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This chapter begins with an exploration of the epidemiology of illicit drug use. Measuring the use of illicit drugs accurately can be challenging, and the initial focus is on the various potential sources of data in the UK. Methods for estimating the prevalence of opiate and crack cocaine use are discussed, and the prevalence and trends in both specialist addiction and mental health services are reviewed. The aetiology of drug use and dependence is then explored using a framework of risk and protective factors. The brain disease model of addiction is described alongside challenges to its validity, with a consideration of why some people get addicted and others do not. Psychological models of addiction are reviewed and integrated into a wider biopsychosocial model. Finally, protective factors against drug use in adolescence are considered, and the evidence for prevention strategies summarised.
This chapter traces the evolution of the term ‘addiction’ over time, demonstrating how its meaning has altered in the face of social and political changes in society. The second half explores the story behind the diagnostic terminology used in clinical practice today, and describes the recent changes to the addiction section of the major classificatory systems. Addiction is conceptualised as a disorder involving a loss of the normal flexibility of human behaviour, leaving a dehumanised state of compulsive behaviour (‘overwhelming involvement’). It has acquired a variety of terminology over time, much of it inferring moral weakness. Addiction may be associated with psychoactive substances or other pleasurable behaviours and occurs on a spectrum of use and harms, which vary in severity. The term ‘dependence’ may refer to physiological aspects of addiction (tolerance or withdrawal), but is also used to define the severe end of the spectrum. Confusion around this terminology has led to it being removed from the latest version of the Diagnostic and Statistical Manual (DSM-5).
This chapter begins by arguing that a complete view of substance use disorders needs to take into account the focal client’s wider family and social network, as members of this network are both potential sources and recipients of help. Evidence is presented to suggest that the impacts of alcohol, drugs and other addiction problems on others may constitute a major neglected public health problem. Two methods are then described in detail – the 5-Step Method and Social Behaviour and Network Therapy (SBNT). Both incorporate a fuller conceptual understanding of these problems, embedding the primary substance use disorder within a wider social context. Both the 5-Step Method and SBNT can be used within an integrated pathway for service users, where affected family members can be identified and engaged in 5-Step Method help if necessary while also supporting the user in SBNT-type sessions. Both interventions can be offered as stand-alone or in combination.
This chapter starts by describing the key features of drug use disorders and how to assess them, including using objective tests of substance use. The principles of medical treatment are described, incorporating harm reduction strategies, medically assisted withdrawal, agonist therapies and relapse prevention. Opiates are used as a case study to consider the theory and practicalities of each approach, before describing how to integrate psychosocial interventions into an integrated approach to treatment. Stimulants and cannabis are then considered, before a review of the overarching concept of recovery and its application in recovery-orientated systems of care.
This extensively revised new edition provides a practical guide to understanding, assessing and managing physical, psychological and social complications related to drug and alcohol use. It presents a clear review of the aetiology, epidemiology, prevention and treatment of the problematic use of and dependence on alcohol, illicit and prescribed drugs. In doing so it strikes a balance between theory, recent research and practical clinical guidance. New chapters focus on novel psychiatric substances, smoking cessation interventions, mutual aid groups and family interventions. Written by leading specialists in the field and closely following the MRCPsych curriculum, this book is an ideal resource for trainees preparing for their RCPsych membership examinations, but is also relevant to psychiatrists at all career levels. It will also appeal to other healthcare professionals, all of whom should be able to screen for alcohol and drug use disorders, deliver brief interventions, and signpost those with more severe disorders to specialist care.
Cannabis use is a global public health issue associated with increased risks of developing mental health disorders, especially in young people. We aimed to investigate the relationships between cannabis exposure and risks of receiving mental illness diagnoses or treatment as outcomes.
A population based, retrospective, open cohort study using patients recorded in ‘IQVIA medical research data’, a UK primary care database. Read codes were used to confirm patients with recorded exposure to cannabis use who were matched up to two unexposed patients. We examined the risk of developing three categories of mental ill health: depression, anxiety or serious mental illness (SMI).
At study entry, the exposed cohort had an increased likelihood of having experienced mental ill health [odds ratio (OR) 4.13; 95% confidence interval (CI) 3.99–4.27] and mental ill health-related prescription (OR 2.95; 95% CI 2.86–3.05) compared to the unexposed group. During the study period we found that exposure to cannabis was associated with an increased risk of developing any mental disorder [adjusted hazard ratio (aHR) 2.73; 95% CI 2.59–2.88], also noted when examining by subtype of disorder: anxiety (aHR 2.46; 95% CI 2.29–2.64), depression (aHR 2.34; 95% CI 2.20–2.49) and SMI (aHR 6.41; 95% CI 5.42–7.57). These results remained robust in sensitivity analyses.
These findings point to the potential need for a public health approach to the management of people misusing cannabis. However, there is a gross under-recording of cannabis use in GP records, as seen by the prevalence of recorded cannabis exposure substantially lower than self-reported survey records.
Clinical audit methodology was used to compare the treatment of alcohol misusers at risk of Wernicke's encephalopathy in an acute medical setting, and to assess the impact of providing information about best practice to prescribing doctors. All patients prescribed thiamine during an admission to an acute hospital trust over a 6-month period were identified, and data about their treatment episode were collected retrospectively. Hospital pharmacists then provided all prescribers with a flowchart summarising current prescribing guidelines, and prescribing patterns were re-audited 6 months later.
Over two audit periods, half of the patients prescribed thiamine whose case notes we examined had symptoms suggestive of Wernicke's encephalopathy, and another 30% were at high risk. Prescribing adhered to hospital guidelines only in 14% of cases, with the pharmacy-led intervention associated with a small but significant increase in the number of patients receiving adequate treatment for Wernicke's encephalopathy.
Wernicke's encephalopathy is relatively common in alcohol-dependent individuals admitted to hospital, and it is easily and cheaply managed. However, even when potential cases are identified, prescribing guidelines are followed in a minority of cases, even with prompting by a hospital pharmacist. This may be related to the limited research base concerning the optimum dosing schedule of thiamine, or fears about possible anaphylaxis when using parenteral preparations.
A 4-month pilot was conducted to assess whether the clinical librarian model, which has been successfully used within acute hospitals, would work in a mental health setting. A librarian attended weekly clinical team meetings in two community mental health teams to help generate clinical questions. A summary of the evidence on each topic was then presented the following week. An evaluation of the pilot was carried out using a questionnaire survey, focus groups and interviews.
Results suggest that the project had produced a positive impact within the teams and begun the process of embedding evidence-based information within clinical practice.
With some adaptations, the clinical librarian model can be an effective method of implementing evidence-based practice and addressing continuing professional development needs within mental health clinical teams.