Dr Soraya Mayet Consultant Psychiatrist Humber NHS FT ...

1 Dr Soraya Mayet Consultant Psychiatrist Humber NHS FT honorary Senior Lecturer Hull and York Medical School (HYMS) Workshop Aims Introduction /would you like from this workshop? What is drug induced psychosis? How common is drug-induced Psychosis? Managing drug-induced psychosis Clinical scenario and group feedback Reflection on learning Feedback on workshop BBC Newsbeat 6/4/16 -easier-to-buy-them Warning over new UK legal high law after Irish ban 'made it easier to buy them' BBC Newsbeat6/4/16 Interview with patient from news "Looking out of this window I can see the psychiatric unit I ended up in for 30 days and it wasn't nice. "I was coming out with stupid thoughts, saying to my family that there was people after me. "I started attacking them every day." He says he was introduced to synthetic cannabis by a friend. "They said we have got this stuff in and it's cheaper and better.

2 So I tried it and then didn't stop trying it. "After two to three months you get very addicted. I went down to seven stone because I was just drinking water and smoking. "It's absolutely nothing like cannabis. It is awful, one of the worst drugs out there." Drug-Induced Psychosis Serious consequence of psychoactive substance psychosis during/after substance Feeling suspicious, 'people trying to get me' Unusual beliefs that are not possible Hearing or seeing things that aren t there Often with insomnia, agitation, aggression, suicidal ICD-10 diagnosis Mental and behavioural disorders due to psychoactive substance use - Psychotic disorder Psychotic symptoms: Hallucinations - typically auditory Perceptual distortions Delusions - often persecutory nature Psychomotor disturbances - excitement or stupor Abnormal affect range from fear to ecstasy Sensorium usually clear but disturbance possible During or following psychoactive substance use Not explained by intoxication/withdrawal state Symptoms normally resolve soon after stopping use Drug Induced Psychosis Substance misuse triggers new psychotic symptoms Substance misuse triggers psychosis with pre-existing psychosis Includes a cluster of diagnoses: Schizophrenia type disorders Bipolar disorder Affective psychosis Mental and behavioural disorders due to psychoactive substance psychotic disorder etc What causes drug-induced psychosis Many psychoactive substances including.

3 Amphetamines Cocaine Cannabis Novel Psychoactive Substances - MCAT, legal highs Steroids phencyclidine, LSD, mescaline, anticholinergics Excited delirium White Paper Report on Excited Delirium Syndrome ACEP Excited Delirium Task Force September 10, 2009 Manic Excitement, Delirium of Mixed Origin, Delirium, drug induced, Delirium, induced by drug Agitation, Delirium, Psychomotor Excitement, Psychomotor Agitation, Abnormal Excitement Audience participant please! Psychosis with Cannabis Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review Moore, Theresa HM et al. The Lancet , Volume 370 , Issue 9584 , 319 - 328 Increase in risk of psychosis of about 40% in participants who had ever used cannabis Dose-response effect with an increased risk of 50 200% in the most frequent users. Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study - Di Forti, et al , March 2015 The Lancet Psychiatry Risk of psychotic disorder 3 X to those using skunk vs no cannabis Attributable fraction of first-episode psychosis for skunk 24% Medical Journal of Australia Drug-induced Psychosis up 400% in Australia NDARC report.

4 1994, cases per million people, rising to 253 per million by 2004 Largest increase has been among amphetamine users Another study of emergency department patients More than one in 100 treated for amphetamine use disorder (includes ice, ecstasy and speed) PICU data Service evaluation in progress preliminary data All admissions in 2015 Almost all had Substance Use Disorder Over a quarter had psychoactive substance related psychotic disorder NPS (MCAT), cannabis, amphetamines, steroids People with previous psychosis such as schizophrenia High proportion triggered by substance use cannabis Common Inpatients Community What is the best treatment? Psychosis with substance misuse in over 14s: assessment and management NICE guidelines [CG120] March 2011 . Substance misuse with Psychosis 40% with psychosis misuse substances once in life Double general population Substances may exacerbate the psychosis or interfere with pharmacological or psychological treatment Worse outcomes Higher risk of relapse and hospitalisation Poorer physical health Poor medication adherence, Greater dropout Greater homelessness.

5 Impact on families and CJS NICE Key priorities for implementation with people with psychosis/ substance misuse of psychosis with coexisting substance misuse care mental health services misuse services mental health services people with psychosis/substance misuse Cg120 Mental health services provide care coordination/treatment for the psychosis within joint working arrangements Competence - Recognising psychosis and substance misuse Provide information Working with families Safeguarding Consent capacity and treatment decisions Physical health and testing Pathways into care Cg120 - treatment Use bipolar and schizophrenia guidelines Use alcohol use and drug misuse guidelines Tailor treatment plan based on; Psychosis, substance misuse, social and treatment and readiness for change Use antipsychotics as per guidelines No evidence of any differential benefit antipsychotics Depot/LAI for managing non adherence No medications licensed for drug induced psychosis CG120 Substance misuse services recognise psychosis, complete mental health needs and risk assessment, Know how/when to refer to secondary mental health.

6 Inpatient units Promote drug free environment Comprehensive assessment including withdrawals Tests as part of care plan Planned detoxification only with; sm involvement, inpatient, as part of plan Do not discharge from inpatient unit solely on sm Must have care coordinator on discharge Care plan Risks of od information given to patient Psychosis and schizophrenia CG178 2014 Prevention - CBT First episode - Early intervention, assess trauma Antipsychotic choice made by service user and healthcare professional provide information on side effects Baseline physical health monitoring - antipsychotics Advise against combined antipsychotics Subsequent - family interventions, CBT, clozapine if not responded to two antipsychotics So what do you do? NICE say use their guidelines according to diagnosis Substance misuse guidelines for substance use schizophrenia/bipolar guidelines for psychosis Any other research guidelines?

7 Treatment for amphetamine psychosis Ling et al 2009 Cochrane review One RCT of treatment for amphetamine psychosis Antipsychotics effectively reduce symptoms Olanzapine better tolerability than haloperidol. Two studies did not meet inclusion show that agitation and some psychotic symptoms may be abated within an hour after antipsychotic injection. Aripiprazole and Risperidone for Treatment of Methamphetamine-Associated Psychosis in Chinese Patients aripiprazole and risperidone significant reductions in psychosis No differences between groups Risperidone group significantly greater METH craving reductions 71% completed the study, aripiprazole lower retention side effects Journal of Substance Abuse Treatment - Wang et al 2016 Drug-induced psychoses Review of literature: Management General supportive measures, reassurance, minimizing patient stimulation, and BENZODIAZEPINES as needed Also mentions specific antidotes Poison Centre, University of Arizona, Tucson 85724.

8 Emergency Medicine Clinics of North America. Hulbut 1991 Neuropathology of Drug Addictions and Substance Misuse Chapter 26 Amphetamine-Induced Psychosis Likely common neuropathological and genetic factors between amphetamine-induced and primary psychosis. Dopamine model of psychosis - sensitization may induce psychosis in chronic amphetamine users. Abnormal brain function with amphetamine psychosis. Use of antipsychotic medications resolves symptoms of acute amphetamine-induced psychosis. Australian government guidelines Prevention avoid substance and advised against using. Assessment integrated treatment likely best outcomes What type of psychosis new onset or existing psychosis? Treatment For newly triggered psychosis Short term antipsychotics or benzodiazepines may be indicated The duration of use should be titrated against the symptoms.

9 Psychoeducation and CBT Treatment Symptoms may Stop, as drug wears off, within hours or days However sometimes symptoms do not resolve - longer term antipsychotics clozapine may be more effective than risperidone in reducing cannabis use in people with psychosis some benefit for olanzapine in cannabis induced psychosis Adjunctive treatment for substance misuse as required Naltrexone for alcohol Combined daily dispensing of psychotropic medication at the same time opioids Assessment Comprehensive assessment as per NICE Mental health act assessment if required Mental disorder present? nature or degree to warrant detention under the mental health act? Are there risks to self, health or others? Psychiatric Inpatient admission Inpatient Management Continue assessment Biopsychosocial Multidisciplinary integrated approach Social: Psychiatric ward environment ideally street drug free Secure (PICU) vs non secure units (open units) MDT approach involving community team/SM services Psychological: Motivational, engaging, CBT, relapse prevention Biological.

10 Medication antipsychotics and benzodiazepines short term Physical health examination and tests Longer term Substance misuse services Mental health services care coordination Joint work Psychoeducation CBT As per NICE Clinical scenario and group feedback Fictional Case Example Drug Induced Psychosis with NPS Using cannabis since 13 years, helped with anxiety growing and selling cannabis Lives with partner and her 8 year old three other children with ex, no social services belief shared by partner and of 'illuminati involvement' Legal highs Took legal highs (bath salts) for fun Couldn't sleep for days after Paranoia started, police after him, partner illuminati Suspicious, started carrying a knife for protection Threatened neighbour with a knife, believed they stole Aggressive to partner, punched her What do you do next? 5 min Drove 30 miles with partner & her kid to 'drop off' cannabis Saw police stopping traffic due to accident Decided to 'help out' police and got out car to assist.