Oxford Handbook of General Practice (4 edn)
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Prevention and screening
In all disease, the goal is prevention.
Definitions
Primary prevention Prevention of disease occurrence
Secondary prevention Controlling disease in early form (e.g. carcinoma in situ)
Tertiary prevention Prevention of complications once the disease is present (e.g. DM)
Barriers to prevention
Patient Blinkering (‘It’ll never happen to me’); rebellion (‘I know it’s bad—but it’s cool’); poor motivation (path of least resistance)
Doctor Time; money—health promotion takes time and personnel; motivation—health promotion is repetitive and boring
Society Pressure from big business (e.g. cigarette advertising); other priorities; ethics (e.g. public uproar at threats not to offer cardiac surgery to smokers)
Prevention of coronary heart disease
p. 242
Screening
The idea of screening is attractive—the ability to diagnose and treat a potentially serious condition at an early stage when it is still treatable. An ideal screening test must pick up all those who have the disease (have high sensitivity) and must exclude those who do not (high specificity). It must detect only those who have a disease (high positive predictive value) and should exclude only those who do not have the disease (high negative predictive value). See Table 8.1.
| Disease | |||
|---|---|---|---|
| Present | Absent | ||
Test | Positive | True positive (a) | False positive (b) |
Negative | False negative (c) | True negative (d) | |
Sensitivity = a/(a+c) Specificity = d/(b+d) | Negative predictive value = d/(c+d) Positive predictive value = a/(a+b) | ||
| Disease | |||
|---|---|---|---|
| Present | Absent | ||
Test | Positive | True positive (a) | False positive (b) |
Negative | False negative (c) | True negative (d) | |
Sensitivity = a/(a+c) Specificity = d/(b+d) | Negative predictive value = d/(c+d) Positive predictive value = a/(a+b) | ||
The Wilson–Jungner criteria
All screening tests should meet the following criteria before they are introduced to the target population:
The condition being screened for is an important health problem
Natural history of the condition is well understood
There is a detectable early stage
Treatment at early stage is of more benefit than at late stage
There is a suitable test to detect early stage disease
The test is acceptable to the target population
Intervals for repeating the test have been determined
Adequate health service provision has been made for the extra clinical workload resulting from screening
Risks, both physical and psychological, are < benefits (see Table 8.2)
Costs are worthwhile in relation to benefits gained
| Benefits | Disadvantages |
|---|---|
• Improved prognosis for some cases detected by screening • Less radical treatment for some early cases • Reassurance for those with negative test results • Increased information on natural history of disease and benefits of treatment at early stage | • Longer morbidity in cases where prognosis is unaltered • Overtreatment of questionable abnormalities • False reassurance for those with false-negative results • Anxiety and sometimes morbidity for those with false-positive results • Unnecessary intervention for those with false-positive results • Hazard of screening test • Diversion of resouces to the screening programme |
| Benefits | Disadvantages |
|---|---|
• Improved prognosis for some cases detected by screening • Less radical treatment for some early cases • Reassurance for those with negative test results • Increased information on natural history of disease and benefits of treatment at early stage | • Longer morbidity in cases where prognosis is unaltered • Overtreatment of questionable abnormalities • False reassurance for those with false-negative results • Anxiety and sometimes morbidity for those with false-positive results • Unnecessary intervention for those with false-positive results • Hazard of screening test • Diversion of resouces to the screening programme |
UK screening programmes
Performance of screening tests
See Table 8.1. For a screening programme to be effective and ↓ morbidity and mortality there must be:
Adequate participation of the target population
Few false-negative or false-positive results
Screening intervals shorter than the time taken for the disease to develop to an untreatable stage
Adequate follow-up of all abnormal results
Effective treatment at the stage detected by screening
There is no ideal screening test. Always explain:
Purpose of screening
Likelihood of positive/negative findings and possibility of false-positive/negative results
Uncertainties and risks attached to the screening process
Significant medical, social, or financial implications of screening for the particular condition or predisposition
Follow-up plans, including availability of counselling and support services
Further information
Wilson JMG, Jungner G (
Prevention of travel-related illness
Pre-travel assessment
8wk pre-departure where possible. Check:
Age
General health
Where and when intending to travel (including areas within a country and stopovers elsewhere)
Type of accommodation
Purpose of travel
Previous experience (including experience with antimalarials)
Current vaccination status
Health risks
Environmental hazards (e.g. changes in altitude/climate) Avoid rapid changes of altitude—take time to readjust; avoid sunburn. Advise women taking combined hormonal contraception and trekking to altitudes of >4500m for >1wk to consider an alternative method of contraception
Accidents Avoid potentially dangerous tasks under the influence of alcohol, e.g. swimming, driving. Avoid motorbikes—especially without helmets and protective clothing
Illness abroad MI causes 61% deaths related to international travel. Do not travel if unwell. Ensure adequate insurance including repatriation costs. Take enough supplies of regular medication when travelling to last the entire trip, and take preventative steps to avoid infection
Transport related problems
Fitness to fly: p. 132
Motion sickness (take OTC medication if afflicted)
Jet lag
DVT—on flights >3h: drink plenty of water, avoid alcohol, regularly get up and walk around, consider prophylactic support stockings
Psychological effects of travel
Prevention of travellers’ diarrhoea
50% travellers experience some diarrhoea. Most cases last 4–5d. 1–2% last >1mo.
Take care to eat and drink uncontaminated food and water
Food should be freshly cooked and hot
Avoid salads and cold meats/fish
Eat fruit that can be peeled
Stick to drinks made with boiling water or bottled drinks and water with an intact seal; avoid ice in drinks
Use water purification tablets if necessary
Action
If diarrhoea occurs when abroad advise patients to use oral rehydration fluids. Only take antidiarrhoeals if impossible to get to a toilet. Seek medical advice if blood in stool, fever, or not resolving in 72h (24h for the elderly or infants).
Do not use antidiarrhoeals if blood in stool, fever, or <10y old.
Prevention of malariaND
Awareness of risk High-risk areas are Central and South America; South East Asia; Pacific islands; sub-Saharan Africa—however brief the time there. Pregnant and asplenic patients are at particular risk
↓ mosquito bites Mosquitoes bite at night
Accommodation—sleep in screened accommodation spraying screens with insecticide each evening and use a pyrethroid vaporizer. If screens are not available use a permethrin-impregnated bed net (kits are available)
Person—in the evenings wear long-sleeved shirts and trousers; protect limbs with diethyl toluamide-containing repellant
Chemoprophylactic drugs See Table 8.3. Regimes vary with location and time of year. Information is available via the Travax website (
www.travax.nhs.uk—registration needed) and travel information clinics
Awareness of residual risk Chemoprophylaxis is not 100% effective. Advise all travellers to malaria regions to seek medical advice if unwell for up to 6mo after return. Malaria is a great mimic. Have a high level of suspicion
| Drug | Dose | Start | Stop |
|---|---|---|---|
Chloroquine | 310mg weekly | 1wk before entering malaria area | 4wk after leaving malaria area |
Mefloquine | 250mg weekly | 2.5wk before entering malaria area | 4wk after leaving malaria area |
Proguanil | 200mg daily | 1wk before entering malaria area | 4wk after leaving malaria area |
Malarone® (proguanil + atovaquone) | 1 tablet daily | 1–2d before entering malaria area | 1wk after leaving malaria area |
Doxycycline | 100mg daily | 1–2d before entering malaria area | 4wk after leaving malaria area |
| Drug | Dose | Start | Stop |
|---|---|---|---|
Chloroquine | 310mg weekly | 1wk before entering malaria area | 4wk after leaving malaria area |
Mefloquine | 250mg weekly | 2.5wk before entering malaria area | 4wk after leaving malaria area |
Proguanil | 200mg daily | 1wk before entering malaria area | 4wk after leaving malaria area |
Malarone® (proguanil + atovaquone) | 1 tablet daily | 1–2d before entering malaria area | 1wk after leaving malaria area |
Doxycycline | 100mg daily | 1–2d before entering malaria area | 4wk after leaving malaria area |
Prevention of HIV and hepatitis B and C
Avoid casual sexual contacts. If these occur use barrier methods of contraception (Femidom®, condoms)
Avoid shared needles (e.g. tattooing/ear piercing/drugs)
Medical kits—if travelling to high-risk areas, take a clearly labelled medical kit containing sutures, syringes, and needles for use in emergencies
Avoid blood transfusion. Two-thirds blood donations in the developing world are unscreened. Know your blood group. Have good travel insurance, including repatriation costs. In an emergency the Blood Care Foundation can arrange screened blood to be provided anywhere in the world (
01403 262652; www.bloodcare.org.uk)
Vaccination for hepatitis B prior to travelling
Vaccination
4% deaths related to travel are due to infectious disease—ensure fully vaccinated for areas intending to visit. Information is available from the Travax website ( www.travax.nhs.uk)—registration is needed.
Useful information
Health Protection Agency (HPA) Guidelines for malaria prevention in travellers from the UK (2007) www.hpa.org.uk
Fit for Travel Information for people travelling abroad from the UK. Includes a list of yellow fever vaccination centres www.fitfortravel.nhs.uk
Diet
The role of the GP and primary care team
Screening Identification of obese patients and patients in need of dietary advice for other reasons
Assessment Current diet, motivation, and barriers to change
Discussion and negotiation Exploration of knowledge about diet; negotiation of goals
Goal setting Provide information and 2–3 food-specific goals on each occasion—set a series of mini-targets that appear realistic and achievable; tailor them to existing diet and usual schedule
Monitoring progress
Barriers to a good diet
Ignorance—posters in surgeries/leaflets may help
Cultural differences—modify information to be relevant
Enjoyment—perception of healthy diet is not enjoyable
Poverty—fresh fruit/vegetables and lean meat/fish are expensive—some elements are cheap, e.g. potatoes, pasta, rice
Lifestyle—convenience foods contain a lot of salt, sugar, and fat
Peer pressure—children are under pressure to eat sweets, crisps, etc.
Habits of a lifetime—we like the foods we have grown up with
Confusion about what is good—packaging may be misleading, e.g. breakfast cereals claiming health messages but containing high sugar
Mixed messages—one minute the press says something is good for you, the next it causes some horrible disease and should be avoided
Fatalism/apathy
The ideal diet
Use starchy foods (e.g. bread, rice, pasta, potatoes) As the main energy source
Eat plenty of fruit and vegetables (>5 portions of fruit and/vegetables/d) Do not overcook vegetables; steaming is preferable to boiling, and keep the delay between cutting and eating fruit/vegetables to a minimum
Eat plenty of fibre Good sources are: high-fibre breakfast cereals, beans, pulses, wholemeal bread, potatoes (with skins), pasta, rice, oats, fruit/vegetables
Eat fish At least 2x/wk. including one portion (max. two portions if pregnant) of oily fish (e.g. mackerel, herring, pilchards, salmon). ↓ cooked red or processed meat; consider substituting meat with vegetable protein (e.g. pulses, soya)
Choose lean meat Remove excess fat/poultry skin and pour off fat after cooking; avoid fatty meat products (e.g. sausages, salami, meat pies); boil, steam, or bake foods in preference to frying; when cooking with fat use unsaturated oil (e.g. olive, sunflower oil) and use cornflour rather than butter and flour to make sauces
Use skimmed milks And low-fat yoghurts/spreads/cheese (e.g. Edam or cottage cheese)
Avoid adding salt to foods. Aim for <6g of salt/d. Avoid processed foods, crisps, and salted nuts
Avoid adding sugar and cut down on sweets, biscuits, and desserts
Drink at least 4–6 pints (2–3L) of fluid daily Preferably not tea, coffee, or alcohol. Drinking a large glass of water with meals and instead of snacks can reduce the urge to overeat
Avoid excessive alcohol intake <21u/wk for men and <14u/wk for women— p. 184
The plate model. Developed nationally to communicate current recommendations for healthy eating. It shows rough proportions of the various food groups that should make up each meal.
Obesity
p. 178
Weight loss
Non-specific symptom. Treat the cause. Consider:
GI causes Malabsorption, malnutrition, dieting
Chronic disease Hyperthyroidism, DM, heart failure, renal disease, severe COPD, degenerative neurological/muscle disease, chronic infection (e.g. TB, HIV) or infestation
Malignancy
Psychiatric causes Depression, dementia, anorexia
Malnutrition
50% of women and 25% of men aged >85y are unable to cook a meal alone. Malnutrition is common amongst the elderly.
Poor nutritional status
Slows rate of wound healing, ↑ risk of infection, ↓ muscle strength, is detrimental to mental well-being, and ↓ the ability of elderly people to remain independent.
Risk factors
Low income
Living alone
Mental health problems (e.g. depression)
Dementia
Recent bereavement
Gastric surgery
Malabsorption
↑ metabolism
Difficulty eating and/or swallowing (stroke, neurological disorder, MND)
Presence of chronic disease (e.g. Crohn’s disease, UC, IBS, cancer, COPD, CCF)
Management
General advice Encourage to eat more and ↑ consumption of fruit and vegetables; consider using nutritional, vitamin (e.g. vitamin D for the housebound and institutionalized), and mineral supplements
Inability to prepare meals/shop Consider referral to social services, meals on wheels, community dietician; community day centre; local voluntary support organization
Difficulty with utensils Consider aids/equipment, e.g. special cutlery, non-slip mats—consider OT referral
Nausea Consider antiemetics
Swallowing difficulty Investigate cause. If none found or unable to resolve the problem, consider pureed food and/or thickened fluids
Further information
Scientific Advisory Committee on Nutrition (SACN) www.sacn.gov.uk
British Nutrition Foundation www.nutrition.org.uk
Malnutrition Universal Screening Tool (MUST) www.bapen.org.uk/screening-for-malnutrition/must/introducing-must
NICE Nutrition support in adults (2006) www.nice.org.uk
One portion of vegetables or fruit is roughly equivalent to:
1 normal portion (2 tablespoons) of any vegetable
1 dessert bowl of salad
1 large fruit, e.g. apple, banana, orange, pear, peach, large tomato, or a large slice of pineapple or melon
2 smaller fruits, e.g. satsumas, plums, kiwi fruits, apricots
1 cup of small fruits, e.g. strawberries, raspberries, blackcurrants, cherries, grapes
1 tablespoon of dried fruit
2 large tablespoons of fruit salad, stewed or canned fruit in natural juices
1 glass (150mL) of fresh fruit juice
Discourage uncontrolled snacking of junk food between meals. Advise patients to ask themselves the following questions when they feel like eating between meals:
Am I hungry? If unsure, wait 20min, and then ask the same question again
When was the last time I ate? If <3h ago, it may not be real hunger
Could a small snack tide me over until the next meal? Have ready-to-eat fruits or vegetables on hand for this
For children, BMI child reference tables must be used (available from www.healthforallchildren.co.uk). Overweight is defined as weight ≥ 91st centile; obese as weight ≥ 98th centile.
Obesity
Obesity is one of the most important preventable diseases in the UK (see Table 8.4). The best measure of obesity is body mass index (BMI).
Greatly increased risk (RR >3) Mortality (BMI >30) Type 2 DM (BMI of 35 confers a 92x ↑ risk of DM) Gall bladder disease Dyslipidaemia Insulin resistance Breathlessness Sleep apnoea | Slightly increased risk (RR 1–2) Cancer (breast in post-menopausal women, endometrial, oesophageal, colon)—14–20% of cancer deaths are due to obesity Reproductive hormone abnormalities PCOS Impaired fertility Low back pain Stress incontinence Anaesthetic and post-operative risk Fetal defects associated with maternal obesity Suicide School/workplace prejudice |
Moderately increased risk (RR 2–3) CHD (5–6% deaths are due to obesity) ↑ BP OA (knees) Hyperuricaemia/gout |
Greatly increased risk (RR >3) Mortality (BMI >30) Type 2 DM (BMI of 35 confers a 92x ↑ risk of DM) Gall bladder disease Dyslipidaemia Insulin resistance Breathlessness Sleep apnoea | Slightly increased risk (RR 1–2) Cancer (breast in post-menopausal women, endometrial, oesophageal, colon)—14–20% of cancer deaths are due to obesity Reproductive hormone abnormalities PCOS Impaired fertility Low back pain Stress incontinence Anaesthetic and post-operative risk Fetal defects associated with maternal obesity Suicide School/workplace prejudice |
Moderately increased risk (RR 2–3) CHD (5–6% deaths are due to obesity) ↑ BP OA (knees) Hyperuricaemia/gout |
Classification
BMI (weight in kg ÷ (height in m)2) (see Figure 8.2):
Body mass index (BMI) ready reckoner for adults.
Waist circumference
See Table 8.5. Alternative measure of body fat correlated with CHD risk, DM, hyperlipidaemia, and ↑ BP. Measured halfway between the superior iliac crest and the rib cage. Use in addition to BMI to aid assessment of health risks.
| Waist circumference | White Caucasians | Asians |
|---|---|---|
Male | ≥102cm (40 inches) | ≥90cm (36 inches) |
Female | ≥88cm (35 inches) | ≥80cm (32 inches) |
| Waist circumference | White Caucasians | Asians |
|---|---|---|
Male | ≥102cm (40 inches) | ≥90cm (36 inches) |
Female | ≥88cm (35 inches) | ≥80cm (32 inches) |
For every 1cm ↑ in waist circumference, the RR of a CVD event ↑ by ~72%.
Causes
Physical inactivity
Smoking cessation—mean weight ↑ 3–4kg
Cultural factors
Low education
Polygenic genetic predisposition—~1 in 3 obese people—more prone to obesity again after successful dieting
Childbirth—especially if not breastfeeding
Drugs—steroids, antipsychotics (e.g. olanzapine), contraceptives (especially depo-injections), sulfonylureas, insulin
Endocrine causes (rare)—hypothyroidism, Cushing’s syndrome, PCOS—only investigate if there are other symptoms/signs of endocrine disease
Ongoing binge eating disorder ( p. 1015)
Prevention
Begins in childhood with healthy patterns of exercise/diet.
Management
When the body’s intake > output over a period of time, obesity results. Management aims to reverse this trend on a long-term basis through healthy diet, adjustment of calorie intake, physical exercise, and psychological support.
Initial assessment
Assess willingness to change, eating behaviour and diet, physical activity, psychological distress, and social and family factors affecting diet. Check a baseline BMI and waist circumference. Check BP, blood glucose, and fasting lipid profile.
Advice
Diet
Advise a weight loss diet for any patient who is overweight/obese and willing to change:
↓ calorie diets All obese people lose weight on a low-energy intake. Aim for weight loss of 1–2lb (0.5–1kg)/wk using a ↓ in calorie intake of ~600kcal/d with a target BMI of 25, in steps of 5–10% of original weight. There is no health benefit of weight ↓ below this. If simple diet sheets are not effective, refer to a dietician
Very low calorie diets (<1,000kcal/d). Only limited place in management—use for a maximum of 12wk for obese patients when weight loss has plateaued
Drug therapy
BNF 4.5.1. Orlistat (120mg tds with food) is the only drug licensed for treatment of obesity in the UK. It acts by ↓ fat absorption. Consider if a 3mo trial of supervised diet/exercise has failed and BMI ≥30kg/m2 or ≥27kg/m2 + co-morbidity (e.g. DM, ↑ BP). Continue treatment >3mo only if weight ↓ is ≥5% of initial body weight.
Surgery
Consider if BMI >40kg/m2 and non-surgical measures have failed. Adjustable gastric banding is the most common procedure. Complications: band slippage/damage; gastric erosion, pouch dilatation; infection; malabsorption.
Group and behavioural therapy
Group activities, e.g. Weight Watchers, have a higher success rates in producing/maintaining weight ↓. Behavioural therapy together with low calorie diets is also effective.
Maintenance of weight loss
Once a patient has lost weight, continue to monitor diet. Ongoing follow-up helps to sustain weight loss. Weight fluctuation (yo-yo dieting) may be harmful.
Further information
SIGN Management of obesity (2010) www.sign.ac.uk
NICE Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children (2006) www.nice.org.uk
National Obesity Forum www.nationalobesityforum.org.uk
Exercise
In the UK, 60% of adults are not active enough to benefit their health.
Adults ≥30min/d moderate intensity exercise on ≥5d/wk
Children ≥1h/d moderate intensity exercise every day
Assessing levels of physical activity
See Table 8.6. Use a validated tool to assess levels of physical activity, e.g. General Practitioner Physical Activity Questionnaire (GPPAQ).
| Occupation | ||||
|---|---|---|---|---|
| Physical exercise and/or cycling (h/wk) | Sedentary | Standing | Physical | Heavy manual |
0 | Inactive | Moderately inactive | Moderately active | Active |
Some but <1 | Moderately inactive | Moderately active | Active | Active |
1–2.9 | Moderately active | Active | Active | Active |
≥3 | Active | Active | Active | Active |
| Occupation | ||||
|---|---|---|---|---|
| Physical exercise and/or cycling (h/wk) | Sedentary | Standing | Physical | Heavy manual |
0 | Inactive | Moderately inactive | Moderately active | Active |
Some but <1 | Moderately inactive | Moderately active | Active | Active |
1–2.9 | Moderately active | Active | Active | Active |
≥3 | Active | Active | Active | Active |
Health benefits of exercise
Regular physical activity:
↓ risk of
DM—through ↑ insulin sensitivityS
ObesityS— p. 178
Cardiovascular disease—physically inactive people have ~2x ↑ risk of CHD and ~3x ↑ risk of strokeS
Osteoporosis—exercise ↓ risk of hip fractures by ½S
Cancer— ↓ risk of colon cancer ~40%. There is also evidence of a link between exercise and ↓ risk of breast and prostate cancersS
Is a useful treatment for
↑ BP—can result in 10mmHg drop of systolic and diastolic BP; can also delay onset of hypertensionS
Hypercholesterolaemia—↑ high-density lipoprotein (HDL),↓low-density lipoprotein (LDL)C
DM—improves insulin sensitivity and favourably affects other risk factors for DM, including obesity, HDL/LDL ratio, and ↑ BP
HIV—↑ cardiopulmonary fitness and psychological well-beingC
Arthritis and back pain—maintains functionC
Mental health problems— ↓ intensity of depression; ↓ anxietyS
Benefits the elderly
Maintains functional capacity
↓ levels of disability
↓ risk of falls and hip fracture
Improves quality of sleepC
Negotiating change
See Figure 8.3.
Management plan for increasing activity levels
Effective interventions
Healthcare Counselling is as effective as more structured exercise sessions. Specialist rehabilitation schemes are available for patients with specific conditions (e.g. post-MI, COPD); exercise schemes operate in some areas, offering low cost, supervised exercise for patients who might otherwise find it unacceptable to visit a gym and are accessed via GP ‘prescription’; many sports facilities offer special sessions for pregnant women, the over-50s, and people with disability
Workplace Interventions to ↑ rates of walking to work are effective
Schools Appropriately designed and delivered physical education curricula can enhance physical activity levels. A whole-school approach to physical activity promotion is effective
Transport Well-designed interventions ↑ walking/cycling to work
Communities Community-wide approaches ↑ activity
Further information
NICE Physical activity guidance (2006) www.nice.org.uk
DH The General Practice Physical Activity Questionnaire (2006) www.dh.gov.uk
Smoking
Facts and figures
In England, 21% of adults (♂ 21%; ♀ 20%) smoke. Prevalence is highest amongst those aged 20–24 (32%) and lowest aged >60y (12%). 6% school children aged 11–15y are regular smokers (♀ 10%; ♂ 8%). Surveys of smokers show 73% want to stop and 30% intend to give up in <1y—but only ~2%/y successfully give up permanently.
Risks of smoking
Smoking is the greatest single cause of illness and premature death in the UK. Half of all regular smokers will die as a result of smoking—106,000 people/y. Smoking is associated with ↑ risk of:
Cancers ~29% all cancer deaths. Common cancers include: lung (>90% are smokers); lip; mouth; stomach; colon; bladder
Cardiovascular disease CHD, CVA, peripheral vascular disease
Chronic lung disease COPD, recurrent chest infection, exacerbation of asthma (29% of respiratory deaths result from smoking)
Problems in pregnancy PET, IUGR, preterm delivery, neonatal and late fetal death
DM
Osteoporosis
Thrombosis
Dyspepsia and/or gastric ulcers
Passive smoking is associated with
↑ risk of coronary heart disease and lung cancer (↑ by 25%)
↑ risk of cot death, bronchitis, and otitis media in children
Helping people to stop smoking
Advice from a GP results in 2% of smokers stopping—5% if advice is repeatedCE. See Figure 8.4.
Management plan for smokers in the surgery
Aids to smoking cessation
BNF 4.10
Nicotine replacement therapy (NRT)
↑ the chance of stopping ~ 1½xN. All preparations are equally effectiveC. Start with higher doses for patients highly dependent. Continue treatment for 3mo, tailing off dose gradually over 2wk before stopping (except gum which can be stopped abruptly). Contraindicated immediately post-MI, stroke, or TIA, and for patients with arrhythmia.
Bupropion (Zyban®)
Smokers (>18y) start taking the tablets 1–2wk before intended quit day (150mg od for 3d, then 150mg bd for 7–9wk). ↑ cessation rate >2xN. Contraindications: epilepsy or ↑ risk of seizures, eating disorder, bipolar disorder.
Varenicline (Champix®)
Smokers (>18y) start taking the tablets 1wk before intended quit day (0.5mg od for 3d, 0.5mg bd for 4d then 1mg bd for 11wk). ↓ dose to 1mg od if renal impairment/elderly. ↑ cessation rate >2x. If the patient has stopped smoking after 12wk, consider prescribing a further 12wk treatment to ↓ chance of relapse. Contraindications: caution in psychiatric illness.
Alternative therapies
Hypnotherapy may be helpful in some casesC.
Support
In many areas, ‘stop smoking’ services are provided by PCOs. These programmes vary but generally consist of a combination of group education, counselling and support ± individual support in combination with nicotine replacement, bupropion, or varenicline.
Smoking cessation medication Prescibe only for smokers who commit to a target stop date. Initially, prescribe only enough to last 2wk after the target stop date, i.e 2wk nicotine replacement therapy, 3–4wk bupropion, or 3wk varenicline. Only offer a second prescription if the smoker demonstrates continuing commitment to stop smoking.
If unsuccessful, the NHS will not fund another attempt for ≥6mo.
Smokeless tobacco
Misri India tobacco, qimam, naswar, gul, khaini, gutkha, zarda, mawa, Manipuri, or bethel quid with tobacco. Particularly used in South Asian communities. Carries risk of nicotine addiction, CVD, dental disease, and mouth/throat cancer. Provide brief advice and consider NRT to help with stopping.
Further information
NICE www.nice.org.uk
NRT and bupropion for smoking cessation (2002)
Brief interventions and referral for smoking cessation in primary care and other settings (2006)
Varencline for smoking cessation (2007)
Smokeless tobacco cessation: South Asian communities (2012)
Useful contacts
NHS Smokefree 
0800 022 4332 
http://smokefree.nhs.uk
Action on smoking and health (ASH) 020 7739 5902 www.ash.org.uk
Quit 0800 00 22 00 www.quit.org.uk
Alcohol
‘An alcoholic is someone you don’t like who drinks as much as you do’
Dylan Thomas (1914–1953)
Alcohol misuse is a major public health and social concern. Alcohol-related problems cost the NHS ~£1.7 billion/y. Most harm is caused by non-dependent drinkers. Screening and brief interventions in primary care can identify drinkers in this group and ↓ consumption and harm.
Recommended limits for alcohol consumption
See Table 8.7.
| Recommended limits (units) | Men | Women | |
|---|---|---|---|
Weekly | <21 | <14 | As a rough guide: 1 unit = 8g of alcohol ½ pint of beer (strong beer >1.5u) A small glass of wine/sherry or A spirit measure of spirits (in Scotland 1.2u) |
Daily | <8 | <6 |
| Recommended limits (units) | Men | Women | |
|---|---|---|---|
Weekly | <21 | <14 | As a rough guide: 1 unit = 8g of alcohol ½ pint of beer (strong beer >1.5u) A small glass of wine/sherry or A spirit measure of spirits (in Scotland 1.2u) |
Daily | <8 | <6 |
Prevalence of excess alcohol use
Hazardous/harmful drinking—excess drinking causing potential or actual harm but without dependence—affects 32% ♂; 15% ♀
Binge drinking (>8u for ♂ or >6u for ♀ in 1d)—affects 21% ♂; 9% ♀
Alcohol dependence—affects 6% ♂; 2% ♀
Health risk
Continuum—individual risk depends on other factors too (e.g. smoking, heart disease). Alcohol-associated problems:
Death
15–22,000 deaths/y in the UK are associated with alcohol misuse (most related to stroke, cancer, liver disease, accidental injury/suicide).
Social
Marriage breakdown
Absence from work
Loss of work
Social isolation
Poverty
Loss of shelter/home
Mental health
Anxiety, depression, and/or suicidal ideas; dementia and/or Korsakoff’s ± Wernicke’s encephalopathy (
p. 581).
Physical
↑ BP
CVA
Sexual dysfunction
Brain damage
Neuropathy
Myopathy
Cardiomyopathy
Infertility
Gastritis
Pancreatitis
DM
Obesity
Fetal damage
Haemopoietic toxicity
Interactions with other drugs
Fatty liver
Hepatitis
Cirrhosis
Oesophageal varices ± haemorrhage
Liver cancer
Cancer of the mouth, larynx, and oesophagus
Breast cancer
Nutritional deficiencies
Back pain
Poor sleep
Tiredness
Injuries due to alcohol-related activity (e.g. fights)
Beneficial effects of alcohol
Moderate consumption (1–3u/d) ↓ risk of non-haemorrhagic stroke, angina pectoris, and MI.
Management of alcohol misuse
Assessing drinking
Suspicious signs/symptoms
↑ and uncontrolled BP; excess weight; recurrent injuries/accidents; non-specific GI complaints; back pain; poor sleep; tired all the time.
Ask
Use standardized questionnaires to identify patients with harmful and hazardous patterns of alcohol consumption, e.g. AUDIT (see Box 8.1).
| Questions assessing hazardous alcohol use | Questions assessing dependence symptoms | Questions assessing harmful alcohol use | ||||
|---|---|---|---|---|---|---|
| Question | Score: | 0 | 1 | 2 | 3 | 4 |
1. How often do you have a drink containing alcohol? | Never | <1x /mo | 2–4x /mo | 2–3x /wk | ≥4x /wk | |
2. How many drinks containing alcohol do you have on a typical day when you are drinking? | 1/2 | 3/4 | 5/6 | 7–9 | ≥10 | |
3. How often do you have 6 or more drinks on one occasion? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
4. How often during the last year have you found that you were not able to stop drinking once you started? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
5. How often during the last year have you failed to do what was normally expected of you because of drinking? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
7. How often during the last year have you had a feeling of guilt or remorse after drinking? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
8. How often during the last year have you been unable to remember what happened the night before because of your drinking? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
9. Have you or someone else been injured because of your drinking? | No | Yes—not in the last year | Yes—in the last year | |||
10. Has a relative, friend, doctor or other health care worker been concerned about your drinking or suggested that you cut it down? | No | Yes—not in the last year | Yes—in the last year | |||
Total: | ||||||
| Questions assessing hazardous alcohol use | Questions assessing dependence symptoms | Questions assessing harmful alcohol use | ||||
|---|---|---|---|---|---|---|
| Question | Score: | 0 | 1 | 2 | 3 | 4 |
1. How often do you have a drink containing alcohol? | Never | <1x /mo | 2–4x /mo | 2–3x /wk | ≥4x /wk | |
2. How many drinks containing alcohol do you have on a typical day when you are drinking? | 1/2 | 3/4 | 5/6 | 7–9 | ≥10 | |
3. How often do you have 6 or more drinks on one occasion? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
4. How often during the last year have you found that you were not able to stop drinking once you started? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
5. How often during the last year have you failed to do what was normally expected of you because of drinking? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
7. How often during the last year have you had a feeling of guilt or remorse after drinking? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
8. How often during the last year have you been unable to remember what happened the night before because of your drinking? | Never | <1x /mo | Monthly | Weekly | Daily/ almost daily | |
9. Have you or someone else been injured because of your drinking? | No | Yes—not in the last year | Yes—in the last year | |||
10. Has a relative, friend, doctor or other health care worker been concerned about your drinking or suggested that you cut it down? | No | Yes—not in the last year | Yes—in the last year | |||
Total: | ||||||
| Action*: | ||||||
|---|---|---|---|---|---|---|
Audit score 0–7 | Alcohol education | |||||
Audit score 8–15 | Simple advice | |||||
Audit score 16–19 | Simple advice + brief counselling + continued monitoring | |||||
Audit score 20–40 | Referral to specialist for evaluation and treatment | |||||
| Action*: | ||||||
|---|---|---|---|---|---|---|
Audit score 0–7 | Alcohol education | |||||
Audit score 8–15 | Simple advice | |||||
Audit score 16–19 | Simple advice + brief counselling + continued monitoring | |||||
Audit score 20–40 | Referral to specialist for evaluation and treatment | |||||
Provide the next highest level of intervention to patients who score ≥2 on Questions 4, 5 and 6, or 4 on Questions 9 or 10.
Risk factors
Previous history
Family history
Poor social support
Work absenteeism
Emotional and/or family problems
Financial and legal problems
Drug problems
Alcohol associated with work, e.g. publican
Examination
Smell of alcohol, tremor, sweating, slurring of speech, ↑ BP; signs of liver damage.
Investigations
FBC (↑ MCV); LFTs (↑ GGT identifies ~25% of heavy drinkers in general practice; ↑ AST; ↑ bilirubin). USS—fatty liver/cirrhosis. Often incidental findings.
Alcohol management strategies
See Figure 8.5.
Alcohol management strategy
Patients drinking within acceptable limits
Reaffirm limits.
Non-dependent drinkers Brief
GP intervention → ~24% ↓ drinking. Present results of screening interventions, e.g. AUDIT ( p. 185) and identify risks. Provide information about safe amounts of alcohol and harmful effects of exceeding these. Assess whether the patient is receptive to change. If so, agree targets to ↓ consumption, give encouragement, and negotiate follow-up.
Alcohol-dependent drinkers
Suffer withdrawal symptoms if they ↓ alcohol consumption (e.g. anxiety, fits, delirium tremens— p. 1070).
If wanting to stop drinking—refer to the community alcohol team; suggest self-help organizations, e.g. Alcoholics Anonymous; involve family and friends in support
Detoxification in the community usually uses a reducing regimen of chlordiazepoxide over a 1wk period (20–30mg qds on days 1 and 2; 15mg qds on days 3 and 4; 10mg qds on day 5; 10mg bd on day 6; 10mg od on day 7 then stop)
Community detoxification is contraindicated for patients with:
Confusion or hallucinations
History of previously complicated withdrawal (e.g. withdrawal seizures or delirium tremens)
Epilepsy or fits
Malnourishment
Severe vomiting/diarrhoea
↑ risk of suicide
Poor co-operation
Failed detoxification at home
Uncontrollable withdrawal symptoms
Acute physical or psychiatric illness
Multiple substance misuse
Poor home environment
If ambivalent/unwilling to change
Provide information; reassess and re-inform on each subsequent meeting; support the family.
Vitamin B supplements
People with chronic alcohol dependence are frequently deficient in vitamins, especially thiamine—give oral thiamine indefinitely (if severe, 200–300mg/d; if mild, 10–25mg/d)G. During detoxification in the community—give thiamine 200mg od for 5–7d.
Relapse
Common. Warn patients; encourage to re-attend. Be supportive. Maintain contact (↓ frequency and severity of relapsesG). Consider drugs to prevent relapse, e.g. acamprosate, disulfiram (specialist initiation).
Delerium tremens
p. 1070
Alcohol and driving
p. 131
Further information
WHO Alcohol Use Disorders Identification Test (AUDIT): guidelines for use in primary care www.who.int
NICE www.nice.org.uk
Alcohol dependence and harmful alcohol use (2011)
Alcohol use disorders—preventing the development of hazardous and harmful drinking (2010)
Alcohol use disorders—physical complications (2010)
Patient advice and support
Drinkline (government-sponsored helpline) 0800 917 8282
Alcoholics Anonymous 0845 769 7555 www.alcoholics-anonymous.org.uk
ADFAM Support for families 020 7553 7640 www.adfam.org.uk
Assessment of drugs misuse
14% of men and 8% of women aged 16–59 report taking illicit drugs in the past year. The majority of patients on treatment programmes report opioid misuse (heroin—54%; methadone—13%) but the most frequently abused drugs are cannabis, amphetamine, ecstasy, and cocaine. Three factors appear important: availability of drugs; vulnerable personality; and social pressures—particularly from peers.
Detection
Warning signs suggesting drug misuse:
Use of services
Suspicious requests for drugs of abuse (e.g. no clear medical indication, prescription requests are too frequent).
Signs and symptoms
Inappropriate behaviour
Lack of self-care
Unexplained nasal discharge
Evidence of injecting (e.g. marked veins)
Hepatitis or HIV infection
Unusually constricted/dilated pupils
Social factors
Family disruption, criminal history.
Assessment
Assess on >1 occasion before deciding how to proceed. Exceptions are severe withdrawal symptoms and/or evidence of an established regime requiring continuation. Points to cover:
General information
Check identification (ask to see an official document)
Contact with other agencies (including last GP)—check accuracy
Current residence; family—partner, children
Employment/finances
Current legal problems
Criminal behaviour—past and present
History of drug use/risk taking behaviour
Reason for consulting now and willingness to change
Current and past usage
Knowledge of risks
Unsafe sexual practices
Medical and psychiatric history
Complications of drug abuse, e.g. HIV, hepatitis, accidents
General medical and psychiatric history and examination
Alcohol abuse
Overdose—accidental/deliberate
Investigations
Consider urine toxicology to confirm drug misuse
Consider blood for FBC, LFTs, hepatitis B, C and HIV serology (with consent and counselling— p. 744), and other tests according to medical history/examination
Specific drugs
| Name (street/trade names include) | How usually taken | Effects sought | Harmful effects |
|---|---|---|---|
Heroin (smack, horse, gear, H, junk, brown, stag, scag, jack) | Injected, snorted, or smoked | Drowsiness, sense of warmth and well-being | Physical dependence, tolerance Overdose can lead to coma and death Sharing injecting equipment brings risk of HIV or hepatitis infection |
Cocaine (coke, charlie, snow, C) | Snorted in powder form, injected | Sense of well-being, alertness and confidence | Dependence, restlessness, paranoia Damage to nasal membranes |
Crack (freebase, rock, wash, stone) | Smokable form of cocaine | Similar to those of snorted cocaine but initial feelings are much more intense | As for cocaine but, because of the intensity of its effects, crack use can be extremely hard to control May additionally cause lung damage (‘crack lung’) |
Ecstacy (E, XTC, doves, disco bisuits, echoes, scooby doos) Chemical name: MDMA | Swallowed, usually in tablet form | Alert and energetic, but with a calmness and a sense of well-being towards others. Heightened sense of sound and colour | Possible nausea and panic Overheating and dehydration if dancing that can be fatal Use has been linked to liver and kidney problems Long-term effects are not clear but may include mental illness and depression |
LSD (acid, trips, tabs, dots, blotters, microdots) | Swallowed on a tiny square of paper | Hallucinations, including distorted or mixed-up sense of vision, hearing, and time. An LSD trip can last as long as 8–12h | There is no way of stopping a bad trip which may be a very frightening experience Increased risk of accidents Can trigger long-term mental problems |
Magic mushrooms (shrooms, mushies) | Eaten raw or dried, cooked in food, or brewed in a tea | Similar effects to those of LSD, but the trip is often milder and shorter | As for LSD, with the additional risk of sickness and poisoning |
Amphetamines (speed, whizz, uppers, billy, sulph, amp) | In powder form, dissolved in drinks, injected, sniffed/ snorted | Stimulates the nervous system, wakefulness, feeling of energy and confidence | Insomnia, mood swings, irritability, panic The comedown (hangover) can be severe and last for several days |
Khat (quat, chat) | Chewed as leaves | Stimulant, ↓ sleep, calm | Insomnia, irritability, panic |
Barbiturates (barbs, downers) | Swallowed as tablets or capsules, injected—ampoules | Calm and relaxed state, larger doses produce a drunken effect | Dependency and tolerance Overdose can lead to coma or death Severe withdrawal symptoms |
Cannabis (hash, dope, grass, blow, ganja, weed, shit, puff, marijuana) | Rolled with tobacco into a spliff, joint, or reefer and smoked, smoked in a pipe, or eaten | Relaxed, talkative state, heightened sense of sound and colour | Impaired coordination and increased risk of accidents Poor concentration, anxiety, depression Increased risk of respiratory diseases, including lung cancer |
Tranquillizers (brand names include: Valium, Ativan, Mogadon (moggies), temazepam (wobblies, mazzies, jellies) | Swallowed as tablets or capsules, injected | Prescribed for the relief of anxiety and to treat insomnia, high doses cause drowsiness | Dependency and tolerance Increased risk of accidents Overdose can be fatal Severe withdrawal symptoms |
Anabolic steroids (many trade names) | Injected or swallowed as tablets | With exercise, can help to build up muscle. However, there is some debate about whether drug improves muscle power and athletic performance | For men: erection problems, risk of myocardial infarction or liver disease For women: development of male characteristics Injecting equipment brings risk of HIV or hepatitis infection |
Poppers (alkyl nitrates, including amyl nitrate with trade names such as Ram, TNT, Thrust) | Vapours from small bottle of liquid are breathed in through mouth or nose | Brief and intense head-rush caused by a sudden surge of blood through the brain | Nausea and headaches, fainting, loss of balance, skin problems around the mouth and nose Particularly dangerous for those with glaucoma, anaemia, breathing, or heart problems |
Solvents (including lighter gas refills, aerosols, glues). Some painter thinners and correcting fluids | Sniffed or breathed into the lungs | Short-lived effects similar to being drunk, thick-headed, dizziness, possible hallucinations | Nausea, blackouts, increased risk of accidents Fatal arrhythmias can cause instant death |
| Name (street/trade names include) | How usually taken | Effects sought | Harmful effects |
|---|---|---|---|
Heroin (smack, horse, gear, H, junk, brown, stag, scag, jack) | Injected, snorted, or smoked | Drowsiness, sense of warmth and well-being | Physical dependence, tolerance Overdose can lead to coma and death Sharing injecting equipment brings risk of HIV or hepatitis infection |
Cocaine (coke, charlie, snow, C) | Snorted in powder form, injected | Sense of well-being, alertness and confidence | Dependence, restlessness, paranoia Damage to nasal membranes |
Crack (freebase, rock, wash, stone) | Smokable form of cocaine | Similar to those of snorted cocaine but initial feelings are much more intense | As for cocaine but, because of the intensity of its effects, crack use can be extremely hard to control May additionally cause lung damage (‘crack lung’) |
Ecstacy (E, XTC, doves, disco bisuits, echoes, scooby doos) Chemical name: MDMA | Swallowed, usually in tablet form | Alert and energetic, but with a calmness and a sense of well-being towards others. Heightened sense of sound and colour | Possible nausea and panic Overheating and dehydration if dancing that can be fatal Use has been linked to liver and kidney problems Long-term effects are not clear but may include mental illness and depression |
LSD (acid, trips, tabs, dots, blotters, microdots) | Swallowed on a tiny square of paper | Hallucinations, including distorted or mixed-up sense of vision, hearing, and time. An LSD trip can last as long as 8–12h | There is no way of stopping a bad trip which may be a very frightening experience Increased risk of accidents Can trigger long-term mental problems |
Magic mushrooms (shrooms, mushies) | Eaten raw or dried, cooked in food, or brewed in a tea | Similar effects to those of LSD, but the trip is often milder and shorter | As for LSD, with the additional risk of sickness and poisoning |
Amphetamines (speed, whizz, uppers, billy, sulph, amp) | In powder form, dissolved in drinks, injected, sniffed/ snorted | Stimulates the nervous system, wakefulness, feeling of energy and confidence | Insomnia, mood swings, irritability, panic The comedown (hangover) can be severe and last for several days |
Khat (quat, chat) | Chewed as leaves | Stimulant, ↓ sleep, calm | Insomnia, irritability, panic |
Barbiturates (barbs, downers) | Swallowed as tablets or capsules, injected—ampoules | Calm and relaxed state, larger doses produce a drunken effect | Dependency and tolerance Overdose can lead to coma or death Severe withdrawal symptoms |
Cannabis (hash, dope, grass, blow, ganja, weed, shit, puff, marijuana) | Rolled with tobacco into a spliff, joint, or reefer and smoked, smoked in a pipe, or eaten | Relaxed, talkative state, heightened sense of sound and colour | Impaired coordination and increased risk of accidents Poor concentration, anxiety, depression Increased risk of respiratory diseases, including lung cancer |
Tranquillizers (brand names include: Valium, Ativan, Mogadon (moggies), temazepam (wobblies, mazzies, jellies) | Swallowed as tablets or capsules, injected | Prescribed for the relief of anxiety and to treat insomnia, high doses cause drowsiness | Dependency and tolerance Increased risk of accidents Overdose can be fatal Severe withdrawal symptoms |
Anabolic steroids (many trade names) | Injected or swallowed as tablets | With exercise, can help to build up muscle. However, there is some debate about whether drug improves muscle power and athletic performance | For men: erection problems, risk of myocardial infarction or liver disease For women: development of male characteristics Injecting equipment brings risk of HIV or hepatitis infection |
Poppers (alkyl nitrates, including amyl nitrate with trade names such as Ram, TNT, Thrust) | Vapours from small bottle of liquid are breathed in through mouth or nose | Brief and intense head-rush caused by a sudden surge of blood through the brain | Nausea and headaches, fainting, loss of balance, skin problems around the mouth and nose Particularly dangerous for those with glaucoma, anaemia, breathing, or heart problems |
Solvents (including lighter gas refills, aerosols, glues). Some painter thinners and correcting fluids | Sniffed or breathed into the lungs | Short-lived effects similar to being drunk, thick-headed, dizziness, possible hallucinations | Nausea, blackouts, increased risk of accidents Fatal arrhythmias can cause instant death |
Notification of drug misusers
Report patients who start treatment for drug abuse to the relevant authorities (see Table 8.8). All types of problem drug misuse should be reported. Databases cannot be used as a check on multiple prescribing as data are anonymized.
England | National Drug Treatment Monitoring System (NDTMS) |
Scotland | Substance Misuse Programme (SMP) |
Wales | Welsh National Database for Substance Misuse [email protected] |
Northern Ireland | Northern Ireland Drug Misuse Database (NIDMD) |
England | National Drug Treatment Monitoring System (NDTMS) |
Scotland | Substance Misuse Programme (SMP) |
Wales | Welsh National Database for Substance Misuse [email protected] |
Northern Ireland | Northern Ireland Drug Misuse Database (NIDMD) |
Driving and drugs misuse
p. 131
Overdose
p. 1116
Controlled drugs regulations
p. 150
Prescribing for drug misusers
Approach with special caution. Some controlled drugs can be dispensed to substance misusers in instalments providing they are prescribed on special NHS prescription forms (FP10 MDA—England; WP10 MDA—Wales; GP10—Scotland; HS21—NI). As a general principle, prescribe substitute opioid medicines in daily instalments. Specify: number of instalments; intervals to be observed between instalments, and if necessary instructions for supplies at weekends or bank holidays; total quantity of CD providing treatment for a period ≤14d; quantity to be supplied in each instalment.
The prescription must be dispensed on the date on which it is due.
Other equipment for drug misusers
Doctors, pharmacists, and drug workers may provide supplies of alcohol swabs, sterile water (≤10 ampoules of 2mL or less), mixing utensils, filters, and citric acid to drug misusers for the purposes of harm reduction.
Travelling abroad with controlled drugs
p. 151
Advice and support for patients and their families
‘Talk to FRANK’ (England and Wales) Government-run information, advice, and referral service (24 hour) 0800 77 66 00 www.talktofrank.com
‘Know the Score’ (Scotland) 0800 587 5879 www.knowthescore.info
Drugscope Information about drug misuse and how to get treatment www.drugscope.org.uk
Drugs-info Information about substance abuse for families of addicts www.drugs-info.co.uk
ADFAM Support for families of addicts 020 7553 7640 www.adfam.org.uk
Benzodiazepines www.benzo.org.uk
Solvent abuse 01785 810762 www.re-solv.org
The RCGP Substance Misuse Unit provides certificate courses in management of drug abuse www.rcgp.org.uk
Management of drugs misuse
Aims to
↓ risk of infectious diseases; ↓ drug-related deaths; and ↓ criminal activity used to finance drug habits.
Avoid working in isolation. Anyone involved in substitute prescribing should wherever possible be doing so through their local shared care arrangements. The GP and primary healthcare team have a vital role in:
Identifying drug misusers
Assessing health/willingness to modify drug behaviour (see Figure 8.6)
Referring for specialist assessment and treatment of drug abuse, and
Routine screening/prevention (e.g. cervical screening, contraception)
Stages of change in addiction
General measures
If ongoing care, at each meeting consider:
Education
Safer routes of drug administration, e.g. smoking/rectal administration for heroin abusers. Discourage IM/subcutaneous administration
Specific risks of drugs (e.g. psychosis with amphetamines; local risks, such as contaminated street drugs)
Safe injecting advice and overdose prevention
Safe sexual practices/condom use
Driving and drug misuse ( p. 131)
Other local services
Medical care
Treatment of/advice about complications of drug misuse
Testing/treatment for blood-borne disease, e.g. hepatitis B or C, HIV
Hepatitis B immunization
For injecting drug misusers not already infected/immune and close contacts of those already infected. Use accelerated regime—immunization at 0, 7, and 21d, and a booster after 12mo.
Treatment of dependence
Set realistic goals—aim to help the patient remain healthy, until, with appropriate care and support, he/she can achieve a drug-free life. Consider ↓ in illicit drug use, ↓ duration of periods of drug use, ↓ risk of relapse, ↓ need for criminal activity to finance drug misuse, improving personal and social functioning. These aims are often best met by maintenance substitute prescribing, e.g. with methadone/buprenorphine for heroin abuse
Set conditions for acceptable behaviour/treatment withdrawal. Agree on the pharmacy to be used and involve the pharmacist
Review regularly and include the whole team
Give contact numbers for community support organizations ( p. 189)
Send notification to national authority ( p. 188), if not already done
Seek advice/refer to a community substance misuse team as needed
Further information
DH Drug misuse and dependence—guidelines on clinical management (2007) www.nta.nhs.uk/guidance
NICE Substance misuse interventions (2007) www.nice.org.uk
National Treatment Agency for Substance abuse www.nta.nhs.uk
Substance Misuse Management in General Practice (SMMGP) www.smmgp.org.uk
Never inject alone
Always inject with the blood flow and rotate sites—avoid neck, groin, penis, axilla, foot and hand veins, and any infected areas/swollen limbs—even if veins are distended
Use sterile, new injecting equipment with the smallest bore needle possible and dispose of all equipment safely after use
Avoid unsuitable preparations e.g. crushed tablets and/or injecting cocktails of drugs (injection of heroin and cocaine together is known as ‘speedballing’ or ‘snowballing’)
Learn basic principles of first aid and CPR (provide information on courses available). Encourage calling for an ambulance
Poor veins indicate poor technique—find out what the patient is doing
Be aware of risk factors:
Injecting heroin
Longer injecting career
Recent non-fatal overdose
High levels of use/intoxication
High levels of alcohol use
Lowered tolerance through detoxification/imprisonment
Depression, suicidal thoughts
Multiple drug use—particularly CNS depressants
Sharing equipment/other high risk injecting behaviour—may indicate low concern about personal risk
Not being on a treatment programme or premature exit from a methadone programme
Insomnia
From the Latin meaning ‘no sleep’: describes a perception of disturbed or inadequate sleep. ~1:4 of the UK population (♀ > ♂) are thought to suffer in varying degrees. Prevalence: ↑ with age, rising to 1 in 2 amongst the over 65s. Causes are numerous—common examples include:
Minor, self-limiting Travel, stress, shift work, small children, arousal
Psychological ~½ have mental health problems: depression, anxiety, mania, grief, alcoholism
Physical Drugs (e.g. steroids), pain, pruritus, tinnitus, sweats (e.g. menopause), nocturia, asthma, obstructive sleep apnoea
Definition of ‘a good night’s sleep’
<30min to fall asleep
Maintenance of sleep for 6–8h
<3 brief awakenings/night
Feels well rested and refreshed on awakening
Management Careful evaluation.
Many do not have a sleep problem themselves but a relative feels there is a problem, e.g. the retired milkman continuing to wake at 4 a.m. Others have unrealistic expectations, e.g. they need 12h sleep/d. Reassurance alone may be all that is required.
For genuine problems
Eliminate physical problems preventing sleep, e.g. treat asthma or eczema; give long-acting painkillers to last the whole night; consider HRT or fluoxetine for sweats; refer if obstructive sleep apnoea is suspected ( p. 338)
Treat psychiatric problems, e.g. depression, anxiety
Sleep hygiene—see Box 8.2
Relaxation techniques—compact discs (borrow from libraries or buy from pharmacies); relaxation classes (often offered by local recreation centres/adult education centres); many physiotherapists can teach relaxation techniques
Consider drug treatment Last resort. Benzodiazepines may be prescribed for insomnia ‘only when it is severe, disabling, or subjecting the individual to extreme distress’.
Don’t go to bed until you feel sleepy
Don’t stay in bed if you’re not asleep
Avoid daytime naps
Establish a regular bedtime routine
Reserve a room for sleep only (if possible). Do not eat, read, work, or watch TV in it
Make sure the bedroom and bed are comfortable, and avoid extremes of noise and temperature
Avoid caffeine, alcohol, and nicotine
Have a warm bath and warm milky drink at bedtime
Take regular exercise, but avoid late night hard exercise (sex is OK)
Monitor your sleep with a sleep diary (record both the times you sleep and its quality)
Rise at the same time every morning regardless of how long you’ve slept
Drug treatment
Benzodiazepines (e.g. temazepam), zolpidem, zopiclone, and low-dose TCA (e.g. amitriptyline 10–75mg) nocte are all commonly prescribed for patients with insomnia.
Side effects: amnesia and daytime somnolence. Most hypnotics do affect daytime performance and may cause falls in the elderly. Warn patients about their effect on driving and operating machinery
Only prescribe a few weeks’ supply at a time due to potential for dependence and abuse
Beware the temporary resident who has ‘forgotten’ his/her night sedation.
Complications of insomnia
↓ quality of life; ↓ concentration and memory, affecting performance of daytime tasks; relationship problems; risk of accidents. 10% motor accidents are related to tiredness.
Patient information and support
Royal College of Psychiatrists Patient information sheets www.rcpsych.ac.uk
