Title: Session A Definitions and prevalence of co existing mental health and substance use disorders Develo
1Session A Definitions and prevalence of co
existing mental health and substance use
disordersDeveloped by Dr Adam R Winstock MRCP
MRCPsych FAChAM
2Commonly 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
3Why 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)
4Why 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
5What 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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7Prevalence
- 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
8Prevalence
- 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
9Patterns 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
10Risks 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
11Substance related problems
Behavioural MVA, sex, violence, crime
Toxicological Physical Psychological Overdose
Route of use HIV, hepatitis C, Lung disease,
gastritis
12Route of administration
Less common Very common Extremely
common
13IntranasalSnorting
- Rhinitis
- Nose bleeds
- Ulceration
- Septal perforation
- Viral transmission through straws
14Smoking
- Infection
- Cough
- Pneumothorax
- COPD
- Cancer
15Inhalation
- Peri-oral dermatitis
- Aspiration
- Asphyxiation
16InjectIntramuscular (IM) Subcutaneous (SC)
- Scarring
- Vessel damage
- Pain
- Haematoma at injection site
17InjectIntravenous (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
18Intravenous
- Vessel damage
- Thrombophlebitis
- Venous thrombosis
- Deep Vein Thrombosis (DVT)
- Arterial occlusion
- Venous ulcers
- Acute vascular damage may resolve but may leave
residual vascular damage
19Intravenous
- 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
20Drug types
- Cannabis
- Amphetamines
- Opioids
- Benzodiazepines
21Cannabis
- Herbal marijuana hydroponic cannabis most common
(and most potent) - Active ingredient THC tetrahydrocannabinol
- Dealing unit 1gm or multiples there of (ΒΌ 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
22Amphetamines
- 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
23Heroin
- 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
24Benzodiazepines
- 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
25Over the counter (OTC) preparations
- Diphenhydramine
- Promethazine
- Doxlamine
- Cough medicine
- Mersyndol
- Melatonin
- Medication risks include
- NSAIDS Gastrointestinal bleeding
- Paracetamol Hepatotoxicity
- Codeine Dependence
26Drug terminology, classification, cost
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28Characteristic 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
29Summary
- 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
30End 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