December 2013
Dr Yasir Hameed (SpR)
General Adult/Old Age Psychiatry
Northgate Hospital
Great Yarmouth
 What is TADS (NRP)?
 Drugs and Mental Health (dual
diagnosis, alcohol, opiates and
benzodiazepines dependence)
 Useful...
 Open access
 Drugs AND alcohol
 9-5 Mon-Fri
 5 bases throughout Norfolk, including in-
patient beds at Hellesdon and ...
 GENERAL
◦ Comprehensive assessment
◦ Holistic care planned treatment
◦ Counselling – MI, CBT, individual and group
 SPE...
 DOH Dual Diagnosis Good Practice Guide
“…covers a broad spectrum of mental health and
substance misuse problems that an ...
 A primary psychiatric illness precipitating or
leading to substance misuse
 Substance misuse worsening or altering the
...
Primary Care Service:
 Approximately 75% of drug users approach their GP
before being seen in centralised services.
Gener...
1. Psychiatric disorder is due to
a) Acute intoxication (drug induced psychosis)
b) Chronic effects / Damage (depression /...
Poorer prognosis
Increased incidence of suicide / violence / homicide
Increased use of in-patient services
Poor medication...
I need to take a DRUG AND
ALCOHOL HISTORY when I assess
people
When?
ALWAYS
 HISTORY
◦ what drugs / alcohol?
◦ when last used
◦ Quantity, frequency, daily pattern
◦ route of administration
◦ Length...
 Assessment of intoxicated people
 Admitting patients who are dependent
◦ Alcohol withdrawal
◦ Opiate withdrawal
 Care ...
Intoxication is a clinical diagnosis which can be
aided by investigation (e.g. urine dipstick
and/or breath alcohol)
BUT
I...
04/12/2013Dr Hayley Pinto TADS
04/12/2013Dr Hayley Pinto TADS
ALCOHOL
Shaking
Confusion /
disorientation
Hallucinations
Fits
BOTH
Anxiety and agitation
 P , BP
Sweating
Nausea and vom...
Diagnosis to be made if three or more of the following have occurred
for at least 1 month or if persisting for periods of ...
 CAGE questionnaire
 AUDIT
 SAD-Q
 FAST
04/12/2013Dr Hayley Pinto TADS
 In the UK around 1 in 5-6 adults drink at
hazardous levels and around 5% are alcohol
dependent.
 Alcohol is now the com...
04/12/2013Dr Hayley Pinto TADS
04/12/2013Dr Hayley Pinto TADS
 Easiest way to work it out:
◦ ABV x amount in litres = number of units
 Rough estimate of 1 unit:
◦ ½ pint of normal-st...
 Increased size of red blood cells
◦ Raised MCV and MCH
 Raised liver enzymes
◦ GGT, AST, ALT, Alk P
 More concerning
◦...
 Chronic liver disease
◦ Cirrhosis
◦ Hepatitis C
 Poor nutrition/losing weight
◦ high risk of complication
 Evidence of...
 Withdrawal seizures (12-48 hours)
◦ Usually self-limiting
◦ Potentially fatal
 Delirium tremens (24-96 hours)
◦ Occurs ...
 Wernicke’s encephalopathy
◦ Confusion, ataxia, ophthalmoplegia
◦ Brainstem bleeding
◦ Potentially fatal
 Korsakoff’s ps...
◦ Alcohol intake > 15 units /day
Action - immediate referral for alcohol detoxification if
◦ Requesting detoxification
◦ H...
 Inpatient or community
◦ Severe withdrawal symptoms, significant physical/mental
health problems, failed home detox, lac...
 Acamprosate (GABA/Glutamate receptor
agonist)
◦ First-line treatment
 Naltrexone (opiate receptor antagonist)
 Disulfi...
OPIATES
 Opiates - any opioid drug found
in the natural poppy plant
 Opioids – any morphine like
drug active at the opioid
recep...
HEROIN
(di-acetyl morphine)
CODEINE
Mono-acetyl morphine
(MAM)
MORPHINE
•Tramadol
•Oxycodone
•Dihydrocodeine
(DF118)
•Tram...
WANTED EFFECTS
 Euphoria – sense of comfort and wellbeing
 Sedation
 Pain relief
 Cough suppression
 Reduces pupil size
 Constipation
 Nausea and vomiting
 Itchy rash
 Slows heart rate and drops blood pressure
 Suppr...
Immune suppression
Menstrual abnormalities (delayed recognition of
pregnancy)
Tooth decay
Malnutrition
Lethargy and depres...
 Vein /artery / nerve damage
 Clots - DVT / embolism
 Infections – BBV and others
INCREASED RISK OF
OVERDOSE
DVT
Esp groin
injectors
 HIV - < 1 % of Norfolk IDUs (1.3%)
 Hepatitis C - 36% of Norfolk IDUs (45%)
 Hepatitis B - 19% of Norfolk IDUs (15%)
(...
 Superficial Abscesses are common
 Septicaemia (blood poisoning)
 Endocarditis (infection in the Heart).
 Embolism –de...
Bertschy, G. Methadone maintenance treatment: an update. 1995
Marsch L. A. The efficacy of methadone maintenance intervent...
 Long acting full agonist
 PK levels 1-6 hrs after 1st dose
 3-10 days to reach steady state
 Prolongs QT interval
 P...
 Partial agonist
 High affinity / low intrinsic activity
 Precipitated withdrawal
 Reduced intoxicating effects
 Lowe...
Opiate system
Dampening effect
Noradrenergic
drive
Opiate Detoxification
METHADONE / BUPRENORPHINE – Slow reduction
SYMPTO...
Naltrexone
Relapse Prevention Work
•Triggers – things associated with using, boredom, negative
emotions (past trauma), ‘tr...
 500 000 – 1 million “therapeutic”
 200 000 recreational
◦ ~50% demonstrate classic dependence
 Estimates suggest up to...
 Onset 3-10 days, duration 3-6 weeks
 Physical
◦ Sweating, tremor, palpitations, lethargy, muscle
tension/pain, nausea, ...
 Shorter acting drugs are more prone to formation
of dependence
◦ Reward centres
 Withdrawal is more extreme with short-...
 Z drugs
◦ Zolpidem, zopiclone, zaleplon
 Act in a similar but distinct way to
benzodiazepines
 Short acting
 Possibly...
 No strict rule on how fast - negotiate
 Generally, 10-12 week reduction
 CONVERT TO DIAZEPAM
 Aim to reduce at 1/8 – ...
Think about drugs and alcohol
Care and respect
Get advice
04/12/2013Dr Hayley Pinto TADS
04/12/2013Dr Hayley Pinto TADS
Call TADS 786786
TADS Guidelines Intranet
Norfolk Recovery Partnership website:
http://www.norfolkrecoverypartnership.org....
 Alcohol Detoxification in the Inpatient Setting - C102
 Opioid Detoxification and Stabilisation onto Substitute
Medicat...
Tads junior doctors induction dec 2013
Tads junior doctors induction dec 2013
Tads junior doctors induction dec 2013
Tads junior doctors induction dec 2013
Tads junior doctors induction dec 2013
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Tads junior doctors induction dec 2013

  1. 1. December 2013 Dr Yasir Hameed (SpR) General Adult/Old Age Psychiatry Northgate Hospital Great Yarmouth
  2. 2.  What is TADS (NRP)?  Drugs and Mental Health (dual diagnosis, alcohol, opiates and benzodiazepines dependence)  Useful resources
  3. 3.  Open access  Drugs AND alcohol  9-5 Mon-Fri  5 bases throughout Norfolk, including in- patient beds at Hellesdon and Northgate Hospital.
  4. 4.  GENERAL ◦ Comprehensive assessment ◦ Holistic care planned treatment ◦ Counselling – MI, CBT, individual and group  SPECIFIC TREATMENTS ◦ Opiate Substitution therapy ◦ Structured reduction ◦ Detox – inpatient / community ◦ Prescribing to support maintenance of abstinence ◦ Referral for Residential Rehab.  SPECIAL GROUPS ◦ Under 18 ◦ Liaison – NNUH, Gastro, Obstetrics, A+E, pre-op ◦ Child and adult protection
  5. 5.  DOH Dual Diagnosis Good Practice Guide “…covers a broad spectrum of mental health and substance misuse problems that an individual might experience concurrently. The nature of the relationship between these two conditions is complex.”
  6. 6.  A primary psychiatric illness precipitating or leading to substance misuse  Substance misuse worsening or altering the course of a psychiatric illness  Intoxication and/or substance dependence leading to psychological symptoms  Substance misuse and/or withdrawal leading to psychiatric symptoms or illness
  7. 7. Primary Care Service:  Approximately 75% of drug users approach their GP before being seen in centralised services. General Adult Services  1 in 4 patients classed as dual diagnosis  92% of drug users are polysubstance users  Substantial under-recording of drug / alcohol history in general mental health notes TADS  1 In 2 patients classed as dual diagnosis
  8. 8. 1. Psychiatric disorder is due to a) Acute intoxication (drug induced psychosis) b) Chronic effects / Damage (depression / anxiety / alcoholic hallucinosis) c) Withdrawal state (delirium tremens) 2. Self medication (depression / anxiety) 3. Substance use as a result of mental state (disinhibition) 4. Shared risk factors (genetic / environmental)
  9. 9. Poorer prognosis Increased incidence of suicide / violence / homicide Increased use of in-patient services Poor medication adherence ↑ rates of  Homelessness  BBV infection  Contact with the criminal justice system Poor social outcomes including impact on carers and family (Department of Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide 2002; Avoidable Deaths: 5 year report of the national confidential enquiry into suicide and homicide by people with mental illness. 2006)
  10. 10. I need to take a DRUG AND ALCOHOL HISTORY when I assess people When? ALWAYS
  11. 11.  HISTORY ◦ what drugs / alcohol? ◦ when last used ◦ Quantity, frequency, daily pattern ◦ route of administration ◦ Length of history ◦ Withdrawal sx  Diet  Physical examination  UDS within 24 hours / breath alcohol
  12. 12.  Assessment of intoxicated people  Admitting patients who are dependent ◦ Alcohol withdrawal ◦ Opiate withdrawal  Care of in-patients with alcohol and opiate detox OUT OF HOURS.
  13. 13. Intoxication is a clinical diagnosis which can be aided by investigation (e.g. urine dipstick and/or breath alcohol) BUT In individuals who are dependent on alcohol breath alcohol can be extremely high without clinical intoxication.
  14. 14. 04/12/2013Dr Hayley Pinto TADS
  15. 15. 04/12/2013Dr Hayley Pinto TADS
  16. 16. ALCOHOL Shaking Confusion / disorientation Hallucinations Fits BOTH Anxiety and agitation  P , BP Sweating Nausea and vomiting Insomnia OPIATES •Dilated pupils •Abdominal cramps •Diarrhoea •Anorexia •Gooseflesh •Muscle twitching •Aching – bones and muscles •Hot and cold flushes •Yawning •Running eyes and nose
  17. 17. Diagnosis to be made if three or more of the following have occurred for at least 1 month or if persisting for periods of less than 1 month, should have occurred together repeatedly within a 12 month period. 1) Strong desire or compulsion to use the substance. 2) Difficulties in controlling substance taking behaviour in terms of onset, termination, or levels of use. 3) Physiological withdrawal state when substance use had been ceased or been reduced. 4) Evidence of tolerance 5) Progressive neglect of alternative pleasures or interests because of psychoactive substance use. 6) Persisting with substance use despite clear evidence of overtly harmful consequences (physical and mental).
  18. 18.  CAGE questionnaire  AUDIT  SAD-Q  FAST
  19. 19. 04/12/2013Dr Hayley Pinto TADS
  20. 20.  In the UK around 1 in 5-6 adults drink at hazardous levels and around 5% are alcohol dependent.  Alcohol is now the commonest cause of death in young people  70% of late-night attendances to A&E are alcohol-related  An average GP will see 364 excessive drinkers per year  Excessive drinkers consult their GP twice as often
  21. 21. 04/12/2013Dr Hayley Pinto TADS
  22. 22. 04/12/2013Dr Hayley Pinto TADS
  23. 23.  Easiest way to work it out: ◦ ABV x amount in litres = number of units  Rough estimate of 1 unit: ◦ ½ pint of normal-strength beer ◦ 125ml glass of wine ◦ Single (25ml) spirit measure
  24. 24.  Increased size of red blood cells ◦ Raised MCV and MCH  Raised liver enzymes ◦ GGT, AST, ALT, Alk P  More concerning ◦ Raised bilirubin ◦ Prolonged blood clotting ◦ Low platelets ◦ Low albumin
  25. 25.  Chronic liver disease ◦ Cirrhosis ◦ Hepatitis C  Poor nutrition/losing weight ◦ high risk of complication  Evidence of active bleeding ◦ GI bleeding can be suddenly fatal ◦ Not always asked about  Recent fits or hallucinations  Active suicidality ◦ Consider need for CRHT referral  Polysubstance use
  26. 26.  Withdrawal seizures (12-48 hours) ◦ Usually self-limiting ◦ Potentially fatal  Delirium tremens (24-96 hours) ◦ Occurs in 5% of people ◦ 5-10% mortality rate ◦ Characterised by withdrawal symptoms plus hallucinations, delusions and disorientation ◦ Treat with benzos plus supportive care
  27. 27.  Wernicke’s encephalopathy ◦ Confusion, ataxia, ophthalmoplegia ◦ Brainstem bleeding ◦ Potentially fatal  Korsakoff’s psychosis ◦ Preceded by Wernicke’s ◦ Short-term memory failure ◦ Mostly non-reversible ◦ Rarely compatible with independent living
  28. 28. ◦ Alcohol intake > 15 units /day Action - immediate referral for alcohol detoxification if ◦ Requesting detoxification ◦ H/O severe withdrawal symptoms, including complications such as delirium tremens or alcohol withdrawal seizures ◦ Poor physical health (e.g. compromised liver function, heart problems) ◦ Significant mental health problems or cognitive impairment ◦ They are at risk of intentional or unintentional overdose Should be seen within 10 working day
  29. 29.  Inpatient or community ◦ Severe withdrawal symptoms, significant physical/mental health problems, failed home detox, lack of home supervision, unsuitable setting  Chlordiazepoxide (librium) used locally ◦ High initial dose ◦ Gradually withdrawn over 6-9 days ◦ Alternatives used in severe liver disease  Vitamin injections – pabrinex  Daily monitoring
  30. 30.  Acamprosate (GABA/Glutamate receptor agonist) ◦ First-line treatment  Naltrexone (opiate receptor antagonist)  Disulfiram (Antabuse) ◦ Third-line from NICE ◦ Interferes with alcohol metabolism, causing build up of acetaldehyde ◦ Rare risk of acute hepatitis
  31. 31. OPIATES
  32. 32.  Opiates - any opioid drug found in the natural poppy plant  Opioids – any morphine like drug active at the opioid receptor One of the oldest drugs recorded Majority of the worlds heroin is still sourced from Afghanistan
  33. 33. HEROIN (di-acetyl morphine) CODEINE Mono-acetyl morphine (MAM) MORPHINE •Tramadol •Oxycodone •Dihydrocodeine (DF118) •Tramadol •Oxycodone •Dihydrocodeine (DF118) •Methadone •Buprenorphine •Fentanyl •Methadone •Buprenorphine •Fentanyl
  34. 34. WANTED EFFECTS  Euphoria – sense of comfort and wellbeing  Sedation  Pain relief  Cough suppression
  35. 35.  Reduces pupil size  Constipation  Nausea and vomiting  Itchy rash  Slows heart rate and drops blood pressure  Suppresses breathing
  36. 36. Immune suppression Menstrual abnormalities (delayed recognition of pregnancy) Tooth decay Malnutrition Lethargy and depression IMPACT OF USE ON SELF CONCEPT AND STIGMA
  37. 37.  Vein /artery / nerve damage  Clots - DVT / embolism  Infections – BBV and others INCREASED RISK OF OVERDOSE
  38. 38. DVT Esp groin injectors
  39. 39.  HIV - < 1 % of Norfolk IDUs (1.3%)  Hepatitis C - 36% of Norfolk IDUs (45%)  Hepatitis B - 19% of Norfolk IDUs (15%) (national averages in brackets) Shooting Up: Infections among people who inject drugs in the UK 2010 London HPA 2011
  40. 40.  Superficial Abscesses are common  Septicaemia (blood poisoning)  Endocarditis (infection in the Heart).  Embolism –debris, clots, or septic emboli Unusual infections may occur due to reduced immunity, injection in damaged tissue and contaminated batches of drugs such as  Anthrax  Botulism - , There are about 100 cases of botulism in injecting drug users in the UK per year. It presents as a descending paralysis and can be fatal. The classic symptoms comprise blurred vision, slurred speech, difficulty swallowing – IE – they look drunk  Tetanus  TB  Fungal Candida species are natural commensals in citrus fruit..
  41. 41. Bertschy, G. Methadone maintenance treatment: an update. 1995 Marsch L. A. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behaviour and criminality: a meta-analysis. Addiction 1998 Gossop M. NTORS REDUCES  Illicit opiate use  Use of other illicit drugs  Criminal bhvr  HIV risk bhvrs  Death rate IMPROVES  Quality of life  Physical health  Mental health  Employment  Perinatal outcome BECAUSE IT WORKS
  42. 42.  Long acting full agonist  PK levels 1-6 hrs after 1st dose  3-10 days to reach steady state  Prolongs QT interval  Prescribing on medication card in line with Controlled Drugs Px Guidelines.
  43. 43.  Partial agonist  High affinity / low intrinsic activity  Precipitated withdrawal  Reduced intoxicating effects  Lower retention rates  Higher abstinence and detox rates
  44. 44. Opiate system Dampening effect Noradrenergic drive Opiate Detoxification METHADONE / BUPRENORPHINE – Slow reduction SYMPTOMATIC TREATMENT Sedatives –agitation and sleep Simple pain killers – aches and pains Anti-diarrhoeals / anti-sickness Stomach cramps – buscopan LOFEXIDINE / CLONIDINE (2 adrenergic agonist) 2-4 weeks
  45. 45. Naltrexone Relapse Prevention Work •Triggers – things associated with using, boredom, negative emotions (past trauma), ‘treats’ •Coping with Craving •Re-structuring life 12 Step Programs Residential Rehabilitation Beware of swapping one substance for another
  46. 46.  500 000 – 1 million “therapeutic”  200 000 recreational ◦ ~50% demonstrate classic dependence  Estimates suggest up to 40-50% of “other” substance users also use benzos  Black market diversion common  Internet purchase becoming more common  “Silent” dependence
  47. 47.  Onset 3-10 days, duration 3-6 weeks  Physical ◦ Sweating, tremor, palpitations, lethargy, muscle tension/pain, nausea, flu-like illness, formication ◦ Convulsions  Psychological ◦ Agitation, irritability, restlessness, poor concentration, nightmares, insomnia ◦ Depersonalisation, derealisation, hallucinations and other psychotic symptoms
  48. 48.  Shorter acting drugs are more prone to formation of dependence ◦ Reward centres  Withdrawal is more extreme with short-acting drugs, but over quicker  Shorter acting drugs are used more for insomnia  Long acting more useful for reduction and alcohol detox
  49. 49.  Z drugs ◦ Zolpidem, zopiclone, zaleplon  Act in a similar but distinct way to benzodiazepines  Short acting  Possibly less prone to cause dependence  Still clearly able to cause dependence  Some black market diversion, though ?less common  Dependence managed in similar ways
  50. 50.  No strict rule on how fast - negotiate  Generally, 10-12 week reduction  CONVERT TO DIAZEPAM  Aim to reduce at 1/8 – 1/10 of dose every two weeks  May need to slow reduction towards end, but should be planned  Generally not repeated
  51. 51. Think about drugs and alcohol Care and respect Get advice
  52. 52. 04/12/2013Dr Hayley Pinto TADS
  53. 53. 04/12/2013Dr Hayley Pinto TADS
  54. 54. Call TADS 786786 TADS Guidelines Intranet Norfolk Recovery Partnership website: http://www.norfolkrecoverypartnership.org.uk /Pages/default.aspx Orange Guidelines www.nta.nhs.uk
  55. 55.  Alcohol Detoxification in the Inpatient Setting - C102  Opioid Detoxification and Stabilisation onto Substitute Medication - C103  Benzodiazepine Detoxification in the In-patient Setting - C104

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