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Case Presentation Claire Morbey

Case Presentation Claire Morbey. Jennifer. 17 year old presented to A+E PC: 1/52 h/o fevers 3/7 h/o haemoptysis O/E: Febrile - temp 40 o C CXR + bloods unremarkable Recalled as cultures grew Staph. aureus in both bottles. Admitted for investigation Echocardiogram Bone scan

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Case Presentation Claire Morbey

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  1. Case PresentationClaire Morbey

  2. Jennifer • 17 year old presented to A+E • 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

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

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

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

  6. What part of the history have I missed?

  7. Heroin Aka….horse, brown,china white, smack, gear,H, junk,skag,dragon

  8. Opiate • Juice of opium poppy • Papaver somniferum

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

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

  11. Methods of Use • Smoked (Chasing the dragon) • Sniffed • Injected • PR (black tar)

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

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

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

  15. 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

  16. Why is Drug Abuse Important to Us?

  17. 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

  18. As Part of the Medical Profession? • 1985-1995 saw a marked increase in drug related deaths among young people aged 15-19 • Mortality risk12 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

  19. 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

  20. Where do we fit in at the BRI?

  21. 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”

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

  23. 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

  24. First 24 hours • Grade 1 • Restlessness • Lacrimation • Rhinorrhea • Yawning • Diaphoresis • Goose flesh “cold turkey”

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

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

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

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

  29. Doses

  30. 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

  31. 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

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

  33. Other drugs used to alleviate symptoms • NSAIDS • Ibuprofen • Muscular pains and headaches • Paracetamol • Pyrexia • Metoclopramide • Nausea and vomiting • Loperamide • Diarrhoea • Gaviscon • Stomach upset

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

  35. 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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