Download 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
