Chapter 21: Drug and alcohol problems

Drug-related problems are true masquerades in family practice. This includes prescribed drugs, over-the-counter drugs and social or illegal street drugs. It is important therefore that all prescribing doctors maintain a high index of suspicion that any clinical problem may be associated with their treatment of the patient.

An adverse drug effect is defined as ‘any unwanted effect of treatment from the medical use of drugs that occurs at a usual therapeutic dose’. Almost every drug can cause an adverse reaction, which must be elicited in the history. Any substance that produces beneficial therapeutic effects may also produce unwanted, adverse or toxic effects. The severity of the reaction may range from a mild skin rash or nausea to sudden death from anaphylaxis. A study has shown that the incidence of adverse reactions increases from about 3% in patients 10–20 years of age to about 20% in patients 80–89 years of age.¹

Reactions can be classified in several ways—side effects, overdosage, intolerance, hypersensitivity and idiosyncrasy. However, a useful classification of unwanted effects is divided into type A and type B.

Type A reactions are the most common and involve augmented pharmacology; that is, they are caused by unwanted, albeit predictable, effects of the drug. Examples include:

• constipation due to verapamil

• blurred vision and urinary outflow problems due to tricyclic antidepressants

• hyperuricaemia due to thiazide diuretics

Type A reactions are dose-dependent.

Type B reactions are idiosyncratic. The reactions are unpredictable from known properties of the drug. Examples include hepatotoxicity and blood dyscrasias.

Golden rules for prevention of adverse effects

Before prescribing any drug the prescriber should consider the following rules:

1. Is the drug really necessary?

2. What will happen if it is not used?

3. What good do I hope to achieve?

4. What harm may result from this treatment?

Common adverse effects

There is an extensive list of clinical problems caused by drugs as side effects or interactions that are highlighted throughout this book. Common side effects include:

• CNS—malaise, drowsiness, fatigue/tiredness, headache, dizziness

• CVS—palpitations, peripheral oedema, hypotension

• GIT—nausea, vomiting, dyspepsia, change in bowel habit (diarrhoea, constipation)

• skin—rash, pruritus, flushing

• psychiatric/emotional—insomnia, irritability, anxiety, depression, agitation

Drugs that commonly produce adverse effects

• Antidepressants (number 1 cause): tricyclics, MAOIs, SSRIs

• Antimicrobials: penicillin/cephalosporins, sulphonamides, tetracyclines, streptomycin, ketoconazole

• Anticonvulsants: carbamazepine, phenobarbitone, phenytoin, sodium valproate

• Anti-inflammatories and analgesics: aspirin/salicylates, opioids (e.g. codeine, morphine), NSAIDs, gold salts, DMARDs, bDMARDs

• Antihypertensive agents: several

• Cardiac agents: digoxin, quinidine, amiodarone, other antiarrhythmics

• Diuretics: thiazides, frusemide

• Tranquillisers: phenothiazines, benzodiazepines, barbiturates, chlordiazepoxide

• Other drugs: cytotoxics, hormones, allopurinol, warfarin

‘Smoking is good for you’, according to an old Arab proverb. ‘The dogs will not bite you because you smell so bad; thieves will not rob you at night because you cough in your sleep and you will not suffer the indignities of old age because you will die when you are relatively young.’

Tobacco smoking is the largest single, preventable cause of death and disease in Australia. It has been estimated to have caused approximately 15 000 deaths in 2004–05, over six times the number of deaths from road accidents.² Diseases attributed to smoking are summarised in FIGURE 21.1. Signs of major dependence are smoking within 30 minutes of waking and ≥20 cigarettes a day.

Advice to patients (quitting)

Several studies have highlighted the value of opportunistic intervention by the family doctor. It is important not only to encourage people to quit but also to organise a quitting program and follow-up. In Australia 80% of smokers (representing about 30% of the adult population) have indicated that they wish to stop smoking. Point out that it is not easy and requires strong will power. As Mark Twain said, ‘Quitting is easy—I’ve done it a thousand times.’

• Educate patients about the risks to their health and the many advantages of giving up smoking, and emphasise the improvement in health, longevity, money savings, looks and sexuality.

• Point out the following advantages to quitting:

  • – food tastes better

  • – sense of smell improves

  • – exercise tolerance is better

  • – sexual pleasure is improved

  • – bad breath improves

  • – risk of lung cancer drops: after 10–15 years of quitting it is as low as someone who has never smoked

  • – early COPD can be reversed

  • – decreases URTIs and bronchitis

  • – chance of premature skin wrinkling and stained teeth is less

  • – removes effects of passive smoking on family and friends

  • – removes problem of effects on pregnancy

• The extent of nicotine dependence can be assessed using a questionnaire (based on the Fagerstrom Test) and scoring system.³ As a baseline ask about the number of cigarettes smoked per day, how soon after waking to smoking the first cigarette of the day and any difficulties with coping with antismoking venues (e.g. cinemas, plane travel).

• Ask them to keep a smoker’s diary.

• If they say no to quitting, give them motivational literature and ask them to reconsider.

• If they say yes, make a contract (example below).

• These motivated patients will require educational and behavioural strategies to help them cope with quitting. Ongoing support by their GP is very important.

• Organise joining a support group.

• Contact your local Quitline (or similar service) for information about and support for quitting, especially if smoking ≥20 cigarettes a day.

• Arrange follow-up (very important), at least monthly, especially during first 3 months.

• Going ‘cold turkey’ (stopping completely) is preferable but before making the final break it can be made easier by changing to a lighter brand, inhaling less, stubbing out earlier and reducing the number. Changing to cigars or pipes is best avoided.

Withdrawal effects³

The initial symptoms are restlessness, cravings, hunger, irritability, poor concentration, headache and frustration (refer TABLE 21.1). After about 10 days most of these effects subside but it takes about three months for a smoker to feel relatively comfortable with not smoking any more. Nicotine replacement therapy certainly helps patients cope.

Treatment

Pharmacological³

Nicotine replacement therapy (NRT), which should be used in conjunction with an educational support program, has been proved to be effective and is available as chewing gum, inhaler, oral spray, lozenges, sublingual tablets or transdermal patches (the preferred method). Ideally the nicotine should not be used longer than 3 months. Eight weeks of patch therapy is as effective as longer courses.

NRT should be directed at smokers with a moderate to high nicotine dependency who are motivated to quit. There is little evidence that drug treatment will benefit individuals with low levels of nicotine dependence who smoke fewer than 10 cigarettes a day.⁴

All forms of NRT are effective: a pooled analysis of all NRT trials showed an absolute increase in cessation at 1 year of 7% compared to placebo.⁴

NRT should start at the quit date, not while still smoking.

Nicotine gum³

This is available as 2 mg and 4 mg.

• Low dependence (less than 10 cigarettes per day, not needing to smoke within 30 minutes of waking): use non-pharmacological methods rather than replacement

• Moderate dependence (10–20 cigarettes per day, smoking within 30 minutes of waking): 2 mg every 1–2 hours, chew max. 8–12 pieces daily

• High dependence (>20 per day, waking at night to smoke or first thing after waking): 4 mg initially, 6–10 pieces chewed daily changing to 2 mg after 4–8 weeks (max. 12 pieces/24 hours)

Useful points:

• Chew each piece slowly for about 30 minutes.

• Ensure all the nicotine is utilised.

• Chew at least 6 pieces per day, replacing at regular intervals (not more than 1 piece per hour).

• Use for 3 months, weaning off before the end of this period.

Transdermal nicotine³

This is available as 16-hour or 24-hour nicotine patches in three different strengths. The patients should stop smoking immediately on use.

Recommendations:

• low to moderate dependence (10–20 cigarettes/day): 15 mg/24 hour or 10 mg/16 hour patch, daily; aim to cease within 12 weeks

• high dependence (>20/day): 21 mg/24 hour or 15 mg/16 hour patch; change to 15 mg or 10 mg patch after 4–6 weeks; aim to cease within 12 weeks; use lower dose if patient is <45 kg or has CVS disease

Apply to non-hairy, clean, dry section of skin on upper outer arm or upper chest and leave in place for 24 hours. Rotate sites with a 7-day gap for reuse of a specific site.

Nicotine inhaler

Uses cartridges in a mouthpiece resembling smoking.

• 6–12/day for 12 weeks then taper

Nicotine oral spray

• 1 mg/spray: 1–2 sprays into mouth orally (max. 64 sprays/24 hours)

Nicotine lozenges and sublingual tablets

These are available in 2 mg and 4 mg strengths, the strength used according to the level of dependence, e.g. high dependence: suck 4 mg lozenges (max. 15/24 hours).

Combination therapy

Controlled trials have shown enhanced outcomes when nicotine patches are combined with gum or inhaler. Consider it for highly addicted smokers.

Other agents for smoking cessation⁵

Bupropion (Zyban)

This oral agent has a similar effectiveness to NRT.

Adverse effects include insomnia and dry mouth (both common), with serious effects, such as allergic reactions and increased seizure risk.⁶ It is contraindicated in persons with a history of epilepsy.

Recommended dose: 150 mg (o) daily for 3 days then bd for 8 weeks.

Varenicline tartrate (Champix)^3,5

• Commence with 0.5 mg (o) daily with food for 3 days titrating slowing to 1 mg bd by day 7 until the end of the 9-week course

It is an effective agent but there are several adverse side effects, especially nausea with a concern about neuropsychiatric effects.⁶ Avoid in end-stage kidney disease and take care with diabetics.

Nortriptyline

• Start with 25 mg (o), increasing gradually to 75 mg (o) daily, starting 14 days before quit date then continue for 12 weeks

Note: Regular follow-up for all methods is essential for outcome.

Vaping

This involves inhaling and exhaling the vapour from ‘electronic cigarettes’ (no nicotine). Its use is controversial. There is a concern that it could be a ‘gateway’ to smoking in young people but there is currently no evidence for this impression. Banned by the Australian Government’s Therapeutic Goods Administration (www.tga.gov.au) but legal in some countries.

Alcohol problems

Excessive drinking of alcohol is one of the most common and socially destructive problems in the world. One survey found that 5% of Australian men and 1% of women were alcohol-dependent. It also showed that 86% of men and 79% of women drink alcohol, with 8.3% of the population drinking alcohol every day.⁶

• Alcohol is estimated to have a harmful effect on about 1 in 10 people.

• At least 20–40% of acute general and psychiatric hospital admissions have an alcohol-related illness.

• About 20%-plus of fatal traffic accidents involve alcohol.

• The author’s study⁸ identified alcohol dependence in 9.7% of the population studied and a further group of problem drinkers that included the ‘explosive’ or binge drinker (see FIG. 21.2). Problem drinkers represent about 15–20% of the population.

National Health and Medical Research Council (NHMRC) revised guidelines addressing harmful drinking are presented in TABLE 21.2.^3,7

High-risk and harmful drinking occurs at >6 standard drinks (SDs) a day (average) for men and >4 SDs for women.

The main causes of alcohol-related deaths are road trauma, cancer and alcoholic liver disease.⁷

Clinical pointers to alcohol abuse

Facial features of the patient can be a helpful pointer, albeit of the more advanced drinker. These include:

• plethoric facies

• puffy ‘greasy’ facies

• telangiectasia

• rosacea + rhinophyma

• suffused (‘bloodshot’) conjunctivae

• prominent lower lip with chelitis of corners of mouth

• smell of stale alcohol or very ‘minty’ sweet breath (masking effect)

Taking a drinking history

This requires tact and skill and it must be noted that many problem drinkers considerably understate the level of their intake.

Useful strategies⁸

• Ask questions as part of a matter-of-fact enquiry into health risk factors, such as smoking and diet.

• Place the onus of denial on the patient by asking questions such as ‘When did you last drink alcohol?’ rather than ‘Do you ever drink alcohol?’

• Record your patient’s intake quantitatively in terms of standard drinks or grams of alcohol.

• Confirm the history by enquiring about the time spent drinking per day and expenditure on alcohol.

Useful questionnaires

There are several questionnaires that can be most helpful, assuming the patient is fully cooperative. Two or more positive replies for the CAGE questionnaire⁹ are suggestive of a problem drinker.

1. Have you ever felt you should CUT down on your drinking?

2. Have people ANNOYED you by criticising your drinking?

3. Have you ever felt bad or GUILTY about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (an EYE-OPENER)

Another very practical questionnaire is AUDIT (the Alcohol Use Disorders Identification Test) developed by the World Health Organization (www.who.int/substance_abuse/publications/audit/en) to facilitate the early detection of problem drinkers in primary care.

The following blood tests may be helpful in the identification of excessive chronic alcohol intake:

• blood alcohol

• serum GGT: elevated in chronic drinkers (returns to normal with cessation of intake)

• MCV: >96 fL

Other changes:

• abnormal liver function tests (other than GGT)

• carbohydrate deficient transferrin (quite specific—dependent on an enzyme induced by alcohol)

• HDLs elevated

• LDLs lowered

• serum uric acid elevated

One standard drink contains 10 g of alcohol, which is the amount in one middy (or pot) of standard beer (285 mL), two middies of low-alcohol beer or five middies of super-light beer. These are equal in alcohol content to one small glass of table wine (122 mL), one glass of sherry or port (60 mL) or one nip of spirits (30 mL) (see FIG. 21.3).

• 1 stubbie or can of full-strength beer = 1.4 standard drinks

• 1 light beer = 0.9 standard drinks

• 1 × 750 mL bottle of beer = 2.6 standard drinks

• 1 × 750 mL bottle of wine = 7 standard drinks

Alcohol dependence is a syndrome in which an individual demonstrates clinically significant impairment or distress as manifested by three or more of the following, occurring at any time in the same 12-month period:

1. tolerance

2. withdrawal

3. drinking in larger amounts or for a longer period than intended

4. unsuccessful attempts to cut down or control drinking

5. a great deal of time spent in activities necessary to obtain, use or recover from the effects of alcohol

6. important social, occupational or recreational activities reduced or given up because of drinking

7. continued drinking despite knowledge of having persistent or recurrent problems caused by or exacerbated by drinking

The challenge to the family doctor is early recognition of the problem. There are specific target areas which should be considered carefully by the GP. Several studies have shown that early intervention and brief counselling by the doctor are effective in leading to rehabilitation.¹⁰ Some of the results are very revealing.

• Patients expect their family doctor to advise on safe drinking levels.

• They will listen and act on our advice.¹¹

• Treatment is more effective if offered before dependence or chronic disease has developed.¹¹

Of prime concern to the GP is the assessment of whether the patient is interested in changing his or her excessive drinking behaviour. The proposed model of change by Prochaska and Di Clemente helps identify the stage reached by the patient (see FIG. 21.4).¹²

Precontemplators are satisfied users who are either unconcerned about their drinking or have no desire to change. However, if there is any evidence of ambivalence or concern about drinking then the opportunity exists for motivational interviewing techniques.

Patients are not likely to offer concern about their drinking problem spontaneously but are often receptive to the initiative coming from their doctor.

The family doctor is ideally placed to identify and treat the problem of alcohol because the individual who abuses alcohol will tend to surface at some point in the provision of primary health care.

A brief practical management plan¹³

Giving patients feedback about their level of alcohol consumption, presenting objective evidence of harm and setting realistic goals for reducing alcohol intake induces many to change their drinking behaviour.

A six-step management plan, which has been employed in a general-practice early intervention program, is as follows:

1. Feed back the results of your assessment and specifically the degree of risk associated with their daily alcohol intake and bout drinking. Emphasise any damage that has already occurred.

2. Listen carefully to their reaction. They will need to ventilate their feelings and may respond defensively.

3. Outline the benefits of reducing drinking (e.g. save money, better health, weight loss).

4. Set goals for alcohol consumption that you both agree are feasible. In most cases this will involve reduction to below certain ‘safe limits’.

   • For men: aim for fewer than 12 SDs per week.

   • For women: aim for fewer than 8 SDs per week. It is best for pregnant women not to drink.

   • For patients with illness who are physically dependent on alcohol, long-term abstinence is advisable.

5. Set strategies to keep below the upper safe limits, e.g.:

   • quench thirst with non-alcoholic drinks before having an alcoholic one

   • switch to low-alcohol beer

   • take care which parties you go to: avoid constant parties and other high-risk situations

   • explore new interests—fishing, cinema, social club, sporting activity

6. Evaluate progress by having patients monitor their drinking by using a diary; check that any abnormal blood test results are returning to normal. Make a definite appointment for follow-up and give appropriate literature such as Alcohol: Harmful Use of Alcohol. Obtain consent for a telephone follow-up. A useful minimum intervention plan is presented in TABLE 21.3.

Follow-up (long consultation 1 week later)

Review the patient’s drinking diary. Explore any problems, summarise, listen and provide support and encouragement. If appointment is not kept, contact the patient.

Specialist services

According to progress and the patient’s wishes and consent, specialist treatment units, group therapy and attendance at meetings of Al-Anon or AA are potential sources of help to keep the alcohol-dependent person abstinent and coping.

‘Anti-craving’ drugs

The following show a modest effect on assisting abstinence:

• acamprosate 666 mg (o) tds

• naltrexone 50 mg (o) daily (under close supervision)

• consider a combination of the above 2 drugs

Note: Disulfiram can be helpful in highly motivated people but its use is recommended under specialist advice.

Symptoms of a ‘hangover’ include headache, nausea, irritability, malaise and a mild tremor. Withdrawal from alcohol in a chronic problem drinker includes:

• agitation

• prominent tremor

• sweating

• insomnia

• seizures

• delirium tremens (DTs)

The aim of treatment for acute withdrawal symptoms is to prevent development of DTs. Maintain fluid, electrolytes and nutrition. Add vitamin B complex, including thiamine, because the patient is invariably thiamine deficient.

If medication is required (specialised advice):

• diazepam 20 mg (o) every 2 hours (up to 100 mg (o) daily) titrated against clinical response (taper off after 2 days) in the hospitalised or well-supervised patient

• thiamine 100 mg IM or IV daily for three days, then 300 mg (o) daily for several weeks

• vitamin B group supplement (o) or IM daily

• for psychotic features add haloperidol 1.5–5 mg (o) bd or 5 mg IM as single dose if necessary

Alcohol withdrawal delirium (delirium tremens)

DTs is a serious life-threatening withdrawal state. It has a high mortality rate if inadequately treated and hospitalisation is always necessary.

Clinical features

• May be precipitated by intercurrent infection or trauma

• 1–5 days after withdrawal (usually 3–4 days)

• Disorientation, agitation

• Clouding of consciousness

• Marked tremor

• Visual hallucinations (e.g. spiders, pink elephants)

• Sweating, tachycardia, pyrexia

• Signs of dehydration

Treatment¹⁴

• Hospitalisation with alcohol specialist advisory service

• Correct fluid and electrolyte imbalance with IV therapy

• Treat any systemic infection

• Thiamine (vitamin B1 300 mg IM or IV daily for 3–5 days, then thiamine 300 mg (o) daily

• Diazepam 20 mg (o) every 2 hours (up to max. 60 mg daily) until symptoms subside. This dose is usually required for 2–3 days, then should be gradually reduced till finished. If psychotic features (e.g. hallucinations and delusions) add haloperidol 0.5–2 mg (o) bd every 2 hours, titrated to clinical response (max. 10 mg/24 hours).

Note: Chlorpromazine is not recommended because of its potential to lower seizure threshold. Diazepam and haloperidol may worsen the symptoms of hepatic toxicity.

Alcohol overdose¹⁴

Overdose is potentially fatal. The average lethal blood alcohol concentration is about 0.45–0.5%. Death from a lower concentration may occur with other sedative drugs. Alcohol withdrawal may begin at 0.1%. Treatment of overdose is supportive and symptomatic. No stimulants should be given. Overdose may cause hypoglycaemia and metabolic acidosis.

Hangover

A type of acute drug toxicity causing headache, nausea and fatigue.

Prevention

• Drink alcohol on a full stomach.

• Select alcoholic drinks that suit you: avoid champagne.

• Avoid fast drinking—keep it slow.

• Restrict the quantity of alcohol.

• Dilute your drinks.

• Avoid or restrict smoking while drinking.

• Drink three large glasses of water before retiring.

Treatment

• Drink ample fluids especially water because of relative dehydration effect of alcohol.

• Take two paracetamol tablets for headache.

• Drink orange juice or tomato juice, with added sugar.

• A drink of honey in lemon juice helps.

• Tea is a suitable beverage.

• Have a substantial meal but avoid fatty food.

Several psychotropic substances are used for their effects on mood and other mental functions. Many of the severe problems are due to withdrawal of the drug. Symptomatic behaviour common to illicit drugs includes:

• rapid disappearance of clothing and personal belongings from home

• signs of unusual activity around hang-outs and other buildings

• loitering in hallways or in areas frequented by addicts

• spending unusual amounts of time in locked bathrooms

• inability to hold a job or stay in school

• rejection of old friends

• using the jargon of addicts

The drug list

Illicit drugs taken by injecting drug users in Victoria, Australia in 2005 were:

• heroin 89%

• cannabis 87%

• speed 75%

• ice 29%

• cocaine 15%

• base 13%

Source: Illicit drug reporting system

A summary of the effects of illicit or hard street drugs is presented in TABLE 21.4.

A list of street drugs and their slang names is presented in TABLE 21.5.

Opioid (narcotic) dependence

This section will focus on heroin dependence, although opioids such as codeine and controlled dose agents such as oxycodone and morphine are problematic.

Typical profile of a heroin-dependent person¹⁵

• Male or female: 16–30 years

• Family history: often severely disrupted, such as parental problems, early death, separation, divorce, alcohol or drug abuse, sexual abuse, mental illness, lack of affection

• Personal history: low threshold for toleration, unpleasant emotions, poor academic record, failure to fulfil aims, poor self-esteem

• First experiments with drugs are out of curiosity, and then regular use follows with loss of job, alienation from family, finally moving into a ‘drug scene’ type of lifestyle

Methods of intake

1. Oral ingestion

2. Inhalation (see FIG. 21.6)

   • intranasal

   • smoking

3. Parenteral

   • subcutaneous

   • intramuscular

   • intravenous (see FIG. 21.5)

Opioid withdrawal effects^14,15

These develop within 12 hours of ceasing regular usage. Maximum withdrawal symptoms usually occur between 36 and 72 hours and tend to subside after 10 days.

• Anxiety and panic

• Irritability

• Chills and shivering

• Excessive sweating

• ‘Gooseflesh’ (cold turkey)

• Loss of appetite, nausea (possibly vomiting)

• Lacrimation/rhinorrhoea

• Tiredness/insomnia

• Muscle aches and cramps

• Abdominal colic

• Diarrhoea

A secondary abstinence syndrome is identified¹⁵ at 2–3 months and includes irritability, depression and insomnia.

Complications of opioid dependence

Medical

• Overdose reaction: agitation, respiratory depression—may include fatal cardiopulmonary collapse. Since the early 2000s opioid deaths have fallen from peak levels of the 1990s, when there was a glut of heroin.

• Injection site: scarring, pigmentation, thrombosis, abscesses, ulceration (especially with barbiturates)

• Distal septic complications: septicaemia, infective endocarditis, lung abscess, osteomyelitis, ophthalmitis

• Viral infections: hepatitis B, hepatitis C (refer to CHAPTER 58), HIV infection (refer to CHAPTER 27)

• Neurological complications: transverse myelitis, nerve trauma

• Physical disability: malnutrition

Social

• Alienation from family, loss of employment, loss of assets, criminal activity (theft, burglary, prostitution, drug trafficking)

Management

Management is complex because it includes the medical management not only of physical dependence and withdrawal but also of the individual complex social and emotional factors. The issues of impaired liver function, hepatitis B and C and HIV prevention also have to be addressed. Sociological tests for these illnesses should be considered.

Patients should be referred to a treatment clinic and then a shared-care approach can be used. The treatments include cold turkey (abrupt cessation) with pharmacological support, acupuncture, high doses of vitamin C, methadone substitution and drug-free community education programs.

Maintenance programs that include counselling techniques are widely used for heroin dependence. Acute toxicity requires injections of naloxone.

Opioid withdrawal¹⁴

Buprenorphine controlled withdrawal (short term) is used to prevent the emergence of a withdrawal syndrome in contradistinction from buprenorphine maintenance, where there is an extended treatment period.

Initial dose

• buprenorphine 4–8 mg (sublingual) as a single daily dose, increasing to 12 mg (max) on day 3, then reduce gradually over the next 3–5 days

Note: If autonomic signs, use clonidine 5–15 mg/kg/day (o) in 3 divided doses for 7–10 days then taper off. If anxiety and agitation, use diazepam 5–20 mg (o) qid (with care). Clonidine can be used as first-line treatment because of relative safety but buprenorphine is preferred to clonidine and methadone for the management of opioid withdrawal. Avoid benzodiazepines unless supervision is available.

Maintenance programs for long-term opioid dependence¹⁴

There are currently three alternative programs—methadone, buprenorphine and naltrexone—which are substitutes for heroin and other opioids.

Methadone

Seek specialist advice before starting treatment. The dose needs to be determined individually according to past use and initial response to methadone.

• Methadone 20 mg (o) daily initially. Stabilise dose over 3 weeks. Beware of doses >40 mg, especially in unwell patients. Maintenance 50–80 mg (o) daily.

Buprenorphine

• Buprenorphine 2–8 mg sublingual, once daily initially, increase to 8–24 mg daily or alternative days once stabilised. It is less dependent and prone to overdose than methadone but can precipitate withdrawal if used too soon.

Naltrexone

Care is required in giving naltrexone to a person physically dependent on opioids. A naloxone challenge test is used.¹⁴ If no evidence of withdrawal give:

• Naltrexone 25 mg (o) initially increasing to 50 mg daily on day 2 if tolerated. Careful supervision with appropriate counselling is required.

The natural history of opioid dependence indicates that many patients do grow through their period of dependence and, irrespective of treatments provided, a high percentage become rehabilitated by their mid-30s.

Stimulant substance abuse

The stimulants include amphetamines and their analogues, ephedrine, designer drugs such as MDMA and ‘fantasy’, cocaine and certain appetite suppressants. The amphetamines include the common methamphetamine, dexamphetamine and the original amphetamines.

The drugs also include crack, which is a cocaine base where the hydrochloride has mostly been removed, usually in a microwave oven. Crack can be inhaled or smoked (see FIGS 21.6 and 21.7). Ice is the crude form of methamphetamine, a derivative of amphetamine (FIG. 21.7). Speed is dexamphetamine.

Party drugs

Ecstasy is another ‘designer’ drug which is an amphetamine derivative—methylenedioxy-methamphetamine (MDMA). It has high abuse potential, some hallucinogenic properties and a tendency to neurotoxicity, as proved on PET brain scans. It is popular in rave parties. Deaths have occurred, reportedly in association with relative dehydration or excessive hydration. Treatment for overdosage involves correction of fluid and electrolyte disturbances. An increasingly popular drug is fantasy (gamma-hydroxybutyrate), which has sedative and anaesthetic effects similar to alcohol. A popular party drug, it is implicated as a ‘date rape’ drug. There is no specific antidote.¹³ Another party drug is ketamine, which is a short-acting anaesthetic with hallucinogenic properties. It can produce nausea and vomiting if used with alcohol. Like fantasy, treatment of overdosage is symptomatic. Local anaesthetics can be dangerous in amphetamine users because of cardiotoxicity.

Stimulant-induced syndrome¹⁴

• Aggressive behaviour

• Paranoid behaviour

• Irritability

• Transient toxic psychosis

• Delirium

• Schizophrenic-like syndrome

• Increased sexual behaviour

Treatment

• Withdrawal of drugs

• Cognitive behaviour therapy

• No firm evidence on effectiveness of drugs

Stimulant-withdrawal syndrome¹⁴

This syndrome should be suspected in people whose occupation involves shift work, interstate transport driving or multiple jobs presenting with the following symptoms:

• drowsiness

• hypersomnia, then insomnia

• irritability

• hyperphagia

• aggressive behaviour

• depression/dysphoria

• urge to resume drugs

Treatment

• Psychological support and encouragement, e.g. CBT

• Desipramine (or similar tricyclic antidepressant) 75 mg (o) nocte (increasing as necessary)

• Bromocriptine 1.25 mg (o) bd has also been used for cocaine withdrawal

Hallucinogen abuse

Hallucinogens in use include lysergic acid diethylamide (LSD), phencyclidine (angel dust), the tropical plant products (Kava and Betel nuts) and many synthetics. Symptoms include psychotic behaviour, including severe hallucinations. Withdrawal from these drugs is not usually a problem but ‘flashbacks’ can occur. Treatment, especially where there is fear or anxiety, is diazepam 10–20 mg (o) statim.

Treatment (medication to counter symptoms)¹⁴

• haloperidol 2.5–10 mg (o) daily

  or

• diazepam 10–20 mg (o) repeated every 2 hours prn (to max 120 mg daily)

Cannabis (marijuana) use

Cannabis is a drug that comes from the plant Cannabis sativa, the Indian hemp plant. It is a stimulant and a hallucinogen. It contains the chemical tetrahydrocannabinol, which makes people get ‘high’. It is commonly called marijuana, grass, pot, dope, hash or hashish. Other slang terms are Acapulco gold, ganga, herb, J, jay, hay, joint, reefer, weed, locoweed, smoke, tea, stick, Mary Jane, Panama red and spliffy (see TABLE 21.5). Marijuana comes from the leaves, while hashish is the concentrated form of the resinous substances from the head of the female plant and can be very strong (it comes as a resin or oil). The drug is usually smoked as a leaf (marijuana) or a powder (hashish), or hashish oil is added to a cigarette and then smoked. The effects of taking cannabis depend on how much is taken, how it is taken, how often, whether it is used with other drugs and on the particular person.¹⁶ The effects vary from person to person. The effects of a small-to-moderate amount include:

• feeling of well-being and relaxation

• decreased inhibitions

• woozy, floating feeling

• lethargy and sleepiness

• talkativeness and laughing a lot

• red nose, gritty eyes and dry mouth

• unusual perception of sounds and colour

• nausea and dizziness

• loss of concentration

• looking ‘spaced out’ or drunk

• lack of coordination

• delusions and hallucinations (more likely with larger doses)

• a form called skunk or mad weed causes paranoia

The effects of smoking marijuana take up to 20 minutes to appear and usually last 2 to 3 hours and then drowsiness follows.¹⁶ The effect on psychomotor function is similar to alcohol and this can impair driving skills. The main problem is habitual use with the development of dependence; dependence (addiction) is worse than originally believed.

Long-term use and addiction

The influence of pot has a severe effect on the personality and drive of the users. They lose their energy, initiative and enterprise. They become bored, inert, apathetic and careless. A serious effect of smoking pot is the inability to concentrate and loss of memory. Some serious problems include:

• deterioration of academic or job performance

• anxiety and paranoia

• respiratory disease (more potent than tobacco for lung disease): causes COPD, laryngitis and rhinitis

• often prelude to taking illicit drugs

• becoming psychotic (resembling schizophrenia): the drug appears to unmask an underlying psychosis¹⁶

• impaired ability to drive a car and operate machinery

Withdrawal

Sudden withdrawal produces insomnia, night sweats, nausea, depression, myalgia, irritability and maybe anger and aggression. However, the effects are often mild with recovery within a few days in many, but heavy users have a severe withdrawal.

Management

No specific pharmacological treatment is available. CBT is advisable.

The best treatment is prevention. People should either not use it or limit it to experimentation. If it is used, people should be prepared to sleep it off and not drive.

Anabolic steroid misuse

The apparent positive effects of anabolic steroids include gains in muscular strength (in conjunction with diet and exercise) and quicker healing of muscle injuries. However, the adverse effects, which are dependent on the dose and duration, are numerous.

Adverse effects in women are:

• masculinisation—male-pattern beard growth

• suppression of ovarian function

• changes in mood and libido

• hair loss

In adult men, adverse effects are:

• feminisation: enlarged breasts, high-pitched voice

• acne

• testicular atrophy and azoospermia

• libido changes

• hair loss

Severe effects with prolonged use include:

• liver function abnormalities, including hepatoma

• tumours of kidneys, prostate

• heart disease

In prepubescent children there can be premature epiphyseal closure with short stature.

It is important for GPs to have a basic understanding of drugs that are banned and those that are permissible for elite sporting use. The guidelines formulated by the International Olympic Committee (IOC) Medical Commission and the World Anti-Doping Agency (WADA) are generally adopted by most major sporting organisations.¹⁰ TABLES 21.6 and 21.7 provide useful guidelines. The IOC’s list of prohibited drugs is regularly revised. Banned drug groups include stimulants, narcotics, cannabinoids (e.g. marijuana), anti-oestrogen agents (e.g. tamoxifen), glucocorticosteroids (e.g. prednisolone), anabolic agents, diuretics and various hormones. Banned methods include blood doping (the administration of blood, red blood cells and related blood products), enhancement of oxygen transfer (e.g. erythropoietin, efaproxiral), gene doping and pharmaceutical, chemical and physical manipulation (substances or methods that alter the integrity and validity of the urine testing).

Restricted drugs include alcohol, marijuana, local anaesthetics, corticosteroids and beta blockers. Practitioners can check the guidelines and provide written notification to the relevant authority. Be cautious of anorectics and weight-reducing agents.

Other drug groups permitted by WADA:

• antidepressants

• antihypertensives (excluding beta blockers)

• caffeine

• eye medications

• oral contraceptives

• skin creams and ointments

• sleeping tablets

Check websites including www.olympic.org.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Alcohol: harmful use of alcohol

• Amphetamines

• Cocaine

• Ecstasy

• Heroin

• Smoking: quitting

• Cannabis (marijuana)

• Global DRO, Athletes, check your medications! (countryspecific), <www.globaldro.com>

• Department of Health, National drug campaign, <www.campaigns.health.gov.au/drughelp>

• <www.usada.org/substances/prohibited-list>