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Case Presentation Claire Morbey. Jennifer 17 year old presented to A+E 17 year old presented to A+E PC: 1/52 h/o fevers 3/7 h/o haemoptysis PC: 1/52 h/o.

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Presentation on theme: "Case Presentation Claire Morbey. Jennifer 17 year old presented to A+E 17 year old presented to A+E PC: 1/52 h/o fevers 3/7 h/o haemoptysis PC: 1/52 h/o."— Presentation transcript:

1 Case Presentation Claire Morbey

2 Jennifer 17 year old presented to A+E 17 year old presented to A+E PC: 1/52 h/o fevers 3/7 h/o haemoptysis PC: 1/52 h/o fevers 3/7 h/o haemoptysis O/E: Febrile - temp 40 o C O/E: Febrile - temp 40 o C CXR + bloods unremarkable CXR + bloods unremarkable Recalled as cultures grew Staph. aureus in both bottles Recalled as cultures grew Staph. aureus in both bottles

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

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

5 Jennifer 2/7 later disappeared from the ward 2/7 later disappeared from the ward Returned the next day Returned the next day Repeating pattern over the course of several days 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 Opiate –Juice of opium poppy –Papaver somniferum

9 Opioid 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 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) Smoked (Chasing the dragon) Sniffed Sniffed Injected Injected PR (black tar) PR (black tar)

12 Average use 0.25-2g per day 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 Cost has more than halved in last 15 years £20 buys a wrap == ½ g £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 1985 in Bradford –20-350 BRI 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 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 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 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 Mortality risk 12 times greater than the general population Injectors 22 times more likely to die Injectors 22 times more likely to die Importance of drug treatment services has been increasingly recognised as evidence of their effectiveness has grown 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 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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21 Where do we fit in at the BRI?

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

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

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26 Signs and Symptoms of Opiate Withdrawal Course: Course: –Heroin »Onset 8-12 hours »Lasts 5-10 days –Methadone » Onset 24-48 hours »Lasts 2-4 weeks

27 First 24 hours Grade 1 Grade 1 –Restlessness –Lacrimation –Rhinorrhea –Yawning –Diaphoresis –Goose flesh cold turkey

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

29 Grade 3 Grade 3 –Tachycardia –Hypertension –Tachypnea –Fever –Anorexia –Nausea –Extreme restlessness

30 Grade 4 Grade 4 –Diarrhoea –Vomiting –Severe sneezing –Dehydration –Hyperglycaemia –hypotension

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

32 Doses Grade 1 5mg Grade 2 10mg Grade 3 15mg Grade 4 20mg

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

34 Non-Opiate Treatment Lofexidine 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

35 Clonidine Clonidine –Not licensed –Widely used, esp in USA –Anti hypertensive

36 Other drugs used to alleviate symptoms NSAIDS NSAIDS –Ibuprofen »Muscular pains and headaches Paracetamol Paracetamol »Pyrexia Metoclopramide Metoclopramide »Nausea and vomiting Loperamide Loperamide »Diarrhoea Gaviscon Gaviscon »Stomach upset

37 Longer term Naltrexone Naltrexone –Opiate antagonist –Prevents relapses in abstinant/drug free for 7-10 days

38 Conclusion Heroin abuse is a serious and growing problem in Bradford Heroin abuse is a serious and growing problem in Bradford Far reaching implications for society 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 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 Potential to initiate a withdrawal program

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