicted ?

Longer term addiction, quick detox less chance of success

Younger patient less suitable for long-term maintenance as 1st option

Examination and Investigations Examination for injection sites etc Urine screen for opiates and other drugs

Opioid Treatment

• Pharmacological – detox or maintenance – with methadone or buprenorphine - NICE approved. Supervised consumption.

• Psychological interventions - key working, brief interventions, self-help, contingency management – NICE approved

• Social support – housing, employment, parenting, finance

Contingency management

• Drug services should introduce these programmes as part of phased implementation

• Programme should offer incentives e.g. vouchers, privileges which are contingent on each presentation of a drug-negative test

• For people at risk of physical health problems from their drug misuse material incentives should be considered to encourage harm reduction. e.g one-off £10 voucher for completion of hep B immunisation

Cycle of Change (Prochaska & DiClemente 1986)

Case study

• Laura is a 26 year old woman who comes to see you for the first time having recently joined your list. She tells you that for the last five years she has been using heroin daily and that she now uses at least three £10 bags a day, sometimes more and injects three or four times a day. She smokes about thirty cigarettes a day but does not drink alcohol. She uses occasional crack cocaine.

• Laura tells you that she does not have anywhere permanent to live at present and is staying with her brother.

• Laura has never received treatment for her drugs problem in the past and she tells you that she has come to see you “to get off all drugs as soon as possible – I’ve had enough”

• On examination you find that Laura has old and new track marks on both arms and is very thin, but otherwise appears healthy.

Questions

• 1. What are the issues raised by this scenario?

• 2. What are the options?

• 3. What action do you take?

Case study

• You are on call on Saturday morning for the local co-op and a call comes in from a patient. She is desperate and wants help. She has just come to the area from Liverpool and is staying with her mum. She is 7 months pregnant. She has left her methadone in Liverpool and is ‘clucking real bad’

1. What issues do you want to think about?

2. What are your options? And their consequences?

3. In ideal circumstances what can be done in these cases?