1. December 2013
Dr Yasir Hameed (SpR)
General Adult/Old Age Psychiatry
Northgate Hospital
Great Yarmouth

2.  What is TADS (NRP)?
 Drugs and Mental Health (dual
diagnosis, alcohol, opiates and
benzodiazepines dependence)
 Useful resources

3.  Open access
 Drugs AND alcohol
 9-5 Mon-Fri
 5 bases throughout Norfolk, including in-
patient beds at Hellesdon and Northgate
Hospital.

4.  GENERAL
◦ Comprehensive assessment
◦ Holistic care planned treatment
◦ Counselling – MI, CBT, individual and group
 SPECIFIC TREATMENTS
◦ Opiate Substitution therapy
◦ Structured reduction
◦ Detox – inpatient / community
◦ Prescribing to support maintenance of abstinence
◦ Referral for Residential Rehab.
 SPECIAL GROUPS
◦ Under 18
◦ Liaison – NNUH, Gastro, Obstetrics, A+E, pre-op
◦ Child and adult protection

5.  DOH Dual Diagnosis Good Practice Guide
“…covers a broad spectrum of mental health and
substance misuse problems that an individual
might experience concurrently. The nature of the
relationship between these two conditions is
complex.”

6.  A primary psychiatric illness precipitating or
leading to substance misuse
 Substance misuse worsening or altering the
course of a psychiatric illness
 Intoxication and/or substance dependence leading
to psychological symptoms
 Substance misuse and/or withdrawal leading to
psychiatric symptoms or illness

7. Primary Care Service:
 Approximately 75% of drug users approach their GP
before being seen in centralised services.
General Adult Services
 1 in 4 patients classed as dual diagnosis
 92% of drug users are polysubstance users
 Substantial under-recording of drug / alcohol history in
general mental health notes
TADS
 1 In 2 patients classed as dual diagnosis

8. 1. Psychiatric disorder is due to
a) Acute intoxication (drug induced psychosis)
b) Chronic effects / Damage (depression / anxiety / alcoholic hallucinosis)
c) Withdrawal state (delirium tremens)
2. Self medication (depression / anxiety)
3. Substance use as a result of mental state (disinhibition)
4. Shared risk factors (genetic / environmental)

9. Poorer prognosis
Increased incidence of suicide / violence / homicide
Increased use of in-patient services
Poor medication adherence
↑ rates of
 Homelessness
 BBV infection
 Contact with the criminal justice system
Poor social outcomes including impact on carers and
family
(Department of Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide 2002; Avoidable Deaths: 5 year
report of the national confidential enquiry into suicide and homicide by people with mental illness. 2006)

10. I need to take a DRUG AND
ALCOHOL HISTORY when I assess
people
When?
ALWAYS

11.  HISTORY
◦ what drugs / alcohol?
◦ when last used
◦ Quantity, frequency, daily pattern
◦ route of administration
◦ Length of history
◦ Withdrawal sx
 Diet
 Physical examination
 UDS within 24 hours /
breath alcohol

12.  Assessment of intoxicated people
 Admitting patients who are dependent
◦ Alcohol withdrawal
◦ Opiate withdrawal
 Care of in-patients with alcohol and opiate
detox OUT OF HOURS.

13. Intoxication is a clinical diagnosis which can be
aided by investigation (e.g. urine dipstick
and/or breath alcohol)
BUT
In individuals who are dependent on alcohol
breath alcohol can be extremely high without
clinical intoxication.

14. 04/12/2013Dr Hayley Pinto TADS

15. 04/12/2013Dr Hayley Pinto TADS

17. ALCOHOL
Shaking
Confusion /
disorientation
Hallucinations
Fits
BOTH
Anxiety and agitation
 P , BP
Sweating
Nausea and vomiting
Insomnia
OPIATES
•Dilated pupils
•Abdominal cramps
•Diarrhoea
•Anorexia
•Gooseflesh
•Muscle twitching
•Aching – bones and
muscles
•Hot and cold flushes
•Yawning
•Running eyes and
nose

19. Diagnosis to be made if three or more of the following have occurred
for at least 1 month or if persisting for periods of less than 1 month,
should have occurred together repeatedly within a 12 month period.
1) Strong desire or compulsion to use the substance.
2) Difficulties in controlling substance taking behaviour in
terms of onset, termination, or levels of use.
3) Physiological withdrawal state when substance use
had been ceased or been reduced.
4) Evidence of tolerance
5) Progressive neglect of alternative pleasures or
interests because of psychoactive substance use.
6) Persisting with substance use despite clear evidence
of overtly harmful consequences (physical and mental).

20.  CAGE questionnaire
 AUDIT
 SAD-Q
 FAST

21. 04/12/2013Dr Hayley Pinto TADS

22.  In the UK around 1 in 5-6 adults drink at
hazardous levels and around 5% are alcohol
dependent.
 Alcohol is now the commonest cause of death
in young people
 70% of late-night attendances to A&E are
alcohol-related
 An average GP will see 364 excessive drinkers
per year
 Excessive drinkers consult their GP twice as
often

23. 04/12/2013Dr Hayley Pinto TADS

24. 04/12/2013Dr Hayley Pinto TADS

25.  Easiest way to work it out:
◦ ABV x amount in litres = number of units
 Rough estimate of 1 unit:
◦ ½ pint of normal-strength beer
◦ 125ml glass of wine
◦ Single (25ml) spirit measure

27.  Increased size of red blood cells
◦ Raised MCV and MCH
 Raised liver enzymes
◦ GGT, AST, ALT, Alk P
 More concerning
◦ Raised bilirubin
◦ Prolonged blood clotting
◦ Low platelets
◦ Low albumin

28.  Chronic liver disease
◦ Cirrhosis
◦ Hepatitis C
 Poor nutrition/losing weight
◦ high risk of complication
 Evidence of active bleeding
◦ GI bleeding can be suddenly fatal
◦ Not always asked about
 Recent fits or hallucinations
 Active suicidality
◦ Consider need for CRHT referral
 Polysubstance use

29.  Withdrawal seizures (12-48 hours)
◦ Usually self-limiting
◦ Potentially fatal
 Delirium tremens (24-96 hours)
◦ Occurs in 5% of people
◦ 5-10% mortality rate
◦ Characterised by withdrawal symptoms plus
hallucinations, delusions and disorientation
◦ Treat with benzos plus supportive care

30.  Wernicke’s encephalopathy
◦ Confusion, ataxia, ophthalmoplegia
◦ Brainstem bleeding
◦ Potentially fatal
 Korsakoff’s psychosis
◦ Preceded by Wernicke’s
◦ Short-term memory failure
◦ Mostly non-reversible
◦ Rarely compatible with independent living

31. ◦ Alcohol intake > 15 units /day
Action - immediate referral for alcohol detoxification if
◦ Requesting detoxification
◦ H/O severe withdrawal symptoms, including complications such
as delirium tremens or alcohol withdrawal seizures
◦ Poor physical health (e.g. compromised liver function, heart
problems)
◦ Significant mental health problems or cognitive impairment
◦ They are at risk of intentional or unintentional overdose
Should be seen within 10 working day

32.  Inpatient or community
◦ Severe withdrawal symptoms, significant physical/mental
health problems, failed home detox, lack of home
supervision, unsuitable setting
 Chlordiazepoxide (librium) used locally
◦ High initial dose
◦ Gradually withdrawn over 6-9 days
◦ Alternatives used in severe liver disease
 Vitamin injections – pabrinex
 Daily monitoring

33.  Acamprosate (GABA/Glutamate receptor
agonist)
◦ First-line treatment
 Naltrexone (opiate receptor antagonist)
 Disulfiram (Antabuse)
◦ Third-line from NICE
◦ Interferes with alcohol metabolism, causing
build up of acetaldehyde
◦ Rare risk of acute hepatitis

34. OPIATES

35.  Opiates - any opioid drug found
in the natural poppy plant
 Opioids – any morphine like
drug active at the opioid
receptor
One of the oldest drugs
recorded
Majority of the worlds
heroin is still sourced from
Afghanistan

36. HEROIN
(di-acetyl morphine)
CODEINE
Mono-acetyl morphine
(MAM)
MORPHINE
•Tramadol
•Oxycodone
•Dihydrocodeine
(DF118)
•Tramadol
•Oxycodone
•Dihydrocodeine
(DF118)
•Methadone
•Buprenorphine
•Fentanyl
•Methadone
•Buprenorphine
•Fentanyl

37. WANTED EFFECTS
 Euphoria – sense of comfort and wellbeing
 Sedation
 Pain relief
 Cough suppression

38.  Reduces pupil size
 Constipation
 Nausea and vomiting
 Itchy rash
 Slows heart rate and drops blood pressure
 Suppresses breathing

39. Immune suppression
Menstrual abnormalities (delayed recognition of
pregnancy)
Tooth decay
Malnutrition
Lethargy and depression
IMPACT OF USE ON SELF CONCEPT AND STIGMA

40.  Vein /artery / nerve damage
 Clots - DVT / embolism
 Infections – BBV and others
INCREASED RISK OF
OVERDOSE

41. DVT
Esp groin
injectors

42.  HIV - < 1 % of Norfolk IDUs (1.3%)
 Hepatitis C - 36% of Norfolk IDUs (45%)
 Hepatitis B - 19% of Norfolk IDUs (15%)
(national averages in brackets)
Shooting Up: Infections among people who inject drugs in the UK 2010 London HPA 2011

43.  Superficial Abscesses are common
 Septicaemia (blood poisoning)
 Endocarditis (infection in the Heart).
 Embolism –debris, clots, or septic emboli
Unusual infections may occur due to reduced immunity, injection in
damaged tissue and contaminated batches of drugs such as
 Anthrax
 Botulism - , There are about 100 cases of botulism in injecting drug
users in the UK per year. It presents as a descending paralysis and
can be fatal. The classic symptoms comprise blurred vision, slurred
speech, difficulty swallowing – IE – they look drunk
 Tetanus
 TB
 Fungal Candida species are natural commensals in citrus fruit..

44. Bertschy, G. Methadone maintenance treatment: an update. 1995
Marsch L. A. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk
behaviour and criminality: a meta-analysis. Addiction 1998
Gossop M. NTORS
REDUCES
 Illicit opiate use
 Use of other illicit
drugs
 Criminal bhvr
 HIV risk bhvrs
 Death rate
IMPROVES
 Quality of life
 Physical health
 Mental health
 Employment
 Perinatal outcome
BECAUSE IT WORKS

46.  Long acting full agonist
 PK levels 1-6 hrs after 1st dose
 3-10 days to reach steady state
 Prolongs QT interval
 Prescribing on medication card in line with
Controlled Drugs Px Guidelines.

47.  Partial agonist
 High affinity / low intrinsic activity
 Precipitated withdrawal
 Reduced intoxicating effects
 Lower retention rates
 Higher abstinence and detox
rates

48. Opiate system
Dampening effect
Noradrenergic
drive
Opiate Detoxification
METHADONE / BUPRENORPHINE – Slow reduction
SYMPTOMATIC TREATMENT
Sedatives –agitation and sleep
Simple pain killers – aches and pains
Anti-diarrhoeals / anti-sickness
Stomach cramps – buscopan
LOFEXIDINE / CLONIDINE (2 adrenergic agonist)
2-4 weeks

49. Naltrexone
Relapse Prevention Work
•Triggers – things associated with using, boredom, negative
emotions (past trauma), ‘treats’
•Coping with Craving
•Re-structuring life
12 Step Programs
Residential Rehabilitation
Beware of swapping one substance for another

51.  500 000 – 1 million “therapeutic”
 200 000 recreational
◦ ~50% demonstrate classic dependence
 Estimates suggest up to 40-50% of “other”
substance users also use benzos
 Black market diversion common
 Internet purchase becoming more common
 “Silent” dependence

52.  Onset 3-10 days, duration 3-6 weeks
 Physical
◦ Sweating, tremor, palpitations, lethargy, muscle
tension/pain, nausea, flu-like illness, formication
◦ Convulsions
 Psychological
◦ Agitation, irritability, restlessness, poor concentration,
nightmares, insomnia
◦ Depersonalisation, derealisation, hallucinations and
other psychotic symptoms

53.  Shorter acting drugs are more prone to formation
of dependence
◦ Reward centres
 Withdrawal is more extreme with short-acting
drugs, but over quicker
 Shorter acting drugs are used more for insomnia
 Long acting more useful for reduction and alcohol
detox

54.  Z drugs
◦ Zolpidem, zopiclone, zaleplon
 Act in a similar but distinct way to
benzodiazepines
 Short acting
 Possibly less prone to cause dependence
 Still clearly able to cause dependence
 Some black market diversion, though ?less
common
 Dependence managed in similar ways

55.  No strict rule on how fast - negotiate
 Generally, 10-12 week reduction
 CONVERT TO DIAZEPAM
 Aim to reduce at 1/8 – 1/10 of dose every two weeks
 May need to slow reduction towards end, but should be
planned
 Generally not repeated

56. Think about drugs and alcohol
Care and respect
Get advice

57. 04/12/2013Dr Hayley Pinto TADS

58. 04/12/2013Dr Hayley Pinto TADS

59. Call TADS 786786
TADS Guidelines Intranet
Norfolk Recovery Partnership website:
http://www.norfolkrecoverypartnership.org.uk
/Pages/default.aspx
Orange Guidelines
www.nta.nhs.uk

60.  Alcohol Detoxification in the Inpatient Setting - C102
 Opioid Detoxification and Stabilisation onto Substitute
Medication - C103
 Benzodiazepine Detoxification in the In-patient Setting -
C104