Gp safer op transcript — SMP305 lecture transcript

Come OK, just keep working on this question and give it another few minutes to see if anybody else turns up. Just think about what you've seen prescribed as well on your placements. Probly seen a few opioids prescribed. Good So let's have a think about this for the people who have just entered the room, it's got 5 minutes just to. Think about How many opioids do you know? And if you've been here for a bit longer and you've renamed some opioids, think about any side effects maybe. Maybe when certain opioids might be used rather than others, why you would choose one opioid over another. OK, let's think about Starting, so. We'll come back to your opioids list in a moment. Um, So, hello again, so. You haven't seen me since the start of the rotation, come and grab a seat. Uh, it's Mark Loveland gave your polypharmacy. Um Seminar, I won't lie on the floor like Doctor Loveland does, I think she's very good. it. Um, so yeah, so I hope your rotation's all going OK, I hope you've seen plenty of stuff on placement, learning stuff, getting to see patients, spending time with other healthcare professionals, um, yeah, if you have got any questions or concerns, you can email me, um, and we can talk about it, but, uh, today we're talking about opioid prescribing. The idea being that you need to be safe at prescribing opioids, know when to prescribe opioids, know some concerns with opioids, and we'll think about this in a primary care setting mainly, but we will talk a bit about secondary care as well, because that's where you will be working, especially when you start your irritations. So the aims of the seminar to understand acute and chronic harms of opioids, opioid medication. Approaches to prescribing opioids. This will ultimately help you prepare for your PSA which comes. Is it about 18 months for you guys, is that about right? Hold up, phase 4, phase 4, I think you can play 4, not the end of 3B is it? And then, so yeah, but all, all the prescribing work you do and when you're in placements, cos you should be looking at medication lists when you're on placements, all of that will help you uh with your PSA so you that should always be something which is you're naturally uh preparing for throughout the course, and recognising acute opioid toxicity and drug seeking behaviours, so that is a factor that we. OK. Just an important point about. Today's seminar, so we're thinking about opioids in the context of non-malignant pain, so we're not talking about patients with cancer, there will be a different approach with opioids with patients with cancer, OK, so we're making that distinction straight away, so this is not thinking about opioids in the world of palliative care. You'll be doing palliative care, next year, you'll spend a week in the hospice and you'll be thinking more about palliative care as part of your GP rotation in 3B. So, uh this is thinking about more chronic non-malignant pain. Um, good. Right, so we're back to that first slide that we had at the beginning. So What opioids do you know, what have you seen prescribed? Come grab a seat, come and grab a seat. Who can say, who can name an opioid. Codeine, good, most commonly described opioids. So we have Cody. Curtis and Cody prescribed. Everyone, Pretty much everyone, yeah, yeah, very commonly described. Right, so we've got code, number one, what else have we got? Or as we know. Or a more. So Horomorph is a Trade name, so oromorph is you wanna describe what oromorph is? I don't know who said it, did you say it? What degree, how would you describe Aw? Full of morphine. Well yeah, so, so it's oral. Liquid. Very good. And you could even go up another step and say it's immediate release. sustained release effects, it's immediate release. OK, good, very good, thank you for raw. Um, what opioids do we know? Fentanyl, good We'll talk about some of the differences between the opioids in a moment. No, let's do it together along. Right, so fentanyl. Fentanyl, um. Safe and renal failures, if you are prescribing to thinking about the things that we talk about safer opioid prescribing, the fentanyl, you can do as a patch. Um, there's some conversions of fencing itself. It's safe in. Renal failure, OK, so it doesn't accumulate in the same way. So, for example, when I was an SHO just learning from my mistakes, when I was working in orthopaedics, I was looking after patients on the ward who'd had a hip fracture and they went into acute kidney injury, and I didn't drop the codeine dose, and they became overly toxic from having a high dose of codeine for 24, 48 hours without me dropping the dose, and then, I mean, he lost a day of his life because he just sucked it up, but, you know. That is something that can happen, so you have to think about how medication excreted from your body, so if somebody's physiology changes, you might need to change the dose of the medication, so this guy was over toxic, um, he wanted to stop the codeine, he slowly excreted it over a longer period of time, and he just woke up the next day, OK, but still, fentanyl would have been a safer choice, fentanyl patch. Reduce the dose or space out the dose. time, so the kidneys. Excre A rate OK, so let's think about some differences. Obviously fence will give the patch, to cut, what other opioids do we know? Oxycodone, very good. Oxycodone.

Oh, might be on board. Uh synthetic opioid, um. commonly prescribed So that's the one that we got big with the epidemic in America, where the, who's seen Dope sick? One, I've got one head nod to ask the seen dope sick. Top of the class, right, this guy's top of the class because he seemed dope sick, alright, right, so dope sick is a really good programme, I actually recommend you watch it cos it actually explains quite well how big pharmaceutical companies push drug drugs sometimes, so Purdue Pharma in America, and they kept telling people, or doctors, prescribers, oxycodone's safe for chronic pain, it won't cause any problems, use it, use it, use it, and they kept pushing the doses up. Um, obviously it created, created a massive problem in America, um, opioid addiction, and then when all the doctors stopped prescribing it, because they realised it was a problem, we've got a load of, um, opioid addicts. Uh, heroin and things because they're gonna buy it on the streets where it's cheaper because it's. So, I would recommend watching Dope 6, that's part of your homework from this, um, this seminar. Yeah, oxycodone, the syntheid go for it. Is fairly safe in renal failure as well, so you might see this being prescribed for people with a poor renal function, um. It would be safe about one-off doses and immediate release. If you're given sustained release or as a syringe driver, it will still accumulate and cause opioid toxicity. You It's fairly safe, and you're seeing real protocols, it's fairly safe for people with er poor ring. Good, so oxycodone. And this 56 you prescribed. the common one. Cocodamol, I'm gonna put that next to Cody. Cocodol. So when you see code at the start of the drug, that means it's a combined drug, so the code is combined, that bit of code is codeine. Our seats and all that. OK? Anything else? Methadone, good. Where do you commonly see methadone in more of a primary care? Drug misuse services unit to try and get people off. Opioid addiction, so you try and, instead of at a dose and you try and wean it down over a period of time in a controlled environment, you try and weed it down with variable effects. The problem with methadone is it doesn't change the social environment. So somebody's still in an environment where the drug dealer's going to go and see them. really control that, so I think, I think as a principle it probably has some good foundations, but to help get people off drugs takes a lot. OK, the drug misuse services does have, it is, um, obviously an analgesic as well, so if people are on methadone. It will still give them pain relieving. What other drug, what other alcohol is used in drug misuse services? Yeah, People closer. services Um, Subutex. would Also used as patch. slow Yeah, so steady state, pain. The patch, OK. Any other opioids, commonly prescribed ones? There's one that's commonly prescribed, you may see prescribed. The gain, the gain is a gabapentin, so it's not an opioid, but yeah, thank you for answering. Any? Tramadol, tramadol, there's two answers at the same time, you've got tramadol. It's got a fairly high SSRI effect um as well. Yeah becomes an immediate release. Sustained release. And Um Yes, Trad are very commonly prescribed. Um Opioids, we're gonna talk about negative effects of opioids in this. There's another answer at the same time, someone said tramadol, someone said. Morphine, good, so we've got. Or more. Uh, morphine, yes. They're the ones that I would have expected you to perhaps come across at this point in your training. I think there are others. OK, good, so let's get your brains thinking so what opioids, what medications are we actually talking about in this seminar, um. And this is them. Right, let's move forward. So why, why even have this seminar, why, why pick opioids rather than any other. Medication. Well, Do So this is the prescribing rates of opioids in South Yorkshire, so there is a direct. Um You know, it's not, you're, you know, it's implicated in the area that you're training, so in South Yorkshire we can see that, um, per 1000 patients over 3 months, so 3 months is the time frame where you think somebody's been using, you count that as long term drug usage, so if someone's on it for a month, they might have used it for an acute problem of back pain, and that's got a level of appropriateness to it, but long term opioid use, you would say is where you get above 3 months, OK, so, This is what happens in South Yorkshire, so there's about 20 to 21 patients per 1000 having opioids for more than 3 months, and the national average sits between 15 and 16, so we're we're above the national average. Might be because the industrial past of South Yorkshire, um, there's lots of deprivation in South Yorkshire, areas of, um, you'll be working in them, you'll be seeing them, most of you will be seeing them in your placements, not everybody, but a lot of you will be. Um, opioid prescribing goes up in areas of social deprivation. So there is work within the um ICB there are GPs looking at this, trying to decrease the amount of opioids that have been prescribed across the board, so it's something that's been actively looked at, but you will be seeing this in, in practise. So it's directly applicable to where you're training, so that's why we think about it, and obviously there's negative effects from opioid prescribing, which is why we're having this conversation. Right, I want you guys to do a bit of thinking. So With the people around you, sit and chat and think about this presentation, so you're in clinic, you'd have seen something similar to this I'm sure when your placement, you've a 34 year old man who presents to his GP who's got lower back pain which started a week ago. He works in a builder's yard, which involves moving heavy items and driving a forklift truck. So obviously this is quite short. scenario, but think, just think about what you want to ask, think about what you, um, any tests you might do, just think about the presentation, what management you would think about putting in place and how you'd help manage your back pain overall, OK, so think of all the options, so we're talking about opioids, think of all the other options that might come into your head as well when you're managing someone's back pain, in a week, so it's only a week long, OK? So talk to the people around you, just think and think about the cases you've seen in placement, you would have seen things similar to this, how is it managed and how should we manage it? Right, so you've got 5 minutes on this.

I Uh. I don't know, I, I just, I think I'm just, I like. I I I've got other reason They I. I, I. I I Yeah. No. Let the fat steak in the oven. I like I It's probably just like a sandwich. I think Yeah It I I. Yeah. Oh yeah, the I I It's like a nice. We wouldn't have any. I'm excited. I. I. that It I OK no you The this one. he's OK. Just for the purpose of time, I'm gonna, I'm gonna bring this all back together, so there's been a few, just walk around the back, got to speak to a few groups. Um, there are different ideas, and I think it's good to see that everyone's sort of thinking about really important things, uh, but there's actually quite a lot to unpick with just these two sentence, two sentence presentation. So, so you've got this 34 year old man coming with a lot of back pain which started a week ago, so. One group I spoke to very rightly was talking about, thinking about red flag symptoms, so there's a lot of conversation about expanding the history, um, um, but we're thinking about, you know, the, the, the pain history, so understanding the pain in more depth, but also thinking about any red flags with the history taking as well, so, um, is there any reason for an urgent assessment, um, has he lost use of his legs, has he become incontinent of urinal faeces, um, is there any numbness anywhere, any saddle numbness anywhere, night sweats? Um, weight loss, so we started to think about these red flags, which is good, that means, um, we're not gonna miss anything, we're hopefully not gonna miss anything, and depending on the outcomes that question would drive you to do all the tests. We can think about the pain history, um, so we need to think about the onset of the pain, what aggravates the pain, so we've got this. We've got the manual job there, so does that make it a lot worse, is it worse after work, um, is the pain worse in the morning, um, you know, we have to think about a few other things like rheumatological conditions as well, morning stiffness that settles within half an hour or so, um, any other joint problems anywhere else, so I have to think, think quite broadly as well. But then, let's say we've got a feeling from this that it's a more of a muscular work related back pain. We have to think about some of the questions as well, so what. What has he taken over the counter, paracetamol, ibuprofen? Because if he hasn't taken those, that's a good place to start. If he has taken those and he's used top dose ibuprofen, and he's had the inflammatory effect, he's using paracetamol, we might think we need to prescribe something now to help this man out. Um, So let's say we're gonna think about prescribing some codeine, he's in a lot of pain, he looks in pain, he's, he, you know, he's he's clearly not moving very freely around the uh around the room, he's struggled to stand up from the uh waiting area, so sometimes it's quite good to call people in because if someone stands up really slowly and they're a bit stiff, you think that person looks in pain. If they just stand up and freely walk in like you know it's a spring day, then you're thinking maybe not enough. OK, so let's say this guy looks in pain. What might you think about prescribing next off your. List You've got your opioid opioids that you've listed before, which one do you think would be most appropriate and what have you seen prescribed the most in similar situations? We're describing in 2 years. You have cocodamol, good, OK, fine, yeah, that's a good choice. I've picked either cody or co-codamol. Um, if you are prescribing co-codamol, just let the person know that it contains paracetamol, so they don't accidentally overdose themselves over a period of time, um, with the sort of paracetamol content. But yeah, uh, codeine, co-codamol. OK, so I'd say that's a fairly solid choice if we're gonna prescribe something. What information are you to give to the person when you prescribe it? Good, and this man drives a forklift truck. So yeah, so that's really important for this chap, so we need to make sure we talk about that. Uh, so even if somebody isn't driving a forklift truck, just driving in general, you know, you've got a HGV driver as well, bus drivers, you know, you have to you have to talk about this. What is the DVLA guidance on opioids and and driving? If you're gonna be safe prescribers of opioids. There isn't any really, and there's no like sort of dose cut off, it is how the person feels, so you talk to the person, you basically say, well I say, my way of doing it is if I'm prescribing opioids for the first time, I'll say take it on a weekend when you don't have to drive or go to work or take it on a day when you're not at work if they work shift happens, whatever, take it at a time where you can understand how it affects you and then you know if you're safe to drive, OK, so some people who might have other, Needs might be on high dose opioids in a different scenario, maybe they've got cancer, and they can drive but they're taking much higher doses, but they're tolerant to it, so you build a tolerance to it. OK, we're good, we have to talk about safety with driving, that's important for this chat. We also have to think about explaining that we're not going to be using this codeine long-term. So you set your stall out early, you talk about this is just a short-term month, maybe 6 weeks is what I'm thinking, and we're using it to get over that acute pain and keeping you mobile, because part of your treatment is staying mobile, perhaps physiotherapy when things get a little bit better. So you've set your sort out, so if the person comes back and keeps asking for repeat prescriptions, you can refer back to your initial consultation and say look, we talked about this at the start, it's not gonna help you long-term, it's gonna help you more in a short-term space while we work on other things to help. Maybe there's weight loss to be done here as well, you don't know, we've got, you know, we haven't fully described the patients, but you know, you have to think about other things around the pain to help. Um The other thing that we have to think about for managing pain in the workplace is occupational health assessment. So You all might be getting slightly bad necks because you're looking slightly down at your laptops, OK, you know, hold your phones up like that, hold them down like that for your next, but you know, what you do affects your health and your body, so this chap is lifting things incorrectly, he's gonna get bad back pain, so an occupational health assessment might help him stave off getting long. have OK, so good. Has anybody else had any other thoughts or conversations that I've not touched upon, I've kind of just try to summarise that as best as I could. the time we've got. Any other thoughts? If he, right, so, good, good question, thank you, prompting me to think about something, thank you. um, so if the over the counter medications hadn't been tried, so we hadn't used paracetamol or ibuprofen, that's what I'll be advising too. If it comes to me and says I've already tried it, it doesn't work, then I'd be thinking about the code, just to clarify. With back pain, so 90% of lower back pain will get better within about 6 weeks, so I wouldn't dive in for physio at this point, what I would do is print off or give a link, Basic exercises, stretches, maybe think about yoga, Pilates, um, which I advise people to look up on YouTube rather than spend money because it's quite it's expensive, um, so getting people to think about stretching their hamstrings, stretching their back, touching their toes, and just staying mobile so they're not sitting still, and talk about that first, if they came back to see me maybe around week 4 and it's no better, then I'm getting physio involved. And in primary care we can do direct booking into physiotherapists as well, so that helps. So that's the time frames that I've worked. Low back pain is Second largest reason in South Yorkshire for disability adjusted days lost, so basically it's got a very high presentation rate and it also causes people having disability issues, not be able to function in society as well as they would like. OK, so back pain's really important. Number one is ischemic heart disease. That causes, um, lost days of good life. OK, right, so let's think about uh prescribing. So, opioids are very effective in treating acute pain and are best used as part of a multimodal analgesic approach, so that's important, so. When you are managing people with uh pain needs or chronic pain, you have to think about what is the best type of analgesic, so it's not just the ladder, sometimes you've got to think about what is most appropriate for this person, that's why you have to think about non-pharmacological and pharmacological approaches to managing pain, um, so opioids are really good at treating acute pain, if I was about to have an operation, if I fell over and broke my leg, I'd want some opioids, you know, they're pretty good, OK, so you know, if you have to have a laparotomy or a big operation, you want that as part of your, Approach, and if you've got acute back pain in primary care, you can use these for a period of time. And this is why we set our stall out early, so we want to talk about what we expect from the opioids, acute pain management, and we want our patients to understand that we're not using them long-term. We discussed that at the point of prescribing them for the first time. How often are you seeing that in practise? A GP's good at this across the board? Oh very good. Oh, I thought the slide came later. Uh I might come back to it. Uh, let's see what, yeah, when we come back to that, we'll go forward. Um, OK, so chronic pain is commonly thought of as pain that is greater than 3 months. So we're just going to take a moment to think about chronic pain, then we'll go back to the case. So chronic pain is a disease in its own right, and it's uh got monumental impacts on society and on individuals, um. So when people come and tell you about chronic pain, and we're talking about chronic pain, probably not in the guise of fibromyalgia, I think fibromyalgia sits slightly differently. For which you'd never prescribe opioids for for fibromyalgia, just doesn't help, doesn't help a person, um, but for chronic pain, you know, it's, it's a huge, huge problem uh for people. So let's just think about that for a moment, so, um, so we've got no susceptive pathways, so what, what you just think for the people around you again in a second. So how chronic pain sort of manifests itself and predisposing factors to getting chronic pain. So sort of social expectations about what people expect from pain and how it should disappear, past pain experiences, so we're sort of setting a foundation for how people interact with pain themselves on a personal level, how our pain pathways work. Financial barriers, so in, you know, we have the NHS which is quite slow at the moment, um, but other countries don't have access to healthcare at all. If you have good or job good or job uh good or bad job satisfaction, um, that can impact. Whether you're getting propane, previous substance abuse, support systems, language and cultural barriers. The thing about biological or physical, just take a minute with the people around you before we move to the next slide. Think about the psychological aspects that can predispose to chronic pain, and biological or physical aspects. So stay with the people around you for the next minute.

Let's turn it off. OK. So, sort of biological physical aspects that might predispose to chronic pain, sort of genetics, so there's genetic predisposition, um. Magnitude of injury or disease, so, you know, if you have a very large injury, car crash, something of that nature, obviously that may well lead to chronic pain, um, as opposed to just. Um, your gender. Nervous system characteristics of obviously linked some of the genetics bullet points. People You know, we have pathways in our brains to dampen down pain signals ourselves, so if you have ongoing pain, uh. Be transmitted to your brain, um. A painful stimulus, your body does have pathways to try and dampen down that pain, so people, some people are better at it than others, um, sleep, if you're, Deprived of sleep, then your pain threshold will drop, you'll feel more pain. And with increasing age, um. it Which would make sense if you got arthritis. And then obviously other psychological impacts of depression, obviously chronic pain and depression, anxiety, uh, they interlink, if your pain's worse, you're gonna feel low, if you feel low, your pain will be uh magnified, uh different coping skills, um, you know, your personality. Pro the police, emotional stress. Not quite sure what it means, but yes, so if there's other things going on in your life, um, you feel emotionally stressed, um, maybe things external to yourself, and that can make chronic pain worse, so chronic pain is more prevalent in deprived areas as well, um. Diffical neighbourhoods, then yes, probably pay more. And the effects of chronic pain. So why does the WHO Acknowledging such a problem. Well this is why all the, all the problems that come with chronic pain, then we have to think about how we're gonna manage chronic pain as doctors. So, but a lot, they're all important, but all these things that jump out at me is sort of dysfunctional relationships with people in pain all the time, it's very hard to have uh ongoing good relationships with the important people around you, uh, deconditioning, so if you're in pain, you don't do as much activity, you decondition, therefore you can't get back to where you were, um, the big one, sort of cognitive impairment, loss of grey matter, so if you're in chronic pain, you're at higher risk of cognitive issues, um, medication use or abuse? Trying to find a way to escape the pain. Social withdrawal, poor concentration, I mean they're all important, aren't they, you can just, you read them all yourself, so, chronic pain. Has wide effects on people and society, and we have to try and help manage it. It's good. However, how we manage it might not be using opioids, so. There's no evidence-based argument that can be made to use high dose opioids. 200 milligrammes morphine equivalent, I'll come to that phrase at the minute, or daily in clinical practise. So using high dose opioids does not improve your pain management in chronic pain long-term, opioids are good in acute pain, not so good. Do you know what 200 mg morphine equivalent means? So, have you ever seen opioid conversion chart? So if you all just take 30 seconds to Google opioid conversion charts, and that'll help me explain what this means. Again, this is a prescribing. It took a moment to think this is Important with the practicalities of prescribing opioids. So open conversion charts, they allow you to Move from one opioid to another at roughly equivalent doses, so for example, if you need to convert somebody's morphine because they've gone into acute kidney injury, you need to know what dose of fentanyl that's equivalent to, so the opioid conversion charts allow you to move people between roughly equivalent doses of medication should their clinical. OK, so for example if somebody can't swallow all of a sudden, you might need to put them on a patch or a syringe driver, so the opal, so when you're prescribing, practical aspects of prescribing. No. So the oral morphine equivalent, so if you're doing studies, let's say you're doing a systematic review and you want to look at the effects of opioids, and everyone's used, you've got loads of studies using different opioids, you could convert everything back to oral morphine, so you can have direct comparisons. Does that make sense? So you've got tramadol, you've got oxycodone, you've got fentanyl, convert all that to oral morphine, you can see what doses each study use. OK, so we often talk about that. So yeah, and the idea being, so it says 200 here, um. In the Cochrane review, however, When the opioid epidemic in America started to become very problematic, studies were saying that if you're taking more than 120 milligrammes of morphine in a day, you've got an increased risk of all-cause mortality, um, above 90%, statistically demonstratable, so. You really have to be very careful about using sort of opioids long-term and you have to be very careful of any dosage. OK, so high doses equal negative outcome. So I rarely describe. I try to think of practical, what I do in practise. Um, yeah, I, I tend to look after old people at home, if they've got some really chronic pain. I really try and avoid opioids, but stop and when pressed, I might use a very low dose Butrans patch, it'll be nowhere near these. So what are the negative effects of opioids?

What do you know? But I have a minute to think with the people around you, and then we'll stick to on the board, so what negative effects of opioids do you know? Side effects, negative effects, let's just have a think for a minute. OK, let's see what we've, uh, what we thought of then. So who wants to start by shouting one out? I say negative because I always think side effects are things that you might be able to sense, but some of the negative effects you won't be able to sense, so. Um, what do you think the negative effects of opioids are? Constipation, very common. patients, they come with all opioids, codeine's very constipating, uh, theperamide, Imodium is a opioid which doesn't cross the blood brain barrier. Constipated as well, in the same way. So when you activate um new receptors on the Gut, it slows them down, which is why you get constipated. So just think about this for a moment, if you're prescribing an opioid, especially to an more elderly population, what should you co-prescribe with it? Laxatives, good. Now I just told you Codeine and other opioids will slow down, slow down peristalsis, so what type of laxatives do you want to prescribe? Stimulant. OK. Can you name any? Do you know any? Senate is Very good. Another Example as far as carry on, so yeah, so you want to prescribe a skin a laxative, there are other classes of laxatives which you can look up at your own leisure, um. Yeah, constipation, you see, and when we're thinking about our safe prescribing and what we're gonna say to patients when prescribed opioids, we have to talk about some of the negative effects. So constipation, and if they, you can talk about buying, selling it over the counter or prescribing it if you need to. So yeah, good, so constipation. Anything else? Sorry. OK, good, and you said We'll So respiratory Depression. When, OK, so you, you get that in toxicity, somebody's flat, if they're not toxic, when would you most notice the change, when would they most experience or have respiratory problems? Without being sort of toxic lying the floor, I'm out of it. Daytime or nighttime? Quite time, yeah, so you can get um sort of nocturnal breathing problems, so increase your risk of apnea. So if someone says they get really, really tired and that person's also really, really at risk of having sleep apnea, maybe they're obese, large necks come from. Um, Yeah, cause apneic episodes. OK, so somebody describes worsening sort of daytime. Falling asleep at the drop of a hat. It might be something that Oprah. OK Other analgesics that can cause disordered breathing at nighttime are your pregabalins, gabapentins, diazepam, your benzodiazepines, alcohol, so if someone's on a combination of these things, it, it obviously increases your risk. Night, OK, so there's a cumulative effect across it. We're good, yes, uh opioids affect your respiratory uh drive. In palliative medicine, if someone's really short of breath, we sometimes use low doses. To use that effect in a positive way, so if somebody feels less short of breath, their breathing doesn't improve, but they're not bothered by it so much. So opioids can help manage dyspnea. Abuse, yes. OK. Abuse. So people get addicted, and Right, so only one person's seen Dope sick, so who's seen Trainspotting? 1234, this guy just watches a lot of TV. Uh, yeah, right, so you've got, if you haven't seen Trainspotting watch Trainspotting, if you haven't seen Dopesick watch Dope sick, so Trainspotting. Is a good It's a good film, it's a good story, it's a good book, um, but it looks into the world of heroin addiction in Glasgow, uh, where I think Scotland's got the highest number of drug related deaths in the EU at the minute, statistically, so like it's quite apt still, even though it's. Um, but yes, you'll see the effects of abuse. Um, you know, the desire to want more, and the thing with, um, abuse, people using drugs inappropriately, uh, we'll talk about that in a moment, um. So they use it for, you know, the euphoric effects, might be using it gets to help them sleep, um, so they're not using the medication for the right for the purpose it was designed. Um, yeah. So heroin, but that's dimorphine. Yeah, so abuse, and then of course if someone is becoming addicted and they're abusing the medication. They might then start to commit.