Drugs and Alcohol in Primary Care Steve Brinksman Clinical Lead SMMGP Medical Director Cranstoun Group GP
Trends and Issues • “Traditional” drugs • Prevalence • Alcohol • Age • Addiction to Medicines • Co-morbidities • Novel Psychoactives • Recovery v Harm Reduction
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 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
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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 Recovery Supported Reducing Abstinence engagement Reintegration Stability Harm
Alcohol in the mix Public Health advises just one glass of wine 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
Opioid Analgesics
Opioid deaths mirror prescribing* 250 Other opiate 200 “may signal an emerging problem Tramadol 150 in the UK similar to the issue that is 100 now well Dihydrocodeine established in the not from 50 USA .” compound Codeine not 0 from compound 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 •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
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
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