Substance Use and Misuse

What are the effects of the following drugs: cocaine, spice, heroin, ecstasy, china white (fentanyl), nicotine, alcohol, cannabis and valium?

Stimulant, depressant, opioid effects, stimulant, opioid effects, stimulant, depressant, depressant and anxiolytic/muscle relaxant

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Describe the extent of the problem

100,000 people die in the UK each year due to smoking (cancers, COPD, heart disease). 30-40 K alcohol related deaths per year. >9 million people drink more than recommended amount daily. Alcohol costs NHS £3.65 bn per year

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What are the number of deaths due to substance abuse?

Tobacco (100,000), alcohol (33,000), opioids (1000), benzodiazepines (250), VSM (80), cocaine (38) and ecstasy (11)

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What is poly substance misuse?

Users combining substances for hedonistic purposes or to recover from adverse effects

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What are the consequences of poly substance misuse?

Accumulation effects and increased risk of overdose. Eg. using substances with the same pharmacological effects (contribute to the mechanism for respiratory depression)

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Describe the concept of recreational use of drugs

Recreational use is using any drug as an adjunct to leisure. Recreational drugs are associated with rave/dance scene (e.g. ecstasy, amphetamines, cocaine, LSD, ketamine, GHB, alcohol). Meow Meow (mephedrone).

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Describe the typical pathways of drug use

Nicotine (all age groups in UK except 16-21 girls) used in peer pressure groups. Alcohol (pre-eminent recreational drug). Cannabis (first popular illicit drug for school children). Use of e-cigarettes increasing

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Describe features of nicotine

Highly addictive. Stimulant (increases HR), quickly become dependent (compulsion to use, need cigarette first thing in the morning, crave in social situations). Huge health risks (longer use). Girls > boys. Reduces life expectancy (>30 yrs old)

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What are the components in an e-cigarette?

Cartridge (hold nicotine dissolved in PEG). Heater (vaporise nicotine). Sensor (detect smoking taking drag). Microprocessor (control heater/lighter), battery, LED (lights up when smoking draws on cigarette)

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Describe features of e-cigarettes

E-liquid/juice (mixture of PEG and glycerol/glycerine). E-liquid heated up during use and converted to vapour (vaping). Different brands (same ingredients), flavours (cherry, mango)/nicotine concentration different. Little control of sale/manufacture

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What is cannabis?

Generic term used to denote several psychoactive preparations of marijuana (hemp) plant, Cannabis sativa. Cannabis can be flowering tops of cannabis plant. Cannabis resin (separated resin, chara), mainly smoked but also used as edibles

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Describe features of the use of cannabis

Most prevalent illicit drug in the UK/Europe/World. Contains at least 60 cannabinoids. Most active constituent is THC. Many countries discussing legalisation of cannabis. USA/Canada have 'medicinal cannabis'

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Describe the acute intoxication caused by cannabis

Euphoria and exhilaration. Sense disinhibition (increased laughter). Increased talkativeness (volubility). Hyperactivity. Heightened hunger/thirst. Dreamlike state/calm/relaxed

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How does smoking before driving affect the risk of RTC?

Smoking before driving doubles the risk of having a RTC

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Describe features of cannabis and mental health (1)

Evokes several types of psychopathological reactions. Strong feeling of anxiety and panic. Paranoid reactions. High doses (cannabis-induced psychosis)

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Describe features of cannabis and mental health (2)

If cannabis is used regularly before 15 yrs old, risk of mental health problems 3.5 times more likely. If cannabis is used regularly before 18 years old, risk of mental health problems is 1.5 times more likely in adulthood

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Describe features of synthetic cannabinoids

Recreational use synthetic cannabinoids emerged in early 2000s. Marketed under a number of suggestive names e.g. Spice, K2. Contains synthetic cannabinoids that have been sprayed onto a herbal substrate. Sold as herbal incense or potpourri

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Give two examples of 'Spice' products

Voodoo spice and magic spice

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What are the effects of synthetic cannabinoids?

Synthetic cannabinoids contained in Spice are high potency. Some effects of Spice may be more intense/unpredictable. Increased reports of serious negative physical and psychiatric effects

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What are the properties of alcohol?

CNS depressant, anxiolytic, context specific, decreased BP/HR

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What does the DOH website state about alcohol and sensible drinking?

For those who drink, alcohol is something to be enjoyed. Most of the time, drinking doesn't cause any problems but drinking too much or at the wrong time can be harmful. The important thing is to know where the benefits end and the risks begin

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What is the safe weekly consumption of alcohol for men and women?

14 units (previously 2-3 units/day for women and 3-4 units/day for men)

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How many units are in a pint of beer?

1-2 units (depending on the strength of the beer)

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How many units if defined as binge drinking?

>8 units at one time for males and >6 units at one time for females

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How many units is safe in pregnancy?

0 units

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What is a unit of alcohol?

10 mL of 8 g of pure alcohol (equals one 25 mL single measure of whiskey (ABV 40%) or 1/3 of a pint of beer (ABV 5-6%) or 1/2 a standard 175 mL glass of red wine (ABV 12%))

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Give examples of alcoholic drinks with the units of alcohol

Pint ordinary strength beer (2 units). Strong lager/Stella (3 units). Pint strong cider (3 units). 175 mL glass of red/white wine @ 13% (2.3 units). Pub measure of spirits (1 unit). Alcopop/Smirnoff Ice, Barcardi Breezer, Reef (1.5 units)

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Who are social drinkers?

Those who drink no more than 2-3 units of alcohol/day and who do not become intoxicated. Drink below weekly limits (<14 units). Best approach to educate

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Describe features of binge drinking (1)

A period of unrestrained/immoderate/excessive or uncontrolled self-indulgence (not bound by specific time frame) leading to intoxication. Over limits in single session but drinking below weekly recommended guidelines

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Describe features of binge drinking (2)

Shift in characterisation of binge drinking away from 'manly' activity to one out of control young women (a wider societal change). DOH foregrounds it to detriment of other areas of increased alcohol consumption e.g. workplace (brief intervention)

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Describe features of hazardous drinking

No single definition for hazardous drinking but the style of drinking is a pattern of consumption that may have negative impacts on either physical or mental well-being. Includes males (up to 50 units/week) and females (up to 35 units/week)

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What is the best approach for hazardous drinking?

Professional specialist help

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Who are harmful drinkers?

Individuals drinking >50 units (400 g) of alcohol/week for men and >35 units (280 g) of alcohol/week for women

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What is alcohol dependence? (1)

Compulsion to drink (inability to stop drinking). Experience withdrawal if intake if reduced. Persist in alcohol use despite clear evidence of harm/recurrent negative consequences (social/psychological/physical)

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What is alcohol dependence? (2)

Evidence of physical dependence (need to take increasing amounts for same effect/tolerance). Negative physiological symptoms when alcohol consumption ceases (withdrawal). Professional specialist help

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How many years does it take to develop alcohol dependence?

~ 15 years (quicker dependence for women compared to men)

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What are the risks with alcohol dependence?

Tolerance (need more to achieve the same effect). Drinking excessively increases risk of gynaecological damage in young women (esp. <17 years old). Permanent damage to body over times. Women more at risk than men. Increased mortality

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What does the evidence suggest about drinking? (1)

50% known drinkers in workplace believed they could disguise any sign of problem at work for at least a year. HCPs remain in post up to 15 years with alcohol problem before formally identifying the issue. Preventative paradox

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What does the evidence suggest about drinking? (2)

Although harmful/dependent drinkers are most at risk of work place accidents, hazardous heavy drinkers (most common) account for majority of such incidents. Only systematic enquiry is likely to uncover this risk factor

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What is cocaine?

An alkaloid obtained from coca leaves or synthesised from ecgonine. Cocaine HCl was commonly used in ENT as a local anaesthetic (vasoconstriction). Powder is sniffed (snorted), effects within 1-3 mins, lasting 30 mins. Powerful CNS stimulant

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Describe features of cocaine

£50/g. Powder. Intranasal (5-10 mins), injecting <1 min, smoking (crack/freebase < 1 min). Duration of 30-60 mins for intranasal and 10-15 mins for injection/crack/freebase. Stimulant effect

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What are the main risks with cocaine?

Dependence (moderate, high with crack/freebase). Eroded nasal septum (with excessive use). Paranoid psychosis (rare - common with crack/freebase). Cardiac arrest (rare, risks intensified with concurrent use of alcohol)

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Describe features of cocaine and crack (1)

CNS stimulant, increase serotonergic activity (risk seizure), 30-50% increase in HR/BP, dilated pupils, hyperactivity. Crack/rock (alkaloidal, free-base of cocaine), beige in colour, intense high 4-6 seconds after crack inhaled, euphoria 5-7 seconds

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Describe features of cocaine and crack (2)

Cocaine availability decreased (replaced by crack, which is extracted from cocaine). High risk of sexual behaviour, violence and criminality. Cardiovascular morbidity linked to use of cocaine/crack.

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Describe features of cocaine and crack (3)

Constriction of coronary arteries causes reduced blood flow to the heart. Risk of an MI

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What are the physical effects of cocaine and crack?

Large doses taken by those not used to it can cause hypertension, cardiac arrhythmias and convulsions. Death due to cardiac or respiratory arrest

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What are the psychological effects of cocaine and crack?

Anxiety and restlessness. Visual and tactile hallucinations

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Describe features of amphetamine sulphate

£5-10/g. Mainly used as a powder (sometimes pills). Onset - Intranasal 5-10 mins, oral 30-60 mins. Duration is 6-10 hours. Stimulant effect

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What are the main risks with amphetamine sulphate?

Heatstroke (rare). Eroded nasal septum (rare). Cardiac arrest (rare). Dependence (moderate risk). Paranoid psychosis (rare - more common with methamphetamine)

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Describe features of ketamine (1)

Used as horse tranquillisers. Anaesthetic, hallucinogenic effects, out of body experiences, mild stimulant in low doses (similar to LSD and mesgline). High doses, unable to experience pain from injuries

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Describe features of ketamine (2)

£25-50/g. Powder. Onset - intranasal 5-10 mins, 30-60 mins for oral. Duration is 30-60 mins. Hallucinogenic effects (dissociative anaesthetic)

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What are the main risks with ketamine?

Accidents occur often (don't feel pain). Panic (low-moderate esp. in new users). Psychosis (rare). Dependence (rare). Advice - cut down, recognise and avoid 'cues'

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Describe the history of ketamine (1)

Appeared in early 1990s in two forms (e.g. Super k, Vitamin K, Green, Mean Green, Jet, K or Special K), tablets or capsules. Appeared as constituent of tablet purporting to be ecstasy often with stimulation (ephedrine)

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Describe the history of ketamine (2)

Experience immobility/hallucinations when empathy or euphoria were expected (came as shock to unassuming ravers)

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What are the effects of ketamine? (1)

Highly sensitive to age, dose, route. Previous experience (expectations, personality, motivation, mood). Anxiety, chest pain, palpitations. Sympathetic overactivity (tachycardia). Ketamine overdose, severe agitation/rhabdomyolysis

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What are the effects of ketamine? (2)

Setting (social/physical and emotional environment). Low dose stimulation effects predominate and environmental conditions are significant

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What are the metabolic effects of MDMA (ecstasy)?

Effects peak at 1 h and last up to 6 h. High profile deaths associated with hugely elevated temperature. Hyperpyrexia (temp > 42 degrees Celsius will bring about death). Advice - drink isotonic drinks and not water

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Describe features of MDMA

£3/pill. Orally (tablet/powder). Onset for oral - 30-60 mins, duration of 4 h. Stimulation and entactogen effects

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What are the main risks with MDMA?

Heatstroke (rare). Neurotoxicity (uncertain). Psychological sequelae, depression/anxiety. Liver damage (rare). Dependence (rare)

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Describe features of MDMA fatalities

Number of high profile deaths. 100-120 in GB in last decade. Risk factors unclear. Adverse psychiatric consequences. Adverse physiological consequences. Acute risk of overheating (hyperthermia)

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What are the consequences of hyperthermia?

Affects sympathetic NS, increase HR/BP, risk dehydration, cerebrovascular events. E.g. excessive intake of hypotonic fluids coupled with increase in plasma vasopressin (AVP) may cause lethal hyponatraemia (cases and data)

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What is khat?

Leafy twigs chewed as a stimulant. Commerical varieties. Obtained from Catha edulis (Celastraceae, Spindle Tree family). Grows in Eastern Africa. Used as stimulant in Ethiopia. Imported for use, Ethiopia, Somalia, Yemeni, Bangladesh, UK communities

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Describe features of Khat in the UK

Class C drug. Illegal to have/supply khat. Offence to bring khat into the UK. Cathinone (major psychoactive component of plant Catha edulis). Tension between adverse/beneficial aspects. Parents prefer children to use khat rather than alcohol/tobacco

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What are the toxic effects associated with khat chewing?

Weak stimulant. Dental problems (bad gum inflammation, loss of teeth). Cancer (no increase in oral cancer, high incidences of oesophageal cancer (Yemen) and stomach cancer (UK)

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Describe features of designer drugs

Synthetic version of controlled substance (MDMA) produced with slightly altered molecular structure to avoid being classified as an illicit drug. E.g. Meow Meow. Mephedrone - synthetic stimulant drug of amphetamine and cathinone classes

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Describe features of GHB

Class C drug. £15/bottle. Mainly used as liquid. Onset 10-20 mins for oral. Duration of 1.5 hrs. Depressant effect. Main risks - overdose (moderate-high, higher with alcohol), dependence (rare), nausea (moderate)

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Describe features of psychoactivity and abuse potential

Known to alter sexual and aggressive behaviour. Likened to alcohol-related behaviour. Excessive cheerfulness, increased libido. Severe mood lability. Withdrawal symptoms (irritability, anxiety, insomnia, hot flushes, anorexia, myaglias (muscle pain)

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Describe features of heroin and the extent of the problem

Mixed messages about current uptake/use of heroin in London. No need to smoke/inject. Dependent forming. 200,000 heroin dependent in treatment. Prescribed methadone but continue to use. Rapidly absorbed/metabolised into morphine. Tolerance/dependence

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What are the properties of opiates?

CNS depressant, pinned pupils, respiratory depressant, emesis, euphoria, analgesic, sleep

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Describe features of methadone

Long acting opioid agonist. Orally effective. Constipation. Sweating. Respiratory depression

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Describe features of benzodiazepines

Marked individual differences. Relief of anxiety. Intoxicated and relaxed. Dysphoria. Talkative. Disinhibited. Some increase prescribed BDZ dosage in ordinary circumstances to develop misuse

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What are the properties of benzodiazepines?

CNS depressant. Anxiolytic. Sleep. Respiratory depression. Huge range. Amnesic (flunitrazepam)

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Describe features of anabolic steroids

Androgenic hormones including derivatives (e.g. testosterone, nandralone, methenolone, ethyltestosterone). Long associated with competitive athletes, weight lifters and body builders. Thought to enhance shape/performance. Hidden group

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What are the endocrine effects with high dose use of anabolic steroids?

Females - hirsutism, coarsening of voice, male pattern baldness and acne (irreversible). Adolescents (stunting of growth, feminising, gynecomastia (growth of breasts in men). Males - increase in balding, testicular atrophy (emaciation)

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Substance Use and Misuse

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