Drugs and Alcohol in

Primary Care Steve Brinksman

Clinical Lead SMMGP Medical Director Cranstoun Group

GP

Trends and Issues

• “Traditional” drugs

• Alcohol

• Addiction to Medicines

• Novel Psychoactives

• Prevalence

• Age

• Co-morbidities

• Recovery v Harm Reduction

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.

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

Estimates suggest over 300,000 problematic heroin & crack users in the UK

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

70% of acquisitive crime drug 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 Methadone 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

engagement Reintegration Reducing Harm

Supported Stability

Abstinence

Recovery

Alcohol in the mix

Public Health advises just one glass of wine a day

Alcohol related deaths

The numbers – PHE data

FACTS FIGURES

LAs 152

Inc + High % 22

Dep % 3.8

Practices 8,261

GPs 33,364

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

18 Alcohol interventions in Primary Care

13 Alcohol interventions in

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

Opioid Analgesics

Opioid deaths mirror prescribing*

•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 opioids

“may signal an emerging problem in the UK similar to the issue that is now well established in the USA.”

0

50

100

150

200

250

1993

1995

1997

1999

2001

20

03

2005

2007

2009

2011

2013

Other opiate

Tramadol

Dihydrocodeinenot fromcompound

Codeine notfrom compound

Newer Drugs

Novel Psychoactive Substances, Club Drugs, Legal Highs

Relevance in Primary Care

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

• LUTS symptoms in young people-Ketamine

• 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