Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
DRUG MISUSE IN THE EMERGENCY CLINIC March 2016 Appreciate dynamic nature of recreational drug scene and rapid emergence of new psychoactive medications Appreciate the need to remain up-to-date with merging patterns Recognise that most cases require support and symptomatic care Be aware of available antidotes and indications for use Recognise the importance of asking all patients about substance use Recognise the attendance at ED provides opportunities for brief intervention and health promotion advice Be aware if of available local addiction services to signpost individuals Recreational drug use is the use of any psychoactive drug for pleasure These include: Traditional illicit drugs e.g. cannabis, cocaine, ecstasy (MDMA), amphetamine Plants with psychoactive properties e.g. khat, psilocybin mushrooms Novel psychoactive substances (NPS) (legal highs) are analogues of and mimic the effects of e.g. stimulants like cocaine and MDMA but are not safe. This poses considerable challenges to ED are limited data on health risks are available 13,917 hospital admissions (not including all Emergency Department episodes) coded with a primary diagnosis of recreational drug toxicity (HSCIC 2014). 7,104 admissions to hospital with a primary diagnosis of a drug-related mental health and behavioural disorder (HSCIC 2014). 2,248 deaths attributed to drugs controlled by the Misuse of Drugs Act 1971, in 2014 for England and Wales. (ONS 2015) Acute toxicity Injuries Psychiatric complications Withdrawal Show geographical variability due to trends and availability Young people reporting problems with NPS tend to present at acute service such as ED departments. Acute intoxication: signs and symptoms dependent on the drug Main groups are depressants or stimulants Often little or no history is available Important to gather as much information as possible Usually from the paramedics Detailed advice is available form the National Poisons Information Service by telephone or password for online access Heroin, methadone, oxycodone, codeine, dihydrocodeine Opiates are powerful analgesics and used in medical practice for this Prone to misuse due to euphoric and addictive properties Excess opiate exposure by oral ingestion, inhalation, intravenous/intramuscular and transdermal routes ED attendance as result of: respiratory depression, coma, collapse Deep vein thrombosis, blood borne viruses, accidental arterial puncture, withdrawal syndrome Failure to treat and recognise toxicity can lead to death from respiratory depression Naloxone is an opiate receptor antagonist Short half life of 1.5 hours so risks relapse of opiate toxicity Indications for use includes respiratory depression Naloxone should be titrated to response as it may trigger acute withdrawal in opiate dependent patients Naloxone should be administered intravenously if possible Can also be administered intramuscularly but difficult to titrate a response Patients should be observed and monitored, & may need an infusion Significant risk of overdose due to small amounts required for intended effect ie euphoria and relaxation The difference between intended effect and overdose is very little eg 0.5.mls Overdose results in collapse, respiratory depression & possible arrest Risk increased with alcohol and other depressants Severe toxicity leads to coma, respiratory arrest, seizures, death if supportive care ie monitoring, intubation and ventilation is not provided No antidote exists Physical dependence may develop with chronic use Withdrawal symptoms include agitation, tremor, seizures, hallucinations and psychosis High doses of benzodiazepines and intubation/ventilation may be required to manage withdrawal Sedative/hypnotic Toxicity includes drowsiness, ataxia, slurred speech, reduced consciousness Potentiation of symptoms with alcohol or other CNS depressants which may lead to vomiting and respiratory depression Severe toxicity leads to hypotension and bradycardia Patients with supra-therapeutic doses of benzodiazepines, should be considered for activated charcoal ED provides supportive care and close monitoring of respiratory rate, and intubation and ventilation if needed Flumazenil is a benzodiazepine antagonist Generally used to iatrogenic benzodiazepine overdose Its use in pre-hospital overdose is not advised unless under the expertise of the national poisons unit Flumazenil in mixed overdose may reduce seizure threshold and result in difficulties controlled fits if they occur Amphetamines, ecstasy (MDMA), cocaine, mephedrone, benzylpiperazine, novel psychoactive substances Symptoms include anxiety, palpitations, chest pain, sweating, disorientation, agitation, hallucinations, delusions, psychosis. Examination may elicit tachycardia, hypertension, hyperpyrexia, neuromuscular excitability, clonus, dilated pupils, seizures, altered GCS There is no antidote Supportive care should be initiated using ABC approach Patients may have tachycardia and hypertension: treat with benzodiazepines Patients may complain of chest pain; treat with benzodiazepines Chest pain due to coronary artery spasm, acute myocardial infarction, aortic dissection Pneumothoraces result from snorting stimulants Patients should have a 12 lead ECG and chest x-ray Temperature should be monitored, & if over 38 degrees, active cooling may be needed Serotonin syndrome may develop: hyperpyrexia, tachycardia, neuromuscular hyperactivity Limited use in ED Majority of patient should be managed symptomatically Routine toxicology identifies a limited number of substances NPS will only be tested in a specialist laboratory Results may not be immediately available so will not influence management Risk of false positives due to cross reactivity with prescribed drugs or drugs used during resucitation Does the patient have any other history including ED attendance related to substance use? Head injury: patients should be assessed according to NICE guidelines and have an CT scan if needed. On discharge they should be given written advice Self harm: enquire if patient took substance to harm themselves or to have a good time and record response Patients who admit to self harm should have a psychiatric assessment before discharge FURTHER POINTS (contd) Immunizations: tetanus status should be documented in patients with sustained cuts, lacerations, abrasions Victimization: patients may be at risk of sexual assault whilst under the influence of drugs. Ask the patient if this is a possibility Drug and other substance use history: explore patterns of drug use and gather whether they feel it is problematic. Contact local drug services if needed Airway – ensure it is clear and normal respiratory rate and pattern Breathing – what is respiratory rate and oxygen saturation; equal air entry bilaterally; any added sounds Circulation – perform 12 lead ECG; what is pulse rate and blood pressure Disability – is patient alert; is there evidence of head injury; is patient moving all 4 limbs equally; assess tone and check for clonus Exposure – check patient for other injuries, “track marks” evidence of venous punctures Glucose – check glucose Advisory Council on the Misuse of Drugs (2011). Consideration of the Novel Psychoactive Substances (‘Legal Highs’) https://www.gov.uk/government/publications/novel-psychoactive-substances-report-2011 American Academy of Clinical Toxicology; European Association of Poisons Centre and Clinical Toxiciologists. Position statement and practice guidelines on the Use of Activated Charcoal in the treatment of acute poisoning. Clinical Toxicology 1999; 37(6): 731-751 https://www.eapcct.org/publicfile.php?folder=congress&file=PS_MultipleDoseActivatedCharcoal.pdf British National Formulary (2014) BNF 67,Opiod Analgesics pp275-286 Brunt TM, van Amsterdam JG, van der Brink W.(2014) GHB,GBL and 1,4BD Addiction. Curr Pharm Des;20(25):4076-85 Buffin J, Roy A, Williams H, Winter A. Part of the Picture Lesbian Gay and Bisexual people’s alcohol and drug use in England (2012) available at: http://www.lgf.org.uk Dargan PI, Wood DM. (2013) Novel Psychoactive Substances: Classification, Pharmacology and Toxicology. Elsevier Press Department of Health (2011) A summary of the health harms of drugs www.nta.nhs.uk/uploads/healthharmsfinalv1.pdf European Association of Poisons Centres and Clinical Toxicologists http://www.eapcct.org/index.php?page=joint European Monitoring Centre for Drugs and Drug Addiction (2015) European drug report- trends and developments. http://www.emcdda.europa.eu/edr2015 Ghodse H (2010) Ghodse’s Drugs and Addictive Behaviour A Guide to Treatment. 4TH edn. Cambridge & New York: Cambridge University Press Glasgow Coma Score http://en.wikipedia.org/wiki/Glasgow_Coma_Scale Health and Social Care Information Centre Statistics (2014) Drug Misuse – England 2014 Tables 3.6a & 3.15 http://www.hscic.gov.uk/catalogue/PUB15943 Lucas A. Johnson, et al (2013) Current “Legal Highs”, The Journal of Emergency Medicine, 44 (6), 1108-1115 http://dx.doi.org/10.1016/j.jemermed.2012.09.147. National Poisons Information Service: On-line at: http://www.toxbase.org/ National Treatment Agency (2013) Falling drug use: the Impact of treatment. www.nta.nhs.uk/falling-drug-use.aspx National Treatment Agency for Substance Misuse. Drug Treatment 2012:Progress made, challenges ahead. Available at: www.nta.nhs.uk/drug-treatment-2012.aspx Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE.(2010) Goldfrank’s Toxicological Emergencies. 9th edn. McGraw-Hill Medical NICE (2014) Head injury: Triage, assessment, investigation and early management of head injury in children, young people and adults http://www.nice.org.uk/guidance/cg176 ONS (2015) Statistical bulletin: Deaths related to drug poisoning in England and Wales, 2014 registrations http://www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/england-and-wales--2014/deaths-related-to-drug-poisoning-in-england-and-wales--2014-registrations.html#tab-Deaths-related-todrug-misuse Patient.co.uk( 2014)Recreational Drugs http://www.patient.co.uk/health/recreational-drugs Public Health England (2015) Young people’s statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2014 to 31 March 2015 http://www.nta.nhs.uk/uploads/young-peoples-statistics-from-the-national-drugtreatment-monitoring-system-2014-2015.pdf Smith C D & Robert S (2014) ‘Designer drugs’: update on the management of novel psychoactive substance misuse in the acute care setting. Clinical Medicine 14 (4): 409–15 Takematsu, et al (2104) A case of acute cerebral ischemia following inhalation of a synthetic cannabinoid. Clinical Toxicology 52 (9):973-975 Wood DM, Brailsford AD, Dargan PI.(2011) Acute toxicity and withdrawal syndromes related to Gammahydroxybutyrate ( GHB) and its analogues gamma-butyrolactone (GBL) and 1,4 butanediol (1,4 BD). Drug Test Anal; 3(7-8):417-25 Wyatt J, Illingworth R, Graham C, Hogg K. (2012) Oxford Handbook of Accident and Emergency Medicine. 4th edn. Oxford University Press