S6) Substance Misuse and Treatment Options

Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs

Dependence syndrome is a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug

• Difficulties in controlling drug use • Persisting drug use despite harmful consequences • Higher priority given to drug use than to other activities • Increased tolerance for drug • Withdrawal symptoms

• Stimulants • Hallucinogens • Depressants

Depressants are substances that make you feel relaxed e.g. alcohol, tranquilisers, cannabis

Stimulants are substances that make you feel more alert and give you more energy and confidence e.g. tobacco, cocaine, amphetamine (speed)

Hallucinogens are mind-altering substances that can change/impact your perceptions, mood and senses e.g. LSD, magic mushrooms and ecstasy

• Detoxification regimes • Substitute prescribing • Focus on the physical condition i.e. tolerance, physical withdrawal symptoms, vitamin deficiency, pancreatitis

• Addiction is an illness, with loss of control the primary symptom • Addiction is genetic & therefore predetermined • Abstinence/avoidance is the only viable treatment e.g. Alcoholics Anonymous / Narcotics Anonymous

• Addiction doesn’t exist, excessive use is merely a ‘mis-learnt coping-mechanism’ for anxiety/low self-esteem • Excessive use/misuse is a result of social, economic & familial learned experiences • Alternative coping mechanisms can be taught, & past experiences addressed

Harm Reduction: • Alcohol: Vitamin B • Opiates: Naloxone • Injecting: Needle exchange, BBV screening, sexual health

Substitute prescribing: - Opiates: Methadone, Buprenorphine • Amphetamine: Dexamphetamine

Detoxification: • Alcohol Benzodiazepines: Chlordiazepoxide • Opiate Substitutes: Methadone, Buprenorphine

Relapsed Prevention: • Disulfiram (Antabuse): Alcohol Deterrent • Acamprosate (Campral): Anti-craving • Naltrexone: Opioid-receptor antagonist

Erratic non-adherence occurs when the patient wants to follow the agree treatment but is prevented from doing so by barriers beyond their control

Intelligent non-adherence occurs when the patient decides not to follow the treatment recommendations

This is best understood in terms of the beliefs and preferences that influence the person’s perceptions of the treatment and their motivation to start and continue with it

• Disease factors: no, few or mild symptoms • Healthcare factors: poor availability of services, long waiting times • Treatment factors: complex regimens, unpleasant side effects • Psychosocial factors: depression, poor support • Patient factors: negative attitudes to treatment

Concordance involves negotiation between patient & doctor over treatment regimes, in which patients beliefs and priorities are respected

⇒ Define problem ⇒ Describe treatment options & consequences of no treatment (convey equipoise) ⇒ Provide info in preferred format ⇒ Check patient understanding of options ⇒ Elicit patient’s concerns and expectations ⇒ Ascertain patient’s preferred role in decision making ⇒ Defer if necessary ⇒ Review decisions