Upload
yasir-hameed
View
173
Download
3
Tags:
Embed Size (px)
Citation preview
December 2013
Dr Yasir Hameed (SpR)General Adult/Old Age Psychiatry
Northgate HospitalGreat Yarmouth
What is TADS (NRP)?
Drugs and Mental Health (dualdiagnosis, alcohol, opiates andbenzodiazepines dependence)
Useful resources
Open access
Drugs AND alcohol
9-5 Mon-Fri
5 bases throughout Norfolk, including in-patient beds at Hellesdon and NorthgateHospital.
GENERAL◦ Comprehensive assessment◦ Holistic care planned treatment◦ Counselling – MI, CBT, individual and group
SPECIFIC TREATMENTS◦ Opiate Substitution therapy◦ Structured reduction◦ Detox – inpatient / community◦ Prescribing to support maintenance of abstinence◦ Referral for Residential Rehab.
SPECIAL GROUPS◦ Under 18◦ Liaison – NNUH, Gastro, Obstetrics, A+E, pre-op◦ Child and adult protection
DOH Dual Diagnosis Good Practice Guide“…covers a broad spectrum of mental health and
substance misuse problems that an individualmight experience concurrently. The nature of therelationship between these two conditions iscomplex.”
A primary psychiatric illness precipitating orleading to substance misuse
Substance misuse worsening or altering thecourse of a psychiatric illness
Intoxication and/or substance dependence leadingto psychological symptoms
Substance misuse and/or withdrawal leading topsychiatric symptoms or illness
Primary Care Service:
Approximately 75% of drug users approach their GPbefore being seen in centralised services.
General Adult Services 1 in 4 patients classed as dual diagnosis 92% of drug users are polysubstance users Substantial under-recording of drug / alcohol history in
general mental health notes
TADS 1 In 2 patients classed as dual diagnosis
1. Psychiatric disorder is due toa) Acute intoxication (drug induced psychosis)b) Chronic effects / Damage (depression / anxiety / alcoholic hallucinosis)c) Withdrawal state (delirium tremens)
2. Self medication (depression / anxiety)
3. Substance use as a result of mental state (disinhibition)
4. Shared risk factors (genetic / environmental)
Poorer prognosisIncreased incidence of suicide / violence / homicideIncreased use of in-patient servicesPoor medication adherence↑ rates of Homelessness
BBV infection
Contact with the criminal justice system
Poor social outcomes including impact on carers andfamily
(Department of Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide 2002; Avoidable Deaths: 5 yearreport of the national confidential enquiry into suicide and homicide by people with mental illness. 2006)
I need to take a DRUG ANDALCOHOL HISTORY when I assesspeople
When?
ALWAYS
HISTORY◦ what drugs / alcohol?◦ when last used◦ Quantity, frequency, daily pattern◦ route of administration◦ Length of history◦ Withdrawal sx
Diet Physical examination UDS within 24 hours /breath alcohol
Assessment of intoxicated people
Admitting patients who are dependent◦ Alcohol withdrawal◦ Opiate withdrawal
Care of in-patients with alcohol and opiatedetox OUT OF HOURS.
Intoxication is a clinical diagnosis which can beaided by investigation (e.g. urine dipstickand/or breath alcohol)
BUTIn individuals who are dependent on alcohol
breath alcohol can be extremely high withoutclinical intoxication.
04/12/2013Dr Hayley Pinto TADS
04/12/2013Dr Hayley Pinto TADS
ALCOHOLShaking
Confusion /disorientationHallucinations
Fits
BOTHAnxiety and agitation
P , BPSweating
Nausea and vomitingInsomnia
OPIATES•Dilated pupils•Abdominal cramps•Diarrhoea•Anorexia•Gooseflesh•Muscle twitching•Aching – bones andmuscles•Hot and cold flushes•Yawning•Running eyes andnose
Diagnosis to be made if three or more of the following have occurredfor at least 1 month or if persisting for periods of less than 1 month,should have occurred together repeatedly within a 12 month period.
1) Strong desire or compulsion to use the substance.2) Difficulties in controlling substance taking behaviour interms of onset, termination, or levels of use.3) Physiological withdrawal state when substance usehad been ceased or been reduced.4) Evidence of tolerance5) Progressive neglect of alternative pleasures orinterests because of psychoactive substance use.6) Persisting with substance use despite clear evidenceof overtly harmful consequences (physical and mental).
CAGE questionnaire AUDIT SAD-Q FAST
04/12/2013Dr Hayley Pinto TADS
In the UK around 1 in 5-6 adults drink athazardous levels and around 5% are alcoholdependent.
Alcohol is now the commonest cause of deathin young people
70% of late-night attendances to A&E arealcohol-related
An average GP will see 364 excessive drinkersper year
Excessive drinkers consult their GP twice asoften
04/12/2013Dr Hayley Pinto TADS
04/12/2013Dr Hayley Pinto TADS
Easiest way to work it out:◦ ABV x amount in litres = number of units
Rough estimate of 1 unit:◦ ½ pint of normal-strength beer◦ 125ml glass of wine◦ Single (25ml) spirit measure
Increased size of red blood cells◦ Raised MCV and MCH
Raised liver enzymes◦ GGT, AST, ALT, Alk P
More concerning◦ Raised bilirubin◦ Prolonged blood clotting◦ Low platelets◦ Low albumin
Chronic liver disease◦ Cirrhosis◦ Hepatitis C
Poor nutrition/losing weight◦ high risk of complication
Evidence of active bleeding◦ GI bleeding can be suddenly fatal◦ Not always asked about
Recent fits or hallucinations Active suicidality◦ Consider need for CRHT referral
Polysubstance use
Withdrawal seizures (12-48 hours)◦ Usually self-limiting◦ Potentially fatal
Delirium tremens (24-96 hours)◦ Occurs in 5% of people◦ 5-10% mortality rate◦ Characterised by withdrawal symptoms plus
hallucinations, delusions and disorientation◦ Treat with benzos plus supportive care
Wernicke’s encephalopathy◦ Confusion, ataxia, ophthalmoplegia◦ Brainstem bleeding◦ Potentially fatal
Korsakoff’s psychosis◦ Preceded by Wernicke’s◦ Short-term memory failure◦ Mostly non-reversible◦ Rarely compatible with independent living
◦ Alcohol intake > 15 units /day
Action - immediate referral for alcohol detoxification if◦ Requesting detoxification◦ H/O severe withdrawal symptoms, including complications such
as delirium tremens or alcohol withdrawal seizures◦ Poor physical health (e.g. compromised liver function, heart
problems)◦ Significant mental health problems or cognitive impairment◦ They are at risk of intentional or unintentional overdose
Should be seen within 10 working day
Inpatient or community◦ Severe withdrawal symptoms, significant physical/mental
health problems, failed home detox, lack of homesupervision, unsuitable setting
Chlordiazepoxide (librium) used locally◦ High initial dose◦ Gradually withdrawn over 6-9 days◦ Alternatives used in severe liver disease
Vitamin injections – pabrinex Daily monitoring
Acamprosate (GABA/Glutamate receptoragonist)◦ First-line treatment
Naltrexone (opiate receptor antagonist) Disulfiram (Antabuse)◦ Third-line from NICE◦ Interferes with alcohol metabolism, causing
build up of acetaldehyde◦ Rare risk of acute hepatitis
OPIATES
Opiates - any opioid drug foundin the natural poppy plant
Opioids – any morphine likedrug active at the opioidreceptor
One of the oldest drugsrecorded
Majority of the worldsheroin is still sourced from
Afghanistan
HEROIN(di-acetyl morphine) CODEINE
Mono-acetyl morphine(MAM)
MORPHINE
•Tramadol•Oxycodone•Dihydrocodeine(DF118)
•Tramadol•Oxycodone•Dihydrocodeine(DF118)
•Methadone
•Buprenorphine
•Fentanyl
•Methadone
•Buprenorphine
•Fentanyl
WANTED EFFECTS Euphoria – sense of comfort and wellbeing Sedation Pain relief Cough suppression
Reduces pupil size Constipation Nausea and vomiting Itchy rash Slows heart rate and drops blood pressure Suppresses breathing
Immune suppression
Menstrual abnormalities (delayed recognition of
pregnancy)
Tooth decay
Malnutrition
Lethargy and depression
IMPACT OF USE ON SELF CONCEPT AND STIGMA
Vein /artery / nerve damage
Clots - DVT / embolism
Infections – BBV and others
INCREASED RISK OFOVERDOSE
DVTEsp groininjectors
HIV - < 1 % of Norfolk IDUs (1.3%)
Hepatitis C - 36% of Norfolk IDUs (45%)
Hepatitis B - 19% of Norfolk IDUs (15%)
(national averages in brackets)
Shooting Up: Infections among people who inject drugs in the UK 2010 London HPA 2011
Superficial Abscesses are common Septicaemia (blood poisoning) Endocarditis (infection in the Heart). Embolism –debris, clots, or septic emboli
Unusual infections may occur due to reduced immunity, injection indamaged tissue and contaminated batches of drugs such as
Anthrax Botulism - , There are about 100 cases of botulism in injecting drug
users in the UK per year. It presents as a descending paralysis andcan be fatal. The classic symptoms comprise blurred vision, slurredspeech, difficulty swallowing – IE – they look drunk
Tetanus TB Fungal Candida species are natural commensals in citrus fruit..
Bertschy, G. Methadone maintenance treatment: an update. 1995Marsch L. A. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk
behaviour and criminality: a meta-analysis. Addiction 1998Gossop M. NTORS
REDUCES
Illicit opiate use
Use of other illicitdrugs
Criminal bhvr
HIV risk bhvrs
Death rate
IMPROVES
Quality of life
Physical health
Mental health
Employment
Perinatal outcome
BECAUSE IT WORKS
Long acting full agonist PK levels 1-6 hrs after 1st dose 3-10 days to reach steady state Prolongs QT interval Prescribing on medication card in line with
Controlled Drugs Px Guidelines.
Partial agonist High affinity / low intrinsic activity Precipitated withdrawal Reduced intoxicating effects Lower retention rates Higher abstinence and detox
rates
Opiate systemDampening effect
Noradrenergicdrive
Opiate Detoxification
METHADONE / BUPRENORPHINE – Slow reduction
SYMPTOMATIC TREATMENTSedatives –agitation and sleepSimple pain killers – aches and painsAnti-diarrhoeals / anti-sicknessStomach cramps – buscopan
LOFEXIDINE / CLONIDINE (2 adrenergic agonist)
2-4 weeks
Naltrexone
Relapse Prevention Work•Triggers – things associated with using, boredom, negative
emotions (past trauma), ‘treats’
•Coping with Craving
•Re-structuring life
12 Step Programs
Residential Rehabilitation
Beware of swapping one substance for another
500 000 – 1 million “therapeutic” 200 000 recreational◦ ~50% demonstrate classic dependence
Estimates suggest up to 40-50% of “other”substance users also use benzos
Black market diversion common Internet purchase becoming more common “Silent” dependence
Onset 3-10 days, duration 3-6 weeks Physical◦ Sweating, tremor, palpitations, lethargy, muscle
tension/pain, nausea, flu-like illness, formication◦ Convulsions
Psychological◦ Agitation, irritability, restlessness, poor concentration,
nightmares, insomnia◦ Depersonalisation, derealisation, hallucinations and
other psychotic symptoms
Shorter acting drugs are more prone to formationof dependence◦ Reward centres
Withdrawal is more extreme with short-actingdrugs, but over quicker
Shorter acting drugs are used more for insomnia Long acting more useful for reduction and alcohol
detox
Z drugs◦ Zolpidem, zopiclone, zaleplon
Act in a similar but distinct way tobenzodiazepines
Short acting Possibly less prone to cause dependence Still clearly able to cause dependence Some black market diversion, though ?less
common Dependence managed in similar ways
No strict rule on how fast - negotiate Generally, 10-12 week reduction CONVERT TO DIAZEPAM Aim to reduce at 1/8 – 1/10 of dose every two weeks May need to slow reduction towards end, but should be
planned Generally not repeated
Think about drugs and alcoholCare and respectGet advice
04/12/2013Dr Hayley Pinto TADS
04/12/2013Dr Hayley Pinto TADS
Call TADS 786786
TADS Guidelines Intranet
Norfolk Recovery Partnership website:
http://www.norfolkrecoverypartnership.org.uk/Pages/default.aspx
Orange Guidelineswww.nta.nhs.uk
Alcohol Detoxification in the Inpatient Setting - C102
Opioid Detoxification and Stabilisation onto SubstituteMedication - C103
Benzodiazepine Detoxification in the In-patient Setting -C104