Case PresentationCase Presentation

Claire MorbeyClaire Morbey

JenniferJennifer

17 year old presented to A+E17 year old presented to A+E PC: PC: 1/52 h/o fevers1/52 h/o fevers

3/7 h/o haemoptysis3/7 h/o haemoptysis O/E: Febrile - temp 40O/E: Febrile - temp 40ooCC CXR + bloods unremarkableCXR + bloods unremarkable

Recalled as cultures grew Recalled as cultures grew Staph. aureus Staph. aureus in in both bottlesboth bottles

Admitted for investigationAdmitted for investigation– EchocardiogramEchocardiogram– Bone scanBone scan

– Commenced on i.v. flucloxacillinCommenced on i.v. flucloxacillin

JenniferJennifer

Continued to spike tempContinued to spike temp

EchoEcho: vegetation on tricuspid valve: vegetation on tricuspid valve

DiagnosisDiagnosis: Infective Endocarditis with : Infective Endocarditis with septic emboliseptic emboli

JenniferJennifer

2/7 later disappeared from the ward2/7 later disappeared from the ward

Returned the next dayReturned the next day

Repeating pattern over the course of several Repeating pattern over the course of several daysdays

What part of the history have I What part of the history have I missed?missed?

HeroinHeroin

Aka….horse, brown,china Aka….horse, brown,china white, smack, gear,H, white, smack, gear,H,

junk,skag,dragonjunk,skag,dragon

OpiateOpiate– Juice of opium poppyJuice of opium poppy– Papaver somniferumPapaver somniferum

OpioidOpioid– Directly acting compound whose effects are Directly acting compound whose effects are

stereospecifically antagonised by naloxonestereospecifically antagonised by naloxone

– E.g. pethidine, methadone, dihydrocodeineE.g. pethidine, methadone, dihydrocodeine

Main source of street heroin is the Golden Main source of street heroin is the Golden Crescent countries of South West AsiaCrescent countries of South West Asia– AfghanistanAfghanistan– PakistanPakistan– IranIran

Methods of UseMethods of Use

Smoked Smoked (Chasing the dragon)(Chasing the dragon) SniffedSniffed InjectedInjected PRPR (black tar) (black tar)

Average use 0.25-2g per dayAverage use 0.25-2g per day– 1g = 50mg methadone1g = 50mg methadone– Roughly ½ smokedRoughly ½ smoked– ½ taken i.v.½ taken i.v.

Cost has more than halved in last 15 yearsCost has more than halved in last 15 years

£20 buys a wrap == ½ g£20 buys a wrap == ½ g

Sudden influx of smokable heroin in Sudden influx of smokable heroin in 1980s caused a dramatic increase in use1980s caused a dramatic increase in use

Numbers of UsersNumbers of Users

1985 in Bradford1985 in Bradford– 20-35020-350

BRIBRI– 5 week period Aug-Sept 2001, approx 874 5 week period Aug-Sept 2001, approx 874

admissionsadmissions– 151 drug related (Ods, MODs)151 drug related (Ods, MODs)– i.e. 18.4% of totali.e. 18.4% of total

Why is Drug Abuse Important to Why is Drug Abuse Important to Us?Us?

As Taxpayers?As Taxpayers?

Number of people found guilty or cautioned Number of people found guilty or cautioned by police for drug offences rose fromby police for drug offences rose from– 44 922 in 199044 922 in 1990– To 120 007 in 1999To 120 007 in 1999

Government estimates of the cost of Government estimates of the cost of policing and supporting those affected by a policing and supporting those affected by a drug habit are put at £3-4 billion in 2001-drug habit are put at £3-4 billion in 2001-20022002

As Part of the Medical As Part of the Medical Profession?Profession?

1985-19951985-1995 saw a marked increase in drug saw a marked increase in drug related deaths among young people aged related deaths among young people aged 15-1915-19

Mortality riskMortality risk 12 12 times times greatergreater than the than the general populationgeneral population

Injectors Injectors 2222 times times more likely to diemore likely to die Importance of drug treatment services has Importance of drug treatment services has

been increasingly recognised as evidence of been increasingly recognised as evidence of their effectiveness has growntheir effectiveness has grown

NTOR (National Treatment Outcome NTOR (National Treatment Outcome Research study) calculated a Research study) calculated a return of £3return of £3 due to savings in the criminal justice system due to savings in the criminal justice system and lower levels of victim costs for every and lower levels of victim costs for every £1 spent on treatment£1 spent on treatment

Where do we fit in at the BRI?Where do we fit in at the BRI?

Where do we fit in at the BRI?Where do we fit in at the BRI?

Addicts presenting with a medical problem Addicts presenting with a medical problem have a right to appropriate treatment have a right to appropriate treatment without neglecting their addiction.without neglecting their addiction.

“ “ in such circumstances it is vital that the in such circumstances it is vital that the doctor fulfil their responsibilities by doctor fulfil their responsibilities by ensuring adequate assessment and ensuring adequate assessment and appropriate management that facilitates the appropriate management that facilitates the retention of the patient in treatment”retention of the patient in treatment”

In the case of Jennifer, we failed to address In the case of Jennifer, we failed to address her addiction and withdrawalher addiction and withdrawal

We therefore failed to treat her acute We therefore failed to treat her acute medical problemmedical problem

Signs and Symptoms of Opiate Signs and Symptoms of Opiate WithdrawalWithdrawal

Course:Course:– HeroinHeroin

» Onset 8-12 hoursOnset 8-12 hours

» Lasts 5-10 daysLasts 5-10 days

– MethadoneMethadone» Onset 24-48 hoursOnset 24-48 hours

» Lasts 2-4 weeksLasts 2-4 weeks

First 24 hoursFirst 24 hours

Grade 1Grade 1– RestlessnessRestlessness– LacrimationLacrimation– RhinorrheaRhinorrhea– YawningYawning– DiaphoresisDiaphoresis– Goose flesh “cold turkey”Goose flesh “cold turkey”

Later..Later..

Grade 2Grade 2– Dilated pupilsDilated pupils– Muscle twitching and spasmsMuscle twitching and spasms– Severe aches in the back, abdomen and legsSevere aches in the back, abdomen and legs

Grade 3Grade 3– TachycardiaTachycardia– HypertensionHypertension– TachypneaTachypnea– FeverFever– AnorexiaAnorexia– NauseaNausea– Extreme restlessnessExtreme restlessness

Grade 4Grade 4– DiarrhoeaDiarrhoea– VomitingVomiting– Severe sneezingSevere sneezing– DehydrationDehydration– HyperglycaemiaHyperglycaemia– hypotensionhypotension

Treatment OptionsTreatment Options

MethadoneMethadone– Only give after signs of withdrawal are Only give after signs of withdrawal are

presentpresent

– Give b.d or tdsGive b.d or tds

– Taper by 20% every other dayTaper by 20% every other day

DosesDoses

Grade 1Grade 1 5mg5mg

Grade 2Grade 2 10mg10mg

Grade 3Grade 3 15mg15mg

Grade 4Grade 4 20mg20mg

Supplement with doses of 5-10mg if signs Supplement with doses of 5-10mg if signs are not suppressed or reappear during first are not suppressed or reappear during first 24 hrs24 hrs

Unusual to require more than 40 mg during Unusual to require more than 40 mg during first 24hrs of withdrawalfirst 24hrs of withdrawal

Non-Opiate TreatmentNon-Opiate Treatment

LofexidineLofexidine– Fully licensedFully licensed– Alpha 2 adrenoceptor agonistAlpha 2 adrenoceptor agonist

» Reduces impulses in sympathetic nervous systemReduces impulses in sympathetic nervous system

– Thought that noradrenaline excess causes Thought that noradrenaline excess causes symptoms such as sweating, diarrhoea, chillssymptoms such as sweating, diarrhoea, chills

– Equally efficacious as methadone in withdrawalEqually efficacious as methadone in withdrawal– Role in those seeking abstinanceRole in those seeking abstinance

ClonidineClonidine– Not licensedNot licensed– Widely used, esp in USAWidely used, esp in USA– Anti hypertensiveAnti hypertensive

Other drugs used to alleviate Other drugs used to alleviate symptoms symptoms

NSAIDSNSAIDS– IbuprofenIbuprofen

» Muscular pains and headachesMuscular pains and headaches

ParacetamolParacetamol» PyrexiaPyrexia

MetoclopramideMetoclopramide» Nausea and vomitingNausea and vomiting

LoperamideLoperamide» DiarrhoeaDiarrhoea

GavisconGaviscon» Stomach upsetStomach upset

Longer termLonger term

NaltrexoneNaltrexone– Opiate antagonistOpiate antagonist– Prevents relapses in abstinant/drug free for 7-10 Prevents relapses in abstinant/drug free for 7-10

daysdays

ConclusionConclusion

Heroin abuse is a serious and growing Heroin abuse is a serious and growing problem in Bradfordproblem in Bradford

Far reaching implications for society Far reaching implications for society If addicts present to the BRI it may be a If addicts present to the BRI it may be a

good opportunity to introduce them to drug good opportunity to introduce them to drug services in Bradfordservices in Bradford

Potential to initiate a withdrawal programPotential to initiate a withdrawal program