Cases addic transcript — SMP305 lecture transcript

s Right, we'll get started if that's OK. My voice is a bit croaky today, can you all hear me at the back? Does anyone need me to wear the microphone because you need this for a recording of it at all? No? OK. I'll leave it here, hopefully it'll pick up my voice in general. I'm gonna dim the lights slightly, if you can't see. Um, move to the front is probably the advice, but you can't quite see the projection if I don't do it. So. Apologies if your timetable's been moved around a bit. I used to give this lecture right at the beginning of the phase 3A cases week, so it was Monday morning at 9 o'clock. Um, and then I got asked for some feedback about kind of how the lectures went, and I said, well, it's Monday morning at 9 o'clock, and in December and January no one turns up because it's snowing or raining and stuff like that. So they, they said, well you can come at the end of the cases week and do it on a, on a Thursday, so I'm guessing you've already had all your psychiatry teaching, yes, is that correct? Good, OK. And have you, cos I'm never quite sure in the rotations where you are, have you been on psychiatry placement? Good, OK. So I'll ask you some questions. Perhaps this lecture goes on a little bit about what you might have seen. So I'm John Barker, I'm a consultant addiction psychiatrist. I'm a Sheffield graduate, so I was doing this where you are. Phase 3A did exist when I was at medical school in 2012, I think I did phase 3A. Um, I wanted to be an addiction psychiatrist pretty much from, um, going on placement to it was Barnsley, and I spent a few days in the addiction service there. I just thought it was amazing. So pretty much the rest of medical school for me was really boring. I just wanted to do this. I'm very lucky to be able to do this as a living. It's what I wanted to do, so everything else is kind of a distraction. Um, I'm here to talk to you about some of the most common substances of abuse. I've only got an hour, so there is not enough time to talk about everything, so there's huge sections of drugs that I just will not talk about, so I don't talk about illicit benzodiazepine use. I don't really talk about novel psychoactive substances because there isn't time. Uh, I'm not talking about alcohol cos I'm presuming that's covered somewhere else. I'm talking about what I see in my clinic. So currently, um, I'm the clinical director for Nottingham's drug and alcohol treatment service. Uh, but a couple of years ago, uh, I used to work in Leeds where I was the clinical lead for its drug and alcohol treatment service and also a consultant working in treating gambling in a sort of big tertiary regional service there as well. So all I've done really as a consultant is treat addictions, uh, and the odd bit of CMHT type work, so. Today's lecture, um, as I say, it's brief, it doesn't cover absolutely everything, but there will be bits of this that you could potentially be examined on. Um, there are bits that you won't be, I will tell you the bits that you won't be expected to be examined on, so you're not furiously making notes of that, then you can at least pay a bit more attention to what I'm saying rather than just copying it down. So, commonly used drugs, their effects and consequences, everything's very structured in the lecture, so you'll see it as we go through. I want you to understand the class, mechanism of action and effects of commonly used drugs. So there's bits here about pharmacology, there's bits about um the kind of um physiology, there's bits about the psychology of why people might use substances. We're gonna talk about treatment, and it's usually when I come and did the lecture on Monday morning and talk about biopsychosocial approaches, most people, I don't know what that is, so I'm hoping after 3 days of psychiatry teaching, you know what a biopsychosocial approach is. Yeah, good. There's a little bit of that and then the last bit I've tagged onto the end, to make you a safe F1 doctor, uh, one of the things that the GMC expects you to be able to do is recognise like a load of life threatening conditions, one of which is acute opiate overdose or opioid overdose, so I've got to tell you a bit about that and that's kind of tagged on to the end. So for the purpose of today's lecture, I've created a kind of hybrid patient out of loads of people that I've seen over the years. I've called her Charlotte, you've got to work out the date of birth, she'd now be 15. What would you be 50? 6, yeah, 56, um. I'm gonna use her as a vehicle for taking you through some of the substances. I'm not trying to stereotype and say that every person who comes into drug and alcohol treatment services has had her particular journey, but I've used her because she's just a kind of nice vehicle for you, seeing how people can sometimes progress through. to That particular destination. So, um, I think that pretty much covers really what we're gonna do. I'm gonna introduce you to Charlotte in a second, but has anybody got any, any questions before we start? It's usually they're here. If you do feel you want to ask me anything, just shout and interrupt me. I'm absolutely happy to. It's beta, so. Um, we're gonna kind of take a step through Charlotte's journey, as I say, this is, it's a bit stereotypical, but not every, every single patient you see is different, so you know, people start using drugs at any age, but, um, there is sometimes a pattern and so this is just the stereotype. Please don't think this is the only way. To our treatment services So she's 15, introduced to a drug that she smokes with some friends in a park, it makes her chatty, hungry, um, slightly nauseous if she has too much of it. I mean there's no prizes for guessing that this is gonna be cannabis. So what you need to know about cannabis, I think from medical school is probably encapsulated in the next two slides, and I'm gonna use the same format for each of the drugs that we come up that we that are taking. So, the bit that you don't need to know for exams is the legal classification, because some of you may leave here and go practise medicine in different bits of the world, it doesn't matter, no one expects you to know the UK legal classification. School exam, it's absolutely fine, I've just put it in for reference, so it's a class B drug currently. 1015 years ago it was class B, then it was reclassified to class C, which means that the punishment if you're caught with it, um, is slightly reduced, it's been reclassified to class B a few years ago. It's um kind of, it's route of administration is the next bit, so more often than not people smoke cannabis, hopefully I'm not. Relatively uh advanced medical students now, you'll, you'll know that, and it can be ingested, so people can sometimes cut it up, cook it into cookies and cakes, that sort of thing. Um, and more recently, I'd say probably in the last maybe 10 years, something like that, um, you've been able to get uh THC that you can vape, and vapes didn't exist. Maybe I'm, I'm kind of showing my age a little bit, Vs didn't exist when I was playing. So Melbourne vet. Now lots of people. And so it's a route of administration for THC or one possible route. Most of the people we see in treatment services smoke. Cannabis, I can't remember the last time I saw anyone whose problems with cannabis came from putting it into cookies or cakes, it was always smoking. So you may or may not know that THC is a psychoactive component, so in the nervous system, it binds to CB1 receptors, so they're on the kind of um inhibitory side of the CNS. So if you give a load of CB1 agonism, then you get a depressant effect, so it slows things down. Yeah, that makes sense? It's fairly straightforward stuff you know remember from pharmacology. Um, if you ingest a load of THC by whatever means, or if you take it in, you will get an increase in dopamine as well. That makes you feel euphoric. So if you get dopamine rises, you get euphoria, and that's actually part of the psychological mechanism that maintains people using drugs. If you get dopamine release, um, that is, uh, makes you feel good, makes you feel euphoric, and it's one of the things that people search for when they want to use substances to modulate how they feel. Part of the underlying mechanism for that is that dopamine release, and we see that in gambling actually, I'm not here to talk to you about gambling, gambling has no exogenous substance that is taken in, it's just the behaviour but you still get the dopamine release and it's one of, or one of the theories around it is that that underpins The maintenance of that psychological behaviour even in the face of adverse consequences. Um, so cannabis interestingly is lipid soluble, so if you do a wee test on someone, which we do in our treatment services quite often, um, if you've been using cannabis for like 12 months daily and then you stop for like 10 days and you come in and give me a wee test, you will still give me a positive wee test because it's been stored in your body fats. If you're a very infrequent user, it doesn't have a chance to build up in your body fats, so you will give an egg. The only reason I put that in, in kind of from a medical student point of view is not to suggest that you might want to learn how to avoid um giving positive samples of weed tests, it's more about occasionally you get queries from kind of hospital wards who say this person who came in who says like they haven't used cannabis for like a week. Um, but they're still peeing like the tests still positive and they're using it while they're on the ward. because if you're chronic users storing in the body fats and it's just leaching out over time. So, second slide about cannabis, this is kind of why people might use it, I've kind of alluded to that a little bit about the stuff about euphoria. So it's psychological effects, because it's a depressant, it relaxes you. So people use depressant drugs generally because they give them a sense of relaxation. So anyone who has had experience of using alcohol or cannabis, they're commonly use depressants, you will know that they make you feel slowed down, relaxed, generally more calm, and that's one of the things why people. Um, you can feel euphoric with cannabis because you do get a bit of dopamine release that I've mentioned. In higher doses or chronic use, you can get altered perceptions and we'll come on to altered perceptions a little bit later in some of the other substances. You may have seen people who've been admitted to hospital wards where they've been irritable or paranoid and some suggestion has been around the cannabis use, perhaps you've had that experience and physical effects, so you get dry mouth, dry eyes, tachycardia, hunger, um adverse, chronic adverse effects. We do see a fair bit of it. Um, in heavy and chronic use, so people who use a lot who are literally waking up out of bed in the morning having to smoke some cannabis because they feel really, really anxious because they're starting to withdraw from it. They're very, very low in mood, often, they're quite anxious, they're very low in motivation, low in energy. You'll be aware of the risk of psychosis with cannabis as well, I'm sure you've seen that in the clinics or in the hospital wards that you were on, um, and there's all the associated risks of smoking tobacco, so if you are mixing your cannabis with tobacco and smoking it, then you've got increased risk of cardiovascular complications, um, head and neck, lung cancers, etc. etc. etc. all that stuff that you get from. Smoking tobacco. So there are your two slides in medical school probably for cannabis done and dusted. Any questions about that before we move on to the next drug? No, OK, fine, so I'll let you read this out. I'll read it out while you read it internally. this might be. So an interesting substance. Makes you feel an intense sense of empathy towards others and an irresistible desire to dance, alters your perceptions, er and gives you strange experiences where you er perceive one sensory input in a different, Century modality, so. Again, probably no prizes for guessing that this is MDMA or ecstasy. So MDMA is obviously the, the, the kind of acronym for the um chemical name for the substance. When it first um became popularised for sort of recreational use, it sort of 19 mid mid to late 1980s. And it was always known as ecstasy then, obviously. Probably know that the two terms are synonymous, but just in case you didn't, they are. Um, class A drug generally comes in a tablet form, although you can uh get it as a powder, so if you get it as a tablet, you ingest it. If you get a powder, um, that can be dabbed on your gums or snorted. Um, how it works, it's a mechanism of action, to take you back to your, um, basic sort of, uh, neuroanatomy now, so you probably all remember synapses, so I'm not gonna draw a pretty picture on the board, but you've got sort of pre-synapse and post-synapse, haven't you, then you've got the synaptic cleft in between and you get electrical impulse going down to one end, it creates a neurotransmitter release across the, across the synaptic cleft. Neurotransmitter binds to the other end and then you get a continuation of the electrical signal, so it basically messes about with that process, so in that synaptic cleft, on the pre-synaptic side you have pumps that bring back neurotransmitters for recycling and storage, and it blocks the reuptake of that, so you end up with more free serotonin in the synapse essentially, and then you get more agonism and more stimulation. And you also get a bit of increased dopamine and noradrenaline through using this substance, so the dopamine gives you the euphoria. Noradrenaline, what kind of effects would noradrenaline give, do you think, subjectively, if you said, if you said to someone who had increased levels of free noradrenaline in your CNS, what might they report back to you? Perfect, yeah. Increase energy, exactly that, so this is why it's a stimulant, so an MDMAF is a stimulant, so we talked about cannabis being something that's active on the inhibitory side of your CNS, this is a drug that's active on the uh excitatory side, so you get lots of stimulant effects, so you've got the increase in serotonin, the increase in dopamine, increase in noradrenaline, and that's one of the reasons why people use it, um, on the picture, before I move away from it, um, it's maybe not, I turn the light down a little bit. I do like to kind of Kind of remind you that as doctors you should be able to spot physical signs, so if you have symptoms of things that patients complain of. Signs of things that you can see as a doctor, there are two signs that are fairly evident from the picture. as a key. Cashew, I eat. of the gas. Pupil dilation which has a, Medical landmark No, it's alright, you've already got that, so that's perfect, yeah. Anything else? The chap in the bottom right, maybe the most evident one. His jaw, yeah, he's got Brooksism, so it's basically jaw grinding. So, um, so Brooksism is a kind of, you know. Irresistible desire to kind of grind your teeth, which I think he probably accept he's doing. You look at the lady in the bottom left, um, her pupils, er, that is her pupil, I think it's a massively dilated pupils and that's a term called madriassis. And you see that with stimulant use, so well done, er. It's gone to the next stone. Next slide. So why black people use MDMA or ecstasy, well, I mean, in fairness, if you look at the label of kind of what it does, it's quite a, it sounds pretty good, doesn't it, increases your levels of empathy, it increases your energy, uh generally makes you feel good, and you can have some, sometimes quite pleasant altered perceptions whilst you're intoxicated with it. Um, physical effects, so you can become a bit hot from your core body temperature, dry mouth, the dryness is dilated pupils. A stimulants generally kind of turn up the kind of body's um regulatory thermostat if you want, so you will end up with a little bit of hypertension, a little bit of tachycardia. The Brooksism I've mentioned, which is the grinding teeth, that's pretty. Actually in terms of using other stimulants like cocaine or amphetamines. Afterwards, so kind of in the immediate sort of aftermath of using it, this particular substance generally. Onset, peak to onset of about 1 hour and then the effects generally last for somewhere between 4 and 6 hours depending on the dose and then afterwards it starts to wear off and you start to have kind of the opposite effects to the effects that the drug gave you, so rather than being um really euphoric, you can be a bit low in mood, a bit low in energy, a bit anxious. Those things tend to resolve after sort of 48 to 72 hours maximum. It depends on As well, and but actually general kind of picture for recreational use. chronic or adverse effects, I'll be honest, we don't really see that that much. There are some negatives, I'm not saying that this is. Untroublesome drugs because that's not true, um but we tend not to see people with issues solely to do with MDMA or ecstasy dependence or harmful use in our clinics, occasionally we. It's not, it's pretty rare. Um, but chronic adverse effects can be low mood, anxiety, you can take too much of it, um, you can drink too much water, so if you're intoxicated on a substance that alters your perceptions and makes you feel, um, you know, slightly. Um, not in control as you would have been, and you're heeding the advice that you should drink water when you take ecstasy. There have been sadly, some people who've died when they've been acutely intoxicated with this substance because they've drunk too much water and they've essentially flushed all the sodium out of their bodies, become hyponatremic, and then had a seizure, which leads leads to cardiorespiratory arrest and death. Because of water intoxication, it's very rare, but it has happened and so it's worth pointing out as an adverse effect. Any questions about ecstasy? We move on. Oh, OK, great, I did flick onto this slide a minute ago. We're gonna meet Charlotte a little bit later on in her life now, so bear in mind she's introduced to cannabis when she's sort of 1516, 18, she started going out and using ecstasy. She's now moved to go and work as a travel rep. Um, still using cannabis and ecstasy recreationally, um, struggles to get up in the morning because she probably hasn't gone to bed from the night before, and so she tries using another substance which gives her loads of energy. However, one of her colleagues was using this drug and he started hearing voices telling him his life was in danger, and he ended up in a local psychiatric hospital. So you may have come across this substance if you've already had your psychiatry placements, wherever you've been, um. It's a drug that's not that common nowadays, I would say, you still see it. Has anyone got any idea what this might be? I have actually mentioned it. Some white powder. Oh, OK, yeah PCP would PCP would probably give you lots of unpleasant kind of. Hallucinatory experience itself, not quite, it cocaine. I always thought that it is a kind of, it's not cocaine but it's a good guess, is that cocaine is a white powder, but there is another white powder that's a stimulant, it's not a, it's the, yeah, amphetamines, so thank you. So we don't see much amphetamine use, now when I was training. So I was a registrar here about 89 years ago, I saw a bit in Sheffield, there's always a lot of amphetamine use in Barnsley. I've no idea why Barnsley is a kind of amphetamine hotbed. Um, and then I went to be a consultant in Leeds, another 20 miles up the M1 where there's no amphetamine use, it's just really weird, but um it's kind of, you get little patterns of substance misuse, which is, is fascinating, but, um, probably not as fascinating to me as an addictions consultant, maybe not to you. Yeah, so amphetamines is the, is the answer to the question. So amphetamines, interesting drug. Um, they're class B, if you've caught in possession with the powdered version, but if you have prepared it for injection, it then becomes a class A drug. You don't need to know that for um for medical school exams, it's just one of those things that we'd like to. Kind of put in because we find it fascinating but nobody else does. route of administration insufflated, so I've mentioned snorting drugs when I was talking about it that's what insufflation is. So you chop the powder out and you snort it and it's absorbed. B stream, you can ingest amphetamines, so people refer to bombing them, it's still quite a, a term that people understand, people who use it. So amphetamines are kind of gastric irritants, so people often wrap them in bits of tissue paper or something like that and slow them down, quite what the tissue paper is gonna do inside, you know, a stomach lining of with a pH of one, I'm not quite sure, but it's still people do it like that, um, and you can inject them, so. I would say ingesting is the most common form, followed by insufflation, followed by injecting. It's rare to find people who inject amphetamines. If you're injecting amphetamines you're probably using daily and you're dependent on them, you've got a physiological dependence, and we have an inpatient detox unit. that back so. And about once every 6 to 8 weeks we get someone in who's up uh for a detox. Injecting, use a amphetamine injector and they can be quite difficult to treat. So, um, in terms of the mechanism of action for amphetamines, there are lots of different theories, but no one, no one universally accepted understanding of how this particular substance works. The general kind of School of thought or most accepted school of thought is those um pumps that I told you about in the pre-synaptic side of your um of your kind of synapse, um, is that amphetamines disrupt those pumps and rather than bringing neurotransmitters back in, it causes them to go the other way and pump things back out into the synapse, and those neurotransmitters are the ones that we talked about with, with MDMA so it's noradrenaline, dopamine. And serotonin in amphetamines, it's noradrenaline, which is the noradrenaline and dopamine are the two neurotransmitters which are most likely and most uh have most, have the biggest increase when you use the substance, and we'll come onto that in a second. That might be, that might be helpful. So, just look at the um the. Psychological effects. there. So why might someone use amphetamines, so to give you loads of energy, you just um at the front there said what the kind of street name of the drug is, speed, think about it, it kind of makes sense, doesn't it, something that gives you more energy and makes you kind of more um more active. That's why it's got to end of speed. So in kind of low to moderate doses, you get an increase in energy, focus and concentration, and that's why in ADHD, The mainstays of pharmacological treatment, not the only treatment because there are other non-stimulant medications that are prescribed, but for ADHD patients are prescribed slow release, low dose amphetamines because they increase levels of, Dopamine and noradrenaline and if you increase those in a controlled, sustained and moderate way you increase people's focus and concentration the basis by which Generally, I'm talking about uh recreational use of that's here so it's different. I'm talking about someone who wants to go out and kind of just wants to have quite amplified effects of having lots of energy and kind of feeling really good and euphoric. And be able to stay awake for. 24 hours or whatever it is. Physical effects, so like with all stimulants, you get a bit of tachycardia, a bit of hypertension, um, decreased hunger and decreased need for sleep, that's common for most stimulants. They come down afterwards, a bit of low mood, a bit of lethargy, if you're not using every day, that goes away. The difficulty with amphetamines is that in chronic use, you can become psychotic, so there's the odd person every now and then on the inpatient wards at psychiatric wards who, Is a heavy amphetamine user in the community and then gets admitted to hospital because they've become psychotic, lots of reasons behind that increase from the kind of um a neurotransmitter level because you've increased dopamine, which is um implicated in psychosis. Also, if you're using substances and not sleeping for several days or for prolonged periods, a profound lack of sleep is also a risk factor for psychosis, it's quite multifaceted. It's rare. I'm not saying that everyone uses amphetamines, becomes psychotic, far from it, very, very small minority, but that's one of the risks. And if you're using every day, um, I've got seen people before who were literally waking up and having to inject themselves with amphetamines like you might have a cup of coffee. No. Function went out and then once they've put out they're fine for. 68, 10 hours and then maybe need to do the same again in the afternoon and the evening and then. They crash at the end of the day and then they repeat the cycle. It's an interesting substances, um, an interesting substance, but not one that we see as much as we used to do, and there's a reason for that that I'll come on to later on, so. We'll go back to Charlotte. So she's er introduced to another drug now, again I'll let you read the um. We didn't open yet. Uh So I think what I've tried to do with these vignettes is just to give you an idea that substance misuse doesn't sit kind of in isolation. And there's often a cultural context to everything, so some substances come in and out of fashion, a bit like I was saying, so amphetamines are very much out of fashion at the minute. And this particular substance was out of fashion at the time frame I'm thinking of, which is sort of late 80s, early 90s. Very much. Um, back in fashion again people started using quite a lot of it. So it's a drug that you swallow on a small bit of paper, nothing happens for an hour-ish, and then you start to feel a bit anxious, then you get the subjective effects, which are things like being able to experience one sensory input in a different modality, we'll talk about that in a minute. Some stuff about your sense of self crumbling away much later on, and then afterwards feeling very, very er kind of er, at peace with yourself and at one with yourself. So, I have Given LSD as an example of that, other hallucinogens can give you similar subjective effects, but the most, Um, I would say for the two most commonly used hallucinogens, the psilocybin in the form of body mushrooms. and LSD, psilocybin is a naturally occurring compound which grows in certain. Certain types of mushroom or occurs in certain types of mushroom, and LSD is synthesised, although it is synthesised with the fungus, but it's only synthesised in a laboratory. It was synthesised about 100 years ago now, the first time it was ever done and then just sat on a shelf for a while and no one did anything with it. There's an interesting story behind it, but I'm not here to tell you about that. It's a class A drug, generally speaking, people ingest it, so you would um, Uh, you would swallow. A bit of blot of paper that has had er the active compound dropped on it, dissolved in the solvent, the solvent evaporates, it leaves the drug on the bit of paper, useful on the bit of paper, you then er take it. You can occasionally get it in liquid form, but generally it's um. supply How it works is it causes quite a lot of serotonin release in the CNS. It binds to um 5-HT. There's lots of different subtypes of 5HT receptors. You do not need to know that for medical school. Pretty much all you need to know is it causes a big load of serotonin release. You indirectly get a bit of dope, meaning glutamate. Glutamate's another exci3 neurotransmitter. The really interesting thing about hallucinogens is, of all the drugs that you will come across. And I don't have time in this lecture really frustratingly for me to talk to you about how to take a drug history. I hope that somebody else has done that somewhere else. If you come across people who use substances, please always, one of your first questions, gently enquire what does that drug do? Yeah, just say kind of, you know. OK, alright, so you say you're using that. Can you just tell me what it feels like when you're using it, what do you get out of it? That's a really nice open question to ask. And if you ask people about alcohol, cocaine. Generally get the same answers back. If you ask people about why they use hallucinogens, you get quite a broad spectrum of answers, and the reason for that is that the kind of subjective experience can vary depending on the type of hallucinogen, depending on the person's state of mind. Drug and depending on who they've consumed it with, so if you have never used LSD before, I wouldn't recommend going out and doing it when you're really anxious before, you know, a week before an exam in an unfamiliar environment. you don't trust, the experience is likely to be a negative. However, If you were in a right way relaxed and you were generally free from anxiety and free from any preexisting. illness. The chances are it might be more. You can never tell, and I'm not suggesting you use this particular substance. There's a very much a correlation between the person's state of mind at the time they use it and the experience they get from it. But like everything, you can bring things into broad kind of categories. So, hallucinogen use in general, you will get altered perceptual states, so you might get visual and auditory hallucinations. You probably know, if you don't, you should, a hallucination is a perception in the absence of a stimulus, so you perceive something to be happening, but there is no stimulus there, so you hear something, but there is no pressure wave hitting your tympanic membrane, causing some electrical transmission into your, into your brain. Um, synesthesia is an interesting psychopathology, that's, I've made reference to it earlier, that's where you experience one sensory input in a different sensory modality. So you might see what is he on about, right, and there may be some people here thinking, oh, I remember doing that, and that'd be great, but uh I don't know, there's a different, it's an interesting audience. I make no assumptions about people's previous. Experiences, but synesthesia is where you might um you might hear a colour, for example, or smell a sound, so your perception is very much like you are getting a sensory input, but somewhere in your brain or in your thalamus probably it things are getting mixed up a little bit and you're then perceiving it in a different sensory modality, and it's one of the reasons why people use hallucinogens because that is for some people. Interesting experience in itself. Ego dissolution is the sense that you, your identity and you has crumbled away, again. That this is a, a, a kind of uh experience pretty much unique to hallucinogens, it's one of the reasons why people use hallucinogens because they often find that actually after, after the drug use, they have understood their purpose in life better or they have kind of, Moved over a particular obstacle, and it's one of the reasons why there's so much interest at the moment in using psychedelic drugs for treating things like refractory, which is treatment resistant depression. Um, because of the experiences that you can have which. Quite enlightening. Physical effects, so it's a stimulant, so a bit of tachycardia, a bit of hypothermia, you get dilated pupils afterwards. The interesting about LSD is it's got a long half-life, so if you take it somewhere between 8 and 12 hours it's often, Commonly quoted Sort of time frame for the effects, so afterwards, you know, the hours or days afterwards, often people feel quite, you can feel a bit anxious, but some people report feeling quite um happy and content in that period. Sometimes don't want to eat for a couple of days. Chronic or adverse effects, so if you have a bad experience, it's pretty horrible and one of the worst things about kind of a, a bad trip on LSD is if you're conscious of the fact that this is a drug that's gonna last for a long time and right at the beginning of the trip it's unpleasant and you know it's gonna be unpleasant, that can further heighten your anxiety and make. Very occasionally, people who use hallucinogens develop psycholysis as a result. And occasionally end up in hospital, it's very rare, but you may have seen it on. And HPPD is something you don't need to know about, I don't think particularly for medical school, but it's an acronym which stands for Hallucinogen Assisting Perceptual Disorder. And that is basically uh a medical term for flashbacks, so if you've heard of flashbacks from using hallucinogens, it's where people have used a hallucinogen, then 6 months, 12 months, 245 years later. They're minding their own business and then all of a sudden they're temporarily transported right back, and have like all the experiences of what they were having in part of one of the trips that they've experienced, or they may have temporary and fleeting visual disturbance, so if I walked across this room and you were having a flashback, you might see trailing lights kind of going behind me, and it's quite difficult to treat and it can be really distressing for people, it can occur after only one, Single episode of hallucinogens. And it's no good if you're a surgeon or a bus driver or an airline pilot or a forklift truck driver, if all of a sudden you're at risk of these things happening, so people often come wanting treatment for it. It is rare, um, and unfortunately there isn't a huge amount of treatment for that, but I think HPPD is probably a bit beyond what you might get asked at medical school, although I don't set the questions that someone might come along with. I think it's a good question to ask. Any questions about LSD hallucinogens? Yeah, neurotransmitters. It's usually mostly serotonin, serotonin. You got that please, man. I'll go back to the slide if you want. And a bit of dopamine. But it's mostly serotonin. There used to be, do you still have like the mock questions that circulate around for the exam, like the multiple choice exams? Do you smile in seat 3D. Do you, there's like a question bank, wasn't there? Everyone knew that there was a question bank in medical school and like people wrote them down after the exams and stuff, but I remember there being a question when I was. It was like which of these substances causes a massive serotonin release in the CNS and the answer was LSD. And obviously I wanted to be an addiction psychiatrist, even at that stage I was like yes, I know that one. But yeah, it was always it might still be there in the band and maybe if they're recording this, I might get sacked. I've just told you what one of the answers is, but that was like 15 years ago, so I'm hoping it moved on. So Charlotte's moved on, so she's 22 now, she's come back to the UK signed Double Glazing, not for me. That exciting, um, going out on the weekend, still using cannabis, but she uses cannabis to calm down from all the stimulant use, such as going out and using. MDMA and LSD together. Sometimes mixing it up with a bit of amphetamines er and also and smoking loads of cannabis on Sunday night to try and bring herself back down so she can go to sleep and go to work on Monday. Finds that's not working anymore because she's using so much MDMA and LSD and amphetamines on a Friday and Saturday night, but on Sunday she's still really wired and you can't sleep. And so someone offers her a brown powder which she smokes and a foil and Instantly. All her agitation and edginess from the stimulant use 24 hours ago has worn off, and she also finds all her psychological distress disappears in an instant. So this is the mainstay of what I suppose I do for a living, or what addictions consultants do for a living, we treat opiate and opioid dependence. When we talk about heroin, there's a couple of things just to get out of the way in terms of definitions, so we someti, I use opiate and opioid pretty much synonymously because I think. Unless you're a pharmacist, why would you want to be that? Uh, that's just the way that it is. There may be some, hopefully there's no pharmacists ex- pharmacists and they bring that ground so, um, so an opiate is any drug that's derived from the opium poppy, that's an opium poppy and an opiate. fields in Afghanistan. Opioids are synthetic opiates. So opioids would be things like um, Panel, for example, doesn't occur naturally, only synthesised in the laboratory. An opiate would be something like morphine, which is derived from the opiate. That's your sort of clarification of terms. And heroin is an opiate because it's derived from the European poppy. That and it is usually smoked, certainly when people first start using it, 95% of people will start smoking it. People then often progress to injecting it, and we'll talk about that in a minute, why you might do that. Um, in very small kits, small number of cases, people snort it and that's a culturally dependent thing. So we've got in Nottingham, um, a group of individuals who've come over from a particular community in the Caribbean where in their, um their drug use culture, no one smokes or injects heroin, everyone's snorts it, and they've brought over that cultural practise with them. And so when they In Nottingham, they're not ejecting our smoking, they're still snoring. So it's quite an interesting kind of, I find it personally quite fascid. But most people are a smoker. And in the brain, once it's gone over to blood brain barrier, heroin, heroin's um sort of pharma pharmaceutical name is dimorphine so it's. Of Um, it binds to neuropioid receptors, so if you give those lots of agonism, you get lots of analgesia, but you also get euphoria and you feel very relaxed. You can also feel a bit sick. Um, you get a bit of Gabba inhibition, Gabba's a. Inhibitory depressant, naturally occurring neurotransmitter. I don't think you need to know that for this really, all you need to know is it binds to mur opioid receptors. Um, the bit about injecting and smoking, I think we're doing alright for time. Why might someone progress do you think, from smoking it to injecting it, and it's all about the route of administration. Yeah, absolutely, yeah, so if you didn't hear that, it's just you get, you get, you essentially get more bang for your buck. So most people will start off smoking heroin, you might be content with like 5 pounds. Worth a day maybe, and then very quickly you build a tolerance up to it, so a tolerance, the definition of that is that you need more of the same drug to, you need more of the same drug to achieve the same effect, because your body gets used. More and more and more. And so if you were then smoking 1015, 20 quid's worth. That's quite expensive actually when you start adding it up. If you progress to injecting it, you can get away with 5 quid a day again because you basically cut out the middleman in terms of um, Things like first fast metabolism, all that stuff, it's gone out of the way, you're basically straight into your um into your circulation and that's one of the reasons why the high is more potent. And it kind of basically makes it more affordable, yeah, so often people run up against the buffers of not being able to afford to smoke as much as they want and then progress to injecting that way and then you get lots of risks with injecting, which we'll talk about uh in subsequent slides, so yeah, well done. Uh, Next slide, this is the most important slide I think I've got of all of the ones to talk to you about apart from overdose. It's why do people use heroin. And so, so there's like I will go to talk to groups of mental health professionals, not psychiatrists generally, but other groups who work in mental health treatment, and they have no idea what heroin does. They have no idea why people use heroin. They've no idea what the subjective effects are. We think it makes people psychotic, it makes people kind of behave in, you know, strange ways, it doesn't, it's just a big CNS depressant that makes people generally feel good about themselves, and the problem with the drug is it's really, really addictive. And you can get a tolerance to it and then a physiological dependence very, very quickly, which I'll talk about in the next slide. If you ask people, and I told you earlier on, please do ask people why they use substance. If you ask people why they use heroin, they will say, you know, it is the most amazing feeling that I've ever had, it feels like I'm like wrapped in cotton wool, feels like I'm taken away, transported somewhere else, I feel, you know, amazing. The feeling lasts for hours and hours and hours. Um, takes away all my anxiety. And then that starts to get to the heart of kind of what is addiction treatment about and why is a psychiatrist coming to talk to you about addictions and. The GP. I'm not stereotyping, and it's really important to make this point, but lots of people who find a substance that takes away lots of unwanted psychological discomfort have got psychological discomfort from previous trauma, and I say I'm not generalising, that's not why people, everyone ends up being addicted to heroin, but a big subset of that population of people. Found this drug by one way or another, find that it gives them some inner peace, and that's one of the reasons why they want to continue using it, that then makes it very difficult to offer people treatment because from a medical point of view, there's no point in sticking you in my detox unit for 10 days and I can get you off of this if when you go back home again, all those problems that were bothering you are still there, so the treatment becomes much more of a bio psychosocial. Well, I've jumped the good one. And physical effects, so, and these are really important, we'll come back to these, if you were wanting to. Sort of assess someone for either acute opiates slash opioid intoxication or even overdose, you'll be looking at things like reduced respiratory rate. Bradycardia, CNS depression, so the GCS it would be 15 out of 15, no it wouldn't, it would be less than that, uh, and constricted pupils, so all the stimulants I talked about earlier cause dilated. The only drug of abuse that you're ever really gonna need to worry about in terms of your practise as a doctor, I think. that will cause restrictive is some form of opiate, and the most common So when people use initially, you don't really get much of a comedown, it's very gentle, maybe a bit of nausea if you're not used to using it, that goes after the first few times. The problem with heroin and most opiates is your tolerance builds up. Which means you need more to achieve the same effect. Um, the chronic and adverse effects are obviously the obvious ones, overdose, um, there are physiological withdrawals. There are all the problems associated with injecting yourself with, um, a substance that is, you know, not pharmaceutical grade, using unclean and unsterile, um, injecting paraphernalia, sharing needles with people in terms of transmission of bloodborne viruses. There's lots of adverse things about heroin, so it's a difficult drug, loads of problems with it, but for some people. A very, very strong physiological and psychological set of maintaining factors as to why they want to So that's heroin. One more drug. Let's talk about, um, which is often goes hand in hand with heroin. So, drug dealers are really Um, entrepreneurial, so we're often try and Encourage their customers to use other substances they can then supply them, particularly if it means So, um, Charlotte's drug dealer has given her a trial of a drug that er he said will make you feel higher than anything you've ever had before. And it's a drug that we've not talked about yet. So I've lumped these two together, but in effect they are two separate drugs really. I've put cocaine and crack cocaine together and I'm going to just very briefly talk about the differences between the two. So, powdered cocaine. No surprises, comes in a powder. Crack cocaine. crystal. And the reason that crack cocaine comes as a crystal is. Smoking, you can't vaporise powdered cocaine and just put I'm, I'm just all beat up, it's just annoying me. I know it's a bit warm, a bit cold up here. Keep waiting to go time zone. I'm Yeah, so powdered cocaine is snorted, so if you get powdered cocaine, most people snort it or rub it on their gums, um, and its half-life is about 1 hour, so you get the subjective effects for 1 hour, 2 hours, something like that. You can't vaporise it, its melting point is too high, unless you get a blowtorch, but then that seems a bit impractical, isn't it, too. it So in the 70s and 80s, before someone worked out how to make crack, people used to set fire to piles of cocaine with a blowtorch called freebasing because you were freeing. That. Doesn't happen now, er because some genius worked out that if you put cocaine powder with load of solvents in a microwave. And create space. Change its form into a crystalline form. It's got a lower melting point. You can set fire to it or you can vaporise it and you can smoke it. Powdered cocaine is one thing, snort it, lasts for about an hour or two. Crack cocaine, you smoke it or inject it because it melts. And it's half-life is about 5 or 10 minutes. There's a big difference. It's a crack cocaine, that is a crack pipe that's being constructed out of a um. A blue inhaler. So basically people get a rock of that lighter, it's enough to vaporise it, you inhale it or you melt it and you inject it. Either way, half-life's really short, um, so you might be thinking, hopefully some of you who are a bit switched on and what happens after the 5 or 10 minutes is up. 5 to 10 days, so. Yeah, you were gone. More and more Keep going and keep going, there's two reasons for that. One, because the high is amazing, apparently I'm not genuinely new so. That I weren't enough people to say, the, the highest, you know, it's the biggest high anyone has ever had, but it lasts so short that means the crash on the other way down is awful. So you're left with two choices then. One, you either redose because it'll take you back up there, or two. You live with that horrible jittery, come down feeling until it wears off, and most people. Go for the bed So, cocaine and crack, we've talked about the kind of difference between the um preparations and re administration, but essentially both of them working the same. So they block um monoamine reuptake transporters and offload pumps that bring things back in. Um, with cocaine, it's the same three neurotransmitters that are sort of uh implicated again, dopamine, noradrenaline, and sucking serotonin. With your cocaine and crack, it's mostly dope meaning noradrenaline and the, um, neurotransmitters that are elevated in its use. If you ask people why do you use this substance, they'll say, oh it makes me feel brilliant, I've got loads of energy, confidence. If any of you regularly, Go out anywhere on a weekend or a night or if you go to like football games or. You know, being in any setting where there are lots of men, then er powdered cocaine use is really common. Generally you can kind of spot those people because they're the ones that are being loud and aggressive. Half an hour, whatever, um, you won't really see people using crack. My dad said. Unless you're walking around some back streets of some city somewhere. That's very, very rare that you'll see people smoking crack, that tends to be done somewhere else and it's a different kind of settings for different use, but the kind of effects are the same, it's just that the hard life is so different. If you see people who are acutely intoxicated, very similar stuff with any other stimulant, so there'll be a bit of tachycardia. A bit of kind of fidelity of pupils decreased appetite. I The come down, obviously the come down from crack is really precipitous because it's up and down, powder cocaine a bit more smooth um but people can be irritable, they can um sometimes have, Concentrating, you can occasionally get tremors. The long-term use of powdered cocaine and crack is really problematic and it's one thing that's not talked about as much as it probably should be. Cardiac myocytes really don't like cocaine, and it's they're it's a toxic substance for them, and bear in mind you've got as many cardiac myocytes when you're born as you're ever gonna have, you don't really want to. Because they don't come back, you can have all the usual ENT complications of smoking or snorting, anything, so people who snort like powder cocaine sometimes turn nasal septums. People who smoke lots of crack, have all the respiratory problems that you would have from smoking stuff. We, in my service in Nottingham, we have once a week, we have a respiratory clinic where the respiratory physicians from Queen's Medical Centre come in and do a respiratory clinic with our patient population, because we've got people in their 30s with COPD from smoking crack, heroin or crack, or both together. Which is ridiculous, isn't it? You would think COPD is usually you maybe think people who smoke in the 60s and 70s, we've got really, really young. I've got that. So lots of physical adverse consequences, smoking crack. So we're going to talk a bit about the treatment now, the last 10 minutes. So, no more substances and so apologies for not mentioning all those things like benzos, NPSs, whatever else you wanna go on about, we're just. Time and leaving the car. People and I think So I've been back to Charlotte, she's now. in a treatment service, which is good, so you're seeing her in a drug and alcohol treatment service. She wants to go on some opiate replacement therapy, which I'm gonna talk to you about in a minute. Um, she's using a lot of substances, so if you add that up, like 30 quid a day of heroin. quid a day of IV crack it's like 9, 100 a month, something like that. Like I. If you're a consultant, any consultant in the NHS, you'd be lucky to get that. Take home tax. Time job, so how do you pay for that? Um, well, two ways, usually our patients, if they're using that much. It's either acquisitive sort of crime, robberies, shoplifting. Oh. Unfortunately, sex working, and so in this case, Charlotte is being forced to work by a pimp. Drugs, he's not even paying her in money, he's just paying her in drugs. So it's a really difficult situation, isn't it, and this is the reality of treatment that sometimes substances and people's. Unfortunate kind of um life stories get them into trouble and we're there to try and help. to The bit about sweating with a runny nose and looks cold is relevant, but we'll come onto that in a minute. So, you're seeing this lady, what are you gonna do? So she tells you she's got a nice ulcer, so that's a unilateral venous ulcer. See a lot of those in my service in Nottingham we don't have this, but when I trained in Sheffield we used to have a tissue viability nurse, um, I think it was 3 days a week or 4 days a week in the service just like sat downstairs in the building, so if anyone came in like just off the street wanting to have some help, we could get absolutely. Please go and see Karen and she can have a look at your ulcers and they can do things like um dressing, bandages, referral into vascular and stuff like that, so it's really, really, it was really good, really good. So. Kind of makes my point for me doesn't it, that complex patients have lots of problems. And one of the nice things from a clinician's point of view about work in this field is You can work within a bigger team to try and help that, so, um, in my profession, you need to know a bit about pharmacology, physiology, psychiatry and psychology to understand how addictions work, and we use a biopsychosocial approach to try and help our patients with their recovery, and I'm just going to talk you through that really quickly. I don't expect you to, hopefully this is on Minerva, so you don't, but it should be, I keep saying I'm sending it through, although people keep emailing me saying it's not there. Um, the biological bit of treating addictions is essentially giving medications, and there are lots of different classes of medications you can give to help treat, um, addiction. I literally could spend like 45 minutes talking about this one slide, I don't have time for it. But just so you know, in terms of people who are using substances, there are lots of different groups of medications we can prescribe to do different things to help them. So if you have had an overdose, we can give you naloxone, that's for opiate or opioid overdoses. Clonazanil, it's for benzodiazepine overdoses, although we, we often see that in A&E and on some hospital wards, but, It's not something that's everywhere. We can detox you so we can give you medications that are substitute a a a a a very, very quick substitution for the drug that you're using that avoids the withdrawal effects, so that then we can bring that down very quickly. In the long-term, we can give substitution therapy which we. We need to rather than you using heroin, I'll give you methadone or buprenorphine and you'll be on that for a few months or years and we will very slowly bring the dose down whilst you, we help you with all the other things that you've got going on. If you drink a lot of alcohol, we can give you a deterrent called disulfim which gives you an unpleasant physical reaction, and obviously we only give you that if you want it, we don't set you up. Consent thing. and One and then anti-craving medications, so if you drink alcohol we can give you a camp for safe. If you've previously used opiates, and very interestingly, if you've ever gambled, we can give you naltrexone, which helps with cravings for um for opiates and gambling, but I'm not here to talk about gambling. And then the psychological bit of it is a kind of, that might look like a random thing that I nicked off the internet, which is actually true, but what that is, is a very, very basic psychological er summary of how CBT works. So if anyone's ever done psychology, either A Level or you've been to like the doctor building in psychology, CBT essentially looks to try and break those yellow, greeny triangles. Because Are looking to break the links that drive human behaviour, and what you're saying in addictions is there's a behaviour here that is unhelpful for you. How do you stop it? And so thoughts, behaviours, experiences, what does that mean? It just looks so abstract doesn't it? So you might have a thought that you know my, my life is, you know, kind of rubbish, worthless, I can't believe I've ended up like this, you know. I I just feel terrible. Feel dreadful, so the behaviour then the thing that makes you feel better is using alcohol for example, you have a few pints of lager, you feel better for a bit, and the next morning you're hungover and you feel awful, you feel dreadful, you get this feeling of guilt about having done that before and then you start to feel bad about yourself again and then that bad feeling makes. You feel better to have a drink. Around and round and round, and CBT looks to try and break those links. There are other things that we do within treatment, some motivation interviewing. Self management, but the cornerstone of psychological treatment in all addictions is CBT and then It's a picture of Park Hill Flats before they got. Gentrified um as it used to be when I was a trainee. Most awful Right law department, so that, that there is a kind of sign that if you um Let's say for example if you are heroin dependent, so you're injecting. You're a cracking heroin. Injector and you live in a block of flats, 6 flats. Underneath you is a crack house, which is a flat where people just go to smoke crack cocaine. Downstairs at the bottom is the drug dealer and the other 3 flats are built by other people. As well, when they get paid. Um, or when They know you've got paid by knocking on your door going, do you want to come and use. Brilliant, I can take you away and put you in my. For night and detox you from the substances we put you back there. You know, a week Surprised if you haven't relapsed, and so one of the things that we try and do is to help people with all the other things around them, so they come to us and say, I really want help with this substance, and we go, OK, fine, we can do that thing, but are you, is your housing OK, are you getting all the benefits that you should be able to get? Are you in any training or education you might want, are you in employment, are your relationships OK, are you the victim of, you know, some unpleasant um relationship yourself, what's going on there? Have you ever been? probation patients in and out of prison, so all those things are factors, and we have people who represent all those agencies, so social workers, housing. Criminal justice in terms of that uh probation workers are based in our services, so we can offer everything under one roof for people, so we're not just going here's some. Methadone, come back in a month. It's much more comprehensive. So, last couple of slides is all about treatment. So I mentioned opiate substitution, so if you came into my drug and alcohol clinic, um, let's say 70% of my patients are opiate dependent on opioids. The mainstay of treatment, if they come in and say look, I'm using heroin, I just wanna stop, please help me, I will say OK well what have you had anything that's helped before, let's say for example at the say no. The two choices you would have is either methadone or buprenorphine. I've I've written the differences and the similarities there, essentially what you're doing is you're saying, OK, you're dependent on heroin, which means that you have such unpleasant physiological withdrawals that you're having. And that's one of the things that drives, you get the nice feelings and everything that I've talked about, but also the thing that's really driving the use is you feel so bad when the substance is worn out of your body that you need it again to you can just feel normal, to be able to function. So the purpose of opiate substitution is to give you another opiate that doesn't give you the high, the euphoria, but staves off the unpleasant withdrawal features. Yeah. In the old days we used to give people heroin. So we used to literally like 30 years ago.