15_Semple_Chap15.indd 562 12/7/2012 3:47:58 PM MAINTENANCE IN ALCOHOL MISUSE 1: PSYCHOLOGICAL METHODS 563 Box 15.2 Alcoholics Anonymous (AA) Alcoholics Anonymous (AA) is the best known and the most widespread of the voluntary self-h elp organizations for problem drinkers. It was founded in 1935 in the USA by Bill Wilson an d Dr Bob Smith, themselves both problem drinkers. Currently there are 73 000 groups in the UK and 788 000 groups worldwide. Associated organizations are Al-Anon (for relatives of pro blem drinkers); Al-Ateen (for teenage children of problem drinkers); and Narcotics Anonymou s (NA) (for addicts of illicit drugs). AA views alcoholism as a lifelong, incurable disease whose symp- toms can be arrested by li felong abstinence. Many other groups will use a variant of the AA model \200\23012-step \200\231 program. AA is a useful and effective intervention in many problem drinkers and al l patients should be informed about AA and encouraged to consider attendance. An AA meeting will generally follow a standard routine: there will be 10 \200\22320 people in each group, only \201 rst names are used; a rotating chair- man will introduce himself with \200\230my name is X, and I am an alcoholic \200\231, then will read the AA preamble ; a number of speakers are called from the \202 oor who give an account of their stories and recovery if possible, lead- ing to general discussion; the meeting ends with a prayer a nd is followed by informal discussions and contact between new members and spon- sors who m ay offer emotional and practical support and perhaps a phone number. Open meetings are held where friends, family, and interested professionals can attend. Closed meetings are for AA members only. (See Useful resources for AA contacts in the UK and Ireland b p. 1014.) The \200\23012 steps \200\231 1. We admitted we were powerless over alcohol \200\224that our l ives had become unmanageable. 2. Came to believe that a power higher than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourse lves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove these defects of character. 7. Humbly asked Him t o remove our shortcomings. 8. Made a list of the persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory, and when we were wrong promptly to admit it. 11. Sought through prayer and meditation to improve our conscious contact with God as we un derstood Him, praying only for knowl- edge of His will for us and the power to carry that o ut. 12. Having had a spiritual awakening as a result of these steps, we tried to carry this mes sage to alcoholics and to practice these principles in our affairs. 15_Semple_Chap15.indd 563 12/7/2012 3:47:58 PM CHAPTER 15 Substance misuse 564 Maintenance interventions in alcohol misuse 2: pharmacological methods Aversive drugs Disul \201 ram Action Irreversible inhibition of acetaldehyde dehydrogenase (ALDH) which conver ts alcohol to carbon dioxide and water. If alcohol is taken, there is a build-up of acetald ehyde in the bloodstream causing unpleasant symptoms of \202 ushing, headache, nausea and vomiting, and tachycardia. There is also recent evidence to suggest it may block dopamine B hydrox- ylase, increasing dopamine and decreasing noradrenaline. Indication Can act as a helpful adjunct to therapy and allow the patient \200\231s relative s/employers to regain con \201 dence in their ability to remain absti- nent (evidence for increased ef \201 cacy with supervised administration). Dose Prescribe once abstinence achieved. Starting dose: give loading dose of 800mg and then reduce over 5 days to 100 \200\223200mg daily or 200 \200\223400mg on alternate days. Side-effects Halitosis and headache. Rare reports of psychotic reactions and hepatotoxicity . Notes \200 Patients should be counseled as to the nature and purpose of the drug and the likely side-e ffects if they drink. It is no longer recommended to give an alcohol \200\230challenge \200\231 to a patient newly started on disul \201 ram. Compliance is increased if the taki ng of the drug is monitored by another person (e.g. spouse). Anti-craving drugs Acamprosate Action Believed to act through enhancing GABA transmission i n the brain. Has been found to reduce alcohol consumption in animal models of alco- hol add iction, with possible neuroprotective effects. Patients taking it report diminished alcohol craving. In RCT, cohort treated with acampro- sate showed an increased percentage remainin g abstinent and a doubling of time to \201 rst relapse. The majority of trials have been conducted with adjunctive psychosocial treatments, and therefore these should accom- pany t reatment. Indications Patients who wish to remain abstinent from alcohol. Dose Once abstinence achieved: 666mg tds. Can be started at the end of detoxi \201 cation. Side effects GI upset, pruritus, rash, altered libido. (Generally well tolerated.) 15_Semple_Chap15.indd 564 12/7/2012 3:47:59 PM MAINTENANCE IN ALCOHOL MISUSE 2: PHARMACOLOGICAL METHODS 565 Notes \200 Discontinue if patient returns to regular drinking or relapses more than once while on the drug. Has no role in assisting with controlled drinking. Has no aversive action if alcohol is taken (though can be used in conjunction with disul \201 ram). Has no addictive potenti al itself. \200 Naltrexone Action Antagonizes the effects of endogenous endorphins released by alcohol cons umption. It is believed that this diminishes both the desirable \200\230high \200\231 expe rienced on taking alcohol and the loss of control reported by most dependent drinkers. Indications In motivated subgroups of alcohol-dependent patients it appears to be effective in reducing total alcohol consumed and number of drinking days. Dose Once abstinence achieved, give 25mg od initially, maintenance 50mg od. Side effects GI upset, feeling anxious/ \200\230on edge \200\231, headache, fatigue, sleep disturbance, \202 u-like symptoms. Notes \200 \200 Does not have an aversive or dependence-producing effect. Not currently licensed in the UK for treatment of alcohol dependence. 15_Semple_Chap15.indd 565 12/7/2012 3:47:59 PM CHAPTER 15 Substance misuse 566 Alcohol misuse disorders 1 Acute intoxication The symptoms of alcohol intoxication will var y depending on the blood alcohol concentration (BAC), individual alcohol tolerance, and to some extent the setting in which the alcohol is taken. In general, as BAC rises from mild i ntoxication (BAC <100mg%) to moderate intoxication (BAC 100 \200\223200mg%) to severe intox ication (BAC >200mg%) a characteristic syndrome of acute intoxication is observed. Initial symptoms are elevated mood, disinhibition, and impaired judgment, followed by slurred speec h, unsteady gait, nystagmus, ataxia, aggressiveness, lability of mood and impaired concentr ation, and eventually sopor and coma. At-risk drinking There are reported bene \201 ts to health (lowered risk of coronary artery disease and strokes) associated with low levels of alcohol consumption as compared with those who are abstinent (the \200\230J-shaped curve \200\231), though this remains a contentious area. Above this low level, health risks incre ase with increasing alcohol consumption. It is therefore arbitrary at which point drinking is considered \200\230at risk \200\231. Patient and situational factors are important (e.g . any alcohol consumption while driving or in pregnancy carries increased risks; for patien ts with established alcohol-related organ damage any consumption is risky). Harmful drinkin g (DSM-IV \200\224alcohol abuse) Non-dependent drinking which continues despite established harm to the patient \200\231s physical or mental health secondary to the alcohol consumpti on. ICD-10 diagnosis considers only physical and mental health harm, not harm related to so cial sanction. Alcohol dependence Harmful use of alcohol + established dependence syndrome (b p. 542). Usually daily, stereotyped drinking pattern with increased tolerance, withdrawa l features on abstinence, and \200\230relief drinking \200\231 (i.e. further drinking to a lleviate the effects of withdrawals). Pathological intoxication ( \200\230mania potu \200\231) This is a medically and legally disputed syndrome which was not included in DSM-I V due to lack of empirical evidence. It is described as an idiosyncratic reaction to a smal l amount of alcohol characterized by severe agitation, belligerence, and violent behavior f ollowed by collapse, profoundly deep sleep, and amnesia for the events which followed the a lcohol consumption. It is a dubious diagnosis which is mainly sought after by defense lawye rs, as most legal systems do not regard normal self-induced intoxication as a valid defense . There is of course a strong association between alcohol and violent crime. Careful re-exa mination of the history will usually demonstrate that signi \201 cant quantities of alcoho l have been consumed. Alcohol-induced amnesia ( \200\230blackouts \200\231 or \200\230pali mpsest \200\231) This term refers to transient amnesic episodes related to periods of intox ication. Characteristically the patient will report a \200\230gap \200\231 in their memory lasting several hours with global or partial amnesia for their actions during that time. T he patient \200\231s behavior as reported by witnesses is usually characteristic of their n ormal behavior when intoxicated. This amnesia seems to be a failure of recall rather than i nitial registration 15_Semple_Chap15.indd 566 12/7/2012 3:47:59 PM ALCOHOL MISUSE DISORDERS 1 567 and represents a reversible form of brain damage. Its occurrence is not predictive of longe r-term cognitive impairment. It occurs in the later stages of a drinking career, if at all, and tends to recur once established. Two forms are described: \200 \200 \200\230En bloc \200\231 Partial preserved memory and variable degrees of recall. \200\224dense amnesia with well demarcated start and \201 nish points. \200\224episodes with indistinct start and end point with islands of There is some degree of state-dependent recall in blackouts and a return to intoxication ma y aid recall. Because of the potential confusion of the term \200\230blackout \200\231 wit h periods of loss of consciousness, the term \200\230alcoholic palimpsest \200\231 is to b e preferred. 15_Semple_Chap15.indd 567 12/7/2012 3:47:59 PM CHAPTER 15 Substance misuse 568 Alcohol misuse disorders 2 Alcoholic hallucinosis This is a substance-induced psychotic illness (de \201 ned in ICD-1 0), which is a rare complication of prolonged heavy alcohol abuse. The sufferer experiences hallucinations \200\224usually auditory \200\224in clear consciousness and while sober. Th e auditory hallucinations may begin as elemental hallucinations (e.g. bangs or murmurings) before, with continued alcohol use, being experienced as formed voices, most usually deroga tory in nature. There may be secondary delusional elaboration. The nature of hallucinations tends to worsen during periods of alcohol detoxi \201 cation, and at times, when intoxica ted with alcohol. \200 Differential diagnosis experiences while intoxicated, delirium tremens, psychotic illnesses . In 795% of patients there is rapid resolution of these Course symptoms on ceasing alcohol consumption but the symptoms rapidly recur on restarting drinking. In 75% there are prolon ged symptoms (<6mths after abstinence) and an emergence of more typical schizophrenic sympt omatology. Management psychotic medication (bearing in mind the medical comorbidities seen in this population). Transitory hallucinatory or illusionary Persisting symptoms may be treated with anti- Alcohol-induced psychotic disorder with delusions Long recognized, but only recently includ ed in DSM-IV. Development of persecutory or grandiose delusions after long history of heavy drinking. No other features of delirium tremens. Resolves on abstinence. Delirium tremens (b p. 558) Alcohol-related cognitive impairment/alcohol-related brain damage (ARBD) The classi \201 c ation of alcohol-related cognitive impairment is unclear, with both ICD-10 and DSM-IV viewi ng it as a number of discrete entities, as opposed to a continuum. ICD-10 describes amnesic disorder (F10.6), dementia (F10.73), and other persisting cognitive disorder (F10.74), DSM - IV-TR using the terms alcohol-induced persisting amnestic disorder and alcohol-induced pe rsisting dementia. It is worth noting that the DSM- IV-TR categories ignore the possibility of slow recovery over 1 \200\2232yrs in this patient group. The majority (50 \200\22360%) of heavy drinkers display some degree of cogni- tive impairme nt on cognitive testing while sober. There is impairment in short-term memory, long-term me mory recall, new skill acquisition, exec- utive function, relative preservation of language ability and mildly impaired visuospatial function. IQ (measured by the WAIS) is generally preserved (in comparison with pre-morbid IQ, measured using the NART). CT/MRI examination o f the brains of heavy drinkers reveals cortical and subcortical atrophy. White matter loss is prominent, which correlates with neuro- pathology \201 ndings. Degree of structural ab normality poorly correlated with degree of functional impairment. In all patients with alco hol-related brain damage (including those with \200\230alcohol dementia \200\231 and Korsa koff 15_Semple_Chap15.indd 568 12/7/2012 3:47:59 PM ALCOHOL MISUSE DISORDERS 2 569 syndrome), a signi \201 cant amount of medical comorbidity is seen, including small vessel disease, repetitive head injuries, and comorbid alcohol liver disease. The neurotoxic effe cts of alcohol on the brain are exacerbated signi \201 cantly by thiamine de \201 ciency, and there is evidence to suggest earlier onset in women. Abstinence from alcohol use has b een shown to corre- late with functional improvement and MRI improvement at 1yr. The term alcohol dementia is used at times, describing a generalized dementia syndrome, in which there is intellectual decline and more pro- nounced neuropsychological de \201 cits. The changes correlate with total lifetime drinking and length of drinking history. Wernick e \200\223Korsakoff syndrome (b p. 572) Pathological jealousy (Othello syndrome) This is a monosymptomatic delusional disorder (see b p. 220) seen most commonly secondary to current or previous alcohol abuse. The form is a primary delusion in which the content is that the patient \200\231s spouse or part- ner ha s been or is being unfaithful. Delusional evidence may be provided to back up this belief a nd the patient may go to great lengths to obtain \200\230evidence \200\231 (e.g. following her, planting tape recorders, examining discarded clothing). There is a signi \201 cant a ssociation with violence and even homi- cide towards the supposedly unfaithful partner. Management \200 \200 Abstinence from alcohol with addition of antipsychotic medication. It may be necessary for the couple to separate and advice to this effect may have to be given to the at-risk partne r. 15_Semple_Chap15.indd 569 12/7/2012 3:47:59 PM CHAPTER 15 Substance misuse 570 Psychiatric comorbidity Anxiety and depressive disorders Symptoms such as generalized anxie ty, panic attacks, and low mood are very frequently reported in alcohol abusers. Many patie nts with alcohol problems also merit diagnoses of depressive illness (750%) or anxiety diso rder (775%). The phenomenology of these disorders is similar to that found when the disorde rs occur in isolation. The dif \201 culty is deciding the sequence of events, as in some c ases the alcohol problem is secondary to the patient \200\230self-medicating \200\231 with alcohol in order to relieve primary anxiety or depressive symptoms. Nonetheless, chronic a lcohol use will act as a direct depressant, its secondary effects will produce depressogeni c life events (e.g. loss of job) and alcohol-related effects such waking at 04.00hr due to withdrawal, or weight loss related to nausea may masquerade as, or mask, biological depress ive features. Patients may emphasize the primacy of the mood or anxiety features and seek their resolutio n before tackling the alcohol problem. Generally a primary mood or anxiety disorder diagnos is should not be made in the presence of continuing alcohol misuse and psychological or pha rmacologi- cal treatment for mood disorder is unlikely to be effective. The correct course is to initiate detox if indicated and to reassess mood/anxiety symp- toms after 4wks of abs tinence, treating residual symptoms at this point. Only a minority will require formal trea tment. An undiagnosed depres- sive illness preceding the alcohol problem is more common in women. Alcohol problems can also arise as a result of self-medication of agora- phobia and social phobia. Suicide Classically quoted as lifetime risk of 10 \200\22315% in dependent d rink- ers. Now estimated at 74% lifetime risk of suicide in those with alcohol problems. Ps ychiatric comorbidity is important, as is social isolation, physi- cal ill health, and repe ated failed attempts at abstinence. Schizophrenia High rates of alcohol and substance use f ound in schizophrenic patients (750%). Increased risk of violence, EPSEs, TD, non- complian ce, relapses, and rehospitalizations. Alcohol is an easily available temporary treatment fo r some of the distressing symptoms of psychotic illness. Drug misuse Comorbid alcohol and d rug misuse can be to enhance effects (e.g. euphoriant effect of alcohol and cocaine combine d) or to minimize unpleasant side-effects (e.g. alcohol to relax after taking stimu- lants) , or as a substitute when the primary drug is unavailable. Comorbid drug misuse is associat ed with poorer outcome. Some comorbidity can have an iatrogenic component where there is mi xed abuse or substitu- tion of BDZs for alcohol. This can result from inappropriate prescri bing of anxiolytics, misdiagnosis of alcohol problems as anxiety disorders, and repeated un supervised withdrawals with hoarding of tablets. Aim to limit new prescriptions, review dia gnosis in patients with treatment-resistance anxiety disorders, and avoid short-acting BDZs (e.g. lorazepam). 15_Semple_Chap15.indd 570 12/7/2012 3:47:59 PM This page intentionally left blank CHAPTER 15 Substance misuse 572 Wernicke \200\223Korsakoff syndrome Wernicke encephalopathy and Korsakoff psychosis represe nt the acute and chronic phases of a single disease process \200\224Wernicke \200\223Korsak off syn- drome \200\224which is caused by neuronal degeneration secondary to thiamine de \201 ciency, most commonly seen in heavy drinkers. Wernicke encephalopathy Clinical features Acute onset of tetrad of: (1) acute confusional s tate; (2) ocu- lar signs (ophthalmoplegia, nystagmus); (3) ataxic gait. Associated features of: peripheral neuropathy, resting tachycardia, and evidence of nutritional de \201 cienc y. Ophthalmoplegia is most commonly 6th nerve palsy (paralysis of lateral gaze). Triad only seen in 10% of cases, confusion in 80% of cases. Etiology Occurs secondary to thiamine (v itamin B1) de \201 ciency. Heavy drinkers are especially vulnerable due to poor intake (al cohol is calorie- rich but vitamin-poor), reduced absorption, and impaired hepatic storage. Other rare causes of thiamine de \201 ciency are starvation, post-gastric resec- tion, an orexia nervosa, and hyperemesis gravidarum. Pathology Hemorrhages and secondary gliosis in periventricular and peri- aqueductal gray ma tter involving the mamillary bodies, hypothalamus, mediodorsal thalamic nucleus, colliculi, and tegmentum of midbrain. Treatment \200 1 replacement \200\224IV Pabrinex , 2 Give high potency parenteral B ampoules by in \202 uince over 30min twice daily for 3 \200 \2237 days. Specialist use. (Note: associated with allergic reactions; facilities for treat ment of anaphylaxis must be available, though recent evidence suggests negligible risk with recent preparations.) Avoid carbohydrate load until thiamine replacement is complete (i.e. do not rehydrate with glucose solutions prior to thiamine). Treat immediately diagnosis is made or strongly suspected. In addition, consider treating all those at high risk (alcohol -dependent patients with poor nutrition) prophylactically with parenteral vitamins. All pat ients with symptoms of Wernicke encephalopathy and those at high risk should have parentera l vitamins as in Treatment. All other patients undergoing detox, or being assessed for alco hol problems, should receive oral replacement \200\224thiamine 100mg tds for 1mth. b p. 558 ). Assess and treat for alcohol withdrawal syndrome ( Prognosis \200 72 weeks with 84% of cases developing Untreated the acute phase lasts features of Korsakoff psychosis. Mortality of 715% in untre ated cases. With treatment, the ophthalmoplegia and confusion resolve within days, but the ataxia, neuropathy, and nystagmus may be prolonged or permanent. Korsakoff syndrome Clinical features Absence or signi \201 cant impairment in the ability to lay down new memories, together with a variable length of retrograde 15_Semple_Chap15.indd 572 12/7/2012 3:47:59 PM WERNICKE \200\223KORSAKOFF SYNDROME 573 amnesia. Working memory (e.g. ability to remember a sequence of num- bers) is unimpaired as is procedural and \200\230emotional \200\231 memory. Thus the affected individual may be able to go with a psychologist to an interview room, perform adequately on working memory t esting, show evidence of a new skill (e.g. mirror writing) they practiced the day before, a nd yet later have no memory of ever having been in that room or having seen that psychologi st before (although, on returning to the room, they may be more relaxed on subsequent occas ions, due to state-related emotional memories). Confabulation for the episodes of amnesia m ay be prominent. Other neuropsychological de \201 cits associated with ARBD may be seen. Etiology Most commonly due to thiamine de \201 ciency, secondary to heavy alcohol use. Rar er causes are head injury, post-anesthesia, basal/tem poral lobe encephalitis, carbon monox ide poisoning, and thiamine de \201 ciency secondary to other causes. It should be remembe red that Korsakoff syn- drome is not invariably preceded by Wernicke encephalopathy, and ca n present in a \200\230chronic \200\231 form. Pathology Pathological features are those of Wernicke encephalopathy. The presumed mechanis m is disconnection of a mamillothalamic pathway crucial for memory formation. Treatment \200 Continue oral thiamine replacement and multivitamin supplementation for up to 2yrs. Treat p sychiatric comorbidity (e.g. depression) OT assessment, cognitive rehabilitation within an appropriate setting, acknowledging that some patients improve and may progress to independe nt living. Therefore, these patients will require continuous assessment of their functionin g, bearing in mind that improvement occurs in approximately 50% of those presenting with Ko rsakoff syndrome. \200 Prognosis \200 20% of cases show complete recovery, and 25% signi \201 cant recovery over time, with the remainder largely unchanged. The degree of functional impairment is directly related to the degree of memory impairment which may be incompatible with independent living. 15_Semple_Chap15.indd 573 12/7/2012 3:47:59 PM CHAPTER 15 Substance misuse 574 Medical complications of alcohol misuse Hepatic \200 Alcoholic liver disease (ALD) damage in the developed world. Presents as fatty change, alco holic hepatis, and, \201 nally, as cirrhosis. \200 is the most common cause of liver Fatty change seen in >90% of heavy drinkers, can emerge after single heavy bout, may be asy mptomatic, or may present as lethargy, malaise, painful and swollen liver, and obstructive jaundice. Reverses with abstinence. Alcoholic hepatitis \200\22440% of heavy drinkers. Cirr hosis \200\224up to 30% of heavy drinkers after 10 \200\22330yrs. Predisposed to by genetic variation (reduced alcohol oxidation and increased acetaldehyde accumulation), female sex (less \201 rst-pass metabolism and lower body water content for alcohol dispersal), comor bid hepatitis B or C infection. \200 Gastrointestinal \200 \200 \200 \200 \200 \200 Gastritis/gastric erosions with consequent haematemesis. Metaplasia of lower third of the e sophagus (Barrett \200\231s esophagus). Mallory \200\223Weiss oesophageal tears secondary t o vomiting. Peptic ulceration. Chronic diarrhea. Chronic pancreatitis (alcohol is most comm on cause) with chronic \202 uctuating abdominal pain and steatorrhoea. Cancers \200 Hepatocellular, esophagus, stomach, mouth, tongue, and pharynx. Cardiovascular \200 Hypertension. \200 Dilated cardiomyopathy. \200 Cardiac arrhythmi as (esp. atrial \201 brillation). \200 CVA. \200 Non- or very light drinkers have hig her risk than light drinkers even after controlling for smoking, hypertension, etc. (i.e. \200\230the J-shaped curve \200\231 for mortality); no speci \201 c drink type (i.e. not r ed wine); mechanism may be increase in protective HDL and reduced platelet adhesion. Respiratory \200 Tuberculosis. \200 Klebsiella and streptococcal pneumonia. \200 Incr eased vulnerability is related to decreased immunity, poor nutrition, and self-neglect. 15_Semple_Chap15.indd 574 12/7/2012 3:48:00 PM MEDICAL COMPLICATIONS OF ALCOHOL MISUSE 575 Neurological \200 \200 \200 \200 \200 \200 \200 b p. 572). Wernicke \200\223Korsakoff syndrome ( Peripheral neuropathy. Central pontine myelinolysis ( pseudobulbar palsy + quadriplegia). Marchiafava \200\223Bignami disease (corpus callosum de generation). Cerebellar degeneration. Optic atrophy. Alcoholic myopathy. Genitourinary \200 \200 Erectile problems. Hypogonadism in men. Other \200 \200 \200 \200 b p. 756). Fetal alcohol syndrome ( Gout. Osteoporosis. Impaired absorption and diminished intake of s peci \201 c vitamins and food overall. Contribution to accidents, particularly RTA. Exacer bating factor in violent crime and assaults. Diminished compliance with treatment for other medical and psychiatric disorders. \200 \200 15_Semple_Chap15.indd 575 12/7/2012 3:48:00 PM CHAPTER 15 Substance misuse 576 Illegal drugs In the UK, community surveys indicate that one third of adults have tried ill egal drugs in their lifetime, with 10% having used them in the previous year. The rates for those aged under 25 are higher, with 50% lifetime use and 33% in the previous year. At all ages males have higher rates of drug use than females (4:5 = 3 \200\2234:1). Cannabis is t he most commonly used illegal drug, while community rates for the other drugs of abuse are low. Users show a variable pattern of consumption with episodic and situ- ational use for d rugs with low dependence potential and a tendency to continuous dependent use for more \200\230addictive \200\231 drugs. Among some users, particularly those in the dance scene, polydrug use is the norm with indi- viduals consuming more than 10 different drugs. Use of illegal drugs is commoner in the young, in the lower socio-economic classes, and in those w ith psychiatric illness. At any one time <33% of dependent users will be in contact with tr eatment services; mean length of dependent use before seeking help is 9yrs. There are as many patterns of drug use as drug user, and individual patient assessment is m andatory; nonetheless a number of patterns of use of illegal drugs can be recognized: \200 Experimental use among young and heavily driven by drug availability and drug use among pee rs. Very common for \200\230softer \200\231 drugs (e.g. cannabis, volatile chemicals), rar er for more \200\230hard \200\231 drugs (e.g. heroin). Situational use raves). Mainly drug s with stimulant/hallucinogenic properties. Recreational use Regular, but non-dependent use . May be limited in time by period of life (e.g. ending at the end of university life) or m ay progress to dependent use. Polydrug use Non-dependent use of variety of drugs. One drug may be taken to potentiate the effects of another or to manage unpleasant after-effects of drug use. Risks can be additive or multiplicative. Dependent use Use of a drug for which a dependence syndrome (b p. 542) has developed. Continued use may be motivated more by the de sire to avoid withdrawals than by positive drug effects which may have diminished due to th e development of tolerance. Tendency is for the use of the dependent drug to predominate, w ith other drugs being taken only if the primary drug is unavailable. Dual diagnosis illness . An important group for therapeutic intervention. Use of drug in order to explore effects. Common Drug use limited to certain situations (e.g. parties, Drug users who also suffer from a major mental Categories of drugs of abuse \200 Opiates: buprenorphine, pethidine. Depressants: Stimulants: Hallucinogens: Others: e.g. heroin, dihydrocodeine, methadone, codeine, \200 \200 \200 e.g. BDZs, barbiturates, alcohol, GHB. e.g. amfetamines, cocaine, MDMA. e.g. LSD, PCP, mushrooms, ketamine. e.g. cannabis, volatile substances, anabolic steroids. 15_Semple_Chap15.indd 576 12/7/2012 3:48:00 PM This page intentionally left blank CHAPTER 15 Substance misuse 578 Street slang associated with drug misuse Table 15.4 Drug \200\230street names \200\231 Street drug name Conventional name Acid LSD Adam MDMA Angel dust PCP Billy Amfetamine Blow Cannabis Brown Heroin C, Charlie, Coke Cocaine Crack Freebase cocaine Dope Cannabis Downers Depressant drugs E, Ecstasy, Eccies MDMA GBH, grievous bodily harm GHB (gammahydroxybutyrate) Gear Heroin Grass, hash Cannabis Jellies Temazepam Marijuana Cannabis Mushies Psilocybin mushrooms Poppers Volatile nitrates Roids Anabolic steroids Rohypnol Roo \201 es Skag Heroin Skunk Potent form of cannabis Smack Heroin Snow Cocaine Special K Ketamine Speed Amfetamine Sulph Amfetamine Uppers Stimulant drugs Vallies Diazepam Vitamin K Ketamine Whizz Amfetamine 15_Semple_Chap15.indd 578 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