Substance use and misuse

50


Substance use and misuse




Study Points



image The main psychoactive substances taken for non-medicinal purposes


image The range of professional interventions used in the field of substance misuse


image The aim of pharmaceutical interventions and their operation


image The role of the pharmacist


image Key factors to consider when providing pharmaceutical care to people with drug misuse problems



Introduction


This chapter begins with some background information before it summarizes current thinking on drug misuse and drug dependence. It then looks at treatment provision in the UK and the range of interventions used, focussing on the practical provision of the two main pharmaceutical interventions: needle exchange and substitute pharmacotherapy provision.



Terminology


Terminology used in the field of drug misuse can be confusing, even for those who work in the area. There are political and philosophical differences behind the use of various terms, a discussion of which is outside the scope of this work. However, it is important to be aware that a variety of terms essentially refer to the same things.


‘Drug use’ in the context of this chapter, is the term commonly used to refer to the consumption of psychoactive substances without medical or healthcare instruction. The term ‘drug misuse’ refers to drug use that is problematical and incurs significant risk of harm. These two terms are often used interchangeably. ‘Drug abuse’ essentially refers to the same thing but its use is less common in recent publications. ‘Substance’ is sometimes used in place of ‘drug’ to include non-medicinal chemicals such as solvents, alcohol and nicotine.


‘Dependence’ or ‘addiction’ refers to the compulsion to continue administration of psychoactive substance(s) in order to avoid physical and/or psychological withdrawal effects. Dependence syndrome is defined by the World Health Organization (WHO) as:



Dependence can be classified in more detail, as found in the Shorter Oxford Textbook of Psychiatry.


‘Drug user’ is commonly used to refer to someone who participates in drug/substance use. The term ‘drug misuser’ refers to someone undertaking drug use in such a way that it is problematical and presents significant risk of harm. The two terms tend to be used interchangeably. Terms such as ‘drug addict’ and ‘drug abuser’ are less used in recent literature.




Substances that are used and their effects


Table 50.1 lists some commonly used psychoactive substances in western societies and summarizes their effects. (Nicotine is included for completeness: the role of the pharmacist in smoking cessation is covered in Ch. 48). The unwanted and harmful effects of some drugs relate to prolonged and excessive use, whereas others occur with single doses of smaller amounts. The method of administration also influences the extent of the risks, e.g. injecting opiates presents greater health risks than taking them by vaporization (‘chasing the dragon’). Table 50.1 is presented as a guide, but it is not comprehensive.




Why do people use psychoactive drugs?



Benefits


Why people use psychoactive drugs is a multifaceted question to which there is no simple answer. As a crude summary, people do so because they expect to experience a benefit in some way. Any awareness of risks is weighed up against the perceived benefits and the decision to take the drug prevails.


The expected or perceived benefits may include: the attainment of pleasurable feelings (e.g. relaxation); increased social interaction (e.g. reduced inhibitions); alteration of the person’s psychological condition to a more desirable state (e.g. escapism); physical change (e.g. anabolic steroids taken by bodybuilders) or avoidance of withdrawal symptoms in someone who is dependent on a drug. The reasons for use may change over time with the same user, e.g. opiate use may be commenced to escape from reality but then continued to avoid the withdrawal effects.






Control and dependence


A lack of specific types of neurological control is sometimes given as the reason why some people develop addictions to specific psychoactive drug(s) whereas others do not. Published studies can be criticized as the models of behaviour are largely shown in animals not humans. Nevertheless, neurological processes manifest positive and negative reinforcement of drug seeking and taking behaviours, with genetic variations influencing these.


The level of control a drug user has over his use will influence the balance between the benefits and harms experienced. With controlled use, harms can be prevented or contained, e.g. the quantity of alcohol consumed may be controlled to avoid unwanted effects. In uncontrolled use, harms can escalate. Uncontrolled use is a characteristic of drug dependence.


When a person loses control over his drug consumption, or rather drug consumption controls the person, this may be described as dependence. Drug dependence can present a significant amount of harm to the individual and to society. There is a clear association between drug dependence and social deprivation. Socially deprived areas tend to have a greater incidence of drug problems. However, drug problems are also found in non-deprived areas.



Withdrawal


When a person stops using a substance they are dependent on, they often experience withdrawal. Withdrawal can be described in two forms.





The harms relating to psychoactive drug use and dependence


The risks and harms that drug use and dependence can present to the individual and society vary with the drug taken, the individual and the circumstances in which the drugs are taken. It is not possible to list all possible consequences from drug use/misuse in this chapter. The risks are categorized below.





Drug-related crime


Drug-related crime includes not only the criminal activities committed against the Misuse of Drugs Act (see below) for which the individual is punished, but also crime that impacts on communities and society at large. The latter may relate to the acquisition of drugs or the effects of drugs, e.g. burglary to obtain money to buy drugs, robbery, violence associated with drunkenness, drunk/drug driving. Drug-related crime is of concern to society and is one of the reasons why treatment of drug problems and drug dependence is a key public health issue (see Ch. 13). Additionally, there is evidence that treatment of drug dependence contributes towards a very marked reduction in drug-related crime. Hence, treatment benefits not only the individual in terms of improved health but also society by making communities safer.


Drug users are often at greater risk than non-drug users of being victims of crime, e.g. violence associated with debt to drug dealers, prostitution, robbery and mugging if homeless or intoxicated.



Legislation



Misuse of Drugs Act


The Misuse of Drugs Act 1971 classifies drugs into Class A, Class B and Class C. The purpose of this legislation is to define the penalties imposed for the illegal undertaking of various activities, e.g. possession, supply, import, and export. These are summarized in Table 50.2. This classification system is different from the Misuse of Drugs Regulations that largely govern dispensing and other activities of the pharmacist.





The management of drug use and dependence


Pharmacists are primarily involved with the treatment of dependence rather than interventions aimed at recreational and non-problematic drug use. The prevalence of drug dependence on a population basis is relatively small compared with national statistics that estimate numbers of people who have ever tried drugs. However, the extent of harm from drug dependence can be large; hence the need for effective strategies to support people in changing their drug use. Since the 1990s, treatment, criminal justice and prevention initiatives in the UK have been guided by government drugs strategies.


Figure 50.1 illustrates the range of methods used in preventing, reducing and controlling drug use and dependence and managing the adverse consequences.


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Jun 24, 2016 | Posted by in PHARMACY | Comments Off on Substance use and misuse

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