Tads junior doctors induction dec 2013

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


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


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



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



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

Health & Medicine

Tads junior doctors induction dec 2013