Session A Definitions and prevalence of co existing mental health and substance use disorders Develo

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Session A Definitions and prevalence of co
existing mental health and substance use
disordersDeveloped by Dr Adam R Winstock MRCP
MRCPsych FAChAM
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Commonly used terms

• WHO definition of a mental health disorder
• Co morbidity Co existence of two or more
  disorders within an individual at a particular
  time
• Dual Diagnosis (DD)
• Mentally Ill Chemical Abusers (MICA)
• Substance Abusing Mentally Ill (SAMI)
• Chemical Using Mentally Ill (CUMI)
• Heterogenous group- different patterns, drugs
  illnesses
• No clear demarcation

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Why substance use in those with mental illness is
so important

• Those with mental illness are sensitive to the
  adverse effects of substance use
• Impact of substance use is greatest in those who
  suffer from chronic schizophrenia or major mood
  disturbance
• Co morbid patients tend to have poorer access to
  health care and a poorer prognosis (higher rates
  of suicide, violence and health service
  utilisation)

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Why now?

• Probable increase in the prevalence of those with
  severe mental illness and drug use is due to
• De-institutionalisation (in the 1970s and 1980s)
• New young population of people with mental
  illness
• A widening of the poverty gap
• Increases in global drug availability and use
• Emergence of trans-generational unemployment and
  disadvantage
• Public concern- violence, homelessness, HIV
• Barriers in treatment access due to service
  organisation, administration, clinical
  polarisation and skills shortages

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What substances?

• Most common tobacco and alcohol
• Type of drug(s), preference and route of use
  fluctuates overtime - reflecting availability
  and cultural trends
• Availability is probably more important that
  direct pharmacological effects of drugs
• Cannabis, amphetamines and benzodiazepines are
  the biggest culprits of harm among people with
  mental health problems

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Prevalence

• Prevalence of drug use among those with severe
  mental illness is higher than in the general
  population
• Rates and patterns of substance use vary by
  country and population
• Prevalence is also determined by availability of
  drugs/ alcohol
• Definitions use, abuse, dependence

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Prevalence

• Schizophrenia 50 lifetime substance use
• Affective disorders 30
• In those with drug/ alcohol dependence 30 - 80
  have co morbid mental illness
• Affective
• Anxiety
• Post Traumatic Stress Disorder (PTSD)
• Personality disorders
• Psychosis
• Methadone clients 10 x frequency of psychiatric
  illness c.f general population
• Co morbidity is no longer the exception- its
  the rule

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Patterns of use and problems

• Substance related problems
• amount frequency
• route duration (pattern of use)
• co morbid disease
• constitutional vulnerability
• Key modifiable factor at an individual level is
  the pattern of use
• Focus not only on toxicological/ psychological
  risks but also drug driven and intoxication
  related behaviours, risks and harm
• Dont forget polydrug use

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Risks related to drug use

• Substance specific related to toxicology of
  substance
• Polydrug use
• Route eg Injecting drug use (IDU) increases
  risk of blood borne viruses (BBV)
• Intoxication related high risk behaviours eg
  sex, violence, and driving
• Withdrawal specific syndromes
• Behaviors related to procurement eg sex work/
  crime
• Impact on other medical/ psychiatric conditions
• Psychosocial consequences of use eg legal,
  familial and financial

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Substance related problems

Behavioural MVA, sex, violence, crime
Toxicological Physical Psychological Overdose
Route of use HIV, hepatitis C, Lung disease,
gastritis
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Route of administration
Less common Very common Extremely
common
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IntranasalSnorting

• Rhinitis
• Nose bleeds
• Ulceration
• Septal perforation
• Viral transmission through straws

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Smoking

• Infection
• Cough
• Pneumothorax
• COPD
• Cancer

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Inhalation

• Peri-oral dermatitis
• Aspiration
• Asphyxiation

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InjectIntramuscular (IM) Subcutaneous (SC)

• Scarring
• Vessel damage
• Pain
• Haematoma at injection site

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InjectIntravenous (IV)

• Infection
• Septicaemia abscesses in lung, brain, joints,
  bone,
• Endocarditis and mycotic aneurysms (of blood
  vessels)
• Viral transmission hepatitis B C (chronic
  liver disease), HIV, abscesses and cellulitis

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Intravenous

• Vessel damage
• Thrombophlebitis
• Venous thrombosis
• Deep Vein Thrombosis (DVT)
• Arterial occlusion
• Venous ulcers
• Acute vascular damage may resolve but may leave
  residual vascular damage

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Intravenous

• Other
• Direct trauma pneumothorax, nerve damage,
  amyloidosis and renal failure
• Pulmonary embolism (needle embolism has been
  reported)
• Intra-arterial injection may cause spasm and may
  lead to amputation
• Coma leading to rhabdomyoloysis

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Drug types

• Cannabis
• Amphetamines
• Opioids
• Benzodiazepines

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Cannabis

• Herbal marijuana hydroponic cannabis most common
  (and most potent)
• Active ingredient THC tetrahydrocannabinol
• Dealing unit 1gm or multiples there of (¼ ounce
  7gm)
• Cost per unit 10 20 / gm, 200 350 / ounce
• Route of administration smoked (often with
  tobacco), oral
• Onset of action 5 - 15 mins when smoked, peaking
  at 30 -120 minutes. Duration 2 - 6 hours
• Slower onset when taken orally (30 - 120 min)
  but more intense and longer lasting (up 12 - 24
  hrs)
• Duration of action 2 - 24 hours depending upon
  type, tolerance and dose

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Amphetamines

• Methamphetamine (ice, crystal, gooey, gas) is
  the most common from in Australia
• Dealing unit 0.1gm 1 gm or eight ball (3.5
  gm 1/8 oz)
• Cost per unit 50 / 0.3 gm
• Route of administration swallowed, snorted,
  smoked or injected
• Onset of action rapid (within seconds) when
  smoked or injected, peaking at 30 - 120 minutes
• Slower when snorted (5 - 15 minutes) or orally
  (30 - 60 mins)
• Duration of action 2 - 24 hours depending upon
  type, tolerance and dose
• Methamphetamine is the most potent of the
  amphetamines and has the longest duration of
  action

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Heroin

• White heroin is most common form in Australia
• Dealing Unit Cap 0.1 0.2gm, 1gm
• Street names Hammer, H, gear, harry, junk
• Route of administration Smoked (chasing the
  dragon) snorted or injected
• Most injectors inject 2 - 4 x / day
• Preparations white or off-white powder
• Purity between 20 - 40
• Other opioids Oxycontin, morphine sulphate and
  oxycodone methadone, physeptone and
  buprenorphine (these may be crushed and injected)
• Over the counter (OTC) opiates panadeine forte

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Benzodiazepines

• Dealing unit milligram dosage of benzodiazapine
• 1- 10mg
• Approximate cost per unit Diazepam 1 for 5mg
  tablet Temazepam, oxazepam and flunitrazepam
  2-5 per tablet
• Route of administration Oral or IV
• Onset of action orally 15 30 min, IV within
  minutes
• Duration of action Depends on half life and
  varies between
• 2 - 24 hours
• Effects similar to alcohol with initial
  disinhibition followed by sedation at higher
  doses. Euphoria/relaxation especially when
  combined with other CNS depressants

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Over the counter (OTC) preparations

• Diphenhydramine
• Promethazine
• Doxlamine
• Cough medicine
• Mersyndol
• Melatonin

• Medication risks include
• NSAIDS Gastrointestinal bleeding
• Paracetamol Hepatotoxicity
• Codeine Dependence

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Drug terminology, classification, cost
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Characteristic physical toxicological
complications of different classes of drugs

• Amphetamines
• Cardiac arrthymias, cardiomyopathy, aneurysm,
  MI, pulmonary hypertension
• Metabolic hyperthermia, dehydration, aortic
  dissection
• CNS choeroathetoid movements, seizures
• CNS depressants
• Opioids, benzodiazepine, alcohol (especially in
  combination)
• Respiratory overdose, aspiration, coma
• Withdrawal specific syndromes

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Summary

• Those with mental illness are more vulnerable to
  the adverse effects of drugs
• Drug use rates are higher among those with mental
  illness
• Drug use among those with mental illness is
  associated with poorer outcomes for both
  conditions
• Drug related harms may be linked to drug specific
  direct toxic effects, the route of use as well as
  intoxication related behaviors
• Assessment must define patterns of use and
  associated risks

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End of Slide Show
The Can Do Initiative Managing Mental Health
and Substance Use in General Practice
Overview Session A Definitions prevalence
Session B Assessment history taking Session
C Common explanations Unit 1 Alcohol Unit
2 Benzodiazepines Unit 3 Cannabis Unit 4
Amphetamines Unit 5 Opioids and pain Unit 6
Pregnancy