heroin - a case
Download
Report
Transcript heroin - a case
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 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
What part of the history have I
missed?
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
Why is Drug Abuse Important to
Us?
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 20012002
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
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?
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
Doses
Grade 1
5mg
Grade 2
10mg
Grade 3
15mg
Grade 4
20mg
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