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 http://www.bbc.co.uk/ne

wsbeat/article/35946152/warning-over-new-uk-legal-high-law-after-irish-ban-made-it-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. 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:

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 http://youtu.be/bKbTbRqXVFg

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: 1994, 55.5 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 e.g. 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, impact on families and CJS

NICE Key priorities for implementation

1. Working with people with psychosis/ substance misuse 2. Recognition of psychosis with coexisting substance misuse 3. Secondary care mental health services 4. Substance misuse services 5. Inpatient mental health services 6. Young 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.

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?

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. 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 e.g 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. 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 e.g.

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: 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. He thought they smelt cannabis, so he 'ate it' Aggressive and stopping police with their job Arrested and in possession of knife, taken to police station Mental health act assessment as concerns Persecutory delusions, believed partner part of illuminati,

appeared to be responding to unseen stimuli and aggressive Detained under section 2 MHA to psychiatric inpatient unit

Summary Drug induced Psychosis diagnostic criteria Drug induced psychosis common Strategies for managing drug induced psychosis Completed a clinical scenario

Resources NICE guidelines https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-

behavioural-conditions Comorbidity of mental disorders and substance use: a brief guide for the primary

care clinician 2009, Australian government http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/con

tent/FE16C454A782A8AFCA2575BE002044D0/$File/m717.pdf Cochrane review http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003026.pub3/abstract Scottish guideline Drug induced psychosis and law http://www.mwcscot.org.uk/media/125271/drug_induced_psychosis_web_version.

pdf

Reflection on learning What did you want to learn? Did this workshop meet your needs? What will you take back from today? How will you use your learning?

Please complete your feedback forms Thank you Dr Soraya Mayet smayet@nhs.net