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Drug misuse - what you need to know

Drug and alcohol misuse specialist Dr Stefan Janikiewicz answers GP Dr Linden Ruckert’s questions on methadone maintenance, benzodiazepine prescribing and managing drug users with alcohol problems

Drug and alcohol misuse specialist Dr Stefan Janikiewicz answers GP Dr Linden Ruckert's questions on methadone maintenance, benzodiazepine prescribing and managing drug users with alcohol problems

1. Is there a changing pattern to the use of drugs and who is affected? Is it possible to predict which factors might make someone more vulnerable to moving from being an occasional user to an addict?

41216287It is important to remember that drug prevention does not seem to be working. UK youth are at the top of the European drug use league table.

How young people use drugs is at the centre of debate. Leading drug misuse specialist Professor Howard Parker has proposed the ACCE profile to describe the consumption of alcohol, cannabis, cocaine and ecstasy. I find it inexplicable that alcohol has separate commissioning, policies and services from illicit drugs.

The proportion of young people taking heroin has reduced, meaning the heroin-using population is getting older. Under-18s with the ACCE profile tend to have much better outcomes than older drug users – only about 10% of adult heroin and crack users appear to become drug-free. There is no scale that shows how someone may be more vulnerable to moving from occasional use to having an addiction problem. But the epicentres of drug use are still in inner-city areas and it is little wonder some emotionally damaged individuals find solace in drug use. We need joint action on any strategy for alcohol and drugs.

2. Are there any drugs that are abused that we might not be aware of? What symptoms might these cause?

So far crystal meth has not undermined the fabric of our society as it has in many parts of the US. But it probably could if cocaine was not so readily available.

In scattered areas the stimulant khat has a minority usage. Plus ketamine also causes sporadic problems.

Anabolic steroids, with their multiple potential side-effects, are easily available in many gymnasiums. Over the past two years, most new patient requests for injecting equipment were for steroids rather than heroin or cocaine.

One of the latest injectable drugs – nicknamed the Barbie drug – is melanotan II, illegal to supply but not to possess in the UK. This drug claims to improve your tan, boost sexual performance and shed weight. The drug is injected once a day for the first week and then once a week thereafter. Little research has been done on its potential side-effects.

Tramadol also has potential misuse problems.

3. Has there been any change in attitude to methadone maintenance – as opposed to withdrawal? If a patient wishes to withdraw from heroin, what is the favoured drug regime and what are the pros and cons of the different methods?

First, buprenorphine maintenance is another option.

If the patient is withdrawing in the community with support, buprenorphine does seem to have certain advantages over methadone for detoxification.

It's important to realise there are very few patients who only use heroin. For these, detoxification is relatively straightforward, but not for multiple drug users. In residential settings, few patients have very much difficulty coming off heroin or methadone. But those also using benzos tend to have more problems.

The most interesting discussion in the drug treatment field is about ‘recovery'. At one end of the debate spectrum lies the philosophy of abstinence as the only form of recovery. At the other is the harm reduction approach – that is, being stable on a prescription and getting on with life.

Good treatment is always patient-led, whether as groups or individuals. The abstinence field now has many different modes of becoming and staying drug-free.

4. Our local drug service will only prescribe benzodiazepines if part of an agreed withdrawal programme. Many patients are very reluctant to do this so we end up with patients asking us to prescribe. Do you have any tips to managing this – especially in multiple drug users?

In practice, I'd advise against disregarding the strategy of your local drug service. Here on the Wirral, we prescribe benzodiazepines to less than 10% of the 1,500 patients in specialist drug treatment and shared care.

So GPs should not prescribe benzos to a patient who is being managed by a local drug service, unless they are confident in their abilities to set boundaries. There is a certain percentage of severely psychologically damaged individuals who I think will always be on benzodiazepines. It is surprising that some have survived and get through life at all.

Benzodiazapine detoxification requires good assessment, planning and support. Sudden cessation of continuous benzodiazepine usage can have severe harmful side-effects.

Internet buying is now more popular, with no quality control or, in fact, any control at all. There is often a temptation simply to ask people to ‘buy less' rather than take on prescribing.

Supervised benzodiazepine consumption is used infrequently but it is a good rule of thumb in specialist services to try to get individuals down below 30mg. I use diazepam because of its long half life and prescribe 2mg tablets with little street value.

5. How do you manage crack cocaine users? Its use seems very commonplace in the inner city.

The RCGP has excellent guidance for working with cocaine and crack users in primary care, which is available to download here (right). Do not work in isolation and bear in mind that using an empathic approach brings more advantages than anything else.

Users are classified into recreational use, binge use and chronic high use. Recreational and binge use are often seen as a blue-collar weekend activity, closely associated with alcohol consumption. But chronic high users of crack and cocaine are a different matter and – I believe – the one set of patients incapable of even looking after pets, let alone children.

There is no gold standard – more a ‘putty' standard – when it comes to prescribing interventions. Many areas have local groups for help and psychological interventions, with complementary alternative therapies maintaining people in treatment.

If individuals are ‘speedballing' – that is, injecting heroin and cocaine simultaneously – then harm reduction strategies are much more difficult.

6. How big a problem is skunk or stronger forms of tetrahydrocanninol (THC)? What is the feeling about the link between cannabis use and progression to other drug use? Is there a link with any long-term damage?

Homegrown skunk now accounts for 70-80% of the British cannabis market, whereas in 2002 this strong form of cannabis accounted for only 15%. Cannabis farms are booming.

Cannabis is thought by some to be a gateway drug, with the dealers offering to sell users other drugs.

There maybe a factor, possibly genetic, that makes some individuals susceptible to developing psychosis with long-term use of cannabis.

The Department of Health has published a useful resource pack called Cannabis and your mental health and NICE issued drug misuse psychosocial interventions guidelines in July 2007, which are also helpful. Both are available to download here (see right).

Tinkering with the legal status of cannabis is not going to have any effect on its use. There is no short cut to a strong public health message on cannabis.

7. What are the short- and long-term risks of ecstasy?

Ecstasy, known medically as MDMA (and I won't spell out the 29-letter word it stands for) had its largest impact on the ‘chemical generation' in the late 80s and early 90s, and is now inexpensive at £3 a tablet.

Research suggests that there maybe some long-term side-effects such as depression and some change in personality.

Some 80-90% of users feel that it helps to keep them going on a night out and enhances listening to music – those who go to raves but do not use ecstasy are in the minority.

There are intermittent national headlines because of death and hyperthermia. Body temperatures can go up to 44°C, hence one nickname for ecstasy is ‘Saturday night fever'. Tablets analysed are rarely pure and are often cut with amphetamines and caffeine.

8. What is your advice on drug misuse combined with a significant alcohol dependency?

This is the topic about which I wish to stand on a soapbox and shout out as loud as I can.

Heroin and cocaine are the most addictive of drugs. But from a public health point of view, nicotine and alcohol – in that order – are desperately worrying.

A look at the European, national and local statistics is enough to make most of us sober up.

In Merseyside one in two men and one in three women misuse alcohol, often binge-drinking. Alcohol misuse can be picked up by the AUDIT (Alcohol Use Disorder's Identification Test) scale. When publicising this, a local paper asked two of our workers to go along to its offices and use this scale on five of its journalists. One was a hazardous drinker, three fell into the category of harmful and one was dependent. I sometimes wonder if some sections of the medical profession are much better.

In the recent deaths of patients who attend the drug unit, most were from terminal alcohol-induced liver disease.

Unless one can address drug abusers' alcohol dependency, there is little chance of coping with any other drug problems they have.

As many patients also have hepatitis C, the long-term outlook can be quite frightening. We need plans for palliative care for end-stage hep C or liver disease.

Often our patients' gamma GT results are in their hundreds and occasionally thousands.

Assessment is based on the SADQ (Severity of Alcohol Dependence Questionnaire) form, sanctioned by the World Health Organization. On this scale, a score above 30 suggests that a person should not be detoxed at home. A copy of the questionnaire is available for download (right).

It is some time since we have come across anyone who has asked for help with their alcohol misuse and had detoxification who has a SADQ below 30.

The future risk management of alcohol detoxification will have the bar raised if we are to keep abreast of the interventions required.

9. What are the key features of a successful shared-care clinic for addicts run between drug services and GPs?

Getting back to a normal setting – that is, being seen in general practice – is what most patients want.

And in my experience GPs who build up their confidence and knowledge about drug misuse, and see it as a chronic relapsing condition, stop simply seeing these patients as manipulative, demanding, abusive, time-consuming, upsetting to other patients or potentially violent.

Even for the few that have a moral objection, it is worth thinking about the rest of the drug user's family, especially children.

You may end up being disappointed, as you do for smoking asthmatics. But it's a very satisfying role, as long as you expect more from your patients than a life on methadone and benefits.

Push for good local shared-care arrangements and stick to the ‘orange book' – the clinical guidance from the National Treatment Agency for Substance Misuse (NTA). If you don't, make sure you can explain why you didn't.

The benefits to the patients are normalisation, a sense of progress through treatment through shared care, a full continuity of treatment and often good health improvements.

For doctors and prescribers there will be good links with local shared-care teams, a much greater awareness of local drug issues, seeing the health improvements in your patients and their families, and even sometimes some remuneration.

10. How do we approach the drug user complaining of depression? Does it make sense to deal with the drug issue first to see the wood for the trees? Or is it reasonable to prescribe antidepressants ‘despite' the drug issue?

It is little wonder that a lot of patients are depressed. Their early childhood and education have often been sadly wanting. They sometimes end up taking a lot of depressants – alcohol, heroin, methadone and benzodiazepines for a start, then stimulants that severely deplete their serotonin levels, and so on.

Nowadays, with so few psychiatric beds in use, having a good local liaison psychiatric service in A&E works well.

Crisis intervention teams that deal with early psychosis have managed to dramatically reduce the number of psychiatric inpatient beds throughout the country. Stabilisation of drug treatment often helps in dual-diagnosis patients.

It is difficult to see how any antidepressants can have much effect if an individual is still using stimulants.

But patients who are stable on an opiate replacement prescription may respond to antidepressant therapy, and cannabis use seems accepted as being as normal as having a cup of tea in the morning.

I always try and remember that most antidepressants are slightly better than placebos in clinical trials.

Lifestyle changes and the hope of regaining dignity and the possibility of work probably have more than a placebo effect.

11. We occasionally get concerned parents bringing in reluctant adolescents saying, ‘I want him tested for drugs'. How should we respond to this?

For a start, it is worth remembering that many of the symptoms and signs of taking drugs can often mirror normal recalcitrant teenage behaviour.

If testing is necessary, mouth swab and urine tests and hair analysis for drugs can be done with some private companies. But parental discussion with the young person, bringing in professional help if necessary, is more important than simply testing.

The confidence and trust of the adolescent in their doctor must be maintained. There are moral and ethical and consent aspects that apply to this situation.

In general, I would suggest more talking and understanding between parents and children – but then that applies to all areas of their lives.

Dr Stefan Janikiewicz is a GP and clinical director for drug and alcohol services within Cheshire and Wirral Partnership Trust

Competing interests: None declared

Working with cocaine and crack users in primary care Working with cocaine and crack users in primary care Cannabis and your mental health Cannabis and your mental health NICE guideline on drug misuse and psychsocial interventions NICE guideline on drug misuse and psychsocial interventions What I will do now

Dr Ruckert considers the responses to her questions

I agree there is a need to think about alcohol and drug services together as it does seem that the two addictions are more often seen together - or perhaps I am just increasingly aware of it. It would also be helpful if there were more services for the 'co-diagnosis' of mental illness and drug problems as either may lead to the other and sometimes the psychiatric services refuse to be involved with those who have addictions.

Cocaine seems very readily available and socially acceptable and I have started asking about it routinely in those with mood or alcohol problems.

It is helpful to consider a model where 'cure' is not the outcome. Someone in our local drug services once told me 80% of clients were the children of drug addicts and/or had been in care. The analogy of the smoking asthmatic helps to normalise the idea.

Benzodiazepines are still a problem. Knowing the 2mg tablets have less street value is helpful as is the notion of 'buying less'
I have yet to hear about melanotan so I will watch out for this.
Patients have started asking for buprenorphine detox but I agree that it is living off drugs rather than the detox that is the problem.

Dr Ruckert is a GP in north London

thps Drug misuse Severity of Alcohol Dependence Questionnaire Severity of Alcohol Dependence Questionnaire

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