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You just say that you want to and the recording has started. That's great. So you in the UK, you just, you know, you can, you can self refer and different countries have it running different ways. But um in the UK, you self refer. So, um here's my little thing about how to become an addiction psychiatrist. But in the UK, you graduate, you do your initial bit of training, then you go and train in psychiatry and you do your first three years is a corps trainee and ideally you do a bit of substance misuse service in there. And then when you, you hire training in psychiatrist as a registrar, you do a one year formal training and addiction psychiatry. Then the easiest bit of that whole process is finding a job as a consultant in drug and alcohol services because there's hardly any consultants left in it because um in the UK, most services are run by the NHS, they run the National Health Service to run by third sector providers, often charities. Um But the thing about addictions is you really do need to know about addictions, whatever specialty you go into because I can't really think of a specialty where you're not going to bump into issues around drug or alcohol misuse. And people might think. Well, what about if I'm going to pediatrics and just work with or even need urinates and work with, you know, premature babies? Well, you'll be dealing with neonatal abstinence syndrome there from mothers who are dependent on opiates and there's a whole range of things and any way you can do it. welcome to anyone who's joint. Just to let you know that if you've got any questions as we go through, just shout them out because this is meant to be a friendly session with a bit of uh which isn't meant to be a hard one. This meant to be a nice friendly one. So what do we do in our drug and alcohol services? Well, there's lots of different things. I won't read all of them out. But, you know, one of the big things we do is substitute prescribing for people, particularly who use opiates heroin, newer stuff creeping in like fentaNYL and what have you um A and E assessment. Uh Any assessments and mental health assessment, harm reduction is a big part of what we do. And I'm going to talk a bit more about harm reduction techniques as well as medicated detoxification. So when we give people who are addicted to opiates like heroin, you can stabilize them on um things uh you know, on substitute therapies like methadone or buprenorphine, but you also can detoxify. So take them off it um and reduce it down. And then there's a couple of other bits and pieces and the health checks are really important. And then there's some other specialist stuff that happens at different services and everywhere is different in the UK and everywhere is slightly different throughout the world. So it depends where you are, you know, but these are the general kind of things that you might see in a community substance misuse uh service. Now, when we break down, you know, the variety of substances that are out there, we can broadly speaking, wrap them into three main categories, depressant, stimulants and hallucinogens. But then there's this crossover that happens as well because things are, you know, rarely uh you know, just any, any one category because um you know, benzodiazepines are one of the ones where they've got a very clear action on Gaba receptors without much other receptor activity. But things like alcohol, for example, will work not just Gaba receptors, but um uh glutamate receptors and opiate receptors and cannabinoid receptors as well, you know. So things are, you know, this can get a bit complicated. But I want you to remember these, these broad ones. So depressants. So ones which have a depressant uh sedative effect, uh typically hallucinogens, those ones that can change your perceptions of things. So LSD DMT Mescaline sitting in there as well and then stimulants. So those ones which work on things like your dopa anergic system, your um uh nicotinic system or the effect of caffeine as well, which is a potent actually uh stimulant when you take enough of it. Um and then the overlap that you can see in the middle there with things like ketamine, cannabinoids, genetic calm, annoyed MDMA. Now, when we think about the use of substances, it's helpful to have a framework by which we think about how people use substances. So, you know, using use of a substance is using something that's not problematic. So my example of that might be someone who has a glass of wine twice a week with their, with their evening meal. That's not a problematic level of use. They're not drinking excessively on that. If we were to stick with alcohol, hazardous use might be, you know, this is where there's a risk to harm to health. So they haven't harmed themselves yet, but there is a risk there. So this might include someone who was say binge drinking on the weekend. So drinking, you know, five points of, you know, strong ish lager on the weekend. Now haven't presently come to any harm, but they're at risk of harm if they carry on that pattern of use in the long term and harmful uses. The point in which it started to cause either physical or mental harm. So that might be someone who's um you know, maybe that binge drinker who, when they go out, they drink so much that they fall over, they harm themselves or maybe they get in trouble with the police. Um, you know, when they, when they drink too much independent uses where they just need to take it just to feel normal. Yeah. So that's the person who's got alcohol use and they got a tremor withdrawal symptoms if they don't drink and if they, and when they do drink those go away and then they prioritize that over other things. So it becomes more important than other things in their life. Okay. So I'm gonna give you an example cause it's all right me putting this up on the screen and saying, well, this is what this is, but what's important is um to think about it in a clinical context. So let's think about Scott. He's 24. He's been using Heroine daily for the past three years and he started smoking heroin on the weekends at 19 and he started injecting it at 20 years old. It's not uncommon that people moved to injecting. Um now using four times a day, 10 lbs of heroin at a time. Uh and from waking, he thinks about his next use. He doesn't think that he could go without using heroin and he started off paying for it with his pay from his, his job, but he lost that job and he's now shoplifting and he's been arrested but his three times and cautious, he's lost weight and he's got a poor diet. So what in his history indicates that he is dependent on heroin. Shouted out guys, what have you picked up? That means he might be dependent on heroin. Uh The fact that he's thinking about your behavior from waking up. Great. Okay. So this is something that's now on his mind and he's thinking about it. So he's got a compulsion to use it and someone said his behavior. So can we elaborate on that a bit more water on his behavior? Uh The behavior in which he has changed his priority from everything? Like getting highest, the most important thing rather than going to a job eating properly or even knowing what is right and wrong. Okay. So, uh what, so he's, he, so there's something there around the use of heroin has now become so important to him that's overtaken other things. And the reason for that probably is because it's so uncomfortable when he doesn't use heroin. So, um, it's important to remember that the reason why people use heroin, uh, four times a day, 10 lbs a day. I don't think they can live without it is that they have such powerful withdrawal symptoms that, uh they can genuinely feel it. I mean, the withdrawal from heroin is extremely, uh difficult, very uncomfortable and that's the reason why they use it. Um, and probably Scott is aware that shoplifting is wrong, but he feels trapped in that circumstance because he can't see another option available to him. Any other things that we've picked up on that might indicate that he's become dependent on heroin. The fact he has lost, uh, weight. Yes. And you picked up that he lost weight. So, he's prioritizing. Paying for heroin. Overeating, isn't he? Yeah. Anything else you got frequency frequency of the use? So, there's something around that. So what's happened is the increase in the frequency which indicates a tolerance to the heroin. So I could start smoking it just on the weekends. But now he needs to inject it and he's using four times a day, 10 lbs at a time. So he's become tolerant to it, hasn't he? Because initially what happens is I'll put it up here. What initially happens is that your smoking, it, you get any effect, your body gets used to it. You need to smoke more of it, smoking, it is very expensive. And so you move to injecting because you get the same effect for uh less amount of heroin. So it's a bit cheaper but the use goes up and up and up and up and you build, you build tolerance over time. We picked up that he's thinking uh next use from waking up. So he's got a compulsion and we picked up on the persistence despite evidence of harm. So even though he's been arrested three times and he's getting in trouble for shoplifting, he has to carry on doing that. He carries on even though there's clear evidence that he's harming himself with this and this is Salience, this putting the use of the substance of other things also known as Primacy. And that's, uh and that indicates uh as a feature of dependence and this is the bull criteria for dependence and withdrawal. So that's that if I stop using heroin, I'm gonna get nauseous or vomit, I'll get diarrhea, I'll get pilo erection and goose bumps. I'll, you know, build very flu like really unwell. Compulsion is a strong desire. Salience is we've talked about that one as, as we have persistence by evidence of harm, impaired control is when you start using it, you find it hard to stop using it as a proportion of us who if we drink alcohol, you know, we're the kind of people who can go without drinking. But if we do drink, we drink too much. Uh you know, some of us are that way. Uh And intolerance is that over time, we need more of the substance to have the same effect. I'm going to share with you something now, which is a body map. So this is from a study where they got someone to draw their experience, they've got people to draw their experiences of being toxic, ated with and withdrawing from heroin. And this person's description of it because it's a bit hard to read of type two that it says after the initial nod. So, and it's really common to see that when you see people who use heroin, you know, after they've used it, they'll have this moment where they become quite drowsy, kind of, you know, they'll, they'll not down jerk awake like we do after they go through that initial sedative period can suddenly become very talkative or interested in something on the radio or the TV describes it as absolute contentment. So you can see how people can get drawn into using heroin. There's, you know, there are, it's an enjoyable substance with people to use the taste and smell. They enjoy cuddling and touch that become hungry. Uh But straightaway after post heroin, they get itchiness, which can be too much and very quick and indicates a true hit to that person that's probably from the citric acid that they mix in with the heroin, which comes with a clean needle care. And I'll show you that in a moment and then, then they describe going into the next stage where they feel very warm content and have an hour nada, kind of a dozy period. Uh And in the last stage, if it's late, they'll sleep. If it's early, they'll carry on with the day. And these are the signs that you'll see with opioid intoxication, euphoria, relaxation, a feeling of well being. So you're getting a lot of peace here. Very reinforcing, isn't it? So constricted, you have pinpoint pupils, drowsiness, slurred speech, poor attention of concentration. But let's contrast that to his experience of withdrawal, very prone to emotional thought, too much emotion anxiety, where, how, who to score, getting sicker. A feeling of disembodied mint kind of trippy difficulty relating to people since he's been very heightened smell, vision, sweating, hot and cold, can't handle being touched. Can't even if he's starving, there are a vital flight, uh that's been activated at that point. So a really horrible and pleasant experience that people have with heroin. It really is. Um If you see people in withdrawal, there's super uncomfortable. If you see them when they come into A and E or, you know, if you're an assessment for their substance misuse service, they all they can think about is getting rid of that really horrible feeling, uh getting and using heroin and then withdrawal has got a lot to it. So I've got this little diagram up here, but you can see there's multiple stages to it. Normal thing to start. It's gonna bit of rhinorrhea, runny, nose, watering eyes, yawning. Those are your early signs that someone's in opiate withdrawal. But as it goes on, you're getting down into this area down, um, you're getting into the stuff that's uh down here, which is like shivers, abdominal cramping, vomiting, nausea, loss of appetite, goose bumps. Um And then what one of the things that I'd like you just to notice is that, you know, we're looking at week to hear people are still getting insomnia and the moods only just starting to stabilize. And then there's this thing where they call post acute withdrawal syndrome where you get anxiety dysphoria, cravings, insomnia, depression, irritability going on for months after people have been using it. So, uh the, the hard work is not over. Once you've been detoxed from opiates, it's an ongoing process that can be really challenging as people go on. So they do need quite a lot of support. All right, let's move on to think about physical health complications that can come alongside uh drug use. Well, these come in a couple of categories, drug effects, contaminants, method of use and lifestyle and the mortality in the UK from opiates is pretty high. Um And I suspect very similar in any country where they're using opiates at the same level 1 to 2%. Um And, you know, medical complications and overdose being probably the biggest ones and suicide. Um an accidental um less common. So when we think about the purity of different substances, this is some stuff that's come from drug seizures in England and Wales, I find this fascinating because uh when you get a little baggie of amphetamine, only 10% of that is likely to be amphetamine with cocaine, you can actually see the quality seems to improve that up to 60%. But a lot of what's sitting in your whatever substance people are buying isn't the drug that you're buying. And that's an important thing because we need to think about what kind of things people put in it. Well, the good news eats right. That the most common stuff that people put in is pretty mild stuff because it's cheap. So sucrose, lactose, dextrose, Mannitol. Very cheap. And if you're a drug dealer, you don't want to harm your, um, profit by putting in dodgy stuff into your, uh, into your drugs. Because if your, if your customers die, they can't come back and buy more drugs. So generally speaking, you're not gonna put a lot of really weird stuff in there, but there are a couple of things that you can, that, that sometimes are mixed in with them. Uh, you know, caffeine sometimes is no PHENobarbital is quite expensive. So people, generally speaking, aren't going to, uh, put that in there quite hard to get hold of. So, let's think about Scott. Here's our reminder of it, what physical health complications might we think about Scott presenting with? And you could have blood borne viruses. Great. Yeah. So, so possibility of blood borne viruses that we share in the needles. What once might well be thinking about in particular? Uh, HIV and HEP. C's okay. Yeah. HIV. And hepatitis would be on top of our list. Yeah. Other physical health problems, a couple of other people and I've got high. He ba Jeb, uh, couple of other people. Any ideas? Good anorexia also be. So, um, anorexia in that, in that very tip in that, you know, the true meaning of anorexia as in he's not eating because of the use. Anorexia, nervosa is a separate thing. So, but he's not eating because he's prioritizing other things. And also heroin often will sap the appetite to a degree and there will be effects of malnutrition. Absolutely. There would be a urinary problem as well because the amount he's taking is not getting filtered properly. So there'll be a renal dysfunction is, um, um, I would, I wouldn't be that high up on my list actually. No, I probably won't worry about any renal impairment with him. There's other stuff that I think would be more like there's a possibility. There is a specific cardiac issue that kind of come from people who are injecting drug users. Any idea anyone, anyone knows infective endocarditis? Yeah. Excellent. So, infective endocarditis is a possibility. So that's something we need to think about. And there's other vascular problems that can happen with injecting drug use have collapsed veins. So you could get, yes. So you're likely to get collapsed veins. So, taking blood could be difficult. And, you know, when you come to take blood from someone who's an injecting drug user, uh, the best thing to do when you want to do that is ask them where they get blood from because they're the experts, they're, the people are going to know where the veins are hiding. Um, and there are times, you know, when I used to work on the water. We would detoxify people from opiates. You know, I used to, I used to use a butterfly needle and I get them to find the vein and pop the needle in and then I would take the blood out because they were the experts at it. Yeah, there are other reason, things that might happen if we're, you know, in injecting multiple times a day, uh regular pattern, uh Trump Trump production, which could lead to so stroke or something. Well, we might have DVT and peeing. That's where we would be going with this. Really okay. But we can keep it simple. So like if I'm clearly puncturing the skin, I'm going to be at risk of cellulitis, phlebitis to a degree abscesses and potentially sepsis. And if I've got an abscess in my groin because that's the only place that I've got a, I can find access. Am I going to stop injecting if I'm dependent on heroin? Know I'm not. So that's high risk for the sepsis. It's important to think about how people are funding it, screen for sex, working and associated problems. And then we've seen a lot of the other ones overdose, the high risk here as well. Um And then we need to opportunistically screen for our complications. Think about screening blood's um, okay, let's think about opiate overdose. What's the triad of symptoms that point to an ap overdose? So anyone who hasn't had a chance to speak yet. Any ideas. Um There's plenty point people with one great pinpoint pupils. Yep, respiratory arrest, well, respiratory depression. Now, could that lead to a point at which they fully stop breathing? Definitely. That's the big risk, isn't it? But it starts at respiratory depression. Everything you uh no. Oh guys, I think you'll, you'll kick yourself unconsciousness. Yeah. So if I've taken loads of heroin and I overdosed on that, I'm gonna be unconscious. My breath, my, my respiratory rate is going to be low and there's a risk and I'm gonna have pinpoint pupils. That's the, that's the ones in order we treat it with. You can shout in unison because everyone knows the answer to this one. No locks on naloxone. Very good. But first, you know, think about establishing an airway ventilation. Naloxone and repeat uh every in 2 to 3 minutes because not so short acting. So there's a little note, got a video there as well that you can watch a proper copy of that up in the chat bar at the end or something. And you can watch that about uh what a naloxone kit looks like and how it's used. So I went, I'll just tell you through this, the risk that he has for overdose. So there's some things that are high risk for him. He's young, he's male, he's white and the UK. That's a risk. You know, these are the people at the highest risk he broke up with his girlfriend six months ago, lives with each other users. Now that is not, that, that, that is a, reduces your risk because you've, you've got a naloxone pen which they give to you, which is one like an EpiPen. Um It's not for you to use because if you've overdosed on heroin, you are going to be unconscious or on your way to be unconscious and it's for those people who are around you to inject you with. Yeah, because you won't be able to do. It's way too late. By the time you're in overdose from opiates, you're not going to be able to treat, treat yourself. But if you've got other people who live with, they might pick up that you're overdosed and implement treatment. He's working. So being unemployed as a risk factor uh and past medical histories got none good. There's no history of chronic pain because chronic pain is a risk factor. Uh And he's got no psychiatric history. Um Although it's worth pointing out that most people, you know, a lot of people who use opiates don't have any formal psychiatric history, but actually a lot of people will have a history of depression, anxiety trauma. Uh and he's got poly drug use, which is a risk factor, but crack use isn't a respiratory depressant. His highest risk of people. He's using heroin plus alcohol or heroin plus benzodiazepine. It's okay. Uh We're past that and then there's lots of psychiatric complications uh mental health problems are very common and lots of social complications that come as well. But I'm gonna whip over those because um I'm actually gonna think about this, how we can reduce heart. So the first thing we can do is we do psychoeducation. Uh talk to people about the risk of sharing needles and how to inject safely. Talk to me about needle exchange X schemes. Um We can prevent uh manage overdose so you don't use alone, tell other people what you're using. Don't mix it with other sedatives. We can give people in the lock, same pens and we can give public health messaging if there's high strength uh opiates around heroin that's tainted with fentaNYL or other adulterants. We can reduce uh illegal drug use by giving people opiates, substitute therapies or getting people to reduce their use rather than stopping it. Because if someone can use methadone, 50 mg a day and inject just once a day when they were injecting four times a day before, we have reduced their risk by three times they're injecting. So that's a good, that's a good result. Yeah. So it's not about always about stopping if the person isn't ready to stop. It's about getting the use as low as we possibly can. And then the other thing is the stuff we talked about identifying health problems early with double virus testing and this is what a clean needle kit looks like. So you'll see a couple of things in, uh, in here, let me annotate it. So, around here and alcohol swab that's for cleaning. Uh, this is where you will mix up your heroin. So it's a spoon. You'll put your heroin in that spoon. You put some water, clean sterile water in that you'll mix in with it. Either vitamin C or citric, which is citric acid. As is your preference. You've got a nice clean needle that you can put on the end of your syringe, you'll draw it up out of the, out of here and then be able to inject and there's a couple of videos there as well which will show you, um which will show you how it is that you can, how people can inject safely. And it's good to know how to advise people to do that. It's quite helpful information today, I've spoken a little about the options that we've got available to us, but maybe it's substitute therapy and depending which country in, there'll be different ones that are favored or available. Methadone is probably the most commonly used. One. It's a liquid, usually green and that's an opiate agonist. So it recreates the action of heroin. Um And this people can you continue using heroin while they use this, so it can be helpful for harm reduction. So again, taking them from injecting four times a day to injecting once a day or maybe going back to just smoking. Um uh but it's got a very long half life. So you take four or five days to stabilize people on that. Whereas buprenorphine, which is a sublingual tablet is a partial agonist at eight P receptors. When you get people up to high doses of this kind of 16 and milligrams and above, it will actually block the action of A P. It's um and so people won't be able to use heroin on top as it would, they actually can put them into with a withdrawal state. So it's really useful for people who say no, I really don't want to use on top, but there are people who won't want to use it for that reason. So fair enough, we move with methadone as the alternative and you can stabilize someone within 24 hours on that. So it's got that plus site. I'm going to move this on and just think about other substances. I would do a little, it's going to be a proper quiz because of the time that we've got available to us. Um, but I think this is the stuff that I would want you guys to know about different drugs. So as we go through, I'll let you uh guess what these are, what I'm gonna say is that people use drugs for a wide range of reasons. Yeah, probably. I would guess that, you know, most of us when we get up in the morning probably use a drug in the form of caffeine uh and we've probably got a mild dependency on caffeine. I smoked for about 15 years and had a, you know, definitely had a dependence on uh, nicotine. No, there are a range of reasons why people do use substances. Um, and when people will come dependent on substances that no one sets out to become addicted to you as substance, it's important to remember that. And it normally, you know, there's normally consistent patterns in people's experiences that we'll talk about here because what you'll notice is that the more adverse childhood experiences people have experienced. Yeah, which is things like physical abuse, sexual abuse, emotional abuse. Um, you know, severe bereavement, um, things like that, the more of those people have experienced much more likely it is that they'll go on to addiction in the future. That doesn't mean everyone who goes through adverse childhood experiences ends up addicted to a substance, but it does put you at a higher risk. And if you've got a predisposition genetically to developing addiction, uh plus you get all of this, uh, you know, stress from, uh, you know, trauma in your childhood. You know, is it a wonder that people rely on substances to get them through very difficult times or to manage complex trauma? I don't think it is really. And when you meet people who are going through addiction, you do tend to see that being a common thread that goes through with some, you know, really terrible stories. So when we think about people who might be acting in a way that we don't think it's helpful or people who become, uh, upset in the context of their addiction, trying to remember the, the heart of it normally is some pretty horrible stuff that went on in their childhood, which they didn't have any control over. Um, and the, you know, that most people wouldn't have had to have experienced in their lives. And these are the kind of things that people might have experienced. And as you can see, know stuff that's pretty difficult to contend with. Now, as I say, not everyone who goes through these experiences will end up with addiction, but this often is the seed from which addiction grows. Uh And the risk goes up and up and up through the more uh different uh more adverse experiences you have. So substance use can be a way to manage trauma. And if you take away the substance just, just taking away the substance by detoxifying someone, those experiences from trauma are going to come back and they're going to get worse. So you need to, if you think about detoxes someone and you, you know that they've got a strong history of trauma in the background, you need to build that into your management plan. How are we going to manage that when we take away your coping mechanism, which is the substance, how are we going to manage your distress when that comes back. Okay. That was a quick message. Let's do a quiz. All right. How we gonna do this? What substances this a powder costing? 10 lbs 0.1 of a gram, uh causing a pleasurable sensation, flushing of the skin and heaviness in the extremities can be snorted, injected or smoked and then overdose causes respiratory depression. Okay. Oh, I type in the chat bar and hit return. Don't copy anyone. I'll tell you when to hit return and hit return. If you typed in a chat bar, you can take return now and put it there. I'm trying to avoid people copying each other. Don't worry if you get it wrong here, it doesn't matter. You can even send the answer just to me so you can take parts when it was my easy one. My warm up for you heroin. It's got a lot of different names attached to it. Okay. We've talked a lot about that. So I don't even need to go to create more detail about that. Okay. Next one, I want you to name four routes that drives can be taken, type them into the chat by. You can send it directly to me if you want to and I'll give you another 20 seconds to type it in. Uh don't hit return yet. Ok. Hit return and let's see what you guys have said four routes that drugs can be taken. Okay? I've got a couple of others had some coming in directly to me, which is great. Okay. Well, let me show you what I've got. Well, so we've got a couple of, of things here. Right. So, oral tablets, capsules pills, you can also take them powders wrapped in things like Rissler. So, um, papers for cigarettes. Um, and you can swallow them. It's called bombing. Can do that with things like amphetamines, liquids, like alcohol. That's one way to do it. You can inject it. You can do IV injection as a quick, intense high. You can do it. I am which is much lower. Not many people do it. I am if you choose heroin. But the people who do use iron injections, that people who might use steroids for, for example, anabolic steroids, you can do it subcutaneously, which is called skin popping in the UK. Um And that's usually when people have lost their access to uh to their veins and it doesn't look very nice and it causes nasty, chemically burned. So it's not very good. You can smoke, you can smoke drugs, you can snort them very quick absorption with that. You can take it sublingually like buprenorphine. You can take drugs rectally, not a common one that people do illicitly, but you can and you can inhale drugs like uh like nitrous oxide, for example. So there's a range of things someone said dermal you could put on a patch but it's not that common to use illicitly, but people might do it in a pitch. Oh, hang on. Ok. My questions went out of order. Felt to worry. So what's this truck type it in as we're going through? But don't hit the return button yet. In toxicity presents with tachycardia, dysrhythmias, coronary Bezos spasm into acute coronary syndrome or strokes associated with higher rates of police involvement related to virus blocks, dopamine, reuptake it transport into the pre synaptic terminal. So lot increases dopamine activity in the synapse. Heavy use can lead to drug induced psychosis and it's taken as a power dot or spoke to crystal form, you could hit return. Now, let's see what comes back. Okay. So this is interesting because um in the UK, when I run this with UK, medical students that tends to go uh mostly cocaine because which is the answer for this one. But I've seen a bit of crystal meth in there which does work on dopamine, but it's got a different mechanism of action and it's not commonly used in the, in the UK. Um And there's a couple other differences there, but this is cocaine which in its um powder form is cocaine powder, but you can also become um that's another form it can come as well. Now, one thing is important to know about cocaine is when you mix it with alcohol, it becomes a new chemical called coco ethylene, which is um uh which is quite toxic. All right, I've got a trip report. So type this one in as we read through it and see if you can figure out what substance this is. The first sign was that my perception had changed slightly. Nothing that one could put a finger on. But my conscious awareness of myself and my surroundings had undergone a subtle shift. The second sign was an increasing numbness and tiredness in my body. Sounds had become distant, stretched out in time, thundery, like a shock wave or tidal wave that washed over me. As I later learned, most of the sounds were t turning the pages of a magazine and pulling the magazine off the table into her lap. A couple of times, I felt that things had changed completely beyond my control. My body transformed my conception of the world completely altered the entire state of my being becomes something else entirely and such a state of being was a little scary for some much short moments. It was a full blown out of body experience. Much of the time. It actually felt like the mind had left the body behind and we went somewhere else into an entirely different dimensions. Then returning to the transformed body at times. I need to leave again. Hit the return button. If you figured out what you think that is, oh, we've got a bit of um debate going on from various people, which is good. Okay. I'll give you the answer guys. Well, this is actually Quetta Me. So I've had a couple of things that come through ranging from LSD, which is pretty common. One DMT marijuana psilocybin amphetamine, I can see where people are going with most of these. But this is ketamine. And the key here is that we've got a dissociative here, right? So we've got someone who's having a full blown, they describe this as a full blown out of body experience. The time dilation as well is very characteristic of Ketamine, what they call a K whole time stretches out. So this person turning the pages of a magazine becomes thundering like a shockwave or a tidal wave. And the other thing that you'll notice here that's um in there as well as the numbness and tiredness in the body. And kids mean used clinically um in anesthesia, anesthesia, isn't it as well? Uh So it's a dissociative. So there you go. Other things to know about ketamine. Ketamine can cause a nasty chemical cystitis that can result people need, need be uh bladder resections, really unpleasant stuff. So, with heavy use over a long time and I met people who have been through that unfortunately. All right. What's the most common non opiate drug that people seek treatment for substance misuse services in the UK type it in the chat bar but don't hit return yet. Not alcohol. This is UK based which a bit unfair but have a guess and see what you think you can hit return whenever you're ready. Okay, I had a couple of things come in. So it's actually cannabis, which came to a great surprise to me because what, because I thought, well, people don't really associate cannabis with being particularly harmful. Um But of course, a lot of people do use cannabis and there are harms associated with it. So, um and let me tell you what the main harm it's, well, the main harm is the risk of psychosis as an association with the development of psychosis. Um And the younger you are, the more kind of issues correlates with development of later psychosis. And there are some genetic vulnerabilities. And one of the things that you need to be aware of is that THC levels have been increasing over the years while CBD levels have been decreasing over time, there's a whole range of reasons why that might be, but the THC is a bit that's probably pro psychotic and the CBD is probably protective against psychosis. So we've been increasing the amount of pro psychotic stuff and decreasing the protective bit. And so over time, we're seeing higher and higher risk for, for that. Oh right. This is a bright and bonus because this is I'm coming from Brighton, right, lecturer Brighton Sussex Medical School and this is actually taken just down the road from me at Brighton Beach. What substances in these canisters you type it in and just hit return when you're ready. Oh, no answers. So this might be a very specific one for the. Well, I know it's not only in the UK because this is happening in other places, but it's actually nitrous oxide also known as laughing gas, which we use clinically, don't we? For anesthesia? Particularly in obstetrics and it's used in catering for, you know, those whipped cream things. And what have you when people use this? It is a mild dissociative with some psychedelic properties. People can get relaxed, change their perception of time, but it was very short acting. People tend to use it frequently and, and you know, when you go overseas and you're a bit of a jolly boy like these boys going over from England to I be through our somewhere, then you can buy helium that these, these balloons and instead of being filled with helium filled nitrous oxide and then they'll uh but those in and have this um you know, uh slightly dissociative experience there downside if you use lots and lots of this and it does have to be rather a lot of it, then it can deplete your vitamin D and B 12 and result in severe peripheral neuropathy and also subacute combined degeneration of spinal cord. It is very rare but it is something that has happened. So it's worth knowing about nitrous oxide and the risks associated with heavy prolonged use of it. All right. I want to know three high risk areas, rejecting sites, three high risk areas type them in. And if your direct messaging, you can send it straight away if you're sending it straight to me, it straight away to test your knowledge before I give you the answers. And I've even given you a clue because I've given you the a drawing and open access drawing of the vascular system, anyone else having to go? Okay. So here's the kind of places that might be high rest for injecting. So, injecting has to be somewhere where we can feel or see a neck. So the neck, where do we start injecting? Well, people start injecting in the same place that we start taking blood. We go the anti cubital fossa because we've got nice, easy to access veins there. The next stop for doctors normally is to go down the arm and head into the hand and the forearm. And after we've exhausted that we might go a little bit higher up into the upper part of the arm, we might head down into the legs. And often as doctors, you'll end up in the feet when our patient's are no different leg back of the knee, quite a good spot. A couple of good ones back there and then people might head up into the neck or the groin. Um And people gonna end up in some, you know, bad places. So the neck is high risk, isn't it? Because we've got a lot of vascular up. You're up there, you're close into an artery. So that's a really high risk arm and hand's pretty low risk. Generally speaking, groin, high risk because you've got lots of vasculature there. But the other thing is that we, you know, it's not a, it's a mucky area, isn't it? It's an area where we can transport quite a lot of, um, uh, bacteria that are going to give us nasty infections here. So that's a concerning area. Legs can be high risk because the access can be difficulty. There's a couple other bits as well around risk of abscesses and the feet as well. Yeah. And again, that's largely around the fact that this is a dirty, a part of the body. It's not as generally as clean as our arms and our hands slightly harder to clean and people often will not take the time to clean as well before injecting. Okay. Uh Coming up towards the end of our quiz. Now what the combination of um combination of heroin and cocaine taken IV Any ideas what this might be? Well, I didn't, I've actually had this up on another slide earlier on. So if you observant, you have picked up on this one. Well, it's called snowballing. And people will use the combination of heroin and crack cocaine or powder cocaine. Now, crack cocaine, I'll talk to you about briefly. It is a different, it's a version of cocaine that has had been treated uh to turn it into uh form that you can smoke easily. Uh It's a very intense high that people get from. This is short acting. Uh and it can be quite Morrish that people tend to use, you know, binge on this quite heavily but long term problems you get from these things, like breathing problems, crack lung. Um and it can be hard on your veins because it is crystal crystal line. So people can get really, uh you know, veins can be destroyed. So snowballing or speed balling is the name of the heroin and crack used in combination. All right, I'm gonna give this example. This is the most common cause of presentations to. It is a common cause of presentation to and it's one of the most common causes of substance related. One to the UK. It's an agonist at CB one and CB two receptors. The effects are variable from calming and dreamlike two euphoria and dissociative effects. But in intoxication cause agitation, seizures, vomiting, collapse of paranoia or psychosis type it in and hit return if you've got an, an idea what that might be okay saying small things coming in. But look, this is actually synthetic cannabinoids and this normally tricks people a little bit because people see the CBD, what's a kind of uh cannabinoid one and kind of annoyed two receptors, but it's actually a synthetic cannabinoids. Now these look like they're plant like they look like that, don't they? But actually the plant matter is irrelevant. It's been sprayed with the chemical. So it looks almost natural but it's not. Um and people smoke it and uh the effects are very variable and there's a lot of variation and, and there could be a range of different chemicals that are put on it as well. But what you can see is that people can have a very difficult time with these substances actually and they can result of people having seizures. I had one patient who used it very frequently, always in a and E having had fits from using spice. Uh and this is not something that's isolated to the UK synthetic cannabinoids used worldwide. Uh um and people can get terribly unwell and they were very psychotic on it as well. So worth knowing about that and novel psychoactive, there's substance is there's loads of them. Um and, and you know, they're legality varies over the over the world um as a wide range of them that happen in different things and they're often have got names, their given names that don't relate to what they are like. Benzo Extreme. It's not a benzodiazepine at all. It's actually more amphetamine in its structure. So that's a marketing tool to use. Alright. Name four items in a clean needle kit. We've been over there. So I'll just show this one to you. There's just a reminder of what we've got in it. So you know the spoon of sterile water, the needle, the syringe, the citrical vitamin, seeing an alcohol swab. Okay. The what substances? This one? So this one get causes release the serotonin and the ref nuclear's is an M pathogen. We're now using it in the treatment of PTSD and it can cause restlessness, hypothermia, palpitation, chest pain, sweating, a bruxism, but it's got a significant come down effect. So, bruxism that's grinding your teeth. Yeah. And I'm going to give you the answer to this one because this is MDMA ecstasy uh is normally is a pill but can come in a powder nowadays is um and it gives you this one is an M pathogen, meaning you feel more connected to other people who will get chatty euphoric. It can be associated with sexual arousal as well. Um We'll get heart increased heart rate and temperature. But if you use it long term, if you think what's happening in your brain, all that serotonin, constantly getting released out of your ref nucleus, it can lead to anxiety and then you take that away and that goes away. All of your receptors have down regulated and you get a nasty bit of anxiety and some dysphoria after that. And I always got this my bonus. This is my bright and favorite, a potent agonist, a clear liquid short half life, 2 to 4 hours long, but a very severe withdrawal syndrome that includes seizures, which can also happen in overdose. And the overdose can be fatal with a very steep dose response curve. Making that quite easy. That's my last question. So if you want one last go having a stab at it, then you're welcome. Have a go well, most people think this is alcohol because it's a Gaba agonist and it's a liquid, but it's actually this industrial solvent uh called uh TH B or GBL and widely available across the internationally. Um and this is very addictive because sometimes use it as a date rape substance, but very addictive because it's very short acting. And what happens people get addicted to this, going to withdraw very quickly within a couple of hours of using it. We have people who need to keep sipping at it all the way throughout the day and then the next, um, you know, and, and so they have to get up in the night actually to drink it as they go through as well, really unpleasant addiction with that one. And then my last, this is my last question, which medical specialty has the highest rates of substance of misuse disorder? I think this is a fun one. So which medical specialty, which doctors, which type of doctor have the highest rates of substance misuse? Anyone want to last go a couple coming in anymore for anymore. Well, everyone's got it right so far which I'm very impressed at it is an S A tests. Yeah, it's really important that, you know, that doctors are at risk of substance misuse, particularly middle career doctors which councils me unfortunately. But the profile might be a bit different if you're younger or a student. So, substance misuse is a real risk and support is available no matter what country you're in their support structures in place for doctors. And it's important to know uh about that and know that if you find yourself using more in terms of substances or alcohol that you're comfortable with that, you know, that you can go out and receive some support and protect every country's going to have a support structure in place. Um for people who are going through uh those and lots that's out specifically for doctors by doctors because we get it and we understand what it's like to be a doctor and the pressures that come alongside that. So uh just a quick message about that say, don't feel um uh you know, it's important if that ever happens to you or someone that you care about that, you know, that's sport available and that's the end of mine five minutes to go. So if there's any questions on substance misuse, I'm happy to answer them. And if not, you're welcome uh to go, how does uh addict who is trying to give up on the addiction goes for therapy as in withdrawal is one of them. But where did they go for a group session as well? Yeah, like a a a session or meeting. So there are lots of different ways that people can access support. So there's alcoholics anonymous there's no narcotics anonymous, cocaine, anonymous. And anyone who uses any substance can attend any of those. There are also smart recovery groups the best way. I, because it's because I know I've got people joining us from all over the world and lots of different medical schools. The best way is to have a look at whatsoever in your local area. Speak to your local drug and alcohol service. If you are working in an area where there isn't a proper drug and alcohol service and it's just done by whoever, then what I would suggest that you do is have a look online, just Google, you know, a drug and alcohol support and see what charities are around because it's often done by charities and figure out what they are because you could be very, um uh it could be very helpful to share with our um colleagues with, with our patient's what is available to them locally. And if you can, if you've got them with you on a ward or in a clinic and they're thinking, or maybe I might like support, you know, pick up the phone or fill in the online form with them there. And then because that first step of making contact is very hard for people. So if you support them through that, they've got the best chance of accessing it down the line. Uh In, in one of your slides, you said that uh doesn't live alone like he's with two people. So that's not a risk factor. But the thing is who does he live with? That is also a big question because he get, he got into the addiction, maybe the people who was living with, they were at extension. So we also have to know who is the Scott living with the patient. So that, that was risk factor for overdose. And so actually, if you live with people who are heroin addicts, it could be. But you know, they're the people who do know how to manage over and over days because they've probably been trained in how to use naloxone pens lots of times. So that's probably helpful for opiate overdose. But you're right, that social setting and where you live is really important. And if you're trying to stop using drugs and you're in with and you're living with people who are still using drugs, it's very hard to stop, to not use to be in recovery whilst other people are using around you. So you need to think about that in your management plan. Definitely uh one of the methods in which when person is trying to quit is uh one is a physical method that the in which the person is trying to stay away, stay away from the drug itself. If he's not positive, if he's not able to do it, then the people around him help him to stay away from the I think the other group of people who have this addiction problems are the ones which are much more difficult one. These are the one who justify it like they have the right or they need it or it's, it's their right to use it and uh they will do anything, they'll be very resistant to like uh any good advice, any, any meeting or anything. The reason I was saying this is because uh I don't know whether this is a good example to use it. But if you have a part of this very famous TV, show Breaking Bad in which uh one of the characters goes for the meeting for like the addicts who are trying to quit in which he says that they try to justify their behavior, even the characters tries to justify the behave that why he needs help, why the person is trying to help is a hypnotism. This is one of the very Yeah, so I'm gonna, I'm gonna pause you there because it's so easy when we're talking about these things to, to use words like um you know, people choosing to carry on using and um you know, being hypocritical and apply things that can be interpreted as um as judgmental. And I think it's helpful to you think about this way of thinking about where people are in terms of changing their behavior. This is the cycle of change you might have come across it against, come across it before. Okay. So what happens is that people start off. Okay. So people who you're talking about there are probably going to be up here, aren't they? In the, in the pre contemplated stage of things? That means they're not thinking about stopping using. Yeah. And with those people were not trying to get them to the point where they, if you try and jump the stages to go in your clinic and say they go doctor, I, I don't want to stop using, I'm very happy with how much I'm using. Uh, you're not going to get them to stop using that day. You would be a, you'll be, it'll be a fool's errand to try it. Okay. There's no chance you're going to convince that person to stop using drugs on that day. So your job is to try and move them a little bit closer to the next stage. You're trying to get them to go from the bit where they're saying I wouldn't even consider stopping to the point of saying, well, I mean, maybe in the future. Yeah. And as you go around this cycle, people start at the point of I'm not going to change anything whatsoever to the point of, well, maybe, maybe, maybe I could think about that one day, but I don't want to do it. Now. Let me be honest with you. I've got too much on my plate right now and it's too stressful for me now. So I'm not going to stop it now and then you get to this point of thinking. Well, yes. No, I will stop and I'm going to change my behavior. Uh, but I'm gonna, I'm gonna get ready for it and that is a process that might take two days, two years, 20 years. We don't know. But the preparation and we, when every time you might meet, people were trying to do a little bit further on and when we meet them and they're in that phase were saying we're getting them to the point of saying okay. Well, actually, you know, should we set a stop date? So we work together to think about when it's going to be the time you're gonna stop, we can bring you in for a detoxification if you're ready to stop and have that time and then they stop using, they've made the change and then they get into the maintenance space and this is the period that at which they stop, they maintain their abstinence and they stop using. Yeah. And at this point, all we're trying to do is keep them here. But some people, what will happen is they will relapse. They will say, do you know what? I think I can handle one more? Drink, one drink. What does that mean? That I'll be fine? I, I haven't had a drink for two years. I'm going to be ok. They have one drink and they'll relapse into use. That happens and that can be part of the process. Doesn't always happen. And in that circumstance, they might, then, then back here, precontemplative, we go around the cycle again, that to me is in a problem. I don't mind people going around this cycle. Uh The point is we're aiming to get them here. Um, two maintenance to not using, but we have to do it in a series of very small steps along the way. And our role is not to get people from up here down to here. Our role is to get people even just the tiniest bit along the way to that in our every meeting that we have. All we're trying to do is move them a little bit closer around. Does that make sense? Yes, sir. Well, I hope it does because it can be. Sometimes people think my job is to get people to stop using, but you're not, we're not as, not as powerful as we think we are, we can tell people what to do. But a big part of helping people through recovery process, stopping using substances is around taking the time to listen to them, to be with them, to ensure we don't make that. So they don't feel judged in any way and they can have those discussions that move them closer to the idea of thinking about stopping using. And then you will see people who stop using and get into maintenance space and many of them will never relapse. All right, that's um that's that bear any other questions, guys, anything else people want to ask about or will I let you go? Okay. I think that's it then guys. Well, it's been a pleasure. Um enjoy, I've kept you a tiny bit over. So thank you so much for your time. Um Good luck with the Oh, it's your break now, isn't it? So enjoy your, your break between terms. Okay. Thank you. Goodbye. You very much, doctor. Have a lovely afternoon. Goodbye. Goodbye.