Working with Substance Misusers

A Guide to Theory and Practice

Trudi Petersen, Trudi Petersen

• Publisher: Routledge
• Year: 2005
• ISBN:
  9781134563609
• Edition: 1
• Topic: Medicina
• Subtopic: Prestazione di assistenza sanitaria

Working with Substance Misusers is a practical handbook for students and those who work with people who misuse drugs or alcohol. Written by experienced teachers and clinicians, the book introduces:
* the substances themselves
* theories relevant to substance use and misuse
* the skills necessary to work with this client group
* the broad range of approaches to treatment
* particular problems of specific groups.The reader is encouraged to read and reflect on the material in relation to their own practice. To help this process, each topic has an identified set of learning objectives. Activities designed to reinforce learning include discussion points, case studies, role plays and group exercises. Working with Substance Misusers makes clear the connection of theory to practice and encourages a skills-based, but reflective, approach to work in this complex field. Cutting across professional boundaries, it provides both new and more experienced practitioners with a key text.

Part I The Basics

Chapter 1 Some Drugs of Misuse

Andrew McBride

DOI: 10.4324/9780203995365-1

Learning Objectives

After you have studied this chapter you will understand the basic effects and ill effects of some of the more commonly used substances in the UK.

Introduction

The drugs described in this chapter, and throughout most of this book, act specifically on the brain and central nervous system and therefore on the mind. They commonly also have effects on many other parts of the body. Drugs not usually considered to be ‘psychoactive’ (mind altering) also commonly have effects on the metabolism of the brain, and in some circumstances cause psychological effects. There are almost no limits to the drug effects that some people will seek out for pleasure (for example, high doses of aspirin) but only commonly used psychoactive drugs will be considered here.

The number of existing and designable potent psychoactive drugs runs to more than a thousand, and the effects at a chemical and cellular level are incomprehensibly complex for all but the specialist neuro-psycho-pharmacologist. Fortunately, for most practical purposes the psychoactive drugs that people take for pleasure can be classified much more simply, by their effects.

A Simple Classification Of Psychoactive Drugs

The simplest such classification might categorise drugs by their most obvious effect into:

• Stimulants; that wake you up, speed you up and give you energy. This group includes amphetamine and cocaine.
• Depressants; that make you calm, drowsy or put you to sleep. This group includes opioids, benzodiazepines, volatile substances and cannabis.
• Hallucinogens; that change your perception of the world, by distorting what you see and hear, or make you experience things that aren't there at all. This group includes LSD and Magic Mushrooms.
• Others; this group might include drugs with relatively little potential for misuse such as antipsychotic and antidepressant drugs.

With enhanced understanding of the chemical structures, actions and effects of different drugs, more sophisticated classifications are now available, usually based on pharmacological mechanisms. Unfortunately this can lead to confusion for anybody with no basic understanding of pharmacology (such as most drug users). Ultimately all different drugs are unique in some respect, so that the best classification is the most helpful for understanding in the relevant context.

It is worth remembering that the interconnectedness of the brain means that the same subjective and objective effects of any drug may be mediated by the same or very different mechanisms, and that drugs which are chemically very similar may have seemingly very different (even opposite) effects.

Drug Effects

The effects of any psychoactive drug depend on several factors, including:

• the amount taken (the dose)
• the number and timing of doses
• the route by which the drug is taken
  1. by mouth
  2. by smoking
  3. by injection (subcutaneous, intramuscular, intravenous)
• the speed with which the drug reaches the brain
• the rate at which the drug is broken down (or excreted unchanged)
• the user's past experience with this and similar drugs
  1. expectations
  2. motivations
  3. physiological tolerance to the drug's effects
• whether the drug is taken alone or in combination with other drugs
• the circumstances in which the drug is taken
  1. place
  2. atmosphere
  3. company
• The person
  1. inherited biology
  2. personality
  3. health
  4. mood

The same dose of the same drug can have different outcomes

It is important to remember that psychoactive drugs have no intrinsic moral value and few inevitable effects. Consider, for example, the likely effect of 10 units of alcohol on:

1. A sixth-form school student, who has never drunk alcohol before, at a post-exam celebration night out, who drinks lager over 3 hours.
2. A middle-aged, middle-class woman at her weekly bridge club, who drinks gin and tonic over a period of 5 hours.
3. An alcohol dependent serial killer who has been taking amphetamine and high doses of benzodiazepines for two weeks, who injects vodka intravenously in the bathroom of a house he is burgling whilst the residents are asleep.
4. A bishop alone, at home, grieving over the death of his wife, who drinks sherry over 2 hours before going to bed, because he hasn't slept for two nights.

The same drug, the same quantity, but the effects might reasonably be expected to be very different.

Drug effects and drug interactions

Users of psychoactive drugs tend to use more than one type of drug. Heavy drinkers commonly smoke tobacco, amphetamine users frequently take benzo-diazepines, methadone users often drink heavily, and for young, non-dependent users of ‘recreational’ drugs, complex patterns of poly-drug use are commonplace. ‘Pure’ single drug use or dependence is sometimes seen but it is unusual in clinical populations. What do we understand about the effects of taking combinations of drugs?

Many drugs of misuse are unlicensed for any medical indication, and have therefore never been subject to mandatory testing and monitoring for effects and side effects. Getting ethical approval and funding to research such effects is therefore potentially problematic. When such testing is undertaken, it can only be with ‘safe’ doses (which may bear no relation to doses taken by misusers) on a small number of occasions (avoiding tolerance and dependence), in healthy volunteers (who will be unlike the ‘typical’ misuser), in laboratory conditions (an unusual setting for drug taking), without any other psychoactive drugs being taken. Any other approach would be unacceptably risky, but it leaves many real-life questions unanswered. For example, I was once asked in a criminal court for the likely effects, on a teenager, of three litres of 6 per cent ABV cider, four ‘ecstasy’ tablets, a large but unknown quantity of two different benzodiazepines, some amphetamine and possibly some LSD.

As a general rule, if you take more than one drug in the depressant group the effect will be increased. The majority of deaths from ‘heroin’ overdoses follow the use of heroin and/or alcohol and/or benzodiazepines and/or other opioid drugs. The use of two or more stimulant drugs will similarly increase stimulant effects. As a rule of thumb, any combination of drugs is more hazardous than any drug taken by itself, and the more complex the cocktail the more unpredictable the effects.

Drug prices

Drugs are commodities, like any other. In a free market, the price of a drug is therefore determined by supply and demand. In the UK the price of alcohol (and tobacco) is inflated by taxation, although this has long been circumvented by smugglers and latterly white-van-man, who import from countries with lower tax rates. Illegal drugs rely entirely on covert manufacture or smuggling, but market forces still apply. Because of the necessarily covert supply chain for illegal drugs, and the difficulty buyers have in checking drugs for purity, unscrupulous sellers adulterate (‘cut’) the drug with other, cheaper substances, usually inert but sometimes potentially poisonous.

Illegal drug prices and purities can change markedly over time. The following two examples come from my own experience.

1. When pharmaceutical amphetamines effectively disappeared because of controls on prescribing, it was replaced by amphetamine sulphate ‘powder’ from illegal laboratories. A gram of good quality (probably 70+ per cent) amphetamine cost around £10 in South Wales in the early 1970s, but would fuel two nights out for a couple of people. Twenty years later the price was the same, but the purity had fallen to between 0 (yes, zero) and 10 per cent. The fall in purity more than made up for price inflation. Increased availability and competition from heroin has since pushed the purity up and the price down.
2. In 1991 heroin was effectively unavailable in South Wales. When it was first brought over the Severn Bridge from Bristol it was sold in £10 wraps which contained maybe one fifteenth of a gram of poor quality stuff. By 2001 heroin was widely av...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Figures and Tables
• Contributors
• Acknowledgements
• Introduction
• PART I The basics 1 Some drugs of misuse
• PART II The care and treatment of substance misusers
• PART III Organisational and policy issues
• PART IV Some specific populations
• PART V Case studies