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| @drchrishilton Current peChristopher Hilton ch PGCertULT sy CP R M S urer B B M

MA linical Senior Lect C on H & re Ca te Dr edia Integrated Interm r

#SSHA2015 fo ad Le al ic lin C , st ri at hi

n Psyc Consultant Liaiso Outline Biography Introduction Intoxicating substances, old and new Dependence and withdrawal Comprehensive SM history Conventional approaches to SM treatment Integration Drugs and alcohol in the sexual health setting Advice for screening and intervention

Services local to C&W Medical and psychiatric training Chelsea & Westminster Hospital: Liaison / HIV Central & North West London: Addictions Special interests: Club Drug Clinic WLMHT Integrated care for patients with LTCs Now WLMHT / Ealing : Consultant Liaison Psychiatrist Home ward Ealing Intermediate Care Service Imperial College: Honorary Senior Clinical Lecturer Medical Council on Alcohol: Executive Committee

Acknowledgements Dr Owen Bowden-Jones David Stuart, Antidote Mark Dunn Stacey Hemmings Dr Pepe Catalan Flick Thorley

Dr Amrit Sachar Prof Anne Lingford-Hughes Declarations CH has in the past received honoraria for travel / lecturing (not related to this work) from: Bayer, Lilly, Pfizer and Janssen Categories of intoxicating substances Depressants Opioids, benzodiazepines, alcohol Stimulants Cocaine, amphetamines, MDMA, caffeine

Hallucinogens LSD, PCP, ketamine Cannabis, nicotine Highs and harms Desirable effects Pleasure Relaxation, anxiety reduction, disinhibition Increased energy, enjoyment, confidence Fatigue reduction, pain reduction Curiosity, new experiences, psychonaut Highs and harms

Undesirable effects Mode of administration Physical and systemic effects Psychiatric effects Dependence potential and withdrawal Behavioural consequences Indirect harms / harms to others Crime Synergistic effects The most harmful drug overall? Nutt et al Lancet 2010; 376:1558

Alcoh ol 'mo g n i m i a l c r o f

heroins tsar sraeckheadrm fudl LtShDa are Drug , crack n a n aanbdisEc n n a c , y

s stlcaoshy'ol Ecsta a n a h t l u f m r

a less h The most harmful drug overall? Nutt et al Lancet 2007; 369:1047 Novel psychoactive substances Club drugs recreational drugs used in nightclubs, festivals, gigs, bars, circuit and house parties Eg: amphetamine, methamphetamine, MDMA, cocaine NPS designed to mimic controlled drugs but synthesised to evade prohibitions

Many now banned after period as legal highs Eg: mephedrone, methoxetamine, GHB/GBL Easily available online, head shops, dealers Novel psychoactive substances Categories of drugs Depressants Opioids, benzodiazepines, alcohol, GBL/GHB, Phenibut, Stimulants Cocaine, amphetamines, MDMA, caffeine m-cat,

NRG-1, BZP, MDAI, Synthacaine, 5/6-APB Hallucinogens LSD, PCP, ketamine, AMT, methoxetamine Cannabis, nicotine Spice Novel Psychoactive Substances - Key points It is impossible for clinicians to remain abreast of all NPS on the market (1 new drug per week) NPS are synthesised to mimic existing drugs / use the same neurotransmitter mechanisms Most NPS are not detected by routine urinary drug testing false negatives

Ask, and have degree of suspicion based on clinical assessment Scale of drug use in England & Wales Adults 16-59: Prevalence of having taken illicit drugs: 36.4% ever 8.6% in last year 3% Class A Young adults 16-24: 48.6% ever 20.4% in last year

6.6% Class A NHS IC 2011 Scale of NPS use EMCDDA 2005-111 164 NPS were formally notified (now ~1 per week) UK - 23% European NPS users Crime Survey E&W 2011-122 1.1% respondents had used mephedrone in the last year, 3.3% in 16-24 age group Global drugs survey 20132 (clubbing last month): 36.1% reported lifetime use of mephedrone EMCDDA-Europol 2011 Annual Report on the Implementation of Councel Decision 2005/387/JHA. EMCDDA/Europol, 2012. | 2

Home Office. Drug misuse declared: findings from the 2011 to 2012 Crime Survey for England and Wales. Home Office, 2012. | 3 Winstock, A. "Global Drug Survey." Mixmag, May 2013. 1 A whirlwind tour of addiction Chronic relapsing brain disorder characterised by neurobiological changes that lead to compulsion to take a drug (or activity) with loss of control over the activity. Transition from recreational to obsessive use From positive to negative reinforcement Psychological factors drive the behaviour

Koob GF and Le Moal M, Science, 1997 But what drives the psychological factors? Inside the brain of a recreational user of drugs Boileau et al Synapse 2003 Inside the brain of a dependent

user of drugs 1. Volkow 2. Koob Outline Biography Introduction Intoxicating substances, old and new Dependence and withdrawal Comprehensive SM history Conventional approaches to SM treatment Integration Drugs and alcohol in the sexual health setting

Advice for screening and intervention Services local to C&W ICD-10 diagnosis of dependence Three or more at once in the last year: Withdrawal symptoms

Tolerance to the effects of the drug Strong desire or compulsion to use the substance Persistent use despite adverse consequences Difficulty controlling use / amount / recidivism Neglect of other activities / primacy (Narrowing of repertoire) Comprehensive SM history Who? (everyone) What substances? (Avoid illegal) Quantity Frequency

Route Circumstances History of use (first, regular, heaviest, cumulative) Negative effects (teachable moment) Features of dependence and withdrawal 2L Cider (3) 7.5% 15 units 1 pint Peroni 5.1%

2.95 units 440mL Special Brew (1.32) 9% 70cL whisky 4 units 40% 28 units 250mL wine 13% 3.25 units

75cL wine 13% 9.75 units Clinical treatment strategies

Education & brief intervention Harm minimisation Stabilisation / maintenance Detoxification Rehabilitation Abstinence NHS Drug Clinics PHE commissioned (via LAs) Outline Biography Introduction

Intoxicating substances, old and new Dependence and withdrawal Comprehensive SM history Conventional approaches to SM treatment Integration Drugs and alcohol in the sexual health setting Advice for screening and intervention Services local to C&W Alcohol and sexual health Family Planning Association Survey 2009 1000 18-30 year olds, Online survey by Mori 37% had unprotected sex with a new partner

Of these: 40% said alcohol was a factor 38% reported sex which they regretted later Of these: 70% said alcohol was a factor 28% reported having sex with someone they wouldnt normally find attractive Of these: 78% said alcohol was a factor Alcohol and sexual health Binge drinking, sexual behaviour and sexually transmitted infection in the UK Int J STD & AIDS 2007; 18; 810-13

86% GU attendees are binge drinkers 32% felt alcohol played a role in their attendance 77% drunk before sex with a new partner Binge drinking assoc with bacterial STI diagnosis and unwanted pregnancy Recreational drugs and GUM: meth Scale of methamphetamine use (UK) CSEW 2011-121: 0.1% used in last yr

GMSS 20072: 4.7% used in last yr HIV testing cohort3: (2002-3): 8.3% in last yr HIV treatment cohort3 (2002-3): 12.6% in last yr Gym cohort (2004)3 21% in last yr Home Office. Drug misuse declared: findings from the 2011 to 2012 Crime Survey for England and Wales. Home Office, 2012. | 2Keogh P et al. Wasted opportunities: Problematic alcohol and drug use among gay men and bisexual men. Sigma Research 2009 | 3Bolding G et al. Addiction 2006; 101, 16221630 1 CNWL (NHS) Antidote (Charity) National / open access

Opened: Jan 2011 First 18 months: 291 patients seen CDC - Presenting drug use (n=291) GBL/GHB Crystal methamphetamine Mephedrone Cocaine Ketamine Alcohol MDMA Cannabis

Other NPS Benzodiazepines Opioids Amyl Nitrate CDC - Presenting drug use (n=52 heterosexual) Ketamine Cocaine Alcohol Mephedrone GBL/GHB

Crystal methamphetamine MDMA Cannabis Benzodiazepines Other NPS Opioids Crystal methamphetamine and HIV Users of crystal methamphetamine in the clinic (n=120) were two times more likely to be HIV positive than non users (n=170). 68% vs 33% (p <0.05)

Users of crystal methamphetamine in the clinic were four times more likely to be HCV positive than non users. 12% vs 3% (p <0.05) Crystal methamphetamine and HIV Do you attribute your HIV status to your drug use? 30% of HIV positive patients responded YES Crystal methamphetamine and HIV

Does your drug use get in the way of taking your prescribed medications regularly? 39% patients on antiretrovirals responded YES Injecting drug use Crystal methamphetamine users: 53% reported having injected the drug 47% never Non crystal users: 6% reported currently injecting (meph, cocaine, G, K) 19% reported previously injecting

75% never MSM and substance use why? Helps to relax and be more sociable Mitigating social unease (general, sexuality, scene) Alleviating loneliness / unhappiness Enabling sexual encounters (sexuality, HIV, raucous integral to sex)

Gay norms of alcohol and substance use (integral to socialising) Keogh P et al. Wasted opportunities: Problematic alcohol and drug use among gay men and bisexual men. Sigma Research 2009 Associations between substance use and HIV related risk indicators Systematic review of 23 studies (2012)1 looked at studies into various substances: only

methamphetamine and binge alcohol drinking associated with sexual risk (see plot) Systematic review of 61 studies (2012)2 highlighted HIV+ MSM who use meth more likely to report high-risk sexual behaviour, incident STI, serodiscordant UAI compared with HIV+ MSM who do not use methamphetamine

1 Vosburgh, HW et al. A Review of the Literature on Event-Level Substance Use and Sexual Risk Behavior Among Men Who Have Sex with Men. AIDS Behav 2012: 16:13941410 2 Rajasingham R et al. A Systematic Review of Behavioral and Treatment Outcome Studies Among HIV-Infected Men Who Have Sex with Men Who Abuse Crystal Methamphetamine. AIDS PATIENT CARE and STDs 2012: 26; 36-51 High risk sexual behaviours

Increased frequency of sex Prolongation of sex (marathon) Increased number of partners Reduced condom use / UAI Increased condom failure Disinhibiting effects Mucosal trauma Co-infection with other STI Colfax G, Guzman R. Club Drugs and HIV Infection: A Review. CID 2006: 42:14639

High risk sexual behaviours Clinical experience Online apps / websites Party and play / parTy Multiple partners Higher risk sexual practices Intravenous use in sexualised contexts Slamming / re-injecting Kirkby T, Thornber-Dunwell M. High-risk drug practices tighten grip on London gay scene. Lancet 2013: 381; 101-2 Interventions

Patient 37 year old HIV+ gay man, working full time in City Recent acquisition of HCV following casual UPSI at party arranged online Binges on drugs 3-4x per month including tina smoked or slammed and meph Reports feeling depressed and being monitored online at times Would like to abstain from drugs, but doesnt see self as a junkie so wont visit mainstream services Multiple lapses related to sex: havent had drug free sex for years, cant manage sex without drugs

Substance misuse in sexual health Investigate the link between substance misuse and sexual health Design interventions to minimise harm from both Social care Disintegrated services Relationships Sex

Social life Family / children Employment Habits Spirituality &c Justice System Addiction services NHS

Third Sector Mental health Physical health HIV Sexual health Other medical problems

Primary care Wellbeing Self esteem Depression, anxiety

Cognitive function Psychosis Self harm Substance misuse in sexual health Clinicians should be aware of the commonly used recreational drugs and their potential short term complications and risks consider screening individuals at risk give simple safety advice and information have agreed referral pathways into local services AK Sullivan, O Bowden Jones, Y Azad (2014)

Drug Screening Qs 1. Did you use drugs before/during sex in the last 3m Yes / No / Yes but not during sex 2. Which drugs did you use? Crystal methamphetamine - Mephedrone - GHB/GBL- Ketamine-

Cocaine- Other (specify)- 3. Did you inject? Yes / No / Yes but not in the last 3m Identification and Brief Advice The teachable moment Change in awareness Change in attitude

Change in behaviour Prochaska & DiClemente Identification and Brief Advice The teachable moment Reflect back to the patient any identified harms Offer advice on making changes Offer further advice/support/referral Cochrane review supports effectiveness of IBA1 To reduce drinking to lower-risk levels, NNT = 8 2 1

Kaner 2007, 2 Moyer 2002 Referral pathways Access to integrated SMHW Mental Health referral pathways Integrated health and social care services Addictions services:

PHE/LA commissioned Increasingly partnerships between 3rd sector and NHS Concern about reduced capacity to deal with complexity including physical / MH comorbidity Culturally competent? Eg MSM specific Clinical treatment strategies PS - Mental health in sexual health Psychological Wellbeing Agenda Support at time of diagnosis Screening for psychological needs: depression, anxiety, SM, stress, self

harm, cognitive impairment Initial management interventions Referral pathways - evidence based, HIV-specific, timely, competent, access to psychological care Resources Specialist services: CODE ChemClinic ReShapeNow.org THT www.drugfucked.tht.org.uk talktofrank.com

erowid.com n o t l i h s i r h c

r d @ 5 1 0 2 A H S S #

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