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Module 5
Special patient groups
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Introduction
• Worldwide, the majority of people in
substitute treatment are men between 25-40
• Even they do not form a homogeneous group
• In addition, there are groups with specific
needs
• And specific settings
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Women
• Often women with severe dependence do not
menstruate. It is important that they
understand that this does not necessarily
mean that they do not ovulate
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Pregnant women
• ST improves outcome regarding pregnancy,
childbirth and infant development:
• Better overall general health of women
• Better (access to) antenatal care
• Physiological changes (accelerated
metabolism) in third trimester requires higher
dosage
• Detoxification not to be encouraged
• Breast-feeding encouraged (when HIVnegative)
• Psycho-social care recommended
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Parents with young children
• Needs of children are paramount
• Care of children to be included in treatment
plan
• Case management
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Young people
• ST not recommended under 16, because they
do not fit the general criteria of:
• Long-term dependence
• Significant tolerance
• Level of problematic use
• Buprenorphine more indicated
• Sometimes need for parental consent
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People with HIV/AIDS
• ST can:
• Reduce risk behaviours which could further
damage the immune system
• Reduce stress
• Improve general health
• Retention in treatment can allow for early
diagnosis and HIV treatment
• Liaison with specialist care
• Interaction of medications
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People with hepatitis
• Vaccination for hepatitis B for all patients
without antibodies
• Hepatitis C prevalent and serious
• Dose of substitute drug may need to be
reviewed (liver function)
• Specialised referral
• Health education regarding risk behaviour
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People with mental health problems
• 30% of patients have mental health problems,
including anxiety and depression
• 25% risk of self harm and suicide
• 10% severe mental disorders requiring
collaboration with mental health specialists
• Note age- or HIV-related dementia
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Multiple drug users
• Assess use of all substances
• Open relationship and discussion
• Risk reduction:
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Increase dose and possibly other medication
Frequency of collection
Supervised consumption
Realistic treatment goals
Suspension?
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Quick metabolisers
• Some patient demonstrate longer or shorter
half life times
• They require significantly lower or higher
dosages
• Most can be treated relying on clinical factors
• Testing blood levels can be helpful
• Various drugs or conditions can alter
substitute drug metabolism
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Minority ethnic groups
• Barriers to treatment, education and
prevention:
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lack of cultural sensitivity
distrust of confidentiality
communication problems - language
lack of awareness of services
stigma
failure to target minority ethnic drug users
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People in prison
• Treatment should be available to start and/or
continue in order to
• improve health
• reduce risk behaviour
• reduce relapse upon release
• Need to continue afterwards when returned to
the community
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People in hospital
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Recognise dependence
Assessment
Liaison with drug treatment
Continue treatment (no detoxification)
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People who travel
• Continuity of care
• Make people think about referral
• standard letter
• Communication between prescribers
• Who is responsible, the regular doctor or the
one who takes over?
• Collaboration between cities and countries
• www.home.muenster.net/-indro/
• www.euromethwork.org
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People with chronic pain
• A complex, difficult-to-treat condition
• Can persist following prolonged tissue or nerve
injury
• Opiates and opioid based medications like
morphine and methadone are used to relieve
patients with chronic pain
• The guiding principles:
• to maintain methadone treatment
• to use short-acting narcotics administered at
higher doses
• as often as necessary, preferably on a fixed
schedule
• supplemental analgesic medication, except that
opiate antagonists must be avoided.
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The aging patient
• Patients in maintenance treatment are getting
older
• Geriatric illnesses such as cardiac and
pulmonary complaints and other signs of
aging (menopause) should be taken into
consideration
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Quick metabolisers
• Some patient demonstrate longer or shorter
half life times
• They require significantly lower or higher
dosages
• Most can be treated relying on clinical factors
• Testing blood levels can be helpful
• Various drugs or conditions can alter
substitute drug metabolism
training manual
Conclusions
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Different patients have different needs
Assessment of needs
Addressing them
Liaison with specialist services