south east england regional conference

Considerations in substance misuse

The treatment of addiction, problems with current treatment programmes and future therapies were dicussed at the annual regional conference of the Royal Pharmaceutical Society's South East England region on March 11

There was evidence to show the effectiveness of treatment services for drug dependency, according to STUART GILL, substance misuse training co-ordinator, West Sussex Health Authority. They were successful in allowing abstinence, preventing infection and reducing crime. But treatment services were underfunded, he said. Only a minority of people who used drugs were in treatment at any one time and waiting lists for people who wanted to enter treatment programmes needed to be reduced. In addition, facilities were lacking for certain subgroups of drug misusers. For example, no crèche facilities were provided for women with children. Equal numbers of male and females started using drugs but three times as many men than women presented for treatment.

Over the past 10 to 15 years, there had been a marked increase in the use of drugs and a decrease in the age of initiation, he said. The percentage of adults who were dependent on drugs in the UK was 2.6 per cent.

Substance misuse could be thought of as a triangle with one corner each for the drug, person and context of use. It was easy always to think of the drug corner but it was important to consider the context in which drugs are used and the life of the person. It was also important to remember the functionality of the drug on people's lives. The addiction kept them very busy, and gave them a purpose for living.

Risk factors for becoming dependent on drugs were:

• Age of onset — earlier use and a greater use meant higher risk
• Low self-esteem; young people with high self-esteem were as likely to use drugs but in a non-problematic, recreational way
• Availability of drugs
• Peer pressure, from both friends and the media
• Environmental issues (eg, housing, there was a link between drug dependence and deprivation, particularly for heroin use)
• Poverty of aspiration, ie, if children grew up thinking that it was not worth striving to succeed
• Genetic predisposition

Mr Gill believed that the most basic intervention to prevent people misusing drugs was “valuing young people and giving them aspirations”. Keeping people in education and giving them job opportunities were two ways of doing this. Prevention had to start at primary school. He suggested that giving young people a “life skills” package at primary school that was reinforced at secondary school has been shown to be a useful method of preventing drug misuse.

Neuropsychiatric disorder

Drug addiction was a neuropsychiatric disorder, said Dr ALISON BRATT, senior lecturer, University of Brighton, either because of a pre-existing affective disorder or as a result of repetitive drug taking.

The process of addiciton involved neural pathways of initiation, maintenance and progression to addiction. Research in animals provided evidence for a drug abuse centre in the brain and suggested that most drugs of abuse regulated midbrain mesolimbic dopaminergic neurotransmission.

In order to treat addiction, we needed to understand how addiction worked on cognitive, behavioural, neuropsychological and neuropharmacological levels, she said. One area of future research would involve examining the genetic component of addiction.

Relapse could occur after protracted abstinence, she said. Drug seeking was reactivated by three main events — taking the drug again, a conditioned stimulus (something associated with the drug, such as seeing a belt used as a tourniquet), and induction of a state of stress (connected with blood cortisol levels).

Aims of treatment

The aims of treatment were harm reduction, detoxification and maintenance of abstinence, said Dr ADAM WINSTOCK, clinical lecturer in addiction, South London and Maudsley NHS Trust and National Addiction Centre.

However, it was important to be realistic about what medication could do. The aetiology of drug use involved many factors,
including genetic factors, poverty, psychological factors and abuse. It was naive to think that one tablet could make a person's whole life better. He thought that it was important to use a holistic approach. In addition, the longer people were kept in contact with methadone treatment programmes the better outcomes they had.

Dr Winstock thought that the future of drug addiction treatment would involve the use of partial agonists and long-acting substitute preparations. Some of the newer approaches to treatment of addiction included:

• Renormalising the dopamine system, using tricyclics and SSRIs
• Aversion therapy with disulfiram for both alcohol and cocaine
• Immunotherapy and catalytic antibodies. Catalytic antibodies locked on to cocaine and accelerated its breakdown. However, there was an ethical dilemma over vaccination against cocaine addiction
• New substitute treatment, eg, long-acting dopamine transport blockers
• Using old drugs for new things, eg, Ritalin offered prolonged blockade of dopamine. (Use of methylphenidate [Ritalin] in children with ADHD seemed to offer protection against later cocaine addiction.)
• D3 partial agonists. (A partial agonist for cocaine increased dopamine enough to ward off craving but acted as an antagonist if cocaine was taken. This treatment was two to three years away from clinical practice.)

Supervised consumption

The Berkshire four-way agreement was discussed by the scheme's co-ordinator, MARION WALKER. [The scheme is described in an article on p547.]

The four-way agreeement involved the patient, general practitioner, key worker and pharmacist. It was set up because patients were getting individual contracts from GPs, pharmacists and key workers that all said the same thing. The idea of the four-way agreement was to combine the different contracts into one. Two key points about the supervision process in the four-way agreement were:

• The methadone has to be dispensed in a bottle labelled with the patient's name and dose so that the patient could check the details and a record was made of each dispensing on the patient's medication record
• The methadone had to be drunk from the bottle or a cup, neither of which could be reused because of a risk of hepatitis A infection

A lack of a private area for consumption of methadone was not a reason not to offer supervised dispensing, she said. It was best if all pharmacies offered methadone supervision and then patients could pick a pharmacy where they felt comfortable. Staff attitude was more important in providing a courteous, discreet service than a private area.

Ms Walker concluded that the four-way agreement meant that the pharmacist, GP, key worker and patient had better working relationships. For example, if a patient was shoplifting the pharmacist did not have to deal with this problem on his/her own but could share the problem with the GP or key worker.

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