12/7/2012 3:48:00 PM STREET SLANG ASSOCIATED WITH DRUG MISUSE 579 Table 15.5 Drug slang terms Slang term Meaning Backtrack Allow blood to \202 ow back into IV syringe and then re-inject Chasing Consume heroin by heating on foil and inhaling the fumes Cold turkey Withdrawal symptoms (referring to the piloerection) Cooking up Melting down heroin prior to injection Fix The required regular dose of drug in a dependent user Gouching Apparent somnolence following heroin use Jag up To inject drugs IV Juggling Selling drugs to \201 nance one \200\231s own dependency Junkie An individual dependent on a drug Mainline To inject drugs IV Nodding, on the nod Apparent somnolence following heroin use Rattling Suffering from withdrawals Score Obtain drugs Script Legitimate prescription for drugs Shooting gallery Place where individuals meet to use drugs IV Skin popping To inject drugs subdermally Sorted Having obtained suf \201 cient drug for one \200\231s own needs Spliff Cannabis cigarette Tab Dose of LSD impregnated onto paper Works Syringe and needles 15_Semple_Chap15.indd 579 12/7/2012 3:48:00 PM CHAPTER 15 Substance misuse 580 Opiates/opioids The opiates are a group of chemicals derived from the opium poppy (papaver somniferum); synthetic compounds with similar properties are called opioids. They have pote nt analgesic properties and as such have wide legitimate uses in medicine. They are widely abused for their eupho- riant and anxiolytic properties. Heroin is the most frequently abus ed opiate. Heroin Illicit heroin is sold as a brown or white powder in \200\230bags \200 \231 or \200\230wraps \200\231, costing 50 \200\223 100/g, with a typical dependent use r taking 0.25 \200\2232.0g/ day. It is most commonly consumed by smoking ( \200\230chasing \200\231), but is also taken orally, occasionally snorted, and parenterally by IV, IM, or s ubcuta- neous routes. Street supplies are of variable purity (25 \200\22350% by volume); oc casionally, a particularly pure batch is associated with a series of deaths and ODs from us ers used to a less concentrated form. In common with other opiates, heroin binds to speci \201 c receptors for which there are e ndogenous ligands (endorphins). There are overall corti- cal inhibitory effects with dimini shed pain sensation. After consumption, effects are virtually immediate with euphoria amoun ting to ecstasy, intense relaxation, and untethering from worries and cares. Although recreational use is not unknown, the tendency is for progres- sion to dependent us e and this is the most usual pattern by the time of presentation to treatment services. An established dependent user may move from smoking to occasional or regular IV use to potenti ate effects. Users develop tolerance with regular use and there is cross-tolerance to other opiates. Dependent patients may describe limited euphoriant effects, with the drug being m ainly taken to avoid unpleasant withdrawals. Acute medical problems associated with heroin use by any route include nausea and vomiting, constipation, respiratory depression, and loss of con- sciousness with aspiration (the cau se of many fatalities). Injected use adds risks of local abscesses, cellulitis, osteomyelit is, bacterial endocarditis, sep- ticaemia, and the transmission of viral infections (hepati tis B and C, HIV). Opiate dependency develops after weeks of regular use and is associated with an unpleasant (but not generally medically dangerous) withdrawal syndrome (b p. 596). Interventions Give harm reduction advice to users who continue to use opiates: do not use o piates while alone; do not use in combination with other drugs; avoid IV route; if injectin g, give safe injecting advice (Box 15.3). Consider managed detox (b p. 598) or transfer to maintenance prescribing (b p. 598) in established dependence. Other opiates/opioids These i nclude dihydrocodeine, morphine, methadone, pethidine, buprenorphine, and codeine. They may be taken in their pre-prepared tablet or liquid form or prepared for injection. Their acut e and chronic risks are similar to heroin. 15_Semple_Chap15.indd 580 12/7/2012 3:48:00 PM OPIATES/OPIOIDS 581 Box 15.3 Safer injecting advice If using heroin it is safest to avoid IV use which has the greatest risk of overdose and ot her complications. If using heroin IV: \200 Use new sterile needles and syringes on each occasion (give details of local needle exchang e services if available) Use sterile water (water from running cold kitchen tap is closest) Never share needles, syringes, spoons, or \201 lters with another user Rotate injection sites Avoid injecting into neck, groin, or breast Avoid injection into infected areas Ensur e that the drug is completely dissolved before injecting Always inject with, not against, t he blood \202 ow Do not take heroin while alone \200 \200 \200 \200 \200 \200 \200 It is safest to use new sterile needles and syringe on each occasion. Failing this, rather than use dirty equipment, \202 ush both needles and syringes several times with thin blea ch, then several times with clean water. 15_Semple_Chap15.indd 581 12/7/2012 3:48:00 PM CHAPTER 15 Substance misuse 582 Depressants Drugs of this group produce their effects by generalized or speci \201 c cor- tical depression. They include the BDZs, alcohol, and the barbiturates. They can be taken f or their pleasurable anxiolytic and relaxant properties alone, or as a way of counteracting unpleasant side-effects of other drugs of abuse (e.g. to \200\230come down \200\231 after stimulant use). Benzodiazepines A class of chemicals initially synthesized in the 1950s. L argely replaced barbiturates in clinical practice as they did not cause fatal respiratory d epression. They have therapeutic uses as anxiolytics, hypnot- ics, anticonvulsants, and mus cle relaxants. Problems of dependency arising from long-term use became recognized in the 1 980s leading to a fall in their legitimate prescription, but did nothing to diminish their popularity as drugs of abuse. All BDZs have similar effects and are distinguished by their length of action: short-acting (e.g. temazepam, oxazepam), medium- acting (e.g. lorazepam, alprazolam), long-acting (e.g. diazepam, nitrazepam, chlordiazepoxide). Benzodiazepines are taken orally, or less commonly by injection. There is hepatic metabolis m to active compounds, some with long half-lives. They enhance GABA transmission and produc e marked anxiolytic and euphoriant effects. Tolerance develops rapidly (with cross-toleranc e to all drugs in the benzodiazepine group), so requiring increasing doses to achieve simil ar effects. Acutely they cause forgetfulness, drowsiness, and impaired concentra- tion and co-ordinatio n with consequent risk of accidents. Use by injection is associated with the same infective risks as IV heroin (b p. 581). An additional problem seen in IV benzodiazepine users is li mb ischaemia sec- ondary to intravenous use of melted tablet contents. Chronic use is asso- ciated with impaired concentration and memory and depressed mood, all of which are more se vere in the elderly. Benzodiazepine dependency develops after 3 \200\2236wks of regular use . There is a withdrawal syndrome (b p. 600) which can be complicated by seizures and deliri um. Interventions Harm reduction advice to user as for opiates (b p. 580), specifying safe injecting advice (b p. 581) if using via IV route. Consider managed detox or transfer to ma intenance prescribing (b p. 600) in established dependence. Flunitrazepam (Rohypnol) A sh ort-acting potent BDZ seen par- ticularly in dance settings with intoxicant and (probably a pocryphal) aph- rodisiac effects. As it can produce impaired judgment and anterograde amnes ia and is tasteless in solution it has been implicated in cases of \200\230date rape \200 \231. 15_Semple_Chap15.indd 582 12/7/2012 3:48:00 PM DEPRESSANTS 583 Gamma-hydroxybutyrate (GHB) A synthetic compound originally developed as an anesthetic whic h is a probable intrinsic neurotransmit- ter. Particularly seen in dance settings usually i n combination with other drugs or alcohol. Produces a sense of dissociation, euphoria, and intoxica- tion. Taken as liquid, 5 \200\22310mg dosage with effects coming on in 15 \200 \22330min and lasting several hours. Side-effects of nausea and vomiting, seizures, and res piratory depression. Usually taken episodically, but a cohort of patients is increasingly s een with consumption of the drug multiple times daily, with consequent physical dependence. Withdrawal from established depend- ence can present as a medical emergency, and is associ ated with delirium, severe behavioral disturbance, psychotic features, autonomic instabil- ity, and occasionally acute renal failure. Such patients will usually require joint psychia tric and medical management. Drug treatment of these with- drawals is via reducing benzodia zepine regime as per alcohol withdrawal (higher doses usually required), with the addition of regular baclofen given as a reducing regime, starting at 20mg \201 ve times daily, red ucing over the subsequent week. Barbiturates Group of compounds used as hypnotics/anxiolyti cs in clin- ical practice prior to the introduction of the benzodiazepines. Now rarely pres cribed and rarely seen as drugs of abuse. They act by facilitating GABA neurotransmission. There is rapidly increasing tolerance to their anxiolytic effects in regular use but not to the associated respiratory depression. 15_Semple_Chap15.indd 583 12/7/2012 3:48:01 PM CHAPTER 15 Substance misuse 584 Stimulants These drugs potentiate neurotransmission and increase cortical excitabil- ity, p roducing effects of increased alertness and endurance, diminished need for sleep, and a sub jective sense of well-being. They include cocaine (and crack cocaine), amfetamines, 3,4,-me thylenedioxymethamfetamine (MDMA or ecstasy), and caffeine. Cocaine The mild stimulant/euph oriant effects of the chewed leaves of the coca shrub have been known to the people of Sout h America for thousands of years, but in its re \201 ned form cocaine is a potent and high ly addictive drug. Cocaine hydrochloride is re \201 ned to a white powder which may be inh aled ( \200\230snorted \200\231) or dissolved and injected. The main route of intake is by inhalation as it undergoes rapid \200\230 \201 rst pass \200\231 liver metabolism. The us er forms the powder into \200\230lines \200\231 and inhales via rolled paper tube (classic ally, a high denomination banknote). Each line contains 725mg cocaine. Freebase ( \200\230c rack \200\231) cocaine (produced by alkalinization, which pro- duces the hydrochloride-free ion form) has a lower vaporization tempera- ture than the hydrochloride and can be smoked. In terms of rapidity of action and peak blood levels this compares with IV use. Cocaine acts as a local anesthetic at the mucous membranes. It has wide- spread effects in potentiating dopaminergic, serotinergic, and noradrena- linergic neurotransmission by block ing neurotransmitter reuptake. Its actions begin a few minutes after consumption. There is increased energy, increased con \201 dence, euphoria, and diminished need for sleep, but w ith rapid fall-off in effects due to rapid metabolism, leading to repeated use. There are v ery intense effects from freebase cocaine use with rapid and intense \200\230high \200\231 with subsequent dysphoria. Cocaine is usually taken in an opportunistic way, sometimes in association with other stimulant drugs. Acute harmful effects include arrhythmias, intense anxiety, hyperten- sion l CVA, acute imp ulsivity, and impaired judgment. Chronic harm- ful effects include necrosis of nasal septum , fetal damage ( \200\230crack babies \200\231), panic and anxiety disorders, persecutory d elusions, and psychosis. It is not associated with classical dependence but a minority of u sers will consume in a regular \200\230compulsive \200\231 pattern. Interventions Harm reduction advice (including safe injecting advice, b p. 581, if appropri ate). No role for substitute prescribing in managing withdrawal or for maintenance prescrib ing. 15_Semple_Chap15.indd 584 12/7/2012 3:48:01 PM STIMULANTS 585 Amfetamines A group of compounds synthesized in the late nineteenth century with current le gitimate uses in child psychiatry (b p. 628) and in narcolepsy (b p. 432). Sold as 5mg tabl ets or as white powder ( 10 per gram). The powder may be swallowed, inhaled, or dissolved and injected. Use is usually situational or recreational, although very regular use with de pendence is recognized. There is chemical similarity to noradrenaline and dopamine, produci ng similar pharmacological effects to cocaine, but its slower metabolism gives a longer dur ation of action. Acute harmful effects include tachycardia, arrhythmias, hyperpyrexia. irritability, post-us e depression, and quasi-psychotic state with visual, audi- tory, and tactile hallucinations . Dependency is not seen but marked psy- chological addiction occurs, particularly in situa tions associated with drug use. Anxiety and depressive symptoms are frequently seen in user s; their proper assessment requires a period of abstinence. Interventions Harm reduction advice (including safe injecting advice, if appropriate). No r ole for substitute prescribing in managing withdrawals. Very limited role for maintenance p rescribing of dexamfetamine sulfate in the management of chronic, primary, heavy IV users ( specialist instiga- tion only). MDMA (ecstasy) This compound was synthesized in 1914. Initi ally, was occasionally used as an adjunct to psychotherapy. Initially legal, it became wide ly used in the mid-1980s in association with house, rave, and techno music. It is taken ora lly as 50 \200\223200mg tablet. A typical pattern of use is two or more tablets taken at we ekends. MDMA causes serotonin release and blocks reuptake. It has structural similarities to mescal ine and amfetamine, therefore has both hallucinogenic and stimulant properties, these effec ts appearing 730mins after ingestion. The initial \200\230rush \200\231 period of intoxica tion lasts 73hrs and is characterized by a feeling of increased camaraderie and \200\230cl oseness \200\231 to others, a pleasurable agitation relieved by dancing, and decreased fati gue. Acute harmful effects include increased sweating, nausea and vomiting, and diminished poten cy despite increased libido. Deaths have occurred associated with dehydration and hyperther mia (a toxic reaction similar to serotonin syndrome appears to exist [b p. 960]). Chronic h armful effects include possible neurotoxicity, hepatotoxicity, and possible chronic cogni- tive impairment. There is tolerance to its effects but dependence does not occur. \200\230 Hangover \200\231 effects develop 24 \200\22348hrs after ingestion including fatigue, anore xia, and depressed mood (which may be severe). Interventions Harm reduction advice regarding maintaining hydration and avoiding overheatin g during use. No role for substitute prescribing in managing withdrawal or for maintenance prescribing. For all stimulant drugs there may be a problem of assessing other aspects of m ental state, particularly affective and psychotic features while chaotic use continues. In selected patients, inpatient assessment will be indicated to allow this. 15_Semple_Chap15.indd 585 12/7/2012 3:48:01 PM CHAPTER 15 Substance misuse 586 Hallucinogens Hallucinogens (or psychedelics) are a heterogeneous group of natural and synt hetic substances which produce altered sensory and perceptual expe- riences. They include: lysergic acid diethylamide (LSD), phenylcyclidine (PCP), magic mushrooms, ketamine, mescali ne, 2,5-dimethoxy-4-methyl- amfetamine (DOM), and dimethyltriptamine (DMT). Lysergic acid d iethylamide (LSD) A compound synthesized by Hofman while working at Sandoz pharmaceuticals in 1944. He reported the hallucinatory experiences that followed his initial, accidental in gestion. The drug also occurs naturally in seeds of the Morning Glory plant. It became stro ngly associated with 1960s culture when its use was at its peak. There was early experiment ation with its role in psychotherapy but there is no current legitimate use. It is very sol uble and intensely potent (effective dose 7250 micrograms). It is sold impregnated onto pap er, in tablets, or as a powder. LSD is an indolealkylamine with structural similarity to serotonin. There are direct and in direct effects on serotinergic and dopaminergic transmitter systems. It is not now thought to provide a good model for endogenous psychosis. Its actions are very markedly situation- and expectation-dependent. Effects develop 15 \200\22330mins after ingestion and last up to 6hrs. There is initial euphoria; a sense of detachment; a sense of novelty in the familiar and a sense of wonder at the normal; visual distor- tions and misperceptions; synaesthesia ; and distorted body image. Somatic effects include dizziness and tremors. Acute harmful effects are behavioral toxicity (i.e. harm related to act- ing on beliefs suc h as having the ability to \202 y) and \200\230bad trips \200\231 (i.e. dissocia- tion, fear of incipient madness, frightening perceptions). There is no risk of overdose and physi ological dependence and withdrawals do not occur. Chronic harmful effects include \202 as hbacks (b p. 96) even many years after consumption, post-hallucinogenic perceptual disorder , persistent psychosis, and persistent anxiety/depressive symptoms. Interventions Harm-reduction advice directed towards maintaining a safe environment during use and avoiding behavioral toxicity \200\224do not use alone, use accompanied by non-user if possible. For all hallucinogens, acute psychotic features should in general be managed b y admission, maintenance of a safe environment, symptomatic treatment of agitation (e.g. wi th benzodiazepine), with expectation of resolution. Continuing psy- chotic features should be managed as for acute psychosis (b p. 192). Phenylcyclidine (PCP) An hallucinogen rarely seen in the UK except as a contaminant of other drugs. May be smoked, snorted, taken orally , or, more rarely, parenterally. There is direct binding to opioid and aspartate excitatory receptors as well as serotonergic and cholinergic effects pro- ducing acute effects of con fusion, visual sensory distortions, aggression, and sudden violence (which may be severe). Intoxication may give way to longer psychotic states. 15_Semple_Chap15.indd 586 12/7/2012 3:48:01 PM HALLUCINOGENS 587 Magic mushrooms About a dozen varieties of hallucinogenic mush- rooms grow in the UK, the b est known being the Liberty cap (Psilocybe semilanceata). They may be eaten raw or cooked, dried or prepared as a drink. Possession and consumption of mushrooms is not an offense unl ess they have been processed or prepared for illicit use. Small doses cause euphoria, while larger doses (>25 mushrooms) cause perceptual abnormalities similar to LSD. They are not a ssociated with dependence or withdrawal features and tolerance develops quickly, making con tinuous use unlikely. Harmful effects include nausea and vomiting, dizziness, diar- rhoea a nd abdominal cramps, behavioral toxicity, and risk of accidental consumption of toxic fungi . Ketamine A compound structurally similar to phencyclidine used as a veterinary anesthetic and in battle \201 eld surgery. It is a unique anaes- thetic as it does not produce retic ular activating system (RAS) depression, instead it prevents cortical awareness of painful stimuli. It is taken illicitly as a sniffed powder, mean dose 7100mg. Small amounts lead to a sense of dissociation, larger amounts to LSD-like synaesthesia and hallucinations, assoc iated with nausea, ataxia, and slurred speech. Rare late effects are \202 ashbacks, psych osis, and amnesic syndromes. 15_Semple_Chap15.indd 587 12/7/2012 3:48:01 PM CHAPTER 15 Substance misuse 588 Other drugs Cannabis The most commonly used illegal drug, with only a small minor- ity of i ts users ever using another illegal drug. Used for centuries as a pleasurable mind-altering substance and as a medication for a wide variety of ailments. Clinical trials are underway to clarify its role in the treatment of chronic pain. Its illegal use is of interest to ps ychiatrists because of its association with other drugs of abuse (as a \200\230gateway dru g \200\231) and because of its exacerbating effect on chronic psychotic illnesses. Cannabis is produced from the dried leaves, \202 owers, stems, and seeds of the weed Cann abis Sativa. It may be distributed as herbal material ( \200\230grass \200\231 or marijuana ), as a resin ( \200\230hash \200\231), or as cannabis oil. Cannabis may be smoked in cigar ettes, alone, or mixed with tobacco; the resin form may be eaten directly or incorporated i nto foodstuffs (e.g. cakes). These vari- ous forms contain at least 60 psychoactive cannabo ids, the most important of which is 9- -tetrahydrocannabinol (THC). The dried herb contain s 75% THC by weight; resin 710%; and cannabis oil 715%. Usage pattern is very variable, from infrequent situational use to daily heavy use; the lat ter at highest risk of harmful effects and most likely to take other drugs. There is a spec i \201 c cannabinoid receptor and a naturally occur- ring agonist at this receptor \200 \224 \200\230anandamide \200\231. The role of this endogenous system has yet to be de \201 ned. In addition, cannabis shows both weak opiate- like and weak barbiturate-like effects. The drug is metabolized to active and inactive metabolites and their absorption into fat m eans that urine tests remain positive for up to 4 weeks after regular use has ceased. The effects of intoxication are apparent within minutes if the drug is smoked, peaking in 7 30min and lasting 2 \200\2235hrs. The effects of orally con- sumed cannabis are slower to b egin and more prolonged. The immediate effects include mild euphoria ( \200\230the giggles \200\231), a sense of enhanced well-be- ing, subjective sense of enhanced sensation, relaxa tion, altered time sense, and increased appetite ( \200\230the munchies \200\231). Physical ly there is mild tachycar- dia and variable dysarthria and ataxia. Acute harmful effects include mild paranoia, panic attacks, and accidents associated with d elayed reaction time. Cannabis is normally smoked with tobacco, therefore all of the health risks associated with tobacco will also apply. The tendency of cannabis smokers to inhale deeply and to retain the smoke in the lungs for as long as possible will exacerbate this ri sk. There are no reports of fatal overdose. Chronic harmful effects include dys- thymia, an xiety/depressive illnesses, the disputed amotivational syndrome (possibly representing a co mbination of chronic intoxication in a heavy user and a long half-life). The drug is not us ually associated with physical dependency but there is a mild but characteristic withdrawal syndrome in the previously heavy regular user who stops suddenly, consisting of insom- nia , anxiety, and irritability. Cannabis use can precipitate an episode of or relapse of schiz ophrenia. In addition, in regular users it is associated with dose-related paranoid ideatio n and other psychotic features. Interventions As an illegal drug there are no set guidelines on safe use. Clinical experien ce suggests that irregular use can be free from major problems. Abstinence is indicated in those with major mental illness and 15_Semple_Chap15.indd 588 12/7/2012 3:48:01 PM OTHER DRUGS 589 continuing cannabis use may expose those recovering from more serious drug problems to deal ers and the drugs subculture. Volatile substances Simple hydrocarbons such as acetone, toluene, xylene, and butane have i ntoxicant properties. These chemicals are found in a variety of common products including g lue, lighter fuel, paint stripper, \201 re extinguishers, aero- sols, paints, gasoline, c orrecting \202 uid, and nail varnish remover. They are rapidly absorbed when inhaled or b y snif \201 ng propellant gasses or aerosols. They cause non-speci \201 c increased perme ability of nerve cell membranes and produce euphoriant effects, disinhibition, slurred spee ch and blurred vision, and visual misperceptions. Acute harmful effects include local irritation, headache, cardiac arrhyth- mias, acute suff ocation by bag or laryngeal oedema, unconsciousness, aspiration, and sudden death. Chronic harmful effects include liver and kidney damage, memory/concentration impairment, and proba ble long- term cognitive impairment. There is a withdrawal syndrome similar to alcohol in v ery heavy regular users. Interventions Education of users and \200\230at risk \200\231 groups. Most use will be exp erimental with few going on to regular use. Legal controls on sub- stance availability. Anabolic steroids These prescription-only medicines (e.g. nandrolone and stanozolol) have l imited legitimate uses in the treatment of aplastic anemia and osteoporosis. They can be ab used by athletes and body builders seek- ing competitive advantage or, more rarely, for the ir euphoriant effects alone. They produce increased muscle mass and strength, with increase d training time and reduced recovery time as well as euphoriant effects and a sense of incr eased energy levels. (Other drugs misused by athletes include levothyroxine, growth hormone , diuretics, erythropoietin, and amfetamine.) Use of anabolic steroids is associated with physical health problems including hypertension , hypogonadism, gynaecomastia, amenorrhoea, liver damage, impotence, and male pattern baldn ess; and with mental health problems including acute emotional instability (sometimes known as \200\230roid rage \200\231), increased aggressiveness, persecutory/grandiose delu- sio ns, depressive illness, and chronic fatigue. If injected they can also be associated with i nfection risks (b p. 582). There is no withdrawal syndrome. Interventions Education of risks through coaches, teachers, etc. Effective monitoring of in dividual sports with out-of-season testing. Legal highs Heterogeneous group of psychoactive substances that are not control- led under the Misuse of Drugs Act, and are therefore legal to possess. It should be noted that a sign i \201 cant number of these drugs are regu- lated under the Medicines Act, and it is again st the law to sell, supply, or advertise them for human consumption. They are broadly sold over the 15_Semple_Chap15.indd 589 12/7/2012 3:48:01 PM CHAPTER 15 Substance misuse 590 Internet and specialist shops. They can consist of plant-based and synthetic compounds, wit h variable effects. A good example is that of mephadrone ( \200\230meow-meow \200\231 or \200\230M-CAT \200\231), a cathenone that acts as a stimulant, with equivalent psychiatric sequelae. A dif \201 culty encountered with these drugs is that synthesis occurs at a rate quicker than regulation, although regula- tory bodies are changing practice to re \202 ec t this. 15_Semple_Chap15.indd 590 12/7/2012 3:48:01 PM This page intentionally left blank CHAPTER 15 Substance misuse 592 Assessment of the drug user In most cases an assessment of a patient \200\231s history of d rug use will form part of a routine psychiatric interview. In addition, all doctors should consider the possibility of, and be prepared to ask about, comorbid drug misuse when interv iewing patients for other reasons. The more detailed assessment described here is appropria te for patients in whom drug use is the primary focus of clinical concern and who are being assessed for entry into a treatment program. The detailed assessment of a patient with dru g use problems will usually be carried out over more than one consul- tation. There are onl y a few circumstances (such as an opiate- dependent patient presenting as an acute medical emergency), where treatment should be considered before full assessment. History should cov er the following topics: Background information Name, address, next of kin, GP, names of ot her professionals involved (e.g. social worker, probation of \201 cer). Reasons for consul tation now Why has the drug user presented now (e.g. pressure from family, pending convicti on, \200\230had enough \200\231, increas- ing dif \201 culty injecting)? What does the us er seek from the program? In females, is there a possibility of pregnancy? Current drug use Enquire about each drug taken over the previous 4wks. Describe the frequency of use (e.g. daily, most days, at weekends); and the number of times taken each day. Record the amount t aken and the route. Ask the user about episodes of withdrawal. Include alcohol, tobacco, an d cannabis. If there is IV use, inquire about needle or other equipment sharing. Lifetime d rug use Record the age at \201 rst use of drugs and the changing pattern of drug use unti l the most recent consultation. Enquire about peri- ods of abstinence or stability and the reasons for this (e.g. prison, relation- ship, treatment program). Complications of drug us e Overdoses \200\224deliberate or accidental. History of cellulitis, abscesses, or phlebiti s. Hepatitis B and C and HIV status if known. Previous treatment episodes Timing, locus, an d type of previous drug treatment. How did the treatment attempt end? Was the treatment hel pful? Medical and psychiatric history All episodes of medical or psychiat- ric inpatient ca re. Contact with hospital specialists. Current health prob- lems. Relationship with GP. Fam ily history Are there other family members with drug or alcohol problems? Family history of medical or psychiatric problems. Social history Current accommodation. How stable is this accommoda- tion? Sexual orientation and number of sexual partners. Enquire about safe sex p recautions. Describe the user \200\231s relationships \200\224sexual, personal, and family. Note how many of these individuals currently use drugs. 15_Semple_Chap15.indd 592 12/7/2012 3:48:02 PM ASSESSMENT OF THE DRUG USER 593 Forensic history Previous or pending convictions. Periods of impris- onment. Enquire about continuing criminal activity to support drug use (remind the patient about con \201 dentia lity). Patient \200\231s aims in seeking treatment What is the patient \200\231s attitude t o drug use? What treatment options do they favor? MSE Observe for history or objective sign s of depressed mood or sui- cidal thoughts or plans. Inquire directly about generalized anx iety and panic attacks (a benzodiazepine user may be self-medicating a neurotic condition). Inquire directly about paranoid ideas and hallucinatory experi- ences and the directness o r otherwise of their relationship with drug use. Physical examination General condition. We ight. Condition of teeth. Signs of IV use (examine particularly arms for signs of phlebitis , abscess, or old scarring). Examine for enlarged liver. Signs of withdrawals on assessment . Urine screening This is essential. Several specimens should be taken over several weeks. Repeated absence of evidence of a drug on screening makes its dependent use unlikely (see T able 15.6). Occasionally, testing errors do occur so do not take action (e.g. stopping main tenance prescrip- tion) on the basis of the results of a single sample. Blood testing FBC, LFTs, discuss with patient the need for HIV and hepatitis screening. Table 15.6 Urine drug testing Substance Duration of detectability Amfetamines 48hrs Benzodiazepines Ultra short-acting (e.g. midazolam) 12hrs Short-acting (e.g. triazolam ) 24hrs Intermediate-acting (e.g. temazepam) 40 \200\22380hrs Long-acting (e.g. diazepam) 7 days Cocaine metabolites 2 \200\2233 days Methadone (maintenance-dosing) 7 \200\2239 days (approximate) Codeine/morphine 48hrs (Heroin is detected in urine as the metabolite morphine) Cannabis Single use 3 days Moderate use (4 times per week) 4 days Heavy use (daily) 10 days Chronic heavy use 21 \200\22327 days Phencyclidine (PCP) 8 days (approximate) 15_Semple_Chap15.indd 593 12/7/2012 3:48:02 PM CHAPTER 15 Substance misuse 594 Planning treatment in drug misuse The longer-term goal of treatment will be eventual abstin ence from drugs, but this may not be an achievable short or medium-term goal in an individu al case. Immediate treatment aims are therefore: to reduce drug- related mortality and morb idity; to reduce community infection rates; to reduce criminal activity, including the need for drug users to sell to others to \201 nance their own habit; to optimize the patient \200\231s physical and men- tal health; and to stabilize where appropriate on an alternativ e substitute drug. Make diagnosis Con \201 rm drug use (history, signs of withdrawals, uri ne testing). Assess presence and extent of dependence. Assess severity of current problems and risk of future complications. Explore social, relation- ship, and medical problems. Ass ess stage of change ( b p. 544 and motiva- tion. What are the short-term and medium-term ai ms of treatment? Consider need for emergency treatment Where there is evi- dence of psychot ic illness or severe depressive illness the patient may require inpatient assessment. Engag e in service Treatment of drug misuse cannot be carried out through \200\230one-off \200 \231 interventions. Patients should be engaged in the service by empathic and non-judgement al interviewing, availability of the service close to the point of need, and ability of the service to respond to change in a previously ambivalent patient. Substitute prescribing wi ll be a strong motivator for engagement in some patients, but should always also have a rol e in helping the patient achieve some worthwhile change. Decide treatment goals and methods After assessment and diag- nosis the doctor should discuss with the patient their thoughts about treatment options given the patient \200\231s drug history and local treatment avail ability. The doctor may have strong feelings about the appropriate- ness of a certain treat ment but this will not be successful unless the patient agrees. Plans may include: \200 Return to dependent use as previously present in withdrawals, without other medical, surgic al, or psychiatric reasons for admission, and where there is no history of complicated with drawal, and where there has been no previous involvement in treatment services, it is inapp ropriate to prescribe. The individual should not receive replacement medication. They shoul d be offered the opportunity to attend for further assessment. Counseling and support episo dic use, this may be the appropriate course. Give drug information and harm-reduction advic e, possibly coupled with referral to a community resource. Detoxi \201 cation dependence a nd the patient wishes abstinence, then a plan for detox is considered. This may be communit y-based, with psychological support, symptomatic medication, or reducing substitute medicat ion, or as an inpatient. Consideration should be given to support after detox. How is absti nence to be maintained? Where individuals For non-dependent drug use, particularly (b p. 598, b p. 600) Where there is drug 15_Semple_Chap15.indd 594 12/7/2012 3:48:02 PM PLANNING TREATMENT IN DRUG MISUSE 595 Supported detox without prescription withdraw from drugs of dependence without use of a pre scription. This may occur particularly where other changes in a person \200\231s life (e.g. change of area, break from dependent partner) facilitate abstinence. Unsupported detox wit hout any medical help is frequently reported by users. Supported detox with symptomatic med ication addition to the support mentioned here, the individual is prescribed other, non-rep lacement drugs to ameliorate withdrawal symptoms (e.g. lofexidine in opiate withdrawal). Co nversion to substitute drug with aim of detox Here the aim is to convert the individual \200\231s drug use from street-bought to prescribed, then, from a period of stability, atte mpt supervised reduction in dose, aiming towards abstinence. Some individuals can Here, in Conversion to substitute drug with aim of maintenance the aim again is to convert from stre et to prescribed drugs, with stabilization via maintenance prescribing in the medium term. In a dependent user who does not feel that they can move to abstinence in the short term, m aintenance prescribing to suitably selected patients is useful and associated with overall health bene \201 ts. Here Address other needs The drug treatment service should consider part of its role as being a gateway to other services which the drug user may require but be reluctant or unable to app roach independently. Patients with social, \201 nancial, or physical health needs should have these explored and the need for referral considered. Do not make such referrals withou t the knowledge and agreement of the patient. Review psychiatric symp- toms which have been attributed to drug use to assess their resolution. Consider \200\230in-house \200\231 or specialist psychiatric treatment of residual anxiety/ depressive symptoms. 15_Semple_Chap15.indd 595 12/7/2012 3:48:03 PM CHAPTER 15 Substance misuse 596 Substitute prescribing 1: principles Withdrawal syndromes Any drug consumed regularly and h eavily can be associated with withdrawal phenomena on stopping, even if not a clas- sical w ithdrawal syndrome. The severity of withdrawal symptoms experi- enced by individual patient s does not correlate well with their reported previous consumption and so it is best to rel y on objective evidence of withdrawal severity. Clinically signi \201 cant withdrawal phen omena occur in dependence on alcohol, opiates, and benzodiazepines and are occasion- ally s een in cannabis, cocaine, and amfetamine use. In general, drugs with short half-lives will give rise to more rapid but more transient withdrawals. Detoxi \201 cation refers to the p rocess of managed withdrawal from drugs of dependence which can be aided by psychological s upport, symptomatic prescribing, or by prescription of reducing doses of the same or simila r drug. Substitute prescribing In many circumstances the management of a drug user will inc lude prescription of substitute medication. This may be to enable detoxi \201 cation from a dependent drug, or maintenance prescribing \200\224 a move from unstable street use to pr escribed dependent use to facilitate change now with abstinence later. The prescription of a drug should not occur in isolation, but should be part of a comprehensive management plan , previously agreed with the patient and with relevant members of the multidisciplinary tea m. Prescribing for drug users should be guided by local procedures and practice, by the Hom e Of \201 ce document Drug misuse and dependence \200\224guidelines on clinical management , and by the British National Formulary (see Box 15.4). Substitute prescribing may have the following indications \200 