Drugs and Alcohol Awareness Pack 2011



Supporting people with Prescription and OTC drugs misuse and dependency Issues

2018

The misuse of prescription and over-the-counter medicines has arisen as a significant public health issue in recent years.

Definitions

The terms ‘prescription-only medicines’ (POM) and ‘over-the-counter’ (OTC) medicines refer to the legal category of medicine described, not the source of these medicines. There is currently a lack of consensus about what constitutes prescription misuse. Inappropriate medication use is frequently defined on the basis of user characteristics (i.e. any non-prescribed use), the reason for use (i.e. use for recreational purposes), the presence of clinically significant symptoms or on the presence of any of these factors

Here we use the International Classification of Diseases (ICD) definitions of the various types of drug misuse and dependence. For all these forms of problem drug use, the drug may be a POM or (OTC) medicine.

Directed use: use in accordance with advice from a medical professional or when OTC medicines are purchased and used in accordance with the label and leaflet

Non-directed use: not used in accordance with medical professional advice, such as use of medicines by an individual for whom they have not be prescribed or taking doses above prescribed levels, or, when OTC medicines are purchased, use that is not in accordance with the label and leaflet

Misuse: legitimate use of a medicine but in an unintentionally incorrect dose

Abuse: intentional and non-medical use of a medicine, to exploit side effects

Prescribed high dose dependence: dependence to a prescription medicine characterised by increasing dose and tolerance.

Dependence

Dependence 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 its use, persisting in its use despite harmful consequences, increased tolerance, and sometimes a physical withdrawal state’.

Individuals may be dependent on a specific psychoactive substance (e.g., diazepam), a class of

substances (e.g. opioid drugs), or a wider range of pharmacologically different psychoactive substances.

Harmful use

Harmful is defined as use causing damage to health. The damage may be physical (e.g., liver toxicity from

ingesting excessive quantities of combination analgesics, or oversedation as a result of misuse of hypnotics, or other psychoactive substances) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of hypnotics).

Iatrogenic dependence

Iatrogenic dependence can occur when patients inadvertently become dependent as a result of taking medically prescribed drugs for an existing condition.8 It is important to distinguish between patients who are misusing drugs from those whose underlying condition is not being adequately treated and who are thus seeking better symptom control. [pic]

Which medications may be used problematically or lead to dependence?

POM/OTC can bring comfort to many people suffering from a wide range of ailments and the overall use of prescription drugs is increasing nationally. However, it is clear an every larger number of people have developed problems with the use of certain medicines

A wide range of medicines can be misused by the public and lead to some form of dependence − including painkillers, sedatives, anti-anxiety medications, antidepressants and laxatives. In this pack we will be focussing on those most commonly associated with problematic use today:

• Opioids used to treat pain, such as tramadol, oxycodone and dihydrocodeine.*

• Sedatives (or hypnotics) and anti-anxiety medications (anxiolytics), including benzodiazepines and Z-drugs (zaleplon, zolpidem and zopiclone). Benzodiazepines can be misused in a variety of ways. Their effects are alcohol-like and they can be used instead of alcohol; more commonly they are used with alcohol to potentiate its effects. They can also be used to ‘come down’ from stimulants, for example by clubbers wishing to sleep after a night out. Large overdoses and overdoses in combination with alcohol are used in suicide attempts

• Stimulants, such as methylphenidate used to treat attention deficit hyperactivity disorder (ADHD) and certain sleep disorders.

• Anticonvulsants and mood stabilising drugs, such as gabapentin and pregabalin.

Problematic use of prescription-only (POM) and over-the-counter (OTC) medicines covers a range of presentations, including individuals who become dependent inadvertently. The risk and consequences vary widely and can lead to physical, psychological and social consequences for individuals, family members and local communities, affecting all age groups.

*The primary Prescription-Only Opioid Painkillers (OP) are those containing the following: morphine, fentanyl, tramadol, buprenorphine, oxycodone. Codeine will also be found as a POM, but in higher dosages than an OTC equivalent. For example, co-codamol contains 30mg of codeine as a POM but only 8mg as an OTC product, although both contain 500mg paracetamol. The main OTC products are all codeine-based and include Nurofen Plus, Solflex, Paramol and Solpadeine.

We cover the use of PIEDs (Performance and Image Enhancement Drugs) and of Cognitive Enhancement Pharmaceuticals ( “smart Drugs”) separately in our NPS and Current Trends course.

Performance and Image enhancing Drugs:

These drugs are used in the context of physical training and development, such as in body-building and athletic settings and other performance and image settings. The key family of drugs of interest are the anabolic androgenic steroids. Please attend our NPS and Current Trends training for detailed discussion of these. You can also visit and read the following KFX resource handbook

Cognitive Enhancement Drugs:

Please attend our NPS and Current Trends training for detailed discussion of these.

What is the prevalence of POM and OTC drug misuse and associated dependence?

There are limited data on prescribing patterns in the UK which show that:

- antidepressant prescribing more than doubled over the last decade, and over 70 million prescriptions were dispensed in 2015 at a cost of over £340 million

- there were 12 million benzodiazepine prescriptions in 2015, costing over £5.5 million, and 366 deaths involving benzodiazepines in England and Wales.

- there were 16 million opioid prescriptions in 2015, costing over £200 million. There has been a 400% increase in prescriptions for those drugs in the past ten years

- Around 80 million prescriptions a year written for tranquillisers and antidepressants, with a 500% increase in prescriptions for antidepressants since 1992

There are no authoritative data on the number of people affected by dependence and withdrawal. Evidence submitted to the BMA estimated that there are over 1 million long-term users of benzodiazepines in the UK, and up to 4 million people taking antidepressants at any one time. These figures need to be treated with caution in the absence of robust data and further research.

Source:

NHS Digital (2016) Prescriptions dispensed in the community, statistics for England – 2005-2015. Leeds: NHS Digital;

NHS National Services Scotland (2016) Prescription Cost Analysis 2016. Edinburgh: NHS National Services Scotland;

NHS Wales Shared Services Partnership (2016) Prescriptions dispensed in the community – Wales. Cardiff: NHS Wales Shared Services Partnership

The extent of problematic use of POM and OTC drugs in the UK is unknown as the area is under-researched and still not fully understood.

The limited information we have comes from prescribing data from GP surgeries and that collated from drug and alcohol treatment services.

Data from the Health & Social Care Information Centre indicate that:

• Between 2004 and 2012, the number of opioid prescriptions in England has more than doubled. In 2012, some ten million people in the UK were prescribed an OP, more than double the next nearest EU country France at four million. In 2013, the UK had the highest sales of morphine by volume than any other country in the EU. In 2013, the UK had the highest sales of opiates like codeine by volume than any other country in the EU Defined Daily Doses for Tramadol in England have increased from 5.9 million in 2005 to 11.1 million in 2012. Between 2001-2011, prescriptions for co-codamol almost doubled from 8.8 million to 15 million

• It should be noted that the OTC availability of opioids in the UK means that there is greater potential for

misuse and dependence than indicated by prescription data alone. The 2015 review of opioid painkiller dependency in the UK concluded: […] there seems little doubt through the limited number of studies that have been conducted and day to day experience of clinicians that there are potentially significant numbers of people struggling with a dependency to prescription and OTC painkillers.

• However, the number of prescriptions for hypnotics and anxiolytics (regularly misused) has decreased slightly during this time, despite an increase in the total number of prescriptions in England.

• Statistics on drug-related deaths in England and Wales collected between 1993-2013 show that

antidepressants were consistently the most frequently cited ‘licit’ substance on death certificates, though the number of deaths where antidepressants were cited has fluctuated over time. The units of the Prescribing Indicator changed in 2013, nevertheless it is still clear that there has been a significant increase in the prescribing of antidepressants throughout the last decade.

• This may in part be attributed to proactive medicines management of these particular drugs in primary

care, ensuring safe and evidence-based prescribing. Public Health England collates data from drug and alcohol treatment services and reports through the National Drug Treatment Monitoring System. The data set includes information reported on the extent of misuse of OTCs or POMs among those seeking treatment:

• 12% (n=9920) of new clients reporting to drug treatment services in 2009–2010 reported problems in relation to POMs or OTC drugs; 17% of these individuals (n=1691) reported problems in relation to POMs or OTC drugs alone.

The data are likely to significantly underestimate the problem because:

• individuals who misuse medicines may be more likely to seek help from their GP and not access specialist

substance misuse centres.

The management of patients with chronic pain can present significant challenges. Opioid analgesics for chronic non-cancer pain is rising across the UK:

- There were nearly 2,000 opioid-related deaths in England and Wales in 2015, an increase from 1500 from 2011 (including misuse of non-prescription opioids).  - Over recent years there have been significant increases in opioid prescribing for chronic pain, and the annual cost opioid prescribing in the UK has risen to over £330 million. - Chronic pain is complex: An estimated 49% of patients in the UK suffering from chronic pain also suffer from depression so might also be taking medicine for this condition.

Tramadol is a prescription opioid with additional, potentially serious, non-opioid effects that has received particular attention. Research shows that from 1994-2009, tramadol prescribing in the UK increased to ten times the initial amount and at the same time deaths recorded for tramadol in England and Wales increased dramatically.

Prescribing data from England shows an approximate 50% rise in prescriptions of pregabalin and gabapentin from 2011 to 2013. The 2014 DrugScope Street Drug Survey highlighted the significant use of antiepileptics, chiefly among Britain’s opiate-using and prison populations. The survey reported evidence that the number of deaths related to these drugs, while low, has been rising.

It also reported anecdotal evidence of a big rise in illicit use of these drugs with ‘horrendous’ effects when mixed with other drugs such as heroin or methadone.

Who is particularly at risk of misusing and dependence to POMs or OTC drugs?

A number of factors are associated with an increased risk:

• Personal or family history of substance abuse. Misuse of POMs and OTC medicines is a problem amongst users of illicit drugs. For example drug treatment service providers have noted that the use of pregabalin and gabapentin (antiepileptic medication) alongside heroin is now commonplace.

• Age 16–45 years.

• Older people with complex physical and psychological needs complicated by pain.

• History of pre-adolescent sexual abuse.

• Certain psychological diseases (ADHD, obsessive–compulsive disorder, bipolar disorder, schizophrenia,

depression).

• Exposure to peer pressure or a social environment where there is drug abuse.

• Easier access to prescription drugs, such as working in a healthcare setting.

• Lack of knowledge or understanding about POMs or OTC drugs by the prescriber.

• Problematic use of prescription drugs in older adults is also a growing problem. This is of particular concern because they are often taking multiple medications, putting them at risk of drug interactions.

In addition, frailty, fluctuating health and long-term conditions also increase the risk of complications of drug misuse such as falls, overdose and toxicity.

Problematic use of POMs and OTC medicines includes inadvertent dependence as a result of long term use or over-prescription of the drug. Additionally, it is reported that some individuals initially seek out the drugs for recreational use and may later become dependent.

The RACGP advises that since ‘the profile of individuals who are dependent on prescription opioids is quite different to individuals who are dependent on illicit opioids’, different treatment approaches may be necessary. There is also evidence to suggest that misuse of prescription drugs is more evenly distributed across age groups, instead of being concentrated in young adults.

It is possible to buy a range of drugs, without need of a prescription, from unregistered online pharmacies. This is despite the ongoing work of the UK Medicines and Healthcare products Regulatory Authority to close such sites down. Research by the Royal Pharmaceutical Society found that an estimated 7% of UK adults have bought a prescription drug in this way at some point in their lives. There are indications that diversion of medication – medication being passed on or sold on by those to whom it has been prescribed – is a major contributor to the ease with which individuals are able to obtain POMs for non-medical use.

Signs that suggest an individual may be misusing or dependent on prescription-only (POM) or over-the-counter (OTC) medicines include:

• taking higher doses than prescribed or running out of prescribed medication before expected

• continually ‘losing’ medication so more prescriptions have to be written

• seeking prescriptions from more than one healthcare professional, e.g., doctor, nurse, non-medical prescriber or from more than one practice

• requesting a specific drug claiming that other medications ‘don’t work’ or that (s)he is allergic to them

• stealing, forging or diverting prescriptions

• appearing to be intoxicated, sedated or experiencing withdrawal

• excessive mood swings or hostility

• increase or decrease in sleep

• evidence of craving or other signs of dependence.

• Problems with work, finances or legal issues.

• Being secretive about the drug use.

• Arguments or disagreements with significant others about the drug use.

• Taking other medications to alleviate side effects of prescription drugs.

• Experiencing withdrawal symptoms when stopping/reducing the drug or between doses.

• Continuing to take the drug despite actual or likely negative consequences.

Healthcare professionals should also be alert to the consequences of more serious problem drug use, e.g. engaging in risky behaviours because of poor judgements, falls, getting into debt, motor vehicle accidents, decreased academic or work performance and troubled relationships. In a small number of cases, prescribed medication misuse and dependence can lead to involvement with illegal drugs and associated criminal activity.

Specific signs and symptoms that a patient may be misusing their medicines overlap with side effects and toxicities of the medicine and can include the following:

Opioids

• Constipation

• Depression

• Low blood pressure

• Confusion

• Sweating

Hypnotics and anxiolytics

• Drowsiness

• Confusion

• Unsteady walking

• Visual disturbances

• Dizziness

Stimulants

• Weight loss

• Irritability

• High blood pressure

• Palpitations

• Restlessness

• Obsessive-compulsive behaviour

Initiating difficult conversations

Opening up conversations with people you suspect to be misusing or to have developed a dependency to POMs or OTC medications can be difficult.

Fear and avoidance of confrontation play into the hands of dependent patients who have a stronger relationship with the prescription than they do with the prescriber.

Below are some questions and statements that could be used to expose or better understand the nature or extent of a problem.

‘I’m feeling pushed by you to write a prescription today that is not medically indicated and therefore I’m concerned about you, and we need to talk about your use of [name of drug].’

‘Have you ever felt the need to cut down on your use of prescription or OTC drugs?’

‘Have you ever felt annoyed by remarks your friends or loved ones made about your use of prescription drugs?’

‘Have you ever felt guilty or remorseful about your use of prescription drugs?’

‘Have you ever used prescription drugs as a way to ‘get going’ or to ‘calm down’?’

Drug Addiction, Dependency and Pain

Managing pain in people with current or past dependence on opioids is more challenging, and has more important consequences, than managing pain in other populations.

Prescribing opioids can contribute to a relapse into addiction in patients who are currently abstinent and, in current addicts, can be associated with diversion and misuse of prescribed medication.

In some patients with no prior history of opioid addiction, iatrogenic addiction may occur, i.e. they may develop opioid dependence as a consequence of prescribed opioid treatment.

The stigma associated with addiction complicates assessment and management.

It is important that healthcare professionals are aware of the implications of addiction when assessing, prescribing and managing pain.

Addiction to opioids also seems to contribute to emotional dysregulation and some addicts appear to develop difficulty containing distress and anxiety. This, combined with the sense of being stigmatized, means addicts are sometimes defensive and overly-sensitive to perceived slights, such as being asked to wait to be seen and contributes to the risk of an unhappy interaction between an addict and the healthcare system.

Both pain and addiction are common problems, and the contemporary epidemics of chronic pain and drug dependence overlap substantially:

- People with current opioid dependence have a high incidence of pain

- Where chronic pain and opioid dependence co-occur, opioid dependence usually precedes onset of chronic pain

- Opioids are prescribed much more commonly for pain in patients with histories of drug dependence than for those with no history of substance misuse

Current or former addicts may seek opioid drugs for several reasons: To relieve pain and distress, as a less stigmatized alternative to drug treatment programmes, or as diversion and misuse of prescribed drugs.

Dependence on prescribed opioids can contribute to pain, disability and distress, even in individuals without prior addiction histories. Opioids contribute to pain through the two biological mechanisms of withdrawal and opioid-induced hyperalgesia (OIH). Cyclical withdrawal and hyperalgesia probably both contribute to the high incidence of pain experienced by people currently dependent on opioids.

Patients reporting pain, using opioids and exhibiting one or more aberrant behaviours may most usefully be approached as needing management of both pain and addiction. It may be that if they were pain-free they would not need drugs, but equally if they were drug-free they might experience less pain.

A key concept in treating addiction is the notion of 'stabilization', which is achieved by prescribing a lower dose, long-acting opioid. Stabilization avoids the peaks of opioid effect and troughs of opioid withdrawal. The benefit is that a regular dose of slowly absorbed, long-acting opioid makes the medication less reinforcing and enables background activity so that patients may concentrate on issues other than when the next dose is due.

Abstinence is difficult to sustain and it is counterproductive to seek abstinence from drug use before initiating management of pain.

Tramadol

Deaths related to tramadol doubled in four years, to 179 in 2013 in England and Wales

Following the increase in deaths, a recent exploration of tramadol misuse was undertaken in the UK. Respondents to an anonymous internet survey were overwhelmingly young, employed or studying, and not heroin users. The report found:

• They used tramadol for a range of reasons other than pain relief, including relaxation, sleep and to get high

• One third obtained the drug from friends, but most obtained it by prescription

• One fifth had used tramadol in conjunction with alcohol to potentiate each drug

• A small number reported withdrawal symptoms and difficulty stopping

Key points:

• Opioid dependence can produce lasting brain changes that render people susceptible to relapse

• Administration of opioids in people with a history of addiction can trigger craving, drug seeking and, sometimes, increased pain

• Opioid dependence can cause reversible dysregulation of pain, i.e. hyperalgesia

• In managing chronic pain and addiction, the first priority is to stabilize addiction

What is current best practice support/treatment for patients who misuse POM/OTC opioids?

• Mono-buprenorphine, buprenorphine-naloxone and methadone are all indicated for the treatment of opioid dependence but currently no guidelines exist in the UK specifically for the treatment of patients who misuse POM/OTC opioids.

• Opioid substitution treatment can be used in cases where dependence on prescribed opioids such as codeine-based painkillers has been diagnosed. Initiation of an OST medication, such as buprenorphine, can be undertaken by GPs, nurses and pharmacists with an interest in substance misuse and addiction psychiatrists who are trained in the initiation and safe prescribing of OST.

• Clinical experience suggests that patients presenting with dependence on codeine preparations benefit from buprenorphine. The risk of patients misusing mono-buprenorphine, either by injection or intranasally, or of diverting (selling or giving away their medication) may be reduced by use of the buprenorphine-naloxone combination product; while the naloxone component has very low bioavailability when taken sublingually as intended, it has high bioavailability if injected and is liable to precipitate withdrawal, thus discouraging further misuse.

• The profile of individuals who are dependent on prescription opioids is quite different to individuals who are dependent on illicit opioids, which suggests a different treatment approach. Individuals who are dependent on prescription opioids tend to earn more, are less likely to be hepatitis-C positive, are more likely to complete treatment and have a higher percentage of opioid-negative urine tests.

• Reducing doses or ceasing prescription of opioids altogether is not considered a satisfactory way of

managing problem opioid use; individuals may ‘doctor shop’ or access opioids OTC in response to dose

reductions or withholding of prescriptions.

• Support groups may be helpful in conjunction with behavioural therapy.



Opioid dependence can produce lasting brain changes that render people susceptible to relapse

Administration of opioids in people with a history of addiction can trigger craving, drug seeking and, sometimes, increased pain

Opioid dependence can cause reversible dysregulation of pain, i.e. hyperalgesia

In managing chronic pain and addiction, the first priority is to stabilize addiction

Patients with a history of, or suspected, drug misuse who present with pain are challenging:

• Abstinent, former heroin addicts with pain are at risk of relapse if severe pain is inadequately treated or if exposed to opioids

• Current opioid-tolerant patients with pain have difficulty receiving analgesia because they often require higher doses and are suspected of drug-seeking

• Some opioid-tolerant people presenting with pain are drug-seeking, either for personal use or to sell to the black market

Management of chronic pain in a person in whom drug dependence or misuse is suspected requires four elements:

• Information, between practitioner and patient, and between practitioners involved in care

• Structure, provided by clear definition of objectives and expectations

• Establishment and maintenance of a therapeutic relationship

• Prescribing, with attention to risk management

How to manage chronic pain:

In chronic pain management, many patients expect, or at least hope, that their life can become pain free. Mostly, this too is 'magical thinking', and is a significant barrier to effective management.

Opioids risk reinforcing unrealistic expectations in chronic pain, especially the use of potent opioids. This reinforces expectations that treatment can produce a pain-free state, but the initial response is seldom sustained. Few patients initiated on long-term opioid therapy achieve reductions of 50% in pain.

The marketing message that medication and medical intervention is an appropriate way to deal with discomfort, distress and aging has produced an epidemic of prescription drug dependence.

Abstinent former heroin addicts and chronic pain

There is a moderate clinical consensus regarding management of pain for former heroin addicts.

The efficacy of opioids for chronic pain is limited and there is a risk of relapse on exposure to opioids, particularly in a patient concerned at the risk of re-addiction, so it is preferable to avoid opioid analgesics for management of chronic pain

The dilemma for abstinent, former heroin addicts is that there is a risk of relapse caused by:Exposure to opioid medication and the stress from inadequate pain relief

Risks of relapse can be minimized when an abstinent ex-addict suffers acute pain by offering other analgesia options, switching to long-acting medication and support.

Active addiction

For patients with active addiction, i.e. drug injecting, alcohol dependence or chaotic drug use, to the same degree as for former addicts who are abstinent, there is moderate clinical consensus about chronic pain management . However, successful management of chronic pain is difficult. The priority is to stabilize the addiction, and US guidelines suggest that identification of an active SUD is an indication that the patient should be referred for formal addiction treatment.

Patients on OST

For patients on OST, there should be caution about prescribing additional opioids in chronic pain. High dose methadone is designed to induce such a high level of opioid tolerance that injected heroin has a markedly diminished effect. On doses of methadone above 60 mg/day, additional opioids have little sustained benefit. Therefore, it is not usually appropriate to prescribe additional opioids for people on methadone, except briefly in the management of acute pain, when higher than usual doses may be required.

Currently using recreational drugs

Patients who are currently using recreational drugs, especially cannabis, are quite common among patients with chronic pain. Again, there is no 'right answer' for how to manage their chronic pain, so the risks require competent assessment and the patients' ongoing management.

Currently receiving prescribed opioids

For patients on prescribed opioids who are not responding well to treatment, again, there is no 'right answer' for how to manage chronic pain. As for other patients in this large group, the risks require competent assessment and the patients require both initial and ongoing management.

What is current best practice support/treatment for patients who misuse benzodiazepines?

• No medications are approved for treating benzodiazepine dependence. Benzodiazepine misuse is invariably treated with gradual tapering and patients may be switched to diazepam because of its prolonged half-life, liquid formulations and daily prescriptions, therefore allowing very small reductions to be made.

Other treatment approaches include switching patients to non-benzodiazepine anxiolytics, or where a

formal diagnosis has been made of depression and anxiety, prescribing adjunctive medications such as

antidepressants or mood stabilisers. Support groups may be helpful in conjunction with behavioural therapy.

•Tapering schedules for benzodiazepines are available at and on the .uk

Withdrawal should be gradual (dose tapering, such as 5–10% reduction every 1–2 weeks, or an eighth of the dose fortnightly, with a slower reduction at lower doses), and titrated according to the severity of withdrawal symptoms. This may take 3–4 months to a year or longer. Some people may be able to withdraw in less time. For advice on withdrawal, see NICE Advice.

Withdrawal may be undertaken with or without switching to diazepam.

For more information on withdrawal schedules for other benzodiazepines and z-drugs, see the Ashton Manual (available online at .uk).

Is this a suitable time for the person to stop taking/gradually taper the drugs?

Enquire about:

- Symptoms of depression/anxiety/long-term insomnia. 

- Any medical problems and whether these are well controlled and stable.

- Can the withdrawal of the benzodiazepine or z-drug be appropriately managed in primary care?

- Are they willing, committed, and compliant, and have social support.

- Have no previous history of complicated drug withdrawal.

- Are able to attend regular reviews.

- Consider seeking specialist advice or referral to a specialist centre for people with:

- A history of alcohol or other drug use or dependence.

- Concurrent, severe medical or psychiatric disorder or personality disorder.

- A history of drug withdrawal seizures. Slow tapering is recommended for individuals on high doses

Managing someone who wants to stop benzodiazepines or z-drugs (Nice guidance)

- Decide if the person can stop their current benzodiazepine or z-drug without changing to diazepam (long half-life 20–100 hours, thus avoiding sharp fluctuations in plasma level, liquid formulation and daily prescription allowing v small reductions)

- Seek specialist advice (preferably from a hepatic specialist) before switching to diazepam in people with hepatic dysfunction

- Negotiate a gradual drug withdrawal schedule (dose tapering) so that they remain comfortable with the withdrawal. Tapering schedules for benzodiazepines are available at

- Review frequently, to detect and manage problems early and to provide advice and encouragement during and after the drug withdrawal.

- Support groups may be helpful in conjunction with behavioural therapy.

If they did not succeed on their first attempt, encourage the person to try again:

- Remind the person that reducing benzodiazepine dosage, even if this falls short of complete drug withdrawal, can still be beneficial.

- If another attempt is considered, reassess the person first, and treat any underlying problems (such as depression) before trying again

It is really worth reading this comprehensive educational pack (from the All Wales Medicines Strategy Group) about the appropriate Prescribing of Hypnotics and Anxiolytics. This pack includes excellent advice on insomnia treatment, generalised anxiety disorder

As part of the care plan each patient would be offered the following evidence-based interventions and

resources:

a. sleep hygiene information

b. signposting to self-help and recovery resources

c. access to peer education/support where available

d. where indicated, guided self-help information for the management of stress and anxiety (online versions

as well)

e. relaxation tips as appropriate through self-help leaflets, signposting to websites, handouts and face-to face sessions.

9. The aim of shared care for patients misusing prescribed medications is to stabilise the patient through

planned medication reductions and then negotiate with the patient and the patient’s own GP how the patient will be stepped back to full GP care

Further reading:







How are patients who misuse POM stimulants treated?

No medications are approved or licensed for treating stimulant dependence. The first steps in treating prescription stimulant dependency may be to taper the drug dosage and attempt to ease withdrawal symptoms. The detoxification process may then be followed by behavioural therapy, e.g. contingency or cognitive-behavioural therapy. Support groups may be helpful in conjunction with behavioural therapy

UK adults are the most likely in Europe to abuse stimulant prescription drugs such as Ritalin and types of amphetamine.

Methylphenidate is a central nervous system stimulant drug that has become the primary drug of choice in treating attention-deficit/hyperactivity disorder. Along with increases in prescribing frequency, the potential for abuse has increased. Intranasal abuse produces effects rapidly that are similar to the effects of cocaine in both onset and type. The clinical picture of stimulant abuse produces a wide array of psychiatric symptoms. Psychiatric symptoms of stimulant overdose may include hallucinations, delusions, paranoia, confusion, disorientation, and loose association of ideas.

Abuse often entails the use of large doses, which may be taken intranasally or intravenously. When methylphenidate is abused intranasally, the effects are usually similar to intranasal use of amphetamines and crack cocaine.

The clinical picture of stimulant intoxication produces a wide array of symptoms including schizophrenic symptoms, manic-like states, psychoses, depressions (especially during withdrawal), and various types of anxiety conditions including panic states. Motor and behavioural symptoms of overdose may include bruxism, repeated touching or stereotypic confusion, disoriented behaviour, pounding, obsessive-compulsive tendencies, aggressiveness, and repetitive behaviours.

These psychiatric and physical side effects resolve over a period of hours to weeks.

Action on Pain

Support for people affected by chronic pain.

Helpline: 0845 603 1593 (weekdays 10am–4pm)

Website: action-on-pain.co.uk/

The British Pain Society

General information about pain.

Website:

The Patients Association

Giving patients the opportunity to raise concerns and share experiences of healthcare.

Phone: 0845 6084455

Website: patients-.uk/



The UK government has ben asked to introduce a national, 24 hour helpline for prescribed drug dependence to provide vital, real time support to individuals affected by prescribed drug dependence. A national helpline would sit alongside a website and act as a single trusted resource for patients on managing prescribed drugs dependence, coping strategies and support for carers and family members. It would also provide a service that doctors could signpost patients to when they need support.

Action is also needed to develop robust guidance on the optimal withdrawal and tapering protocols for benzodiazepines, z-drugs, antidepressants and opiate analgesics

Further reading:













[pic]Pavilions drug & alcohol services (over 18’s)

• Pavilions main referral hub & East access point

Drop-in: Mon – Fri 10am - 4pm, Thurs 10-7pm, Sat 10-1pm.

Address: Richmond House, Richmond Road, BN2 3RL

t: 01273 731 900 / Freephone 0800 014 9819

e: info@.uk

• Pavilions LGBT Worker – Gary Smith supports anyone who identifies as LGBT and wants help to reduce or stop their substance use.

t: 07884 476 634

e: gsmith@.uk

• Pavilions Peer Mentor Coordinator – David Obermayer

t: 079205 46678

e: dobermayer@.uk

• Pavilions Education, Training & Volunteer Coordinator – Chris Smith

t: 07775 551554

e: csmith@.uk

• Pavilions Families & Carers Team & West access point – support for the family and loved ones affected by someone else’s substance misuse.

Address: 9 The Drive, Hove, BN3 3JE

t: 01273 680714

e: familyandcarers@.uk

• Pavilions Women’s Service - women-only drop in including needle exchange services (Friday afternoons 2.30pm - 4.30pm) & crèche facilities.

Address: 11 Richmond Place, Brighton, BN2 9NA

t: 01273 696970

e: info@.uk

• Pavilions Health Promotion & Training Team – deliver free drug & alcohol related training courses promoted via also offered on a bespoke basis, design resources, attend events, support campaigns, manage the Pavilions website & social media accounts and co-ordinate the DAWG (Drug & Alcohol Workers Group), to be added onto their mailing list contact them using details below.

t: 01273 731 900

e: healthpromotion@.uk

• Pavilions Needle Exchange – support & equipment for safer injecting, advice for illicit drugs, NPS and steroids.

Opening times: Mon – Fri 10am – 4:30pm (For services outside of these times see list of pharmacies that provide needle exchange Needle Exchange section.

Address:   Pavilions Needle Exchange is based at Arch Healthcare, Morley Street & 33 Grand Parade.Look at the website for where to go and when.

t: 07919 397421

e: frocha@.uk

• Pavilions group work program – see ‘Recovery, group work & interventions’ section to download a timetable for the groups currently running:

ACT (Acceptance & Commitment Theory) – mindfulness based rolling programme which is open to anyone receiving support from Pavilions

Springboard – a rolling five day programme designed to introduce service users to the potential and tools of recovery, as well as an introduction to the visible recovery community in Brighton and Hove

Forward – a daily alcohol detox group using Cranstoun’s Integrative Recovery model as a means of identifying and developing a bespoke recovery programme meaningful to the individual

Rethink – a structured programme for service users involved with criminal justice agencies. Rethink is a rolling six week programme designed to focus on recovery. The group work content focusses on the development of a personalised, resilient, recovery focussed programme.

Sug@r - a weekly ‘open house’ for service users to come along and give us open and honest feedback regarding how they would like to see their service develop, what’s working well, and what we need to change/improve on. Our aim is to use the feedback we get to inform decisions with regards to new developments as we move forwards. 

[pic]Stay up to date by following us on Twitter or Facebook [pic]

Visit our website: .uk

Citywide services:

[pic] Contraception & Sexual Health Services

Address: Claude Nicol Centre, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE

t: 01273 523 388

e:

Clinic M offers a confidential sexual health service to gay and bisexual men and other men who have sex with men (MSM) regardless of HIV status on Wednesday evening. There are 8 walk in slots from 17:00 –18:00 and appointments from 18:00. The clinic is open Wednesdays 17:00 – 20:00

Clinic T is the sexual health service for anyone who identifies as trans, non-binary or gender variant (partners are welcome too). The clinic runs every month and upcoming dates are posted there.

[pic]RU-OK? (Under 18’s substance misuse services)

Address: 1 Regency Road, BN1 2RU

t: 01273 293966

e:

[pic] Terrence Higgins Trust (THT) – support for gay and bisexual men and all African men and women. Face-to-Face service is a free, confidential & non-judgemental service for men who have sex with men (MSM). Talk to a trained gay male worker in a relaxed environment.

Address: 61 Ship Street, Brighton BN1 1AE

T: 01273 764 200

E: info@.uk

[pic] Safe space YMCA Downslink Group – open on Friday and Saturday nights to support anyone who has become intoxicated, distressed or injured during their night out.

Opening times: Fridays & Saturdays 11pm - 3:30am

Address: St. Paul's Church, West Street

t: 01273 222550

e: rose.allett@

[pic] Cascade Creative Recovery – Positive life choices through informing, connecting and creating. Support for people in recovery from addiction. Recovery coaches, Choir, open mic nights and much more. Find them on Facebook.

Open Tuesday - Sunday, 10am-8pm

Address: Cascade Coffee Shop, 24 Baker Street, BN1 4JN

t: 07411 486111

t: cascadecreativerecovery@

[pic]Health Trainers - here to support and encourage, helping you to set goals and achieve them. The service is free and confidential. Improve your health and general wellbeing by eating more healthily, becoming more physically active, drinking less alcohol, or quitting smoking.

t: 01273 296877

e: healthtrainers@brighton-.uk

[pic] Pathways to health - A high quality, low-cost ear acupuncture service for people affected by stress, anxiety and depression, mental health issues, drug and alcohol dependency, and those living with HIV. For details of clinics visit .uk/clinics.html

Address: Community Base, 113 Queens Road, Brighton  BN1 3XG

t: 01273 234766

e: info@.uk

Resources & further reading

❖ Pavilions – information about the services they provide, download useful resources such as leaflets & posters, check what training is available and other useful links

❖ Blue Light - web forum dedicated to discussion of controlled drugs

❖ EROWID -  educational & harm-reduction resource

❖ Neptune Guidance - developed to improve clinical practice in the management of harms resulting from the use of club drugs and novel psychoactive substances. It is aimed at clinicians working in a range of frontline settings

❖ Drug Science (formerly Independent Scientific Committee on Drugs) - objective information on drugs and drug harms to the public, to educators and to academics

❖ Drug Wise - drug information which is topical, evidence-based and non-judgemental

❖ Drink Aware – Raising awareness about alcohol, health issues, legislation and drinking

❖ NHS Choices – healthy living information for everyone including alcohol, mental health, drugs, smoking eating etc.

DAWG: a fantastic networking, information sharing and service update meeting for Brighton & Hove professionals, volunteers and mentors working with Drugs & Alcohol issues. Contact healthpromotion@.uk to be added to the list.

Health Promotion Library- Audrey Emerton Building, RSCH, library.services@bsuh.nhs.uk 01273 523300

One Stop Clinic- drop in for pregnant women with substance misuse issues, mypregnancymatters.co.uk/substance-misuse/4577620558

- the Alcohol Treatment Matrix is concerned with the treatment of alcohol-related problems among adults (another deals with drug-related problems). It maps the treatment universe for each sub-territory (a cell) lists the most important UK-relevant research and guidance.

o/C6/the-highway-code All the Highway Code harm reduction resources created by Global Drug Survey.

.uk/drugwatch.html Drug specific harm reduction advice and information.

.uk

talktofrank.co.uk

Independent Drugs Commission – Brighton & Hove, Final Report

independent-drugs-commission

.uk Leading UK charity supporting professionals working in drug and alcohol treatment, drug education and prevention and criminal justice. Useful info sheets on specific substances.

bluelight.ru/vb Drugs forum– for real life experiences on substances

.uk Drugs, the law & human rights

.uk Consultancy & training

  includes a unit calculator, tracking your drinks, drink diary, and find out what kind of relationship you have with alcohol and how you can cut down.

  assess your drinking, then learn about the effects, helps you identify why your drink and helps you cut down.

a platform to help people address a range of health related issues (weight, smoking, alcohol, activity etc.. with links to local services and help setting effective goals)

anonymised feedback on your drinking

  anonymous feedback on your drug use

hiv- hep- Can be downloaded as an app- gives info about HIV & Hep medication interactions with common substances

.uk/myhiv/Online-tools Free to anyone who’s HIV+, meds & appointment reminders, CD4 (immune system strength) & viral load (HIV activity) tracker, track side effects and increase HIV knowledge

Phone apps: help to track drinking:  Drink Coach, DrinkAware, Drinkstracker and AlcoDroid

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