GEM - drug misuse educational module

Drug misuse:

• alcohol and psychoactive substances have been woven into every society since the beginnings of the human race. The use of illicit drugs (heroin, cocaine, ecstasy, amphetamines and cocaine) in the United Kingdom has risen year on year over the last few decades and national figures for England (2001/2) report that the number of users (predominately heroin) in treatment with drug services and GPs as around 150,000
• "The RCGP and GPC believe that GPs should offer appropriate care to all patients on their list. Where patients have problems with substance abuse, appropriate care will include aspects of primary care normally provided by the practice health care team, shared care with other services and referral to other appropriate services. Certain GPs may develop experience in their care of substance abuses, and the number and location of these doctors should ideally, be sufficient to avoid substantial workload falling onto only a few GPs" (1)

Cannabis

Cannabis is formed from the dried flowering tops of hemp plants which have euphoric properties. It is classified as a hallucinogen. Cannabis is very widely grown and available, and is usually smoked with or without tobacco. It is obtained as dried leaves or as a resin. It induces feelings of well-being, relaxation and tranquility, though it may also give rise to apprehension, anger and depression. It is usually used socially

- how can cannabis be consumed? Is cannabis smoke potentially carcinogenic?

• GPN reference 1
• GPN reference 2

- the area of cannabis and development of psychiatric illness is controversial. What is the evidence base regarding psychiatric illness and cannabis use?

• GPN reference

- how does cannabis affect motor skills?

• GPN reference

- how does cannabis use affect the risk of coronary heart disease?

• GPN reference

More information then consult Cannabis section on GPN

Alcohol

Nearly one-fifth of patients treated in general medical practices report drinking alcohol at levels considered "risky" or "hazardous" and may be at risk for developing alcohol-related problems as a result. Excess alcohol use plays a significant part in the epidemiology of health and social problems and is responsible for significant morbidity (1)

Excess alcohol consumption has been implicated in:

• up to 22,000 premature deaths per annum
• at peak times, up to 70% of all admissions to accident and emergency departments
• up to 1,000 suicides
• 1.2m violent incidents (around half of all violent crimes)
• 360,000 incidents of domestic violence (around a third) which are linked to alcohol misuse

A tool used to assess alcohol consumption is the CAGE questionnaire. What is the CAGE questionnaire?

• GPN reference

When assessing a person's alcohol consumption, what is the equivalent of one unit of alcohol?

• GPN reference

Chronic alcohol consumption can be associated with a confusional state due to acute intoxication. What other causes should be considered?

• GPN reference

What is Korsakoff's psychosis?

• GPN reference

Regarding pharmacological treatment of alcohol withdrawal:

• should diazepam or chlordiazepoxide be used?
• what supplements should also be given?
• should routine anticonvulsant medication be prescribed?
• GPN reference

More information concerning the alcohol knowledge base see alcohol problem drinking section on GPN

Cocaine

Cocaine was obtained by South American Indians from the leaves of the coca shrub. It was popularised in late nineteenth century middle-class Europe. It is illegally imported from S. America as a white powder and is colloquially refered to as coke or snow. Cocaine is usually sniffed or snorted from a spoon or tube, and absorbed via the nasal mucosa. The stimulant effects wane after 20-30 minutes.

What is crack cocaine?

• GPN reference

What are the complications of cocaine use?

• GPN reference

Heroin

It is more potent than morphine, causes less nausea and hypotension, and its greater solubility allows effective doses to be given in smaller injected volumes - this property is useful in the emaciated patient. Its capacity to produce euphoria gives it great potential for causing dependence. Tolerance develops: an increased dose is needed to produce pleasurable effects. It is usually bought in a brownish powder, and is smoked - "chasing the dragon" - or dissolved in acid for injection

A 20 year old heroin addict has presented to the GP surgery for the first time this afternoon. What are important aspects to consider during this first consultation?

• GPN reference

This gentleman was referred to the local community drug team and is to start on treatment with subutex.

What is subutex? GPN reference

What are the advantages for prescribing subutex rather than methadone? GPN reference

When prescribing methadone, what is equivalence of buprenorphine (subutex) to methadone?

• GPN reference

Is methadone or buprenorphine recommended as the first-line option for opioid detoxification by NICE?

• GPN reference

What is lofexidine?

• GPN reference

For more details see heroin section of GPN

General information

• urine screening
  • which statement below is false
    • cocaine metabolites are testable in the urine for 2-3 days after use
    • amphetamine metabolites are detectable for 1 week after consumption
    • a chronic heavy user of cannabis might have detectable levels of metabolites in the urine more than 3 weeks after use
    • GPN reference

Reference:

1. Royal College of General Practitioners. Curriculum Statement 15.3 Drug and Alcohol problems