Drugs and Alcohol in Primary Care Steve Brinksman Clinical Lead SMMGP

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1 Drugs and Alcohol in Primary Care Steve Brinksman Clinical Lead SMMGP

2 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

3 Trends and Issues Traditional drugs Alcohol Addiction to Medicines Novel Psychoactives Third sector Involvement Prevalence Age Co-morbidities Recovery v Harm Reduction

4 Trends in illicit drug use in the last year among adults, by age group, 1996 to 2013 to 2014, Crime Survey for England and Wales

5 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

6 Ageing Populations

7 Age Effects? Trends in the proportion of reported drug-induced deaths in the age group, in selected EU Member States

8 Co-morbiditity COPD Ischaemic Heart Disease Hypertension and CKD Liver Disease including Cirrhosis Diabetes Mental Health Poly Drug Use

9 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

10 What is Recovery? Recovery is an individual, person-centred journey as opposed to an end state and will mean different things to different people (Drug Strategy 2010) Medical Assisted Recovery and Abstinence both count! An informed choice by an individual Support structures in place Detoxification needs to take place between preparation and after care. It should never be undertaken as a stand-alone procedure

11 Recovery as a journey Recovery Reducing Harm engagement Supported Stability Reintegration Abstinence

12 What else is needed? Psychosocial Interventions access- preferably in house Specialist Support around Complex Issues Access to Medically Assisted Withdrawal and Rehabilitation Links to Mutual Aid Prescribing to support Abstinence

13 Alcohol in the mix Public Health advises just one glass of wine a day

14 The numbers PHE data ENGLAND LAs PRACTICE GP Total Population 53,588, ,554 6,487 1,606 Adult Population 43,580, ,716 5,275 1,306 Dependent drinkers 1,568,911 10, Increasing and Higher Risk 9,849,277 64,798 1, Alcohol interventions in Primary Care 14 FACTS FIGURES LAs 152 Inc + High % 22 Dep % 3.8 Practices 8,261 GPs 33, Alcohol interventions in Primary Care

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16 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

17 English Data Figure 15: Estimated number of people living with HCV-related cirrhosis or decompensated cirrhosis/hcc in England: (95% credible intervals are given in parentheses) Hepatitis C in the UK 2013 Report, Public Health England

18 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 PHE publications gateway number: July 2014

19 Treatment rates in England by SHA Percentage of prevalent population Proportion of estimated prevalent population treated for hepatitis C No SHA area manages to treat more than 3% of their infected population in a year An audit of Strategic Health Authority hepatitis C governance 2009 Hepatitis C Trust

20 Why Treat Hepatitis C? Van de Meer et al JAMA 2012

21 Referral for treatment One report estimated that there are more than 13,000 new cases of hepatitis C infection in the UK per year yet we are only treating around 5,000 per year It has been estimated that <1% of IDUs are being treated. In the dark. An audit of hospital hepatitis C services across England. London: The All Party Parliamentary Hepatology Group, August 2010.

22 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 between 60-85% of patients with chronic HCV can be cured Treatment for HCV has been recommended by NICE

23 Addiction to Medicines

24 Opioid Analgesics

25 Opioid deaths mirror prescribing* Other opiate Tramadol Dihydrocodeine not from compound may signal an emerging problem in the UK similar to the issue that is now well established in the USA. 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

26 Newer Drugs Novel Psychoactive Substances, Club Drugs, Legal Highs

27 A Growing Problem

28 Drug harms in the UK: a multicriteria decision analysis The Lancet, Volume 376, Issue 9752, Pages , 6 November 2010 doi: /s (10) 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.

29 Public Health v Primary Care Oh, East is East, and West is West, and never the twain shall meet Rudyard Kipling

30 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

31 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

32 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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