MANAGEMENT OF DRUG ADDICTION / SUBSTANCE ABUSE

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MANAGEMENT OF DRUG ADDICTION / SUBSTANCE ABUSE

• Dr Jacinta OShea
• Research Registrar ERHA

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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

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Substances of abuse

• Opiods Heroin
• Alcohol
• Benzodiazepines Barbiturates
• Stimulants Cocaine Amphetamines
• Cannabinoids
• Hallucinogens LSD, Mescaline
• Solvents
• Nicotine

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Patterns of Drug Use

• Experimental
• Recreational
• Habitual
• Dependant
• Other - Polysubstance use
• - Dual diagnosis use

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Clinical situations

• Harmful use
• Dependence syndrome
• Withdrawal state /- delirium DTs
• Drug induced Psychosis
• Cognitive impairment syndromes
• Acute intoxification
• Residual disorders

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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

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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

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UK Community surveys

• 3o have tried illegal drugs 10 in last year.
• lt25y.o 50 lifetime 33 in last year.
• At all ages, males have higher rates of drug use
  than females MF 3-41
• Use of illegal drugs commoner in
• - young adults especially
  males,
• - Lower socioeconomic groups
• - Those with psychiatric
  illness
• - Urban areas

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Drug use prevalence Ireland 2002/03
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Factors influencing drug abuse and dependence

• Pharmacological physiochemical properties of
  drugs
• Personality Psychiatric disorder - increased
  risk associated with schizophrenia, BPAD,
  depression, ADHD.
• Genetic factors (that influence metabolism and
  the effects of drugs)

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Pharmacologic and physiochemical properties

• Liposolubility increases the passage through the
  blood-brain barrier
• Water solubility facilitates injection
• Volatility favours inhalation in vapour form e.g
  aerosols / solvents
• Heat resistance favours smoking e.g. cannabis
• Rapid onset and intensity of effect increase the
  potential for abuse
• A short half-life produces abrupt intense
  syndromes of withdrawal

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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

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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

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Opiate Receptors

• 3 Major opiate receptors - µ, d, and ?
• 3 Endogenous opiate peptides
• Encephalins, beta-endorphin, dynoorphin
• Agonist action at µ and ? receptors causes
  tolerance and dependence
• Opiates activate these receptors which then
  couple G proteins

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Opiates The dopamine pathway

• Natural rewards and addictive drugs stimulate the
  release of dopamine from neurones of the
  presynaptic ventral tegmental area into the
  nucleus accumbens, causing euphoria
  reinforcement of the behaviour
• Habituation ( rapid adaptive changes ) occur
  with natural rewards but not with addictive drugs
  each dose stimulates the release of dopamine
• Dopamine binds to a G-protein coupled receptor
  with two subtypes, D1 like, and D2 like.

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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 GABA-
  inhibitory 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 µ receptors

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Opiate tolerance

• Tolerance leads to increasing doses, or reduction
  between intervals, or both
• Short term administration of opiates activates
  the µ-opiod Gai/o- coupled receptor, this leads
  to a decrease in the number of opiod receptors
  and to the development of tolerance

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Opiate withdrawal

• Withdrawal causes reinstatement of drug use to
  prevent or decrease physical symptoms and
  dysphoria
• Inhibition of neurones in the locus ceruleus by
  opiate is a key mechanism in withdrawal
• When opiate levels fall the unopposed neurones
  lead to adrenergic over activity
• Activation of ? receptors in the ventral
  tegmental area decreases dopamine in the nucleus
  acumbens, leading to dysphoria and anhedonia

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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, NV, diarrhoea, increased pulse
  , BP and RR

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Hazards

• Sterility abscesses,
• septicaemia
• endocarditis
• Adulterants gangrene
• DVT and pulmonary emboli
  
• Sharing blood borne diseases
• HIV, Hepatitis B and C

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Blood borne diseasesHIV

• Currently IVDUs account for 37 (1048)
• Though the numbers of IVDUs with HIV increased
  between 1998-2001, it was followed by a reduction
  of almost 50 during 2001-2002. This may reflect
  service expansion or the delay between infection
  and diagnosis
• EMCDDA(2002) record a prevalence rate of
  3.3-8.7 of HIV infection among IVDUs between
  1996-2001

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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 -
• lt2 years injecting 70 ve
• gt2 years injecting 95 ve

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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

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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

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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
  gt110 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

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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

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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

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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

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Naltrexone

• Narcotic antagonist
• Half-life 96 hours
• Dose 50mg daily
• Used after detoxification
• Best when supervised by family
• Breaks the cycle of craving

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Alcohol

• 1 unit 10ml / 8g absolute alcohol ( ½ 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)

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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

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Alcohol related physical problems

• GIT oesophagitis, gastritis, reflux, m-w tears,
  varices, pancreatitis, portal HT, cas
• Liver hepatitis, fatty liver, cirrhosis,
  haemochr, hepatic Ca, hepatic encephalopathy
• Cardiovascular arrythmias, cardiomyopathy,
  coronary/cerebrovascular disease, hypertension
• Metabolic
• Endocrine e.g. pseudocushings, hypogonadism,
  infertility, low libido/impotence
• Musculoskeletal e.g. gout, fractures,
  osteoporosis
• Haematological e.g. anaemia, thrombocytopaenia
• Respiratory
• Dermatological e.g. spider naevi, palmar
  erythema, eczema, worsening psoriasis

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Alcohol Neurological problems

• Acute intoxication
• Mania a potu pathological drunkenness with
  minute amounts of alcohol (not in ICD-10)
• Methanol poisoning
• Amnesic (Korsakoffs) syndrome Wernickes
  encephalopathy
• Cerebellar degeneration
• Ambylyopia- retrobulbar neuritis may be
  associated with peripheral neuropathy
• Central pontine myelinosis
• Dementia, amnesia/blackouts etc
• Fetal alcohol syndrome

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Psychological related disorders

• Alcoholic Hallucinosis- 10-20 gt 6/12
• 
  -5-20...schizoph
• Psychiatric comorbidity ECA study
• -psychiatric dx x3 risk of lifetime
  alc disor
• - 13 alcoholics 2nd mood disorder
• - 22 mood disorder also alcohol
  disorder
• Suicide approx 25 attempt male, divorced,
  personality disorder, older, unemployed, medical
  issues, hx of DSH
• Pathological jealousy- Othello syndrome
• Anxiety states- panic, OCD, phobias
• PTSD - alcohol dampens hyperarousal
• Eating disorders bulemia
• Other drug use

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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

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Delirium tremens

• Toxic confusional state with somatic disturbance,
  occurring in lt 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

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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.

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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

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In Patient Treatment

• Past History of seizures or epilepsy
• Comorbid severe mental illness
• Intercurrent acute illness
• Previous failed OPD attempts
• Elderly patients

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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

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Post Detoxification

• Naltrexone- Opiate receptor antagonist, thought
  to negate the euphoria associated with alcohol
• DOSE
• Acamprosate (Calcium bisacetyl homotaurine)-
  Synthetic GABA analogue
• DOSE
• SSRIs

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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 programmes- minnisota
  model- social skills, relaxation, structured
  relapse prevention

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Cognitive behavioural strategies

• By identifying triggers for relapse
• neg/pos mood states
• - poor coping skills
• - social isolation
• - craving
• - family issues
• And developing global self management strategies
  in areas of cognitive restructuring, skills
  training, lifestyle changes

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Brief intervention

• Assessmint of intake
• Information on harmful drinking, advice
• Decrease by 50, as effective as more expensive
  specialist tx.

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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

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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

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Cocaine

• Substantial increases in drug treatment
  population
• Increasingly reported as 2nd problem drug 50IV
  ( lt 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

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Effects and risks of cocaine

• Perceived as safe
• Increased energy, alertness, talkative, sex drive
• Combined with alcohol more toxic than either
  alone
• Severe psychological dependence, cravings
• Tolerance develops
• unpleasant side effects dry mouth, sweating,
  palpitations, anorexia, headaches, abd pain,
  irritability, paranoia, hallucinations, MI
• Fatigue and depression crash mental problems
  nasal / breathing problems
• Increased sexual risk behaviour association with
  prostitution

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Benzodiazepines