How much Alcohol?

Are UK limits of Safe drinking Safe?

Regular excess drinking can take years off your life, study finds

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National Addictions Conference- Cardiff 2012

It was a matter of pride for hosting the Royal College of Psychiatrists Addictions Annual Conference in Cardiff this year. It is the first time that it was hosted in Cardiff. The feedback of the conference had been very good spanning from the topics covered to the minute details of the venue, the organisation and the hospitality. Dr Tony Jewell’s opening set the Welsh flavour and that carried on throughout. It was timely for the press release regarding the minimum pricing of alcohol to be released just before the conference as well. Listening to the news today, I picked up that the national alcohol consumption is being reported as going down with more health concerns, rising taxes and increased price to buy alcohol and based on that it was being argued that ‘minimum pricing’ should not be a strategic direction.

Most importantly, it is clear that pricing does have an impact on levels of consumption and given all the evidence on price- elasticity, the ‘marketing- mix’ used by the alcohol industry, the impact of availability and licensing, in my opinion, it becomes even more important to endorse ‘minimum pricing’.

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Psychological Trauma and Brain- Part 2

Carrying on from the previous post one can argue whether PTSD or traumatic symptoms following trauma are ‘disorders of memory’ or ‘disorders of forgetting’. The virtue of understanding these concepts lies in understanding what happens in the brain when memories are laid down. So let me spend sometime on that.

What we know from knowledge of memory systems in our brain is that during exposure to the traumatic incidents, the ‘action systems’ are set in motion and settle down to adaptation as one comes through to the other side of the traumatic event. The memories of the event initially are ’emotionally charged’ and get stored in a specific part of the brain. Now as the processing is complete- a narrative quality to the memory is established and it gets stored as yet another complete memory (almost like a photograph in an old picture album). Whenever one needs to access it, it becomes almost a case of going back to the album, picking the photo and describing it as a story in the broader timeline of an individual’s life. A personal example could be demonstrative here- when I learnt to ride my bike without stabilisers, I can recollect from my life’s picture album a memory where my brother, a cousin and dad supported me from behind and I rode round and round in circles in the back garden of my cousins house in Watford and suddenly realised that on my last round I was riding on my own with two of them standing and just watching me ride whilst my dad was in the middle of the garden stopped at the spot where he had left me on my own.

A negative event, similarly, gets processed and on complete processing gets a narrative quality. One could go and access that memory as well without getting unduly distressed or even if does experience a subjective distress, it is but just a memory in the story of life. However, people suffering with sequalae of trauma are not able to process that event completely and the emotional aspects of that event get stored as the main memory with the primitive systems being in a state of ‘chronic activation’ thus restricting the processing from happening, and hence they are ‘not able to forget’ the event and life becomes pre-occupied and organised around the traumatic event. This is seen in various clinical presentations in Psychiatric practice.

So how can psychiatric treatments work? Working in my capacity of a private psychiatrist in Wales, I use both to pharmacological treatments including anti- depressants, Prazosin and others along with Eye Movement Desensititation and Reprocessing (EMDR). The idea behind EMDR is the facilitation of complete processing of the traumatic memory thus helping the establishment of the narrative quality and being able to move on in life.

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Ecstasy has been around for a very long time. Chemically it is 3, 4- methylenedioxymethamphetamine- MDMA. As the name suggests, it is a methamphetamine compound. It is taken orally usually in a tablet or capsule form and the effects start within 30- 60 minutes. Pharmacologically, there is a huge efflux of Serotonin in the brain along with effects on the Dopamine and Noradrenaline sytems as well.The acute effects can often lead to Hyperthermia (raised body temperature) which is compounded by its use in warm, humid climates typically found in the dance clubs and this can be life threatening. The euphoria that is often reported after its use seems to be more related to the contexts of the environment i.e. whether being used in isolation or with club goers and club environment. This has been seen in studies as reported in the 1st International Conference of Psychoactive Drugs in Budapest in March 2012.

Intoxication with Ecstasy has been described as occurring in three stages (Koesters et al, 2002; Parrott and Lasky, 1998)- initial stage of disorientation, second stage of ‘spasmodic jerking and tingling’ and the final stage of increased sociability, increased mental clarity, a feeling of emotional warmth and feeling close to others. Given the context dependent effects, higher doses can give rise to frank euphoria. In toxic doses it can lead to dehydration, hyperthermia (both these can be life threatening in club environment), raised pulse, hypertension, liver failure and/or renal failure (Jonas and Graeme- Cook 2001; Lester et al 2000). There may be anxiety, agitation and even confusion.

The post dose recovery time often leads to depressed mood, irritability, anxiety, sleep impairment, asociability. People who are regular users can experience mid week depression and there are reports of aggression as well.

The chronic effects after regular heavy use can be damaging. Several studies have now indicated that the SERT (Sertraline Transporter) is reduced with chronic use which highlights the diminution of Serotonin in various regions of the brain. As the effects of Ecstasy are on the Frontal Cortex (the part of the brain responsible for planning and executive function), cognitive and memory deficits can be significant. Interestingly, for me working as a Consultant Psychiatrist in Addictions in Wales, what I learnt new from the conference is also that heavy regular use can be associated with Sleep Apnea (serotonin being an important chemical in maintaining lung function).

Whilst experimenting with the drug may be tempting but it can lead to long lasting damage if it becomes persistent or heavy or dependent use.


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Legal highs and Novel Psychoactive Substances (NPS)- Beyond Cocaine, Ecstasy and Amphetamines

The debate regarding the legislating evolving new drugs persists for Addiction Psychiatry. Whilst ‘Legal Highs’ (so called as they are not yet under legislation and illegal) keep growing, the issue of legislation needs to be carefully balanced by the understanding of scientific effects of these drugs.

The 1st International Conference on Novel Psychoactive Substances in Budapest, Hungary on 12- 13 March 2012 was a very useful conference which highlighted its theme of the rapidly changing world of ‘Legal Highs’. The biggest challenge for Addiction Psychiatry seems to be keeping pace with this rapid developments where newer drugs are coming out along with newer market evolution and the trends that are transgressing national and international borders- an impact of globalisation and the internet becoming a massive global market. Also, the epidemiology of these is not yet clear as the new drugs have been not around with us long enough. Fortunately though, EMCDDA is reporting that there are some prevalence studies coming up which may be reflecting the wide variation of use of these substances in different regions and countries. Other information reported in this conference, that is useful to me as a Private Psychiatrist in Wales, UK is that the Novel Psychoactive Substances are not probably the first preference of drug users and that stimulants- Amphetamines, Cocaine, MDMA & Ketamine remain drugs of preference. From the reported results, it seems that the Mephadrone might be on the decline. From Dr Paul Dargan’s findings, the other challenge that faces us in Addiction Psychiatry is that there are no systematic data on toxicology, the ICD coding takes a long time to code for new drugs and when faced with acute presentations which may be in A&Es, general medical wards, Psychiatry Wards or in Addiction services, the analytic confirmation is still not up to speed to be able to confirm or refute the drug in the body. Whilst most NPS seem to be falling under the categories of Piperazine, Cathinone and Synthetic Cannabinoids- variations in these poses clinical management challenges. Piperadole derivatives like DPMP and D2PM have been on the increase as highlighted in the conference and people after having used these have developed neuropsychiatric syndromes.

Similarly, the  marketing of these has changed a lot and the newer social networking sites have been used a lot for advertising. Another MixMag survey had highlighted that the number of online shops has increased exponentially and the number of head shops have gone up as well. What struck me as well is that the products being sold with the same brand name such as ‘Ivory Wave’ has been found to be having no standardization, therefore the person buying the same brand may never be assured of getting the same drug on repeat orders. And Methoxetamine (Ketamine derivative) is being branded as “Bladder Friendly”.

What effects do these have in the long run is a difficult question to answer at the moment and a collaborative effort by clinicians, researchers, policy makers, criminal justice systems and governments is needed to address this new epidemic!

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Buprenorphine Implants

Working in Wales as a Consultant Psychiatrist specialising in Addictions, it is exciting to know and share the developments happening in Addiction Psychiatry.

Opiate dependence is a serious cause for concern and the dependence has evolved from illicit Heroin to other sources of Opiates as well such as Prescription Opioid Dependence. Buprenorphine is a valid treatment option and as with any other Chronic Health condition like Diabetes, Hypertension, Enduring Mental Health Problems- concordance to medication is a real clinical issue. We use Depot medication in cases of mental health disorders to improve medication concordance. The trial of Buprenorphine Implants may hold a promising future for Opiate Dependence Management as well. Watch the space!!

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