ADDICTION Dr Christopher Hilton - PowerPoint Presentation

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ADDICTION

Dr Christopher Hilton

MA MB BS

MRCPsych

PGCertULT | @drchrishiltonConsultant Liaison Psychiatrist, Clinical Lead for Integrated Intermediate Care & Hon Clinical Senior Lecturer#SSHA2015

Current perspectives on Chemsex

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Outline

Biography

Introduction

Intoxicating substances, old and newDependence and withdrawalComprehensive SM historyConventional approaches to SM treatment IntegrationDrugs and alcohol in the sexual health settingAdvice for screening and interventionServices local to C&W

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Medical and psychiatric training

Chelsea & Westminster Hospital: Liaison / HIV

Central & North West London: Addictions

Special interests: Club Drug Clinic

WLMHT Integrated care for patients with LTCsNowWLMHT / Ealing : Consultant Liaison PsychiatristHome ward Ealing – Intermediate Care ServiceImperial College: Honorary Senior Clinical LecturerMedical Council on Alcohol: Executive Committee

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Acknowledgements

Dr

Owen Bowden-Jones

David Stuart, Antidote

Mark DunnStacey HemmingsDeclarationsCH has in the past received honoraria for travel / lecturing (not related to this work) from: Bayer, Lilly, Pfizer and Janssen Dr

Pepe CatalanFlick ThorleyDr Amrit SacharProf Anne Lingford-Hughes

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Categories of intoxicating substances

Depressants

Opioids, benzodiazepines, alcohol

StimulantsCocaine, amphetamines, MDMA, caffeineHallucinogens

LSD, PCP, ketamineCannabis, nicotine

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Highs and harms

Desirable effects

Pleasure

Relaxation, anxiety reduction, disinhibitionIncreased energy, enjoyment, confidenceFatigue reduction, pain reductionCuriosity, new experiences, ‘psychonaut’

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Highs and harms

Undesirable effects

M

ode of administrationPhysical and systemic effectsPsychiatric effectsDependence potential and withdrawalBehavioural consequencesIndirect harms / harms to othersCrimeSynergistic effects

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The most harmful drug overall?

Nutt et al Lancet 2010; 376:1558

Alcohol 'more harmful than heroin, crack and Ecstasy'

Drugs

tsar sacked for claiming Ecstasy, cannabis and LSD are less harmful than alcohol

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The most harmful drug overall?

Nutt et al Lancet

2007; 369:1047

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Novel psychoactive substances

Club drugs

recreational drugs used in nightclubs, festivals, gigs, bars, circuit and house parties

Eg: amphetamine, methamphetamine, MDMA, cocaineNPS designed to mimic controlled drugs but synthesised to evade prohibitionsMany now banned after period as legal highsEg: mephedrone, methoxetamine, GHB/GBLEasily available online, head shops, dealers

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Novel psychoactive substances

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Categories of drugs

Depressants

Opioids, benzodiazepines, alcohol,

GBL/GHB, Phenibut, StimulantsCocaine, amphetamines,

MDMA, caffeine m-cat, NRG-1, BZP, MDAI, Synthacaine, 5/6-APBHallucinogensLSD, PCP, ketamine, AMT, methoxetamineCannabis, nicotineSpice

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Novel Psychoactive Substances - Key points

It is impossible for clinicians to remain abreast of all NPS on the market (1 new drug per week)

NPS are synthesised to

mimic existing drugs / use the same neurotransmitter mechanismsMost NPS are not detected by routine urinary drug testing – false negatives

Ask, and have degree of suspicion based on clinical assessment

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Scale of drug use in England & Wales

Adults 16-59:

Prevalence of having taken illicit drugs:

36.4% ever8.6% in last year3% Class AYoung adults 16-24:48.6% ever20.4% in last year6.6% Class ANHS IC 2011

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Scale of NPS use

EMCDDA 2005-11

1

164 NPS were formally notified (now ~1 per week)UK - 23% European NPS usersCrime Survey E&W 2011-1221.1% respondents had used mephedrone in the last year, 3.3% in 16-24 age groupGlobal drugs survey 20132 (clubbing last month):36.1% reported lifetime use of

mephedrone1 EMCDDA-Europol 2011 Annual Report on the Implementation of Councel Decision 2005/387/JHA. EMCDDA/Europol, 2012. | 2 Home Office. Drug misuse declared: findings from the 2011 to 2012 Crime Survey for England and Wales. Home Office, 2012. | 3 Winstock, A. "Global Drug Survey." Mixmag, May 2013.

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A whirlwind tour of addiction

Chronic relapsing brain disorder

characterised

by neurobiological changes that lead to compulsion to take a drug (or activity) with loss of control over the activity.Transition from recreational to obsessive useFrom positive to negative reinforcementPsychological factors drive the behaviour

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Koob

GF and Le

Moal

M, Science, 1997

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But what drives the psychological factors?

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Inside the brain of a recreational user of drugs

Boileau

et al Synapse 2003

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Inside the brain of a dependent user of drugs

1.

Volkow

2. Koob

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Outline

Biography

Introduction

Intoxicating substances, old and newDependence and withdrawalComprehensive SM historyConventional approaches to SM treatment IntegrationDrugs and alcohol in the sexual health settingAdvice for screening and interventionServices local to C&W

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ICD-10 diagnosis of dependence

Three or more at once in the last year:

Withdrawal symptoms

Tolerance to the effects of the drugStrong desire or compulsion to use the substancePersistent use despite adverse consequences Difficulty controlling use / amount / recidivismNeglect of other activities / primacy(Narrowing of repertoire)

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Comprehensive SM history

Who? (everyone)

What substances? (Avoid ‘illegal’)

QuantityFrequencyRouteCircumstancesHistory of use (first, regular, heaviest, cumulative)Negative effects (teachable moment)Features of dependence and withdrawal

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1 pint Peroni

5.1%

2.95 units

250mL wine

13%

3.25 units

75cL wine

13%

9.75 units

2L Cider (£3)

7.5%

15 units

440mL Special Brew (£1.32)

9%

4 units

70cL whisky

40%

28 units

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Clinical treatment strategies

Education & b

rief intervention

Harm minimisationStabilisation / maintenanceDetoxificationRehabilitationAbstinenceNHS Drug ClinicsPHE commissioned (via LAs)

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Outline

Biography

Introduction

Intoxicating substances, old and newDependence and withdrawalComprehensive SM historyConventional approaches to SM treatment IntegrationDrugs and alcohol in the sexual health settingAdvice for screening and interventionServices local to C&W

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Alcohol and sexual health

Family Planning Association Survey 2009

1000 18-30 year olds, Online survey by Mori

37% had unprotected sex with a new partnerOf these: 40% said alcohol was a factor38% reported sex which they regretted laterOf these: 70% said alcohol was a factor28% reported having sex with someone they wouldn’t normally find attractiveOf these: 78% said alcohol was a factor

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Alcohol and sexual health

Binge drinking, sexual

behaviour

and sexually transmitted infection in the UKInt J STD & AIDS 2007; 18; 810-1386% GU attendees are binge drinkers32% felt alcohol played a role in their attendance77% drunk before sex with a new partnerBinge drinking assoc with bacterial STI diagnosis and unwanted pregnancy

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Recreational drugs and GUM: meth

Scale of methamphetamine use (UK)

CSEW 2011-12

1: 0.1% used in last yrGMSS 20072: 4.7% used in last yrHIV testing cohort3: (2002-3): 8.3% in last yr

HIV treatment cohort3 (2002-3): 12.6% in last yrGym cohort (2004)3 21% in last yr1Home Office. Drug misuse declared: findings from the 2011 to 2012 Crime Survey for England and Wales. Home Office, 2012. | 2Keogh P et al. Wasted opportunities: Problematic alcohol and drug use among gay men and bisexual men. Sigma Research 2009 | 3Bolding G et al. Addiction 2006; 101, 1622–1630

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CNWL (NHS)

Antidote (Charity)

National / open access

Opened: Jan 2011First 18 months:291 patients seen

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CDC - Presenting drug use

(n=291)

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CDC - Presenting drug use

(n=52 heterosexual)

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Crystal methamphetamine and HIV

Users of crystal methamphetamine in the clinic (n=120) were

two times

more likely to be HIV positive than non users (n=170). 68%

vs 33% (p <0.05)Users of crystal methamphetamine in the clinic were four times more likely to be HCV positive than non users. 12% vs 3% (p <0.05)

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Crystal methamphetamine and HIV

Do you attribute your HIV status to your drug use?

30% of HIV positive patients responded YES

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Crystal methamphetamine and HIV

Does your drug use get in the way of taking your prescribed medications regularly?

3

9% patients on

antiretrovirals responded YES

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Injecting drug use

Crystal methamphetamine users:

53% reported having

injected the drug47% neverNon crystal users:6% reported currently injecting (meph, cocaine, G, K)19% reported previously injecting75% never

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MSM and substance use – why?

Helps to relax and be more sociable

Mitigating social unease

(general, sexuality, scene)Alleviating loneliness / unhappinessEnabling sexual encounters(sexuality, HIV, ‘raucous’ – integral to sex)Gay norms of alcohol and substance use(integral to socialising)Keogh P et al. Wasted opportunities: Problematic alcohol and drug use among gay men and bisexual men. Sigma Research 2009

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Associations between substance use and HIV related risk indicators

1

Vosburgh

, HW et al. A Review of the Literature on Event-Level Substance Use

and Sexual Risk Behavior Among Men Who Have Sex with Men. AIDS Behav 2012: 16:1394–14102 Rajasingham R et al. A Systematic Review of Behavioral and Treatment Outcome Studies Among HIV-Infected Men Who Have Sex with Men Who Abuse Crystal Methamphetamine. AIDS PATIENT CARE and STDs 2012: 26; 36-51 Systematic review of 23 studies (2012)1 looked at studies into various substances: only methamphetamine and binge alcohol

drinking associated with sexual risk (see plot)Systematic review of 61 studies (2012)2 highlighted HIV+ MSM who use meth more likely to report high-risk sexual behaviour, incident STI, serodiscordant UAI compared with HIV+ MSM who do not use methamphetamine

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High risk sexual

behaviours

Increased frequency of sex

Prolongation of sex (‘marathon’)Increased number of partnersReduced condom use / UAIIncreased condom failureDisinhibiting effectsMucosal traumaCo-infection with other STIColfax G, Guzman R. Club Drugs and HIV Infection: A Review. CID 2006: 42:1463–9

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High risk sexual

behaviours

Clinical experience

Online apps / websites‘Party and play’ / parTy Multiple partnersHigher risk sexual practicesIntravenous use in sexualised contexts‘Slamming’ / re-injectingKirkby T, Thornber-Dunwell M. High-risk drug practices tighten grip on London gay

scene.Lancet 2013: 381; 101-2

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Interventions

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Patient

37 year old HIV+ gay man, working full time in City

Recent acquisition of HCV following casual UPSI at party arranged online

Binges on drugs 3-4x per month including ‘tina’ smoked or ‘slammed’ and ‘meph’Reports feeling depressed and being ‘monitored’ online at timesWould like to abstain from drugs, but doesn’t see self as a ‘junkie’ so won’t visit mainstream servicesMultiple lapses related to sex: ‘haven’t had drug free sex for years’, ‘can’t manage sex without drugs’

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Substance misuse in sexual health

Investigate the link between substance misuse and sexual health

Design interventions to minimise harm from both

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Disintegrated services

Education

Harm

minimisationStabilisationDetoxificationRehabilitationAbstinencePhysical healthHIVSexual healthOther medical problemsMental health

WellbeingSelf esteemDepression, anxietyCognitive functionPsychosisSelf harmSocial careRelationshipsSexSocial lifeFamily / childrenEmploymentHabitsSpirituality &cAddiction servicesNHSThird Sector

Justice SystemPrimary care

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Substance misuse in sexual health

Clinicians should

be aware

of the commonly used recreational drugs and their potential short term complications and risksconsider screening individuals at risk give simple safety advice and informationhave agreed referral pathways into local servicesAK Sullivan, O Bowden Jones, Y Azad (2014)

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Drug

Screening Qs

Did

you use drugs before/during sex in the last 3m Yes / No / Yes but not during sex Which drugs did you use? Crystal methamphetamine -  Mephedrone -

 GHB/GBL-  Ketamine-  Cocaine-  Other (specify)-  3. Did you inject? Yes / No / Yes but not in the last 3m

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Identification and Brief Advice

“The teachable moment”

Prochaska

& DiClementeChange in awarenessChange in attitude

Change in behaviour

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Identification and Brief Advice

“

The teachable moment

”Reflect back to the patient any identified harmsOffer advice on making changesOffer further advice/support/referralCochrane review supports effectiveness of IBA1To reduce drinking to lower-risk levels, NNT = 8 21 Kaner 2007, 2 Moyer 2002

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Referral pathways

Access to integrated SMHW

Mental Health referral pathways

Integrated health and social care servicesAddictions services:PHE/LA commissionedIncreasingly partnerships between 3rd sector and NHSConcern about reduced capacity to deal with complexity including physical / MH comorbidityCulturally competent? Eg MSM specific

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Clinical treatment strategies

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PS - Mental health in sexual health

Psychological Wellbeing Agenda

Support

at time of diagnosisScreening for psychological needs: depression, anxiety, SM, stress, self harm, cognitive impairmentInitial management interventionsReferral pathways - evidence based, HIV-specific, timely, competent, access to psychological care

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Reso

urces

Specialist services

: CODE ChemClinic ReShapeNow.orgTHT www.drugfucked.tht.org.uktalktofrank.comerowid.com

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@

drchrishilton

#SSHA2015