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Home , Poly drug use

Drugs and in Primary Care Steve Brinksman Clinical Lead SMMGP Medical Director Cranstoun Group GP

Trends and Issues

• “Traditional” • Prevalence

• Alcohol • Age

• to Medicines • Co-morbidities

• Novel Psychoactives • Recovery v

Drug harms in the UK: a multicriteria decision analysis

The Lancet, Volume 376, Issue 9752, Pages 1558 - 1565, 6 November 2010

doi:10.1016/S0140-6736(10)61462-6

Drugs ordered by their overall harm scores, showing the separate contributions to the overall scores of harms to users and harm to others. The weights after normalisation (0–100) are shown in the key (cumulative in the sense of the sum of all the normalised weights for all the criteria to users, 46; and for all the criteria to others, 54). CW=cumulative weight. GHB=γ hydroxybutyric acid. LSD=lysergic acid diethylamide. Estimates suggest over 300,000 problematic & crack users in the UK

Over 6 billion £s a year spent on illicit drugs in the UK

70% of acquisitive crime related

Over a 20 year injecting career, 75% will become infected with hepatitis C

Mortality rates between 6-16x higher than general population

Ageing Populations

Age Effects? Drug Related Deaths

• There were 3,744 drug poisoning deaths involving both legal and illegal drugs registered in England and Wales in 2016, the highest since comparable records began in 1993.

• Of these, 2,539 (or 69%) were drug misuse deaths involving illegal drugs only.

• The mortality rate from drug misuse was the highest ever recorded, at 65.8 deaths per million population. Graph showing deaths, comparing untreated patients with those in maintenance treatment in the Swedish study (2).

(Reproduced from Gronbladh et al) Role of Primary Care

• Chronic relapsing nature of condition – patient stays registered whether still using, on OST or abstinent

• Advantages of primary care treatment, including continuity and the treatment of associated health problems • Familiarity in dealing with complex problems needing behavioural change

“Habit is habit, and not to be flung out of the window by

any man, but coaxed down-stairs one step at a time.”

Samuel Langhorne Clemens Co-morbiditity

• COPD

• Ischaemic Heart Disease

• Hypertension and CKD

• Liver Disease including Cirrhosis

• Diabetes

• Mental Health

• Poly Drug Use

Engaging users with treatment programmes has been shown to vastly reduce the cost of drug addiction to society in a number of ways: for every £1 spent on drug treatment, there is a saving of £9.50 to society as a whole (Department of Health, 2008). Reduce barriers to entry

High quality medical and psychosocial services

Treatment retention

Orientation towards social rehabilitation

Sufficient duration of treatment

Detoxification only of willing, well stabilised patients with established abstinence

Recovery as a journey

Recovery

Supported Reducing engagement Reintegration Abstinence Harm Stability Alcohol in the mix

Public Health advises just one glass of a day Alcohol related deaths The numbers – PHE data

ENGLAND LAs PRACTICE GP

Total Population 53,588,218 352,554 6,487 1,606

Adult Population 43,580,873 286,716 5,275 1,306 Dependent drinkers 1,568,911 10,322 190 47 Increasing and Higher Risk 9,849,277 64,798 1,192 295 FACTS FIGURES LAs 152 Inc + High % 22 Dep % 3.8 Practices 8,261 GPs 33,364

13 Alcohol interventions in Alcohol interventions in Primary Care 18 Primary Care

Chronic Liver Disease

Key drivers for growth in burden and mortality, First 3 all preventable:

•Alcohol

•Chronic viral hepatitis B/C

•Obesity • Non-alcoholic fatty liver disease (NAFLD) leading to non-alcoholic steatohepatitis (NASH)

•Others – including autoimmune or inherited • eg Primary Biliary Cirrhosis (PBC), haemochromatosis Prevalence of HCV Infection

Overall, it is estimated that around 214,000 people (0.4%) in the UK are chronically infected with hepatitis C.

Despite being a curable infection only 3% of those infected receive treatment each year.

Hepatitis C in the UK 2013. PHE publications gateway number: 2014058 July 2014

Why Treat Hepatitis C?

Van de Meer et al JAMA 2012 Primary Care has a key role to play

• Prevent transmission

• Increase detection

• Diagnose infection in people who have the disease

• Arrange treatment in those with chronic infection with the aim of eradicating the virus, or at least minimising its effects

• HBV is preventable with an effective vaccine

• With modern therapy, depending on the genotype of HCV up to 95% of patients with chronic HCV can be cured

• Treatment for HCV has been recommended by NICE

Addiction to Medicines Analgesics Opioid deaths mirror prescribing* 250 Other

200 “may signal an emerging problem 150 in the UK similar to the issue that is

100 now well Dihydrocodeine established in the not from 50 compound USA.”

Codeine not 0 from compound

2003 1995 1997 1999 2001 2005 2007 2009 2011 2013 1993

•ONS ‘Deaths Related to Drug Poisoning in England and Wales, 2013’ and •‘Prescription opioid abuse in the UK’, Giraudon I et al., British Journal of Clinical Pharmacology 2013

Addiction to medicines policy November 2014 * Not including illicit Newer Drugs

Novel Psychoactive Substances, Club Drugs, Legal Highs Relevance in Primary Care

• Secure environments and homeless -SCRAs [Synthetic Receptor Agonists]

• LUTS symptoms in young people-

• Chemsex-GHB,metamfetamine,ketamine

Public Health v Primary Care Oh, East is East, and West is West, and never the twain shall meet Rudyard Kipling Commissioning

• Role of health and Well Being Board

• Other partners –Third Sector, Police & Crime Commissioners, Social Services, Housing etc.

• Links to Secondary Care Services

• Pathways

Funding Issues

• CCG / Public Health split in some areas

• Competing Priorities

• Drug and Alcohol treatment not part core service for GPs

• However required to work with patients

• Huge impact on hospital admissions Key Points

• Long term drug use leads to multiple physical and mental health problems and premature ageing

• Patterns of drug use change but remain worryingly high

• Poly drug use is the usual pattern • Primary Care with support from Secondary Care and the Third Sector can provide effective care and aftercare