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Definition of illicit drug

  • Definition OED
    • Illicit: forbidden by law, rules or custom
      • may be illegal or not approved by common customs
    • Drug: a medicine or other substance which has a psychological effect when ingested

Why are some drugs illegal

Morbidity/mortality?

  • 97% death due to legal drugs
  • Pharmacology? Stimulant vs depressant?
  • Pleasurable vs unpleasant?
  • Cultural background?
  • Historical accident?
  • Harm to the body?
  • Complex social, cultural, economic, geopolitical influences
    • 1961: UN Combined 'single treaty' convention on narcotic drugs
      • limited exclusively to medical and scientific purposes
      • international cooperation to deter and discourage drug traffickers
      • global trade in illicit drugs now second only to arms
      • no evidence of decreased access, growing market in opiates and new synthetics
      • illicit status compounds____
    • reflected in Australian law
      • problem: synthetic cannabis

Global patterns

  • Similarities increasing____


Illicit drug use at the global level, late 1990s-2010/11

  • Slight increase in proportion of people using drugs (largely due to developing countries)
  • Majority of drug use is at the non-harmful level
    • only a tiny proportion is harmful
  • DON'T DRIVE WHEN PREGNANT!

Illicit drug use in Australia

  • Commonly used drugs:
    • Cannabis 10%
    • Pharmaceuticals for non-medical purposes 4% (DOCTORS CAUSE THIS!)

Recent drug use: proportion of the Australian population aged 14 years or older

Recent drug use

  • Men use more, but young women are catching up
  • Peak prevalence is around 18-24 years

Current trends PWID

PWID instead of IDU

  • 2/3 male, 1/3 female
  • Mean age 37
  • Heroin still popular, but prescription opioid use increasing (eg. oxycodone)
  • Heroin availability high but quality is low-medium
  • Increasing ice use among PWID
  • Overdose deaths 400/year ...
  • Methamphetamine = 'crystal', 'base', and 'speed'
    • Used to have amphetamine but now precursors are illegal
  • Cocaine mainly in NSW
  • Re-using and sharing of injecting equipment still occurs, yet HIV prevalence in PWID's remains low because of NSPs
  • 90% PWIDs report a psychiatric disorder

Drug injected most often in the last month, IDRS

  • Mostly heroin, then 'ice', then morphine, then methadone, then cocaine

Crime

  • 1/3 report criminal activity last 1 year (need $ for drugs)
  • Drug-dealing and property crime most common
  • 39% arrested (causes harm
  • Most not incarcerated
  • 75% of funding for illicit drugs goes to law enforcement rather than preventive measures, education, social stuff

Spectrum of psychoactive substance use

  • Beneficial --> substance use disorders

Substance use disorders

  • Hazardous use
    • places a person at risk
  • Harmful use (ICD10) or abuse (DSM IV)
    • repetitive use resulting in damage

Dependence definition

  • ICD 10; >=3 in the past year
    • strong desire or compulsion to use
    • difficulties in controlling use
    • withdrawal syndrome on cessation (vide infra) or take drug to prevent withdrawal symptoms
    • tolerance
    • neglect of alternative activities, increased amount of time necessary to obtain or take the substance or to recover from its effects;
    • persist with substance use despite lear evidence of overtly harmful consequences (e.g. abscesses, infective endocarditis)

Risk factors

  • Dependence related to
    • drug properties
    • individual vulnterability
      • personality, family history, trauma history, previous history of substance dependence, coexisting mental illness
    • environment
      • availability, acceptance (e.g. alcohol)
  • early age of use
  • family history of drug/alcohol use
  • previous drug/alcohol dependency
  • childhood trauma, multiple traumatic events
  • gender, age
  • depression, anxiety, PTSD?

Substance use history

  • Substance use a standard part of history
  • Consumption history: for each drug, how often, how much ($ approximates, amounts), last use
    • $ better indicator than amount, because of purity variability
  • Withdrawal symptoms experienced
  • Other features of dependence
  • Evidence of dependence e.g. injection practices
  • Age of initiation
  • Periods of abstinence
  • Intervention history
  • Complications e.g. infection, O/D

Complications

Related to the drug, illicit status (if legal, we can tell the dose more easily), route of administration

  • Overdose, depends on substance
    • Hypoxic brain injury
    • Rhabdomyelitis
    • Hypertensive stroke (stimulants)
    • Seizures (stimulants)
  • Social and legal consequences
  • STIs
  • Dental complications
    • Caries - dry mouth - opiates
    • Bruxism - psychostimulants; prominent jaws, ground-down teeth
  • Psychiatric
    • Depression/anxiety
    • Psychosis (stimulants, cannabis)
  • Injection complications
    • Infective endocarditis
    • Bacterial infections
      • Local (abscess, cellulitis)
      • Embolic (osteomyelitis, septic arthritis)
      • Endocarditis
      • Septicaemia
    • Viral infections
      • HCV, HBV, HIV
    • .....

NSW Health, substance use assessment

  • Change amphetamines to metamphetamines
  • Trick is "how to ask the question"
    • Open and nonjudgemental way
    • Don't take history when they're intoxicated/withdrawal
    • Develop rapport

Examination

  • Tailored to history e.g.
    • Injection related
      • Stigmata of injection ('track marks') - fresh/old
      • Thrombophlebitis, skin abscesses, cellulitis
      • Endocarditis (steth)
      • HCV: jaundice, liver disease
    • Smoking related
      • COPD
    • Nutritional status
    • Dentition, oral examination
      • Caries, evidence of bruxism
    • Mental state examination, suicide risk assessment
    • Signs of intoxication or withdrawal

Opioids

  • Intoxication
    • Pin-point pupils
    • Low BP, HR, RR --> hypoxia
    • Drowsy
  • Withdrawal
    • Dilated pupils
    • Increased HR, BP, RR
    • Anxiety, irritability
    • Piloerection
    • Rhinorrhea, lacrimation
    • Sweats, yawning
    • Abdominal cramping

Psychostimulants

  • Intoxication
    • Dilated pupils
    • Restlessness, agitation
    • Increased libido
    • Increased HR, RR, BP, T
    • Bruxism
    • Insomnia
    • Decreased appetite
    • Euphoria
  • Withdrawal
    • Depression (suicidality, anhedonia)
    • Anxiety

Cannabis

  • Intoxication
    • Conjunctival injection
    • Euphoria, relaxation - sometimes anxiety and paranoia
    • Dry mouth
    • Increased appetite
    • Altered perception of time
    • Talkative
    • Increased HR, BP
  • Withdrawal

?20% of heavy users

    • Insomnia
    • Irritability
    • Anxiety
    • Lethargy
    • Cravings
    • Modd changes
    • Reduced appetite
    • Muscle spasm
    • Headach
    • Hyperemesis (rare)

Photos

  • External jugular trackmarks (very dangerous site) - evidence of venupuncture, scarring; more damage with blunt needle or infection
  • Injection site abscesses on legs


Treatment

  • Psychosocial support - counselling, brief discussion (harms of use, modification)
  • Substitution therapy - to get life back on track while your withdrawal and injection ARx are gone away
    • e.g. opioid (methadone, buprenorphine)
      • longer-acting than heroin; easier to get stability into their life
      • it would be better to have heroin legal, so this intervention is on offer for addicts who don't like methadone
  • Withdrawal
    • Assisted
      • Symptomatic treatment
      • Tapered buprenorphine (including naloxone, which gives ARx if injected; intended for sublingual)
      • Management of psychiatric complications
    • Residential or ambulatory
  • Relapse prevention

naltrexone = opioid antagonist

Tiered intervention framenwork

(Pyramid - top down)

  • Treatment (high severity dependence, low population impact)
  • Early intervention
  • Prevention
  • Promotion (low severity dependence, high population impact)

Addiction medicine handbook

  • Oxford specialist handbook