Case Presentation Claire Morbey

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Case PresentationClaire Morbey
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Jennifer

• 17 year old presented to AE
• PC 1/52 h/o fevers 3/7 h/o haemoptysis
• O/E Febrile - temp 40oC
• CXR bloods unremarkable
• Recalled as cultures grew Staph. aureus in both
  bottles

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• Admitted for investigation
• Echocardiogram
• Bone scan
• Commenced on i.v. flucloxacillin

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Jennifer

• Continued to spike temp
• Echo vegetation on tricuspid valve
• Diagnosis Infective Endocarditis with septic
  emboli

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Jennifer

• 2/7 later disappeared from the ward
• Returned the next day
• Repeating pattern over the course of several days

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What part of the history have I missed?
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Heroin

• Aka.horse, brown,china white, smack, gear,H,
  junk,skag,dragon

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• Opiate
• Juice of opium poppy
• Papaver somniferum

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• Opioid
• Directly acting compound whose effects are
  stereospecifically antagonised by naloxone
• E.g. pethidine, methadone, dihydrocodeine

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• Main source of street heroin is the Golden
  Crescent countries of South West Asia
• Afghanistan
• Pakistan
• Iran

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Methods of Use

• Smoked (Chasing the dragon)
• Sniffed
• Injected
• PR (black tar)

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• Average use 0.25-2g per day
• 1g 50mg methadone
• Roughly ½ smoked
• ½ taken i.v.

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• Cost has more than halved in last 15 years
• 20 buys a wrap ½ g

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

• 1985 in Bradford
• 20-350
• BRI
• 5 week period Aug-Sept 2001, approx 874
  admissions
• 151 drug related (Ods, MODs)
• i.e. 18.4 of total

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Why is Drug Abuse Important to Us?
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As Taxpayers?

• Number of people found guilty or cautioned by
  police for drug offences rose from
• 44 922 in 1990
• To 120 007 in 1999
• Government estimates of the cost of policing and
  supporting those affected by a drug habit are put
  at 3-4 billion in 2001-2002

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As Part of the Medical Profession?

• 1985-1995 saw a marked increase in drug related
  deaths among young people aged 15-19
• Mortality risk 12 times greater than the general
  population
• Injectors 22 times more likely to die
• Importance of drug treatment services has been
  increasingly recognised as evidence of their
  effectiveness has grown

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

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

• Addicts presenting with a medical problem have a
  right to appropriate treatment without neglecting
  their addiction.
• in such circumstances it is vital that the
  doctor fulfil their responsibilities by ensuring
  adequate assessment and appropriate management
  that facilitates the retention of the patient in
  treatment

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• In the case of Jennifer, we failed to address her
  addiction and withdrawal
• We therefore failed to treat her acute medical
  problem

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Signs and Symptoms of Opiate Withdrawal

• Course
• Heroin
• Onset 8-12 hours
• Lasts 5-10 days
• Methadone
• Onset 24-48 hours
• Lasts 2-4 weeks

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First 24 hours

• Grade 1
• Restlessness
• Lacrimation
• Rhinorrhea
• Yawning
• Diaphoresis
• Goose flesh cold turkey

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Later..

• Grade 2
• Dilated pupils
• Muscle twitching and spasms
• Severe aches in the back, abdomen and legs

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• Grade 3
• Tachycardia
• Hypertension
• Tachypnea
• Fever
• Anorexia
• Nausea
• Extreme restlessness

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• Grade 4
• Diarrhoea
• Vomiting
• Severe sneezing
• Dehydration
• Hyperglycaemia
• hypotension

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Treatment Options

• Methadone
• Only give after signs of withdrawal are present
• Give b.d or tds
• Taper by 20 every other day

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Doses
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• Supplement with doses of 5-10mg if signs are not
  suppressed or reappear during first 24 hrs
• Unusual to require more than 40 mg during first
  24hrs of withdrawal

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Non-Opiate Treatment

• Lofexidine
• Fully licensed
• Alpha 2 adrenoceptor agonist
• Reduces impulses in sympathetic nervous system
• Thought that noradrenaline excess causes symptoms
  such as sweating, diarrhoea, chills
• Equally efficacious as methadone in withdrawal
• Role in those seeking abstinance

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• Clonidine
• Not licensed
• Widely used, esp in USA
• Anti hypertensive

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Other drugs used to alleviate symptoms

• NSAIDS
• Ibuprofen
• Muscular pains and headaches
• Paracetamol
• Pyrexia
• Metoclopramide
• Nausea and vomiting
• Loperamide
• Diarrhoea
• Gaviscon
• Stomach upset

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Longer term

• Naltrexone
• Opiate antagonist
• Prevents relapses in abstinant/drug free for 7-10
  days

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Conclusion

• Heroin abuse is a serious and growing problem in
  Bradford
• Far reaching implications for society
• If addicts present to the BRI it may be a good
  opportunity to introduce them to drug services in
  Bradford
• Potential to initiate a withdrawal program

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