DEALING WITH DRUGS &

ALCOHOL IN GENERAL
PRACTICE
Windmill Drug & Alcohol Team
 Programme
• 9 am Quiz
• 9.15am Quiz Answers
• 9.45 am Break
• 10.00 am Drug & Alcohol Facts
• 10.20 am Services
• 10.30 am GP Trainee
• 10.45 am Break
• 11.00 am Role Plays
 Social drinking is OK
• What is social drinking?
• As much as your friend?
• As much as guy beside you on park
bench?
• Ask specific questions.
• Safe limits
What Drug?
 Drunk people who threaten
suicide never mean it
• FALSE
• Assess when sober
• Suicide can still occur by accident
 AA is a religious cult
• 12 Step Programme
• God as you understand him
• Meetings throughout world
• NA, CA etc
 Opiate Withdrawal is often
fatal
• FALSE
• Very rarely
• Agitation, Anxiety, Muscle aches
Lacrimation, Insomnia, Runny nose,
Sweating, Yawning
• Abdominal cramping, Diarrhoea,
Dilated pupils, Goose bumps, Nausea,
Vomiting
• Time depends on half life opiate.
 All Daily Drinkers Require
Detoxification
• FALSE
• Physical Dependence
• Tremors, sweating, HBP, tachycardia,
seizures, delirium.
• Reducing regime of Diazepam to 0 over
5-10 days.
 A definitive diagnosis of drug
induced psychosis can be made
on presentation
• FALSE
• Can’t make concrete diagnosis from
one episode
• Drug testing and history important
• Only confirm over time
40% of mental health admissions have drug or
alcohol problems

• TRUE
• About a third to a half of those with severe
mental health problems will also have
substance misuse problems.
• About half of patients in drug and alcohol
services have a mental health problem, most
commonly depression or personality
disorder.
• Alcohol misuse is the most common type of
substance misuse and where drug misuse
occurs, it tends also to co-exist with alcohol
misuse.
 You can’t get addicted to OTC
medicines
• FALSE
• Hidden problem
• Codeine Preparations
• Especially Nurofen Plus
• Kaolin & Morphine, Nytol
What Is This?
• Cannabis sativa
 All long term benzodiazepine
scripts should just be stopped
• Abrupt withdrawal may produce confusion,
toxic psychosis, convulsions, or a condition
resembling delirium tremens.
• Chronic withdrawal symptoms - insomnia,
anxiety, loss of appetite and of body-weight,
tremor, perspiration, tinnitus, and perceptual
disturbances.
• Transfer patient to equivalent daily dose of
diazepam preferably taken at night
• Reduce over months/years.
What is this for?
 Heroin is more addictive than
Oxycodone
• False
• Celebrity ‘prescription drug’ addiction.
• Marketed as Targinact
• Does not show up on standard drug
testing
 Substance Use
NON USERS

DEPENDENT EX USERS

HABITUAL EXPERIMENTAL

RECREATIONAL
 ADDICTION
Dependence - physical/psychological
Tolerance
Lack of control
Compulsion to use
Salience
Continue despite negative consequences
Reinstatement
 CAGE QUESTIONNAIRE
• Have you ever felt you should cut down
on your drinking?
• Have people annoyed you by criticising
your drinking?
• Have you ever felt bad or guilty about
your drinking?
• Have you ever had a drink first thing in
the morning to steady your nerves or
get rid of a hangover (eye-opener)?
 Other Screening tools
• AUDIT
– Alcohol use disorders identification tool
– 10 or 5 questions
• MAST
– Michigan Alcohol Screening Test
– 20 Questions
 BRIEF INTERVENTION
• Maximum 4 sessions, couple of minutes to
1hour

• Designed to be delivered by those with no

specialist experience in substance misuse
• Can be used with Dependant and Non-
dependant users
• As effective as more intense interventions
• More effective than no intervention
 FRAMES

• Feedback of Personal Risk

• Responsibility of the Patient
• Advice To Change
• Menu of Ways To Reduce Drinking
• Empathetic Counselling Style
• Self-Efficacy or Optimism of the
Patient
Miller and Sanchez –
 Referral Form
Telephone: 01932 723309 Fax: 01932 722896
Please write clearly, referrals cannot be processed if all parts are not fully filled in.

Date
Referrer i.e.
self, ward etc

Client Name DoB

Address and Postcode Next of Kin
Address and Tel No:
Client Telephone

Client Mobile

Marital Status

Ethnicity

Religion

Patient aware and in agreement of this referral Yes/No

The patient’s GP will be made aware of this referral
Practice
GP
Telephone No:

Current Drug/Alcohol Problem

Please include dates, doctors names and hospitals if possible
Past/Current Mental Health History.

Past/Current Medical History

Is the client pregnant YES/NO
Current Medication
Past convictions:
Any social Issues: (Please include Domestic Violence, number of children,
contact with social services)
Recently in prison/ on probation?

Disability?

History of Aggression?

Under Mental Health Act?

Expected date of discharge if in hospital

Outcome

Referral taken/ received By:

Date
DRINKING DIARY
DAY WHAT WHERE, WHEN, WHO UNITS DAILY
WITH AND FEELINGS TOTA
L
MONDAY
TUES

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

WEEKLY TOTAL
BEVERAGE STRENGTHS:
Beers: Spirits:

1 unit 1 standard single measure 1 unit

½ pint ordinary strength
beer/lager
1 pint ordinary strength 2 units 1 bottle 28
beer/lager units
1 can ordinary strength 11/2 units
beer/lager

1 pint Export beer 21/2 units Table Wine

1 can Export beer 2 units 1 standard glass 1 unit

½ pint strong ale/lager 2 units 1 bottle 7 units
1 can strong ale/lager 3 units 1 litre bottle 10
units
1 pint strong ale/lager 4 units

½ pint extra strong beer/lager 21/2 units Sherry and Fortified Wine

1 pint extra strength beer/lager 5 units 1 standard small measure 1 unit

1 can extra strength beer/lager 4 units 1 bottle 14
units
 Motivational Interviewing
• Therapist style is a powerful determinant of client
resistance and change
• Confrontation is a goal, not a style.
• Argument is a poor method of inducing change.
• When resistance is evoked, clients tend not to
change.
• Motivation can be increased by a variety of therapist
strategies
• Even relatively brief interventions can have a
substantial impact on problem behaviour.
• Motivation emerges from the interpersonal
interaction between the client and therapist.
• Ambivalence is normal, not pathological.
• Helping people resolve ambivalence is a key to
change.
 Motivational Approaches
• Giving Advice
• Removing Barriers
• Providing Choice
• Decreasing Desirability
• Practising Empathy
• Providing Feedback
• Clarifying Goals
• Active Helping
Prescribing Opiate Substitution
Rx
• Drug Test Imperative
• Methadone titration vs
Buprenorphine
• Not diazepam
• Non opiate detox – brufen,
buscopan, loperamide, zopiclone
 NICE guidance

• Oral methadone and buprenorphine are

recommended for maintenance therapy in the
management of opioid dependence.

• Patients should be committed to a supportive care

programme including a flexible dosing regimen
administered under supervision for at least 3
months, until compliance is assured.

• Selection of methadone or buprenorphine should be

made on a case-by-case basis, but methadone
should be prescribed if both drugs are equally
suitable.
Methadone
 Methadone Prescribing
• Urine test and history
• £=mg
• Daily starting dose 30mg or less
• Rising by no more than 5mg daily
• Review within 7 days.
• Risk respiratory depression
• High risk to others
 Buprenorphine
• Opiate agonist and partial antagonist
• Precipitate withdrawal
• Clear headed
• Sublingual
• Gentler withdrawal
• Suboxone
• Less respiratory depression
 Methadone/Buprenorphine
Dispensing
• Daily
• Supervised Consumption (3 months)
• Rationale
• Not punitive
 Other Medication
• Acamprosate
• Disulfiram
• Naltrexone
 ORANGE GUIDELINES
• Drug Misuse and Dependence-
Guidelines on Clinical Management
DoH
 INFECTION IN IVDU
• In 2007, around 25% of IDUs reported direct sharing
in the previous month;
• Almost 50% of IDUs in the UK have been infected
with hepatitis C.
• In England & Wales, the overall HIV prevalence
among IDUs is currently around one in 90. ( 1 in 20
London)

• 33% of IDUs reporting having had an abscess, sore

or open wound at an injecting site in the last year.
• Localised injection site infection - invasive disease
associated
• with MRSA and severe Gp A streptococcal infection.
• Botulism, Tetanus, Anthrax
 Do’s and Don’ts
• Shared Care
• ‘Not before’ date on repeat prescriptions
• Review all BZO + Opiate repeat prescriptions
regularly
• Say No
• Re-issue LOST prescriptions
• Write/phone/send a postcard
• Phone police if behaviour unacceptable
 Do’s and Don’ts
• Child Protection
• Safeguarding Adults
• DVLA
 Alcohol Facts
• 38.2% of adult men and 22.1% of adult women drink
over daily recommended levels
• An estimated 1.8 million adults drink at harmful
levels - over 35 units per week for women and over
50 units a week for men.
• An estimated 1.1 million adults are dependent upon
alcohol.
• Alcohol misuse costs the NHS £1.7 billion per year.
• 35% of all accident and emergency and ambulance
costs are alcohol related.
• Up to150,000 hospital admissions per year are linked
to excess drinking.
Drug misuse among adults (16 -
59 years)
In England and Wales, 2008/09
• 10.1% of adults had used one or more illicit drugs
within the last year
• 3.7% of adults had used Class A drugs in the last
year.
• 207,580 people in contact with structured drug
treatment services
• Total number of deaths related to drug misuse in
England and Wales was 1,738 in 2008
• Accidental poisoning is the most common cause
 Surrey Services
Surrey
DAAT

Tier 4a
Tier 2 Tier 3
Windmill House

SADAS HR Outreach Windmill Acorn Respond Access

 Referral Source 2009
600

500

400

300

200

100

0
GP SELF OTHER
 Case Closures 2009
Died

DNA

Ref On

Rx Comp

0 5 10 15 20 25 30
% N=1271
Community Team
Motivational
Interviewing
Substitute
Counselling
Prescribing

Managing
One to One
Addiction
work
Group

Hep B Women’s
Vaccination Group

Hep C & HIV Recovery

Testing Group

Home Social
Detoxification Support
CBT
 Windmill House

12 bedded in patient unit

5 day patient places

1 day detoxification place

Single bedrooms

Well equipped lounges

Garden
 Facilities
• Alcohol Detoxification
• Opiate Detoxification
• Other substances eg GHB
• Detoxification Groups
• Programme – CBT, Psychodynamic,
Life Reflection, AA, NA.
 Windmill Team
• Not an emergency service
• Medically ill patients need general
hospital
• Treatment a long process
• Crisis treatment rarely successful
longterm
 Helpful Sites
• www.alcoholconcern.org.uk
• www.drugscope.org.uk
• www.drinkaware.co.uk
• www.alcoholics-anonymous.org.uk
• www.al-anonuk.org.uk
• www.ukna.org
• www.talktofrank.com