drugs, legal and illegal dr tim m williams clinical director – specialised services awp mental...
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Drugs, legal and illegal Dr Tim M WilliamsClinical Director – Specialised Services AWP Mental Health NHS Trust
4th July 2014 – Wills Hall, Bristol.
Drug and alcohol harms
Alcohol
Alcohol affordability index, 1980-2010.
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing Group
Real spending on alcohol in UK, 1964-2010.
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing Group
Hospital admissions wholly attributable to alcohol in England, 2002 to 2010
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing Group
The Scots leads the world
Leon and McCambridge, Lancet 2006 (updated)Leon and McCambridge, Lancet 2006 (updated)
Alcohol withdrawalTime since last drink tremor
nausea and vomitinganxiety, irritability, depression BP, pulse, tempinsomniatransient hallucinations/illusions
48 hours seizures (7 - 48 hours)
72 hours Delirium tremens (peak onset 48 - 72 hours after last drink or reduction).
Tremor, hallucinations, confusion, plus delusions, insomnia and agitation, autonomic hyperactivity
What to do when abstinent?
•Relapse Prevention essential
•Not usually offered by statutory/specialist services
•12 weeks treatment only in my service
•Medication???▫Disulfiram, acamprasate, naltrexone▫nalmefene currently hit the headlines
Alcohol harms (is a downer)
Immediate Risks Longer term
• Accidents▫ Head injuries▫ Driving▫ Death (esp drowning /
RTA)
• Vulnerability▫ to exploitation / date
rape
• Heart▫ Seen more in Russia
• Liver• Pancreas • Brain / neurons• Heart• Vessels / kidney’s• GI tract• Sexual dysfunction• Addictive potential
▫ Minority: 3-5% dependence
• Mental health▫ Massive co-morbidity
“Drugs”
UK drug use
Opioids
Benzodiazepines and opioids
•Benzodiazepines plus methadone or buprenorphine - higher opioid toxicity symptoms (Nielsen et al, 2007 Addiction)
- greater peak effects on performance measures (Lintzeris et al, 2006 J. Clin. Psychopharmacology)
- higher mortality among patients co-prescribed methadone and benzodiazepines (McCowan et al, 2009 BMJ)
Gabapentin misuse Smith et al Br J Gen Pract. 2012
Aug;62(601):406-7. • “In primary care, an increasing number and
urgency of prescription requests cannot necessarily be explained by the increased number of cases of neuropathic pain”
5.2% of people in SM services using gabapentin
Mean daily dose 1343mg Of 1400 post-mortems
48 had gabapentin 36 of whom also had morphine/ methadone
▫Is fatal in overdose and unlike opioids or benzo’s is irreversible
Opioid harms (are downers)
Immediate Risks Longer term
• Respiratory arrest▫ Esp when mixed with
alcohol and other downers
• Accidents
• Vulnerability▫ to exploitation
• Crime and poverty▫ Big overlap
• Addictive potential▫ Yes
• Mental health?
• IV use▫ BBV’s
• Smoked▫ COPD
Cocaine
Cocaine (crack) and other stimulants•Difficult to engage•Difficult to treat•High mental health co-morbidity
Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007
380
Psychostimulants did not improve cocaine use, craving, or treatment retention in comparision to placebo
Cocaine harms (is an upper)
Immediate risks Longer term
• CVS risks▫ Could trigger a CVS
event
• Psychosis▫ Could trigger an event
• Specific Risks▫ Nothing acute
• Addictive potential – very potent
• Long-term risks▫ prominent CVS risks MI,
stroke▫ COPD (crack)▫ Nasal septum (snorted
cocaine)
NPS
…….or novel psychoactive substances (NPS)
…….or “club drugs”
…….or “legal highs”
Source- NTA ‘Club drugs: emerging risks and trends’ Dec 2012
3,4 Methylenedioxmethamphetamine (MDMA)
• The recreational drug Ecstasy• Onset 20 minutes• Effects last 2-5 hours• Particular empathogenic /
entactogenic qualities• Physiologically safe in therapeutic
applications
How dangerous is MDMA when used recreationally?
• Between 1997 and 2000 in the UK:• 81 deaths were attributed in part to ecstasy(Schifano F. 2003)
But....
• 59% also included opiates• 60% included alcohol• Only 7% involved MDMA alone; • That is six deaths in three years• After some 300 million ecstasy tablets were consumed by
over a million people.
• And remember: this is NOT clinical use. This is the uncontrolled recreational use of ‘ecstasy’.
4.8% of British soldiers returning from combat in Iraq met the criteria for PTSD (Iversen et al 2009)
US soldiers returning from service in Iraq and/or Afghanistan, the incidence of PTSD is as high as 18%. (Hoge et al 2004)
More returning soldiers from Iraq and Afghanistan have committed suicide from untreated PTSD than ever died in the conflict out there.
2009 - MAPS / Mithoefer MDMA for PTSD Study:
Hypotheses:
1. MDMA subjects will show improved rates of PTSD. 2. MDMA will not be associated with neurotoxicity.
Michael and Annie Mithoefer,
Baseline measurements
Introductory Sessions
First MDMA / Placebo Session
Four non-drug sessions
Second MDMA / placebo session
Four non-drug sessions
Measurements
Measurements Measurement
Two Month Follow-up
THREEYEAR FOLLOW-UP:
Mithoefer © 2009
34
Placebo MDMA0
10
20
30
40
50
60
70
80
90
100
Baseline
final
% w
ith P
TSD
Results for Hypothesis One:% meeting PTSD diagnosis – pre/post
MDMA harms (is an upper)
Immediate risks Longer term
• CVS risks▫ Could trigger a CVS
event
• Psychosis▫ Could trigger an event
• Specific Risks▫ Hyperthermia▫ ?water intoxication
• Addictive potential – very unlikely due to high tolerance
• Very little data on long-term risks▫ no CVS risks recorded▫ No consistent evidence
of long-term memory deficits. Short term reversible deficits recognised.
MDMA/Ecstasy adulterants
•An emerging problem▫Need to develop new harm minimisation
messages.▫Specific advise for coroners essential
•PMA (para-Methoxyamphetamine or 4-MA)▫1 hour onset
•PMMA (para-Methoxy-N-methylamphetamine)▫Linked to deaths, ?less toxic than PMA
PMA / PMMA (is an upper) Immediate risks Longer term
• CVS risks▫ ?Could trigger a CVS
event
• Psychosis▫ ?Could trigger an event
• Specific Risks▫ Hyperthermia (greater
than MDMA)
• Addictive potential ?
• No data on long-term risks
Mephedrone 4-MMC, MMCat, Miaow, Meow Meow, Bubble,
• 4-Methylmethcathinone (4-MMC)
• Stimulant, appeared in or around 2007 (Sweden)
• Sold as powder, crystals or sometimes capsules
• Made illegal from 16/04/10 (Class B). Price nearly doubled
• Had bypassed regulations as ‘plant food’, ‘not for human consumption’
The Scunthorpe two: Louis Wainwright and Nicholas Smith
Died from taking methadone not mephedrone with significant quantities of alcohol
• Professor Sheila Bird, of the Medical Research Council's Biostatistics Unit in Cambridge “deaths from cocaine fell in the first six months of 2009 to 66, a statistically significant drop from 95 in the same period of 2008”
Mephedrone harms (is an upper)
Immediate risks Longer term
• CVS risks▫ Could trigger a CVS
event
• Psychosis▫ Could trigger an event
• ?Specific risk of vasoconstriction
• Specific come down risk and suicide
• Addictive potential
• Very little data on long-term risks▫ Likely CVS risks▫ ?mental health
K, ketamine• and
methoxetamine?
The Observer Sunday 17 April 2011
Every parent's worst nightmare: how ketamine killed our daughterBright, popular, rebellious and creative, 21-year-old Louise Cattell had everything to live for. Then she made a fatal mistake. She took the party drug ketamine and was found dead in the bath by her flatmate.
Ketamine harms (is a downer)
Immediate Risks Longer term
• Accidents▫ especially drowning ▫ and hypothermia▫ driving
• Vulnerability▫ to exploitation
• However is generally a very safe drug used in a medical context
• Stimulant at low doses
• Bladder problems▫ Thickening▫ Urgency▫ ‘K-cramps’▫ Eventually dysfunctional
bladder
• Addictive potential▫ Users 1-12g a day
• Mental health?
GHB, GBL and 1,4-BD
Confusingly sometimes referred to as “liquid ecstasy”
GHB/GBL harms (is a downer)
immediate Longer term
• Respiratory depressant▫ Very dangerous with
alcohol▫ Narrow therapeutic
window
• Accidents▫ Much like alcohol▫ Disinhibits and poor
perception of risks
• Addictive
• Withdrawal syndrome▫ Like alcohol but worse▫ Severe seizures ▫ ?baclofen to treat
KhatMain active ingredients are cathine and cathinone
Khat harms (is an upper)
Immediate risks
• CVS risks▫ Precipitate event
• Psychosis▫ Minor risk▫ But mixed with PTSD
increased
Longer term
• CVS risks▫ Early MI▫ Early stroke
• Dependence▫ Small minority
• GI cancers??▫ Oral▫ oesophageal
M-Cat, madcat and now M2 ie 3,4,DMMC (are stimulants)
See what the are doing here:
• cathinone (in khat)• methcathinone (m-cat)• 4-methylmethcathinone (mephedrone)• 3,4-dimethylmethcathinone (“M2”)
Harms??Immediate Longer term
• CVS
• Mental health
• Specific risks?▫ Anaphylaxis▫ Respiratory??
• CVS
• Mental health
• Dependence
Can include 6-APB in this category (unhelpfully often called “benzofury”)6-(2-aminopropyl)benzofuran
2-CB (MDMA like)
The Sun 24/1/13
“Krokodil”
•CNN -“flesh-eating zombie drug”•USA Today -“Flesh-Rotting ‘Krokodil’
Drug Emerges in USA,”•GQ – “flesh-eating
heroin substitute that has found favour with Russia's homeless, and now "krokodil" has come to Britain.”
“Krockadil” (desomorphine)Immediate Longer term
• CVS▫ Resp depression +
death
• Mental health
• Specific risks?▫ “flesh eating”??
• CVS
• Mental health
• Dependence▫ absolutely
Reports in Russia of homemade ‘krokodil’ by mixing codeine with chemicals such as gasoline, red phosphorus, and hydrochloric acid. Extremely unlikely to be found in Europe and US due to easy availability of opioids
Other drugs (not uppers or downers)
Cannabinoids hallucinogens
• Respiratory if smoked
• Psychosis▫ Precipitated - yes▫ Cause - probably no
• Anxiety
• Amotivational▫ Definitely
• Mushrooms (psilocybin), Acid (LSD)▫ Low risk
• Salvia divinorum▫ Slightly different but
still low risk
• MDA▫ A bit more of a
stimulant(MDMA like)
End
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