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DRUG ADDICTION
Chronic relapsing disorder Compulsive drug seeking & drug taking behaviour, despite serious negative consequences ICD 10 Criteria Induce pleasant states (positive reinforcer) or relieve distress (negative reinforcer) Continued use induces adaptive changes in the CNS, leading to the development of tolerance, dependence, sensitization, craving & relapse
Substances of abuse
Opiods; Heroin Alcohol Benzodiazepines & Barbiturates Stimulants: Cocaine & Amphetamines Cannabinoids Hallucinogens; LSD, Mescaline Solvents Nicotine
Clinical situations
Harmful use Dependence syndrome Withdrawal state +/- delirium; DTs Drug induced Psychosis Cognitive impairment syndromes Acute intoxification Residual disorders
ICD-10 Criteria
A strong desire/compulsion to take the substance Difficulties in controlling substance-taking A physiological withdrawal state Evidence of tolerance Progressive neglect of alternative pleasures Persisting with substance use despite clear evidence of OVERTLY harmful consequences
Epidemiology
British Psychiatric Morbidity study 1993/2000
neurosis- 160/1000 Probable psychosis 5/1000 Personality disorder- 44/1000 Alcohol dependant- 70/1000 Drug dependant- 40/1000
UK Community surveys
3o% have tried illegal drugs; 10% in last year. <25y.o 50% lifetime; 33% in last year. At all ages, males have higher rates of drug use than females; M:F 3-4:1 Use of illegal drugs commoner in: - young adults especially males, - Lower socioeconomic groups - Those with psychiatric illness - Urban areas
OPIATES
Strong narcotic analgesics Derived from the ripe seed capsule of the poppy Crude opium contains morphine, codeine, other alkaloids Diamorphine (heroin) made by acetylation Eaten, sniffed, smoked, injected
OPIATES
Short term effects Euphoria, analgesia, sedation & a feeling of tranquillity
Long term effects / Repeated use Rapid tolerance & physical dependence Over dose Lethal respiratory depression
Opiate Receptors
3 Major opiate receptors - , , and
3 Endogenous opiate peptides Encephalins, beta-endorphin, dynoorphin Agonist action at and receptors causes tolerance and dependence Opiates activate these receptors which then couple G proteins
Opiates Cont
Most drugs that produce elevations in mood or euphoria, release dopamine in either the nucleus accumbens or the prefrontal cortex Opiods release dopamine mainly by an indirect mechanism that decreases the activity of GABAinhibitory neurones in the ventral tegmental area Stimulation of receptors decreases dopamine levels in the nucleus accumbens and produces aversive responses Reward & physical dependence are mediated by the activation of receptors
Opiate tolerance
Tolerance leads to increasing doses, or reduction between intervals, or both Short term administration of opiates activates the -opiod Gi/o- coupled receptor, this leads to a decrease in the number of opiod receptors and to the development of tolerance
Opiate withdrawal
Withdrawal causes reinstatement of drug use to prevent or decrease physical symptoms and dysphoria
Opiate withdrawal
Grade 0 drug craving, anxiety, drug seeking Grade 1 yawning, sweating, runny nose, restless sleep Grade 2 dilated pupils, hot and cold flushes, goose flesh (cold turkey), aches and pains Grade 3 insomnia, restlessness and agitation, abdominal cramps, N+V, diarrhoea, increased pulse , BP and RR
Hazards
Sterility abscesses, septicaemia endocarditis Adulterants gangrene DVT and pulmonary emboli Sharing blood borne diseases HIV, Hepatitis B and C
Hepatitis C
HCV prevalence is very high in all countries and settings in Europe, with infection rates of between 40-90% among different IDU subgroups Prevalence rates 72-73% 1996-2001 (EMCDDA) No routine data collection in Ireland 1st study 1995 HCV prevalence 84% <2 years injecting 70% +ve >2 years injecting 95% +ve
Methadone
Synthetic opiate Administered orally Half-life 24-36 hrs (10-90) ; once daily dosage Steady state 4-5 days Dosage 30-60mg Harm reduction approach Maintenance / Detoxification
Methadone Maintenance
Used in the USA since 1960s Stabilises lifestyle Harm reduction benefits 75-90% of patients Reduces HIV, Hepatitis Reduces crime Aim for a dose of 60mg and over
Harm reduction
As opposed to Abstinence / curing WHO defines Harm reduction as a concept to prevent or reduce negative health consequences associated with certain behaviours Concerns about transmission of HIV; epidemics in >110 countries; relapsing nature of Addiction Focuses on minimising health, personal and social harms associated with drug use - the spread of blood-borne diseases, overdoses etc Ongoing interventions, not short term, as a way to improve health of drug users, their families and society Marginalised groups
Interventions include
Information, education, communication Education about STDs +safer sex, family planning ; injection techniques Health care in relation to infectious diseases; screening, immunisation Substitution with oral drugs Needle exchange programmes Linking with other services e.g. medical, psychiatric, obstetric, dental ; social and forensic other
Benefits of methadone
safe substitution drug Effective in engaging and retaining people in treatment Reduces risk, reduced levels of injection A factor in improving physical/Mental health and quality of life of patients and their families Reduces criminal activity and demands on the criminal justice system
Lofexidine
Alpha-2 adrenergic agonist inhibiting noradrenaline release
Useful in short term users Detoxify over 2-3 weeks using up to 2mg daily Daily BP monitoring is essential Mainly used in in-patient units
Naltrexone
Narcotic antagonist Half-life 96 hours Dose 50mg daily Used after detoxification Best when supervised by family
Alcohol
1 unit = 10ml / 8g absolute alcohol ( pint lager, glass wine, 25ml spirits)
Hydrophilic, with rapid absorption through the gut Peak plasma levels reached 30-60 mins post ingestion Metabolized by hepatic oxidation (ADH)
Neurobiology of alcohol
Stimulant at low doses, sedative at higher concentrations Anxiolytic effects mediated by potentiation of inhibitory effects GABA at GABA-A receptors Disturbs glutamate transmission by inhibiting NMDA receptors,- related to withdrawal seizures, DTs etc Unopposed action of GABA and NMDA, increasing neuronal excitability
Alcohol withdrawal
Important to recognise 25% of male medical patients are problem drinkers
Occurs from 6-24 hours after cessation, peaking at day 2-3, highest risk in first 24-48hrs Range of features sweating, tremor, nausea, anorexia, vomiting, anxiety, insomnia, restlessness, hallucinations, seizures, nightmare, confusion, hallucinosis
Delirium tremens
Toxic confusional state with somatic disturbance, occurring in < 5% Mortality rate of approx 10%( -20%) Symptoms peak at 3-4 days of withdrawal Triad of clouding of consciousness, sensory distortion and tremor Agitation, fear and insomnia, worse at night
Features of DTs
Confusion and disorientation. Clouding of consciousness. Delusions and hallucinations. Psychomotor agitation and automatic dysfx. Perceptual disturbance and fear. Insomnia and truncal ataxia. Electrolyte disturbance and dehydration . Leukocytosis and disordered LFTs. EEG shows an increase in fast activity.
Treatment
Acute withdrawal Short acting benzodiazepines; chlordiazepoxide, diazepam minimise the risk of seizures 40mg clordiazepoxide, 6hourly, (Max 300mg in 24hrs) Reducing doses over 5-10 days Consider anticonvulsants (carbamezepine) Multivitamin preparations- Thiamine / B vitamin - Wernicke-Korsakoff psychosis Treat infection, dehydration, suicidal ideation etc
In Patient Treatment
Past History of seizures or epilepsy Comorbid severe mental illness Intercurrent acute illness Previous failed OPD attempts Elderly patients
Post-detoxification
Disulfuram (Antabuse) Inhibitor of aldehyde dehydrogenase. Blocks ethanol metabolism at the acetaldehyde level. Flushing reaction Loading dose 600-800mg per day for 3-4 days Maintenance 200mg daily Hypotension and MI with heavy alcohol consumption, potentially fatal Useful in highly motivated groups and where assisted by family or friends
Post Detoxification
Naltrexone- Opiate receptor antagonist, thought to negate the euphoria associated with alcohol DOSE Acamprosate (Calcium bisacetyl homotaurine)- Synthetic GABA analogue DOSE SSRIs
Post Detoxification
Psychological interventions; Relapse prevention, MET, cue exposure with response prevention, social skills, relaxation techniques, CBT, Family therapy etc Alcoholics anonymous 12 step programme Residential rehabilitation programmesminnisota model- social skills, relaxation, structured relapse prevention
Brief intervention
Assessmint of intake Information on harmful drinking, advice
Decrease by 50%, as effective as more expensive specialist tx.
Motivational interviewing
Addressing ambivalence, moving through a cycle of change 5 tenets - express empathy -help see discrepancies -avoid argument - roll with resistance - support sense of self efficacy
Prognosis
Poor alcoholic brain damage, comorbidity, divorced, criminal record, low IQ, poor support and motivation Valient 2003 60 yr follow up -25% dependant -Death rate x 2-3, rare after 70; predictors of positive outcome the most and least severe alcoholics appeared to enjoy the best longterm chance of remission
Cocaine
Substantial increases in drug treatment population Increasingly reported as 2nd problem drug 50%IV ( < benzodiazepines ) Anecdotal reports- across general population No substitute drug available Some combined pharmacotherapy's; counselling, CBT, Motivational interviewing 3% general population report lifetime use; increasing
Benzodiazepines