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Tads junior doctors induction dec 2013
1. December 2013
Dr Yasir Hameed (SpR)
General Adult/Old Age Psychiatry
Northgate Hospital
Great Yarmouth
2. What is TADS (NRP)?
Drugs and Mental Health (dual
diagnosis, alcohol, opiates and
benzodiazepines dependence)
Useful resources
3. Open access
Drugs AND alcohol
9-5 Mon-Fri
5 bases throughout Norfolk, including in-
patient beds at Hellesdon and Northgate
Hospital.
4. 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
5. DOH Dual Diagnosis Good Practice Guide
“…covers a broad spectrum of mental health and
substance misuse problems that an individual
might experience concurrently. The nature of the
relationship between these two conditions is
complex.”
6. A primary psychiatric illness precipitating or
leading to substance misuse
Substance misuse worsening or altering the
course of a psychiatric illness
Intoxication and/or substance dependence leading
to psychological symptoms
Substance misuse and/or withdrawal leading to
psychiatric symptoms or illness
7. Primary Care Service:
Approximately 75% of drug users approach their GP
before 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
8. 1. Psychiatric disorder is due to
a) 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)
9. Poorer prognosis
Increased incidence of suicide / violence / homicide
Increased use of in-patient services
Poor medication adherence
↑ rates of
Homelessness
BBV infection
Contact with the criminal justice system
Poor social outcomes including impact on carers and
family
(Department of Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide 2002; Avoidable Deaths: 5 year
report of the national confidential enquiry into suicide and homicide by people with mental illness. 2006)
10. I need to take a DRUG AND
ALCOHOL HISTORY when I assess
people
When?
ALWAYS
11. 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
12. Assessment of intoxicated people
Admitting patients who are dependent
◦ Alcohol withdrawal
◦ Opiate withdrawal
Care of in-patients with alcohol and opiate
detox OUT OF HOURS.
13. Intoxication is a clinical diagnosis which can be
aided by investigation (e.g. urine dipstick
and/or breath alcohol)
BUT
In individuals who are dependent on alcohol
breath alcohol can be extremely high without
clinical intoxication.
19. Diagnosis to be made if three or more of the following have occurred
for 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 in
terms of onset, termination, or levels of use.
3) Physiological withdrawal state when substance use
had been ceased or been reduced.
4) Evidence of tolerance
5) Progressive neglect of alternative pleasures or
interests because of psychoactive substance use.
6) Persisting with substance use despite clear evidence
of overtly harmful consequences (physical and mental).
22. In the UK around 1 in 5-6 adults drink at
hazardous levels and around 5% are alcohol
dependent.
Alcohol is now the commonest cause of death
in young people
70% of late-night attendances to A&E are
alcohol-related
An average GP will see 364 excessive drinkers
per year
Excessive drinkers consult their GP twice as
often
25. 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
26.
27. 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
28. 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
29. 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
31. ◦ 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
32. Inpatient or community
◦ Severe withdrawal symptoms, significant physical/mental
health problems, failed home detox, lack of home
supervision, 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
33. Acamprosate (GABA/Glutamate receptor
agonist)
◦ 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
35. Opiates - any opioid drug found
in the natural poppy plant
Opioids – any morphine like
drug active at the opioid
receptor
One of the oldest drugs
recorded
Majority of the worlds
heroin is still sourced from
Afghanistan
42. 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
43. 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 in
damaged 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 and
can be fatal. The classic symptoms comprise blurred vision, slurred
speech, difficulty swallowing – IE – they look drunk
Tetanus
TB
Fungal Candida species are natural commensals in citrus fruit..
44. Bertschy, G. Methadone maintenance treatment: an update. 1995
Marsch L. A. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk
behaviour and criminality: a meta-analysis. Addiction 1998
Gossop M. NTORS
REDUCES
Illicit opiate use
Use of other illicit
drugs
Criminal bhvr
HIV risk bhvrs
Death rate
IMPROVES
Quality of life
Physical health
Mental health
Employment
Perinatal outcome
BECAUSE IT WORKS
45.
46. 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.
49. 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
50.
51. 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
53. Shorter acting drugs are more prone to formation
of dependence
◦ Reward centres
Withdrawal is more extreme with short-acting
drugs, but over quicker
Shorter acting drugs are used more for insomnia
Long acting more useful for reduction and alcohol
detox
54. Z drugs
◦ Zolpidem, zopiclone, zaleplon
Act in a similar but distinct way to
benzodiazepines
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
55. 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