Drug dependence can not be considered as a diagnosis in itself in isolation from the associated factors like personality, underlying psychiatric illness and organic pain. The adolescent feelings of inferiority and vulnerability to stress may predispose certain personalities to drug abuse. Depression and anxiety may make some people rely on drugs to combat such feelings.

From the legal point of view, psychiatrists can not admit a drug addict to hospital against his/her will (compulsory hospitalization) unless there is a degree of mental disturbance which warrant it.

In fact, alcohol is much more important than all other drugs collectively as a substance of abuse as it interacts with and potentiates other centrally acting drugs. Some other substances are abused and they do not receive the same attention as tobacco (nicotine), Coffee (caffeine) and volatile solvents.

Non-narcotics drugs:

Narcotics:

Medically prescribed - but misused e.g. benzodiazepines, diuretics, laxatives.

Followed Second Brain Report (1965)

(1) Dangerous Drugs (Notification of Addicts, Regulations) February 1968

All addicts on narcotic drugs to be notified to Home Office - Central Register to be kept.

aim:-

(i) Assess trends of addiction

(ii) Central index.

(2) Dangerous Drugs (Supply to Addicts, Regulations), April 1968

The right to prescribe (i) heroin, (ii) Cocaine to Addicts (for this reason alone) restricted to specifically licensed doctors.

This effectively transferred the problem from GP to Hospital with regard to Dangerous Drugs. However, in certain instances, private practitioners are licensed.

Definition of dependence (Russell, 1976)

The crucial feature in dependence is a negative affect experienced in the absence of a drug, object or activity.

Degree of dependence equated with either:

(i) amount of this negative affect (mild Discomfort to extreme distress)

(ii) effort required to do without the drug, object or activity.

In Physical dependence a specific withdrawal syndrome with clinical features and course, following withdrawal.

In psychological dependence, the drug seeking behaviour is manifested. Drug abusers may pressurise their GP for the drug. Life style entails behaviour sometimes exclusively aimed at obtaining the drug(s). Criminal acts may ensue.

Persistant or occasional excessive drug use out of keeping with accepted medical practice.

Escalation of drug dose in order to achieve the original effect whether (a) therapeutic or (b) non-therapeutic.

1. General

1. Psychiatric

(ii) Drug history:

The assessor enquires about individual drugs used; the time of first use; whether used regularly, and if so in what dosage; have there been any periods of abstinence, if so with what effects; record this in respect to : Amphetamines, Cocaine, LSD, Methadone and ? Other substances e.g. Volatile substances, Cannabis and Heroin.

However, deal with each drug in chronological order of their use.

(iii) Offending behaviour directly associated with dependence or prior to drug misuse.

Full routine examination and in addition it is essential to examine injection (IV) sites, axillae and groins (? abscesses due to use of femoral vein)

1. detecting any evidence of confusion or hallucinations (however, do not fall into the trap of reporting these inaccurately just because there is a drug history). Is he depressed?

(ii) deciding degree of MOTIVATION of addict to coming off drugs.

(a) (i) LFT's (ii) Hepatitis R (iii) HLV III antibodies/AIDS

(b) Urinalysis

Assessment is of limited value in view of only QUALITATIVE test being available (i.e., positive or negative result but no information regarding the amount used). Therefore, there is no guide to prescribing requirements of opioids. However, these tests are very helpful in differential diagnosis.

(i) Morphine compounds (Heroin appears as this in urine)

(ii) Methadone (Physeptone), Pethidine

(iii) Amphetamines, cocaine

(iv) Barbiturates

(v) LSD, Cannabis, Phencyclidine

(vi) Benzodiazepines

(vii) Methaqualone

(viii) Propoxyphene

(ix) Ethyl Alcohol

(xi) Tricyclic antidepressants

(xii) Carbamazepine

(i) General Medicine

2. Psychiatry (General)

Readily portable apparatus (Medscreen; Syva).

Rapid result within 90 seconds.

(a)

(ii) Treatment of any infective process (boils etc)

(b) Decision whether or not patient warrants notifying as an addict and having specific drug prescribed. Drug Dependence Clinic if necessary. (Note: this refers to the narcotic group of drugs). However DDC has comprehensive role in rehabilitation, not merely prescribing

(c)

(ii) Family or 'Caring Person'

Rehabilitation -( D.R.O. - job)

1. Non-judgmental caring and supporting focus.
2. community based
3. free.
4. Attending addict responsible for maintenance of own recovery with peer group support.
5. Valuable for person with drug/alcohol problem.
6. NA a strategy with 'withdrawal regime' combats loneliness.
7. Total abstinence not mandatory but very strongly encouraged.
8. Many meetings open to non-addicts including family/key caring person to give them essential support.
9. In London special meetings catering for non-smokers, women (creches) homosexuals (male and female), young people and ex-offenders.
10. Ethos of NA "Just for today, we do not take drugs"
11. They will send a recovering person to meet new referral following his/her telephone call.

A Synthetic substance used in management of opiate (heroin) dependence.

Weight for weight equivalent to heroin in preventing onset of withdrawal symptoms.

(i) Acute emergency - to suppress withdrawal effects from heroin.

NB. May be given by GP or any other doctor, i.e., do not require to be specifically licensed.

(ii) Maintenance programme - when a heroin addict is unwilling to be withdrawn , the substitution of Methadone appropriate. Theoretically, gives less positive euphoria, and so facilitates subsequent withdrawal.

Administration:

Oral (tablets or linctus) Parenteral IM or IV