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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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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
Admitted for investigation • Echocardiogram • Bone scan • Commenced on i.v. flucloxacillin
Jennifer • Continued to spike temp • Echo: vegetation on tricuspid valve • Diagnosis: Infective Endocarditis with septic emboli
Jennifer • 2/7 later disappeared from the ward • Returned the next day • Repeating pattern over the course of several days
Heroin Aka….horse, brown,china white, smack, gear,H, junk,skag,dragon
Opiate • Juice of opium poppy • Papaver somniferum
Opioid • Directly acting compound whose effects are stereospecifically antagonised by naloxone • E.g. pethidine, methadone, dihydrocodeine
Main source of street heroin is the Golden Crescent countries of South West Asia • Afghanistan • Pakistan • Iran
Methods of Use • Smoked (Chasing the dragon) • Sniffed • Injected • PR (black tar)
Average use 0.25-2g per day • 1g = 50mg methadone • Roughly ½ smoked • ½ taken i.v.
Cost has more than halved in last 15 years • £20 buys a wrap == ½ g
Sudden influx of smokable heroin in 1980s caused a dramatic increase in use
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
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
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
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
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”
In the case of Jennifer, we failed to address her addiction and withdrawal • We therefore failed to treat her acute medical problem
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
First 24 hours • Grade 1 • Restlessness • Lacrimation • Rhinorrhea • Yawning • Diaphoresis • Goose flesh “cold turkey”
Later.. • Grade 2 • Dilated pupils • Muscle twitching and spasms • Severe aches in the back, abdomen and legs
Grade 3 • Tachycardia • Hypertension • Tachypnea • Fever • Anorexia • Nausea • Extreme restlessness
Grade 4 • Diarrhoea • Vomiting • Severe sneezing • Dehydration • Hyperglycaemia • hypotension
Treatment Options • Methadone • Only give after signs of withdrawal are present • Give b.d or tds • Taper by 20% every other day
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
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
Clonidine • Not licensed • Widely used, esp in USA • Anti hypertensive
Other drugs used to alleviate symptoms • NSAIDS • Ibuprofen • Muscular pains and headaches • Paracetamol • Pyrexia • Metoclopramide • Nausea and vomiting • Loperamide • Diarrhoea • Gaviscon • Stomach upset
Longer term • Naltrexone • Opiate antagonist • Prevents relapses in abstinant/drug free for 7-10 days
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