Drug addiction

Background

People with drug problems are entitled to the same medical and psychiatric care as other patients. Addicts are frequently admitted to hospital with physical or psychiatric complications of the drug use, and this can be a turning point in their drug using career. The key to avoiding problems with these patients is to treat effectively with a firm, fair and empathic approach within clearly defined boundaries which are known to both patient and staff.

Methadone is never to be given in the Emergency Department.

Take a drug history

• Ask at least one question about each type of drug
• How it is used (e.g. smoked, IV), how often, how long for, what amount, what form, minimum needed to feel OK, how much spent, how money raised, why used and any factors affecting its use and increasing the dangerousness of use (e.g. polydrug use)
• Determine if dependent on the drug, either physical dependence or the full dependence syndrome (ICD-10)
• Note previous attempts at detoxification and why relapse occurred
• Ask about suicidal ideation, accidental and deliberate overdoses
• Ask about physical health including HIV/Hep C risk behaviour, amenorrhoea, libido and symptoms of possible liver disease (nausea, vomiting, anorexia and dark urine). 
• Ask about alcohol, benzodiazepines, chlormethiazole and barbiturates because of the risk of withdrawal fits and delirium tremens, and of respiratory depression in overdose

Mental state examination

Include:

• Observe for changes or fluctuations in conscious state including intoxication, "nodding" or "gauching out" (intermittent inattention or sedation lasting a few seconds or minutes, often associated with slight closing of the eyelids or the head dropping forwards)
• Scratching due to opiates (as a result of histamine release) or the feeling that insects are crawling under the skin due to stimulants, alcohol or cannabis withdrawal
• Changes in activity level or sleep/wake cycle, especially affected by stimulants and depressants including opiates
• Mood changes: High mood during intoxication (especially with stimulants) and low mood during withdrawal (especially with the stimulants). Anxiety or panic attacks may occur with stimulants, hallucinogens and cannabis
• Paranoid ideation/behaviour or psychosis with stimulants, hallucinogens and high dose use of cannabis. It does not occur with benzodiazepine or opiate intoxication or withdrawal

Physical examination

Include

• Pulse (tachycardia with stimulants and withdrawal from alcohol/opiates/bnz)
• Heart (for endocarditis)
• Lungs (asthma, bronchitis)
• Abdomen (liver, constipation)
• Teeth (dental caries) 
• Pupils (affected by opiates, stimulants, hallucinogens, lighting, arousal, anoxia)
• Look at the limbs for abscesses and miss hits, injection sites, and needle tracks

Assessment of Opiate Withdrawal

Objective signs (not subjective symptoms) of opiate withdrawal (see table below) should be used to determine whether to give more opiate such as methadone or buprenorphine during the opiate titration process.

Severity of Objective Opiate Withdrawal *

Signs	Absent or Normal	Mild / Moderate	Severe
Eyes watering	Absent	Eyes Watering	Eyes streaming
Runny nose	Absent	Sniffing	Profuse secretions
Agitation	Absent	Fidgeting	Cannot remain seated
Perspiration	Absent	Clammy skin	Beads of sweat
Goosebumps	Absent	Barely palpable hairs on end	Readily palpable & visible
Pulse rate	< 80	80 - 100	> 100
Vomiting	Absent	Absent	Present
Shivering	Absent	Absent	Present
Yawning (over 10 mins)	Absent	3 - 5	> 5
Dilated pupils	< 3mm	Dilated 4 - 6mm	> 6 mm
*Other objective signs can include raised BP, pallor, sneezing, diarrhoea, leg cramps and stomach cramps

Course of acute opiate withdrawal

Withdrawal symptoms after the last opiate use

• Begins at 8-18 hrs for heroin and 24-72 hrs for methadone
• Peaks at 24-36 hrs for heroin and 36-72 hrs for methadone
• Subsides at 5-10 days for heroin and 2-3 weeks for methadone

Common clinical problems

Benzodiazepine prescribing in addicts:

Avoid in those with a past history of addiction problems, as this population is unusually prone to become dependent on them (unless such treatment is clinically indicated).

HIV and Hepatitis C testing:

Screening should only be performed with the patient's consent, and involves pre and post test counselling. The counselling and testing should be complete in a clinic setting rather than the Emergency Dept. Many drug users are afraid of HIV or hepatitis C when they become ill, and want the reassurance of a negative test result. Be aware that Hep C (present in 50-75% injecting drug users) is much more infectious than HIV (present in 1% of injecting drug users), and therefore great caution must be exercised when taking blood.

Treatment of the pregnant opiate user:

Opiate withdrawal may induce abortion before 14 weeks and premature labour or foetal distress after 32 weeks.

Continuation of medication for drug/alcohol users by GP's after discharge from hospital:

Some GPs refuse to prescribe methadone, naltrexone, lofexidine, acamprosate or other addiction medications. Others do not feel it is their job to treat drug addicts. In order to maintain a good relationship with GPs, it is important to politely ask them if they are willing to continue the prescription following discharge if that is what may be required. If the GP is not willing, discuss the case with the specialist drug and alcohol services (contact details below). At times it may be better not to initiate the prescription in hospital in that patient.