Healthy Living : Smoking, Alcohol

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Healthy Living Smoking, Alcohol Party Drugs.

• By K V Liew, Edmund

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Smoking

• Harms of smoking are well-known. For example
  COAD, cancers (lungs/laryngeal/
  oesophagus/bladder), ischaemic heart disease,
  CVA, peripheral vascular disease peptic ulcers.
• Why do people still smoke ??!!!
• Enhances their feeling of calmness (i.e.
  decreases anxiety), improves mood, improves
  ability to concentrate/think. Addiction.
• Notoriously difficult to quit.
• As doctors, especially frontline GPs, we have
  duty to educate patients, to encourage quitting
  assist quitters.

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• Multiple studies have shown that the majority of
  smokers have thought about stopping (80 in one
  Australian study).

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How to help patients stop smoking

• Educate them about the risks to their health
  emphasise the advantages of giving up.
• Saves money, live longer, food tastes better, bad
  breath improves, decrease frequency severity of
  URTI, better exercise tolerance, less chance of
  premature wrinkling of skin/stained teeth,
  improved sexual pleasure, early COAD can be
  reversed, removes effects of passive smoking on
  family friends.
• Risk of lung cancer decreases. After stopping
  for 10-15 years, risk is as low as someone who
  has never smoked.

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• Opportunistic interventions during GP
  consultations for other matters.
• If patients say no to stopping, provide
  motivational educational leaflets. Asks
  patients to re-consider.
• If patients agree to stop smoking, ask them to
  make a definite date to stop (e.g. during a
  holiday) make a mutual contract.

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Practical advice for successful quitting

• Eat more fruits vegetables (citrus fruits can
  reduce cravings).
• Chewing gum/lozenges/sweets.
• Increase your activity level or take up hobbies
  that make you forget smoking (e.g. swimming/water
  sports).
• Avoid smoking situations and seek the company of
  non-smokers.
• Put aside the money saved have a special treat.

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• For those who find it difficult to stop cold
  turkey, try smoking lighter cigarettes, less
  frequently, stubbing out earlier gradually stop
  completely.

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Pharmacological agents to help stop smoking

• In general, for light smokers with low
  dependence/addiction to Nicotine, use
  non-pharmacological methods rather than drug
  substitute.
• Nicotine chewing gumgtchew at least 6 per day,
  replacing at regular intervals. Chew slowly, not
  more than 1 gum per hour.
• Use for 3 months, slowly weaning off.
• Transdermal nicotine patchgtuseful for moderate
  to severe nicotine dependence. Begin use
  immediately upon cessation of smoking.

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• Available as 16-hour or 24-hour patches in 3
  different strengths (7, 14 21mg).
• Apply to clean, non-hairy dry skin on upper
  outer arm/chest, leave in place for 16/ 24hrs.
  Rotate sites with a 7-day gap for re-use of a
  specific site.

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Adverse reactions contraindications

• Nervousness, sweating, dry mouth, dyspepsia,
  abdominal cramps, angina cardiac arrhythmias.
• Nicotine gumgthiccoughs, jaw pain, exacerbation
  of peptic ulcers.
• Nicotine patchgtlocal skin reaction, sleep
  disturbances (especially 24hr. patch).
• Contra-indications pregnancy breast-feeding,
  severe IHD, recent CVA history of cardiac
  arrhythmias.

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After-care relapse prevention

• Arrange Follow-Up, at least monthly especially
  during the first 3 months.
• Acknowledge that it is very difficult to quit.
  Offer active encouragement advice from GP.
• Consider behavioural modification therapy for
  those encountering difficulties.

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Alcohol

• Alcohol use is pervasive in society, especially
  Western society.
• In suitable quantities, it is a good social
  lubricant makes people more relax and
  disinhibited.
• However, it can interact negatively with
  medications, causes and worsens multiple medical
  and psychological conditions (e.g. liver
  cirrhosis/ traffic accidents) results in
  addiction if consumed excessively.

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• In one estimation from the Census Department, 90
  of adult population in USA drinks alcohol
  60-70 of adult population consumed alcohol
  within the past 1 month. Over 40 of the
  population has had, or will have a temporary
  problem with alcohol during their lifetime.
• It is difficult for doctors to accurately assess
  whether a patient is addicted/dependent on
  alcohol.
• It is therefore important to be aware of the
  problem maintain a high degree of suspicion.

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• Early recognition of the problem means better
  potential for treatment recovery, hopefully
  before any permanent damage occur (e.g.
  neurological deficits/liver cirrhosis).
• Checklist for pointers of alcohol
  dependency/addiction includes
• Are you drinking gt6 glasses per day ?
• Are you drinking in the morning ?
• Do you feel a need for alcohol whenever you feel
  stressed ?
• Do you have any alcohol-related driving offences?

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• Are you concerned about your own drinking habits
  ?
• Has any relatives/friends expressed concern about
  your drinking habits ?
• Do you drink frequently during the working hours
  ?
• Have you lost a job because of your drinking
  habits ?

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Acute effects of alcohol

• Motor performance cognitive functions are
  reduced (e.g. slurred speech, unsteady gait
  nystagmus).
• Judgements are also impaired.
• Mental black-outs occur at higher doses.
• These are memory impairments of all forms
  functions, including long-term, short-term,
  recall and acquisition. Patient is walking,
  talking but not recording.

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Chronic effects of alcohol

• Wernicke-Korsakoff Syndrome.
• Peripheral neuropathy.
• Mallory-Weiss Syndrome peptic ulcers.
• Liver cirrhosis, cardiomyopathy depressed
  immune system.
• Fetal alcohol syndrome in babies of alcoholic
  mothers.

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Alcohol Withrawal

• Delirium Tremens.
• Acute medical emergency requiring intensive care.
• Essentially autonomic nervous system overdrive.
• Treated with supportive measures sedation
  (benzodiazepines) vitamins.

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Treatment for Alcohol Dependency/Abuse

• Ideally, treated in detoxification centres for
  prolonged period of stay. Multidisciplinary
  approach (MSW, Psychiatrist/Psychologist,
  Counsellors, etc...), similar to drug
  detoxification.
• Important issue of dual diagnosis (chicken and
  egg).
• ? No such facilities in Hong Kong.
• Alcoholics Anonymous, tel[phone].

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Party Drugs _at_ Psychotropic Drugs

• Includes Ecstasy, LSD, Marijuana,
  Methamphetamine/Ice, Ketamine Flunitrazepam.
• Came to prominence media publicity with the
  advent of Rave parties.
• Rave parties its techno dance subculture
  originated in Europe (Germany) in the 1980s,
  spread to USA and arrived in Asia/Hong Kong in
  the mid 1990s.

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Epidemiology of party drugs abuse in HK

• Data from the Central Registry of Drug Abuse
  (CRDA), Hong Kong.
• Prior to the arrival of Rave party drugs,
  there was a down-trend in the number of reported
  drug abusers (including young abusers aged lt 21)
  in HK since 1995.
• This downtrend reversed in the first nine months
  of 2000 when compared with the same period in
  1999.

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• The no. of reported drug abusers rose 7.5.
• The no. of reported young drug abusers aged
  lt21 rose 51.1.
• The no. of psychotropic substance abusers
  increased 51.5.
• The no. of young psychotropic substance
  abusers increased 113.5.

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Further breakdown of figures

• Of the total no. of psychotropic substance
  abusers, 76 were male, 51 were aged lt21, 55
  were previously convicted, 41 were unemployed,
  36 have full-time jobs 12 were still going to
  schools. Average age was 24yrs. old.
• The most common drugs abused was Ecstasy (40.1),
  Cannabis/Marijuana (26.7), Ketamine (22.3)
  Ice/Methamphetamine (17.5).

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• Reported use of Ecstasy rose from 179 cases to
  1664 Ketamine rose from 9 to 926.
• Usually spend lt300 /person/day.
• Reasons peer influence, seek euphoria/ sensory
  satisfaction curiosity. Need to consider
  overall socio-economic factors too.

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Methylenedioxymethamphetamine (MDMA/Ecstasy)
GHB

• Synthetic amphetamine analog with stimulant
  properties.
• In US, illegal only since 1985.
• First patented by Merck in Germany in 1914.
  ?appetite suppresant/secret military uses.
• Used by New Age seekers clinical therapists in
  1960s for its properties of inducing feelings of

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• Well-being/warmth, interpersonal
  connection/rapport/empathy, friendliness.
• Causes motor agitation/restlessness that can
  be pleasurably relieved by dancing.
• Mechanism of action involves stimulation of
  serotonin, dopaminergic many other
  neurotransmitter systems.
• Effects amphetamine-like rush initially, then
  nausea then plateau of togetherness

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• For 3 to 4 hours.
• Side-effects of dehydration, exhaustion,
  overheating seizures. Others include
  teeth-gnashing, jaw clenching, decrease appetite,
  hot flashes etc
• After effects of up to few days.
• Usually taken p.o., a liquid Ecstasy (GHB) also
  exists.

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• NO physiological dependence/addiction. Just
  psychological dependence, if at all.
• Neurotoxicity of permanent damage to serotonin
  neurons resulting in ?negative impact on mood,
  causing/exacerbate affective disorders.
• Controversial research, yet to have strong
  evidence.

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Lysergic Acid Diethylamide (LSD/psychedelic/speed/
acid)

• Synthetic hallucinogen.
• First created by Albert Hoffmann, working for
  Sandoz in 1944.
• In US, made illegal in 1966. CIA experimented
  with it as truth serum.
• Experiences heightened perceptual sensations
  hallucinations. Colours become more dramatic,
  synaesthesia develops.

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• Experiences one sensory perception through the
  realm of another sense. For example, smell a
  colour, taste a sound.
• Perceptual disturbance, Trails, develops.
  Similar to seeing moving objects under a
  strobe/disco light.
• Mechanism of action very complex, as yet not
  understood.
• Side-effects of tremors, weakness, nausea/V

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• bad-trip, where the hallucination is
  unpleasant/nightmare.
• Disorientated behaviour, impaired judgement of
  invincibility, paranoid delusions with danger
  to those trying to help.
• Post-Hallucinogenic Perceptual Disorder, can last
  very long time.
• No physiological dependence/addiction.

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Ketamine

• Originally derived from PCP.
• Used as anaesthetic agent in paediatric patients
  farm animals/by veterinarians.
• Feels disassociated from users body delirium.
• Physiological dependence occurs. Acute
  intoxication treated with supportive measures.
• Tx/detoxification as per any addictive drug.

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• Mechanism of action complex and not yet known
  to science.

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Flunitrazepam (Rohypnol)

• Short-acting benzodiazepine.
• Drug of Choice for date-rapes/ party
  rapes/robbery.
• Fast onset of action time, in seconds to tens of
  seconds.
• Causes somnolence, relaxation, disinhibition
  anterograde amnesia.