Dr Tim M Williams Clinical Director Specialised Services AWP Mental Health NHS Trust 4 th July 2014 Wills Hall Bristol Drug and alcohol harms Alcohol Alcohol affordability index 19802010 ID: 432279
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Slide1
Drugs, legal and illegal
Dr Tim M Williams
Clinical Director – Specialised
Services AWP Mental Health NHS Trust
4
th
July
2014 –
Wills Hall,
Bristol.Slide2
Drug and alcohol harmsSlide3
AlcoholSlide4
Alcohol affordability index, 1980-2010.
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing GroupSlide5Slide6
Real spending on alcohol in UK, 1964-2010.
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing GroupSlide7
Hospital admissions wholly attributable to alcohol in England, 2002 to 2010
Appleby J BMJ 2012;344:bmj.e2634
©2012 by British Medical Journal Publishing GroupSlide8
The Scots leads the world
Leon and
McCambridge
, Lancet 2006 (updated)
Leon and
McCambridge
, Lancet 2006 (updated)Slide9Slide10
Alcohol withdrawal
Time since last drink tremor
nausea and vomiting
anxiety, irritability, depression
BP, pulse, temp
insomnia
transient hallucinations/illusions
48 hours seizures (7 - 48 hours)
72 hours Delirium tremens (peak onset 48 - 72 hours after last drink or reduction).
Tremor, hallucinations, confusion, plus delusions, insomnia and agitation, autonomic hyperactivitySlide11
What to do when abstinent?
Relapse Prevention essential
Not usually offered by statutory/specialist services
12 weeks treatment only in my service
Medication???
Disulfiram
,
acamprasate
, naltrexonenalmefene currently hit the headlinesSlide12
Alcohol harms (is a downer)
Immediate Risks
Longer term
Accidents
Head injuries
Driving
Death (
esp
drowning / RTA)
Vulnerabilityto exploitation / date rapeHeartSeen more in Russia
Liver
Pancreas
Brain / neurons
Heart
Vessels / kidney’s
GI tract
Sexual dysfunction
Addictive
potential
Minority: 3-5% dependence
Mental
health
Massive co-morbiditySlide13
“Drugs”Slide14
UK drug useSlide15Slide16Slide17Slide18
OpioidsSlide19
Benzodiazepines and opioids
Benzodiazepines plus methadone or buprenorphine
- higher opioid toxicity symptoms
(Nielsen et al, 2007 Addiction)
- greater peak effects on performance measures
(Lintzeris et al, 2006 J. Clin. Psychopharmacology)
- higher mortality among patients co-prescribed methadone and benzodiazepines
(McCowan et al, 2009 BMJ)
Slide20
Gabapentin misuse
Smith et al Br
J Gen Pract. 2012 Aug;62(601):406-7.
“In
primary care,
an
increasing
number and urgency of prescription requests cannot necessarily be explained by the increased number of
cases of neuropathic pain”5.2% of people in SM services using gabapentinMean daily dose 1343mg
Of 1400 post-mortems48 had gabapentin36 of whom also had morphine/ methadoneIs fatal in overdose and unlike opioids or benzo’s is irreversibleSlide21
Opioid harms (are downers)
Immediate Risks
Longer term
Respiratory arrest
Esp
when mixed with alcohol and other downers
Accidents
Vulnerability
to exploitation
Crime and povertyBig overlapAddictive potential
Yes
Mental health
?
IV use
BBV’s
Smoked
COPDSlide22
CocaineSlide23
Cocaine (crack) and other stimulants
Difficult to engage
Difficult to treat
High mental health co-morbiditySlide24
Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007380
Psychostimulants did not improve cocaine use, craving, or treatment retention in comparision to placeboSlide25
Cocaine harms (is an upper)
Immediate risks
Longer term
CVS risks
Could trigger a CVS event
Psychosis
Could trigger an event
Specific Risks
Nothing acute
Addictive potential – very potentLong-term risksprominent CVS risks MI, strokeCOPD (crack)Nasal septum (snorted cocaine)Slide26
NPS
…….or novel psychoactive substances (NPS)
…….or “club drugs”
…….or “legal highs”Slide27
Source- NTA ‘Club drugs: emerging risks and trends’ Dec 2012Slide28Slide29Slide30
3,4
Methylenedioxmethamphetamine
(MDMA)
The recreational drug
Ecstasy
Onset 20 minutes
Effects last
2-5 hours
Particular
empathogenic
/
entactogenic
qualities
Physiologically safe in therapeutic applicationsSlide31
How dangerous is MDMA
when used recreationally?
Between
1997 and 2000
in the UK:
81
deaths were attributed
in part
to ecstasy
(
Schifano
F. 2003)
But....
59%
also included
opiates
60%
included
alcohol
Only
7%
involved
MDMA
alone;
That is six deaths in three years
After some
300 million
ecstasy tablets were consumed by over a
million people.
And remember: this is NOT clinical use. This is the uncontrolled recreational use of
‘
ecstasy
’
.Slide32
4.8% of British soldiers returning from combat in Iraq met the criteria for PTSD
(
Iversen
et al 2009)
US soldiers returning from service in Iraq and/or Afghanistan, the incidence of PTSD is as high as 18%
.
(
Hoge
et al 2004)
More returning soldiers from Iraq and Afghanistan have committed suicide from untreated PTSD than ever died in the conflict out there.Slide33
2009 - MAPS / Mithoefer
MDMA for PTSD
Study:
Hypotheses:
MDMA subjects will show improved rates of PTSD.
MDMA will not be associated with neurotoxicity
.
Michael and Annie Mithoefer,
Baseline measurements
Introductory Sessions
First MDMA / Placebo Session
Four non-drug sessions
Second MDMA / placebo session
Four non-drug sessions
Measurements
Measurements
Measurement
Two Month Follow-up
THREEYEAR FOLLOW-UP:Slide34
Results for Hypothesis One:
% meeting PTSD diagnosis – pre/postSlide35
MDMA harms (is an upper)
Immediate risks
Longer term
CVS risks
Could trigger a CVS event
Psychosis
Could trigger an event
Specific Risks
Hyperthermia
?water intoxicationAddictive potential – very unlikely due to high toleranceVery little data on long-term risksno CVS risks recordedNo
consistent evidence of long-term memory deficits. Short term reversible deficits recognised.Slide36
MDMA/Ecstasy adulterants
An emerging problem
Need to develop new harm
minimisation
messages.
Specific advise for coroners essential
PMA (
para-Methoxyamphetamine or 4-MA)
1 hour onsetPMMA (para
-Methoxy-N-methylamphetamine)Linked to deaths, ?less toxic than PMASlide37
PMA / PMMA (is an upper)
Immediate
risks
Longer
term
CVS risks
?Could
trigger a CVS eventPsychosis?Could trigger an event
Specific RisksHyperthermia (greater than MDMA)Addictive potential ?No data
on long-term
risksSlide38Slide39
Mephedrone
4-MMC,
MMCat
,
Miaow
,
Meow
Meow, Bubble,
4-Methylmethcathinone (4-MMC)
Stimulant, appeared in or around
2007 (Sweden)
Sold as
powder, crystals
or
sometimes capsules
Made illegal from 16/04/10 (Class B). Price nearly doubled
Had bypassed regulations as ‘plant food’, ‘not for human consumption’Slide40
The Scunthorpe two: Louis Wainwright and Nicholas Smith
Died from taking me
thadone
not
me
phedrone
with significant quantities of alcoholSlide41
Professor Sheila Bird, of the Medical Research Council's Biostatistics Unit in Cambridge “deaths from cocaine fell in the first six months of 2009 to 66, a statistically significant drop from 95 in the same period of 2008”Slide42
Mephedrone harms (is an upper)
Immediate risks
Longer term
CVS risks
Could trigger a CVS event
Psychosis
Could trigger an event
?Specific risk of vasoconstriction
Specific come down risk and suicide
Addictive potentialVery little data on long-term risksLikely CVS risks?mental healthSlide43
K, ketamine
and methoxetamine?Slide44
The Observer Sunday 17 April 2011
Every parent's worst nightmare: how
ketamine
killed our daughter
Bright, popular, rebellious and creative, 21-year-old Louise
Cattell
had everything to live for. Then she made a fatal mistake. She took the party drug
ketamine and was found dead in the bath by her
flatmate.Slide45
Ketamine harms (is a downer)
Immediate Risks
Longer term
Accidents
especially drowning
and hypothermia
driving
Vulnerability
to exploitation
However is generally a very safe drug used in a medical contextStimulant at low dosesBladder problemsThickeningUrgency
‘K-cramps’
Eventually dysfunctional bladder
Addictive potential
Users 1-12g a day
Mental health?Slide46
GHB, GBL and 1,4-BD
Confusingly sometimes referred to as “liquid ecstasy”Slide47
GHB/GBL harms (is a downer)
immediate
Longer term
Respiratory depressant
Very dangerous with alcohol
Narrow therapeutic window
Accidents
Much like alcohol
Disinhibits and poor perception of risks
AddictiveWithdrawal syndromeLike alcohol but worseSevere seizures ?
baclofen
to treatSlide48
Khat
Main active ingredients are
cathine
and
cathinoneSlide49
Khat harms (is an upper)
Immediate risks
CVS risks
Precipitate event
Psychosis
Minor risk
But mixed with PTSD increased
Longer term
CVS risks
Early MIEarly strokeDependenceSmall minorityGI cancers??
Oral
oesophagealSlide50
M-Cat,
madcat
and now M2
ie
3,4,DMMC
(are stimulants)
See what the are doing here:
cathinone
(in
khat
)
methcathinone
(m-cat)
4-methylmethcathinone (
mephedrone
)
3,4-dimethylmethcathinone (“M2”)Slide51
Harms??
Immediate
Longer term
CVS
Mental health
Specific risks?
Anaphylaxis
Respiratory??
CVS
Mental healthDependence
Can include 6-APB in this category (unhelpfully often called “
benzofury
”)
6-(2-aminopropyl)
benzofuranSlide52
2-CB (MDMA like)
The Sun 24/1/13Slide53
“Krokodil”
CNN
-“
flesh-eating zombie drug
”
USA Today
-“Flesh-Rotting ‘Krokodil’ Drug Emerges in USA,”
GQ
– “flesh-eating
heroin substitute
that has found favour with Russia's homeless, and now "
krokodil
" has
come to Britain.
”Slide54
“Krockadil”
(
desomorphine
)
Immediate
Longer term
CVS
Resp
depression + deathMental healthSpecific risks?
“flesh eating”??CVSMental healthDependenceabsolutely
Reports in Russia of homemade ‘
krokodil
’ by
mixing codeine with chemicals such as gasoline, red phosphorus, and hydrochloric
acid. Extremely unlikely
t
o be found in Europe and US due to easy availability of opioidsSlide55
Other drugs (not uppers
or downers)
Cannabinoids
hallucinogens
Respiratory if smoked
Psychosis
Precipitated - yes
Cause - probably no
Anxiety
AmotivationalDefinitelyMushrooms (psilocybin), Acid (LSD)
Low risk
Salvia
divinorum
Slightly different but still low risk
MDA
A bit more of a stimulant
(MDMA like)Slide56
End