Healthy Living : Smoking, Alcohol & Party Drugs.

By K V Liew, EdmundBy K V Liew, Edmund

Smoking :

Harms of smoking are well-known. For example : Harms of smoking are well-known. For example : COAD, cancers (lungs/laryngeal/ oesophagus/bladder), COAD, cancers (lungs/laryngeal/ oesophagus/bladder), ischaemic heart disease, CVA, peripheral vascular ischaemic heart disease, CVA, peripheral vascular disease & peptic ulcers.disease & peptic ulcers.

Why do people still smoke ??!!!Why do people still smoke ??!!! Enhances their feeling of calmness (i.e. decreases Enhances their feeling of calmness (i.e. decreases

anxiety), improves mood, improves ability to anxiety), improves mood, improves ability to concentrate/think. ***Addiction.concentrate/think. ***Addiction.

Notoriously difficult to quit.Notoriously difficult to quit. As doctors, especially frontline GPs, we have duty to As doctors, especially frontline GPs, we have duty to

educate patients, to encourage quitting & assist quitters.educate patients, to encourage quitting & assist quitters.

Multiple studies have shown that the Multiple studies have shown that the majority of smokers have thought about majority of smokers have thought about stopping (80% in one Australian study).stopping (80% in one Australian study).

How to help patients stop smoking : Educate them about the risks to their health & Educate them about the risks to their health &

emphasise emphasise the advantages of giving up.the advantages of giving up. Saves money, live longer, food tastes better, bad breath Saves money, live longer, food tastes better, bad breath

improves, decrease frequency & severity of URTI, improves, decrease frequency & severity of URTI, better exercise tolerance, less chance of premature better exercise tolerance, less chance of premature wrinkling of skin/stained teeth, improved sexual wrinkling of skin/stained teeth, improved sexual pleasure, early COAD can be reversed, removes effects pleasure, early COAD can be reversed, removes effects of passive smoking on family & friends.of passive smoking on family & friends.

***Risk of lung cancer decreases. After stopping for ***Risk of lung cancer decreases. After stopping for 10-15 years, risk is as low as someone who has never 10-15 years, risk is as low as someone who has never smoked.smoked.

Opportunistic interventions during GP Opportunistic interventions during GP consultations for other matters.consultations for other matters.

If patients say no to stopping, provide If patients say no to stopping, provide motivational & educational leaflets. Asks motivational & educational leaflets. Asks patients to re-consider.patients to re-consider.

If patients agree to stop smoking, ask them If patients agree to stop smoking, ask them to make a definite date to stop (e.g. during a to make a definite date to stop (e.g. during a holiday) & make a mutual contract.holiday) & make a mutual contract.

Practical advice for successful quitting : Eat more fruits & vegetables (citrus fruits can Eat more fruits & vegetables (citrus fruits can

reduce cravings).reduce cravings). Chewing gum/lozenges/sweets.Chewing gum/lozenges/sweets. Increase your activity level or take up hobbies that Increase your activity level or take up hobbies that

make you forget smoking (e.g. swimming/water make you forget smoking (e.g. swimming/water sports).sports).

Avoid smoking situations and seek the company Avoid smoking situations and seek the company of non-smokers.of non-smokers.

Put aside the money saved & have a special treat.Put aside the money saved & have a special treat.

For those who find it difficult to stop “cold For those who find it difficult to stop “cold turkey”, try smoking lighter cigarettes, less turkey”, try smoking lighter cigarettes, less frequently, stubbing out earlier & gradually frequently, stubbing out earlier & gradually stop completely.stop completely.

Pharmacological agents to help stop smoking : In general, for light smokers with low In general, for light smokers with low

dependence/addiction to Nicotine, use non-dependence/addiction to Nicotine, use non-pharmacological methods rather than drug substitute.pharmacological methods rather than drug substitute.

Nicotine chewing gum=>chew at least 6 per day, Nicotine chewing gum=>chew at least 6 per day, replacing at regular intervals. Chew slowly, not more replacing at regular intervals. Chew slowly, not more than 1 gum per hour.than 1 gum per hour.

Use for 3 months, slowly weaning off.Use for 3 months, slowly weaning off. Transdermal nicotine patch=>useful for moderate to Transdermal nicotine patch=>useful for moderate to

severe nicotine dependence. Begin use immediately severe nicotine dependence. Begin use immediately upon cessation of smoking.upon cessation of smoking.

Available as 16-hour or 24-hour patches in Available as 16-hour or 24-hour patches in 3 different strengths (7, 14 & 21mg).3 different strengths (7, 14 & 21mg).

Apply to clean, non-hairy & dry skin on Apply to clean, non-hairy & dry skin on upper outer arm/chest, leave in place for 16/ upper outer arm/chest, leave in place for 16/ 24hrs. Rotate sites with a 7-day gap for re-24hrs. Rotate sites with a 7-day gap for re-use of a specific site.use of a specific site.

Adverse reactions & contraindications : Nervousness, sweating, dry mouth, dyspepsia, Nervousness, sweating, dry mouth, dyspepsia,

abdominal cramps, angina & cardiac arrhythmias. abdominal cramps, angina & cardiac arrhythmias. Nicotine gum=>hiccoughs, jaw pain, exacerbation Nicotine gum=>hiccoughs, jaw pain, exacerbation

of peptic ulcers.of peptic ulcers. Nicotine patch=>local skin reaction, sleep Nicotine patch=>local skin reaction, sleep

disturbances (especially 24hr. patch).disturbances (especially 24hr. patch). Contra-indications : pregnancy & breast-feeding, Contra-indications : pregnancy & breast-feeding,

severe IHD, recent CVA & history of cardiac severe IHD, recent CVA & history of cardiac arrhythmias.arrhythmias.

After-care & relapse prevention :

Arrange Follow-Up, at least monthly Arrange Follow-Up, at least monthly especially during the first 3 months.especially during the first 3 months.

Acknowledge that it is very difficult to quit. Acknowledge that it is very difficult to quit. Offer active encouragement & advice from Offer active encouragement & advice from GP.GP.

Consider behavioural modification therapy Consider behavioural modification therapy for those encountering difficulties.for those encountering difficulties.

Alcohol :

Alcohol use is pervasive in society, especially Alcohol use is pervasive in society, especially Western society. Western society.

In suitable quantities, it is a good social lubricant In suitable quantities, it is a good social lubricant & makes people more relax and disinhibited.& makes people more relax and disinhibited.

However, it can interact negatively with However, it can interact negatively with medications, causes and worsens multiple medical medications, causes and worsens multiple medical and psychological conditions (e.g. liver cirrhosis/ and psychological conditions (e.g. liver cirrhosis/ traffic accidents) & results in addiction if traffic accidents) & results in addiction if consumed excessively.consumed excessively.

In one estimation from the Census Department, In one estimation from the Census Department, 90% of adult population in USA drinks alcohol & 90% of adult population in USA drinks alcohol & ~ 60-70% of adult population consumed alcohol ~ 60-70% of adult population consumed alcohol within the past 1 month. Over 40% of the within the past 1 month. Over 40% of the population has had, or will have a temporary population has had, or will have a temporary problem with alcohol during their lifetime.problem with alcohol during their lifetime.

It is difficult for doctors to accurately assess It is difficult for doctors to accurately assess whether a patient is addicted/dependent on alcohol.whether a patient is addicted/dependent on alcohol.

It is therefore important to be aware of the problem It is therefore important to be aware of the problem & maintain a high degree of suspicion.& maintain a high degree of suspicion.

Early recognition of the problem means better potential Early recognition of the problem means better potential for treatment & recovery, hopefully before any for treatment & recovery, hopefully before any permanent damage occur (e.g. neurological deficits/liver permanent damage occur (e.g. neurological deficits/liver cirrhosis).cirrhosis).

Checklist for pointers of alcohol dependency/addiction Checklist for pointers of alcohol dependency/addiction includes : includes :

Are you drinking >6 glasses per day ?Are you drinking >6 glasses per day ? Are you drinking in the morning ?Are you drinking in the morning ? Do you feel a need for alcohol whenever you feel Do you feel a need for alcohol whenever you feel

stressed ?stressed ? Do you have any alcohol-related driving offences?Do you have any alcohol-related driving offences?

Are you concerned about your own drinking Are you concerned about your own drinking habits ?habits ?

Has any relatives/friends expressed concern Has any relatives/friends expressed concern about your drinking habits ?about your drinking habits ?

Do you drink frequently during the working Do you drink frequently during the working hours ?hours ?

Have you lost a job because of your drinking Have you lost a job because of your drinking habits ?habits ?

Acute effects of alcohol :

Motor performance & cognitive functions are Motor performance & cognitive functions are reduced (e.g. slurred speech, unsteady gait & reduced (e.g. slurred speech, unsteady gait & nystagmus).nystagmus).

Judgements are also impaired.Judgements are also impaired. Mental black-outs occur at higher doses.Mental black-outs occur at higher doses. These are memory impairments of all forms & These are memory impairments of all forms &

functions, including long-term, short-term, recall functions, including long-term, short-term, recall and acquisition. Patient is walking, talking but and acquisition. Patient is walking, talking but not recording.not recording.

Chronic effects of alcohol :

Wernicke-Korsakoff Syndrome.Wernicke-Korsakoff Syndrome. Peripheral neuropathy.Peripheral neuropathy. Mallory-Weiss Syndrome & peptic ulcers.Mallory-Weiss Syndrome & peptic ulcers. Liver cirrhosis, cardiomyopathy & Liver cirrhosis, cardiomyopathy &

depressed immune system.depressed immune system. Fetal alcohol syndrome in babies of Fetal alcohol syndrome in babies of

alcoholic mothers.alcoholic mothers.

Alcohol Withrawal :

Delirium Tremens.Delirium Tremens. Acute medical emergency requiring Acute medical emergency requiring

intensive care.intensive care. Essentially autonomic nervous system Essentially autonomic nervous system

overdrive.overdrive. Treated with supportive measures + Treated with supportive measures +

sedation (benzodiazepines) + vitamins.sedation (benzodiazepines) + vitamins.

Treatment for Alcohol Dependency/Abuse : Ideally, treated in detoxification centres for Ideally, treated in detoxification centres for

prolonged period of stay. Multidisciplinary prolonged period of stay. Multidisciplinary approach (MSW, Psychiatrist/Psychologist, approach (MSW, Psychiatrist/Psychologist, Counsellors, etc...), similar to drug detoxification.Counsellors, etc...), similar to drug detoxification.

Important issue of dual diagnosis (chicken and Important issue of dual diagnosis (chicken and egg).egg).

? No such facilities in Hong Kong.? No such facilities in Hong Kong. Alcoholics Anonymous, tel=25225665.Alcoholics Anonymous, tel=25225665.

Party Drugs @ Psychotropic Drugs : Includes Ecstasy, LSD, Marijuana, Includes Ecstasy, LSD, Marijuana,

Methamphetamine/Ice, Ketamine & Methamphetamine/Ice, Ketamine & Flunitrazepam.Flunitrazepam.

Came to prominence & media publicity with the Came to prominence & media publicity with the advent of “Rave” parties.advent of “Rave” parties.

““Rave” parties & its “techno” dance subculture Rave” parties & its “techno” dance subculture originated in Europe (Germany) in the 1980s, originated in Europe (Germany) in the 1980s, spread to USA and arrived in Asia/Hong Kong in spread to USA and arrived in Asia/Hong Kong in the mid 1990s.the mid 1990s.

Epidemiology of “party drugs” abuse in HK : Data from the Central Registry of Drug Abuse Data from the Central Registry of Drug Abuse

(CRDA), Hong Kong.(CRDA), Hong Kong. Prior to the arrival of “Rave” & party drugs, Prior to the arrival of “Rave” & party drugs,

there was a down-trend in the number of there was a down-trend in the number of reported drug abusers (including young abusers reported drug abusers (including young abusers aged < 21) in HK since 1995.aged < 21) in HK since 1995.

This downtrend reversed in the first nine months This downtrend reversed in the first nine months of 2000 when compared with the same period in of 2000 when compared with the same period in 1999.1999.

The no. of reported drug abusers rose 7.5%.The no. of reported drug abusers rose 7.5%. ***The no. of reported ***The no. of reported youngyoung drug abusers drug abusers

aged <21 rose 51.1%.aged <21 rose 51.1%. The no. of psychotropic substance abusers The no. of psychotropic substance abusers

increased 51.5%.increased 51.5%. ***The no. of ***The no. of young young psychotropic psychotropic

substance abusers increased 113.5%.substance abusers increased 113.5%.

Further breakdown of figures :

Of the total no. of psychotropic substance Of the total no. of psychotropic substance abusers, 76% were male, 51% were aged <21, abusers, 76% were male, 51% were aged <21, 55% were previously convicted, 41% were 55% were previously convicted, 41% were unemployed, 36% have full-time jobs & 12% unemployed, 36% have full-time jobs & 12% were still going to schools. Average age was were still going to schools. Average age was 24yrs. old.24yrs. old.

The most common drugs abused was Ecstasy The most common drugs abused was Ecstasy (40.1%), Cannabis/Marijuana (26.7%), Ketamine (40.1%), Cannabis/Marijuana (26.7%), Ketamine (22.3%) & Ice/Methamphetamine (17.5%).(22.3%) & Ice/Methamphetamine (17.5%).

Reported use of Ecstasy rose from 179 Reported use of Ecstasy rose from 179 cases to 1664 & Ketamine rose from 9 to cases to 1664 & Ketamine rose from 9 to 926.926.

Usually spend <$300 /person/day.Usually spend <$300 /person/day. Reasons : peer influence, seek euphoria/ Reasons : peer influence, seek euphoria/

sensory satisfaction & curiosity. Need to sensory satisfaction & curiosity. Need to consider overall socio-economic factors too.consider overall socio-economic factors too.

Methylenedioxymethamphetamine (MDMA/Ecstasy) & GHB : Synthetic amphetamine analog with stimulant Synthetic amphetamine analog with stimulant

properties.properties. In US, illegal only since 1985.In US, illegal only since 1985. First patented by Merck in Germany in 1914. ?First patented by Merck in Germany in 1914. ?

appetite suppresant/secret military uses.appetite suppresant/secret military uses. Used by New Age seekers & clinical therapists Used by New Age seekers & clinical therapists

in 1960s for its properties of inducing feelings in 1960s for its properties of inducing feelings of of

Well-being/warmth, interpersonal Well-being/warmth, interpersonal connection/rapport/empathy, friendliness.connection/rapport/empathy, friendliness.

***Causes motor agitation/restlessness that can ***Causes motor agitation/restlessness that can be pleasurably relieved by dancing.be pleasurably relieved by dancing.

Mechanism of action involves stimulation of Mechanism of action involves stimulation of serotonin, dopaminergic & many other serotonin, dopaminergic & many other neurotransmitter systems.neurotransmitter systems.

Effects : amphetamine-like “rush” initially, then Effects : amphetamine-like “rush” initially, then nausea then plateau of “togetherness” nausea then plateau of “togetherness”

For ~3 to 4 hours.For ~3 to 4 hours. Side-effects of dehydration, exhaustion, Side-effects of dehydration, exhaustion,

overheating & seizures. Others include teeth-overheating & seizures. Others include teeth-gnashing, jaw clenching, decrease appetite, gnashing, jaw clenching, decrease appetite, hot flashes etc…hot flashes etc…

After effects of up to few days.After effects of up to few days. Usually taken p.o., a “liquid Ecstasy” (GHB) Usually taken p.o., a “liquid Ecstasy” (GHB)

also exists.also exists.

******NO physiological dependence/addiction. NO physiological dependence/addiction. Just psychological dependence, if at all.Just psychological dependence, if at all.

Neurotoxicity of permanent damage to Neurotoxicity of permanent damage to serotonin neurons resulting in ?negative serotonin neurons resulting in ?negative impact on mood, causing/exacerbate impact on mood, causing/exacerbate affective disorders. affective disorders.

Controversial research, yet to have strong Controversial research, yet to have strong evidence.evidence.

Lysergic Acid Diethylamide (LSD/psychedelic/speed/acid) : Synthetic hallucinogen.Synthetic hallucinogen. First created by Albert Hoffmann, working for First created by Albert Hoffmann, working for

Sandoz in 1944.Sandoz in 1944. In US, made illegal in 1966. CIA In US, made illegal in 1966. CIA

experimented with it as “truth serum”.experimented with it as “truth serum”. Experiences heightened perceptual sensations Experiences heightened perceptual sensations

& hallucinations. Colours become more & hallucinations. Colours become more dramatic, synaesthesia develops.dramatic, synaesthesia develops.

Experiences one sensory perception through the Experiences one sensory perception through the realm of another sense. For example, smell a realm of another sense. For example, smell a colour, taste a sound.colour, taste a sound.

Perceptual disturbance, “Trails”, develops. Perceptual disturbance, “Trails”, develops. Similar to seeing moving objects under a Similar to seeing moving objects under a strobe/disco light.strobe/disco light.

Mechanism of action : very complex, as yet not Mechanism of action : very complex, as yet not understood.understood.

Side-effects of tremors, weakness, nausea/VSide-effects of tremors, weakness, nausea/V

““bad-trip”, where the hallucination is bad-trip”, where the hallucination is unpleasant/nightmare.unpleasant/nightmare.

Disorientated behaviour, impaired judgement Disorientated behaviour, impaired judgement of “invincibility”, paranoid delusions with of “invincibility”, paranoid delusions with danger to those trying to help.danger to those trying to help.

Post-Hallucinogenic Perceptual Disorder, can Post-Hallucinogenic Perceptual Disorder, can last very long time.last very long time.

No physiological dependence/addiction.No physiological dependence/addiction.

Ketamine :

Originally derived from PCP.Originally derived from PCP. Used as anaesthetic agent in paediatric patients Used as anaesthetic agent in paediatric patients

& farm animals/by veterinarians.& farm animals/by veterinarians. Feels disassociated from user’s body & Feels disassociated from user’s body &

delirium.delirium. Physiological dependence occurs. Acute Physiological dependence occurs. Acute

intoxication treated with supportive measures.intoxication treated with supportive measures. Tx/detoxification as per any addictive drug.Tx/detoxification as per any addictive drug.

Mechanism of action : complex and not yet Mechanism of action : complex and not yet known to science.known to science.

Flunitrazepam (Rohypnol) :

Short-acting benzodiazepine.Short-acting benzodiazepine. Drug of Choice for “date-rapes”/ “party Drug of Choice for “date-rapes”/ “party

rapes”/robbery.rapes”/robbery. Fast onset of action time, in seconds to tens Fast onset of action time, in seconds to tens

of seconds.of seconds. Causes somnolence, relaxation, Causes somnolence, relaxation,

disinhibition & disinhibition & anterograde amnesiaanterograde amnesia..