Handover | Issue 37 – December 2016 – CEP and solutions update

In our conversations with services we often hear many of the people wanting and needing acute mental health services are experiencing co-existing mental and addiction problems (CEP). These messages align with the evidence which says at least half of people receiving treatment from mental health services will have a co-existing addiction problem.

The ability of frontline staff to recognise, assess and respond  to people with a co-existing addiction problem can greatly assist in reducing anxiety, distress, irritability and agitation – therefore reducing the likelihood of restrictive interventions being used. The focus of this article is on co-existing mental health and substance use problems, in particular alcohol, cannabis and amphetamine-type stimulant use and has been written with Lois Boyd and Carolyn Swanson who co-lead the least restrictive practice programme of work at Te Pou.

Mental health and substance use 

People experiencing CEP may have problems with:

  • depressive symptoms and depression 
  • a brief psychotic episode that resolves after stopping substances
  • bipolar disorder, social phobia and post-traumatic stress disorder 
  • positive and active symptoms of psychosis. 

Impact

We know people experiencing CEP are likely to have: 

  • more frequent relapses and repeated admissions to hospital
  • poorer general physical health
  • financial and housing problems with increased risk of homelessness
  • a poorer quality of life overall
  • greater risk of violence, both as perpetrator and as victim
  • higher rates of suicide
  • higher rates of offending
  • difficulties and tensions in relationships with family and whānau.

These can contribute to problems engaging and remaining engaged in treatment.

Substance use and prescribed medication 

The interaction between substances and prescribed medications can result in increased risk, distress and changes in behaviour. Interactions between substances and mental health medication can be discussed with the prescriber or pharmacist. You can check for some potential interactions online, for example at Medscape’s drug interaction checker.

Mental health and alcohol use – key points

  • Withdrawal triggers anxiety and/or depression.
  • Alcohol use can be the sole cause of depression in some people and if they stop drinking, following withdrawal symptoms resolving, they can recover from depression.
  • Use is associated with higher suicide risk.
  • Use by people with bipolar disorder is associated with higher risks of suicide, instability of mood and medication non-adherence.
  • May worsen psychotic symptoms, increase the risk of tardive dyskinesia and have greater effects on cognition (memory and attention).

Withdrawal symptoms include: risk of seizures (often peaks around 6-12 hours after last use and can be fatal), confusion, disorientation and extreme agitation (often peaks around 36-48 hours after last use).  

Recognising signs of recent alcohol use and intoxication

Observing signs of recent alcohol use will inform a co-created plan of care. Signs include: strong smell of alcohol on breath or sweat, slurred speech, repetitive conversation, rapid and repetitive eye movements (nystagmus), flushed skin, irritable and reactive, short term memory loss, disinhibition (disregarding social conventions), impulsivity, poor judgement relating to risk, poor physical co-ordination.

Graph showing how to recognise and respond to alcohol withdrawl symptoms

Mental health and cannabis use – key points

  • Cannabis use can trigger panic attacks.
  • Cannabis use by people with bipolar disorder is associated with higher risks of suicide, mixed mania and medication non-compliance.
  • Cannabis use can trigger more frequent episodes of psychosis in people with schizophrenia 
  • Cannabis withdrawal can trigger anxiety and depressive symptoms when people who have used on a daily or near daily basis for a significant period stop or reduce use. 

Withdrawal symptoms include:

  • irritability, restlessness and anxiety (which often peak around 7 days after last use)
  • anger and aggression (which often peak around 14 days after last use). 

Recognising signs of recent cannabis use

These include: bloodshot or heavy-lidded eyes, strong smell of cannabis on clothes & hair, smirking, distractibility, restlessness,    poor concentration, irrelevant conversation, paranoid thoughts and behaviour.

Diagram 2: Progress of cannabis withdrawal

Mental health and amphetamine-type stimulant use – key points

Irritability, aggression and perceptual disturbance can be an issue for some people who use amphetamine-type stimulants.  When trying to engage with a person you suspect has been using amphetamine-type stimulants, it is important to remember that their judgement and perception may be impaired. Do not assume that they will understand your words or actions, as you intend them to be understood. 

When supporting a person in this situation: speak in a steady quiet manner, actively listen and ask for clarification if you need it, avoid humour and jokes, explain what you are doing and why, in short simple statements, avoid rapid movements towards the person, a low stimulus environment is helpful, if available. 

Recognise and respond to amphetamine-type stimulant withdrawal symptoms

Common methamphetamine withdrawal symptoms

1-3 days since last use

Symptoms – Crash:

  • exhaustion
  • many hours asleep
  • depression.

2-10 days since last use

Symptoms – Withdrawl (in order from common to very uncommon):

  • strong urges to use, cravings
  • mood swings; tearfulness, anxiety,
  • irritability, blah, feeling drained
  • agitation
  • sleep problems
  • poor concentration
  • aches, pains and headaches
  • diarrhoea, hunger
  • paranoia
  • hallucinations.

7-28 days since last use

Most symptoms settle but most peopel could still be having:

  • mood swings
  • depression
  • sleep problems
  • cravings.

1-3 months, sometimes much longer

Over time as brain chemistry adjusts and:

  • sleep patterns improve
  • energy levels get better
  • mood settles.

Sourced from P’d off: A guide for people trying to stop using meth/P/Ice/Speed (Matua Raki, 2010)

Useful CEP resources and links

CEP e-learning

Recommended for all staff working in mental health inpatient units, this resource provides introductory, foundation level information about co-existing mental health and addiction problems and other complex needs (CEP).
Visit the Matua Raki website to access to resource.