Tom Heaps Consultant Acute Physician Clinical Case 1 23yearold female Heroin addiction for 2 years Presents to ED with Rigors Fever 392C Headache Abdominal pain Started on IV Tazocin ID: 934075
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Slide1
Opioid-Dependence and Intravenous Drug Abuse
Tom Heaps
Consultant Acute Physician
Slide2Clinical Case 123-year-old femaleHeroin addiction for 2 yearsPresents to ED with:Rigors
Fever 39.2CHeadacheAbdominal painStarted on IV
Tazocin
® and referred to AMU
Slide3Investigations?MSUCXRBlood culturesWound swabsSputum cultureStool culture
HIV and Hepatitis Serology
Slide4Differentials?Skin & Bone InfectionsCellulitisAbscessesInfected ulcersThrombophlebitisOsteomyelitis
Septic arthritisOther Infections
Aspiration pneumonia
TB
Dental abscess
STIs
Blood-Borne Infections
HIV
Hepatitis B and C
Bacteraemia
Infective Endocarditis
Tetanus
Anthrax
Septic thrombosis / emboli
False / mycotic aneurysms
Common Infections
Slide5Clinical Case 1 cont.Onset of symptoms 5 minutes after last injectingDraws up heroin through cotton wool ‘filter’8h after admissiona
pyrexialasymptomatic wants to be discharged
Diagnosis?
Slide6‘Cotton Fever’Use of cotton-wool as a ‘filter’ to draw up heroinSymptom onset <2
0min after injection:Chills
High fever
Abdominal pain
Headache
Muscle aches
Endotoxin from Gram –
ve
rod
E.
agglomerans
which colonizes cotton plants
Raised WCC, no localizing signs of infection
Blood cultures usually negativeComplete resolution of symptoms <12hSymptomatic treatment
Slide7Clinical Case 240-year-old male ‘ex-IVDU’Admitted to AMU at 02:00 with pneumoniaStates he normally takes methadone 50mg ODWants this
prescribing…..NOW!No signs of opioid withdrawal
Slide8How should you proceed?Ask who normally provides their OST (Opiate Substitution Therapy)
Contact Dispensing Chemist / cSMS / (GP) to confirm:
Drug / formulation / dose / frequency
Supervised (witnessed) or unsupervised?
Date / time of last dispensing
And suspend community dispensing whilst in hospital
Document
conversation, names, contact details in notes
Continue
to prescribe usual OST
50% of dose initially if unsupervised in community
remaining 50% after 8h if no adverse clinical signs
Involve
cSMS / hSMP (Sam Adaway) as soon as possible
Slide9OST (Opiate Substitution Therapy)Methadone
Full agonist at μ receptors
1mg/mL SF liquid
30-180mg daily
Half-life 24-36h
‘clouding’ effect preferred by some
Risk of overdose / heroin use ‘on-top’
Drug interactions (CYP450)
QTc
prolongation
More suitable for heavy heroin users
Cheaper
Subutex
® (Buprenorphine)
Partial agonist at
μ
,
antagonist at
κ
receptors
SL tablets 0.4, 2 and 8mg
8-32mg daily
Half-life 36-48h —may be given alt. daily
‘clear head’ effect
Less risk of OD and safer if risk of heroin use ‘on-top’
Easier to withdraw from quickly
May cause precipitated withdrawal
Risk of diversion to IV (use
Suboxone
®)
5x more expensive than methadone
Slide10How should you proceed if unable to confirm OST or not normally on OST?Take history of drug useConfirm recent use with urinary drug screen if
availableOpiate withdrawal is distressing/unpleasant but is not
a life-threatening emergency (exception = pregnancy)
Wait
up to
24h and assess for symptoms of withdrawal
within
4-6h of last heroin use
>24h
after last methadone use
Use
COWS
Slide11Symptoms of Opiate WithdrawalNausea & vomitingStomach cramps / diarrhoea
Anxiety / irritabilityRestlessness / insomnia
Muscular and joint
pain
Tremor
Lacrimation
Rhinorrhoea (runny nose)
Sneezing
/
yawning
Sweating
/ flushing
Piloerection (
‘
goose bumps’)
Dilated pupils
Slide12COWS (Clinical Opiate Withdrawal Scale)
Slide13COWS <5 → Symptomatic ReliefStomach cramps: mebeverine
/ buscopan
Diarrhoea:
loperamide
Headache / muscle pains:
paracetamol / NSAIDs
Nausea / vomiting:
metoclopramide /
prochlorperazine
Agitation / insomnia:
diazepam /
zopiclone
Slide14COWS ≥5 → start OSTDay 1:
Methadone 10-20mg depending on COWSReassess after 4-6h and give ONE further dose of methadone according to repeat COWS
Day 2 onwards:
give total dose of methadone administered on day 1 as a
single dose
Involve
hSMP
/
cSMS
as soon as possible
Titrate dose by 5-10mg daily depending on response
DO NOT exceed 50mg / day
without expert advice
Observe for signs of cumulative toxicity (steady state ~5d)
Slide15DischargeLiaise with hSMP / cSMS 24h prior to dischargeContact Dispensing Chemist to reinstate script / dispensing (if taking OST prior to admission)
DO NOT prescribe methadone / buprenorphine or symptomatic relief on TTO
unless specifically advised to do so by
hSMP
/
cSMS
Slide16Clinical Case 336-year-old female ‘ex-IVDU’Confirmed OST (methadone 30mg)Admitted to AMU with seizure and fractured olecranonReports significant elbow pain despite regular paracetamol
Slide17How should you proceed?Limit analgesia to non-opioids (paracetamol, NSAIDs) due to risk of ‘relapse’ with opioids?
Do nothing because she is already taking methadone and is probably ‘drug seeking’?
Prescribe opioid analgesia (titrated to pain) if non-opioid analgesia fails to control pain
?
Increase
her dose of methadone to provide additional analgesia?
Slide18Pain & Opioid-Dependence → Common Misconceptions
OST provides analgesiaduration of analgesic action usually 4-8h
t
olerance
o
pioid-induced hyperalgesia (NMDAR
agonism
)
Use of opiate analgesia risks addiction relapse
i
nadequate pain control more likely to trigger relapse
O
piate analgesia with OST causes respiratory / CNS depression
t
olerance to CNS and respiratory depressionReports of pain are usually manipulative ‘drug-seeking’ behaviour
Slide19Analgesia in patients on methadoneUse non-opioid analgesia (e.g. paracetamol, NSAIDs) firstIf pain not controlled prescribe opiate analgesia and titrate to pain
More frequent and higher doses of opiate analgesia are often required (cross-tolerance)
Consider dividing total daily dose of methadone into 6-8h (TDS-QDS) dosing
DO NOT increase methadone dose to provide
analagesia
Slide20Analgesia in patients on buprenorphineUse non-opioid analgesia (e.g. paracetamol, NSAIDs) firstOpiate analgesia likely to be ineffective
partial agonist with high affinity for μ
receptors
Tramadol may have some analgesic effect
c
onsider increasing total daily buprenorphine dose and/or dividing dose into 6-8h dosing
convert to short-acting opiates or to methadone plus opiate analgesia for duration of hospital admission – expert advice
Seek advice from Acute Pain Team
Slide21Key Learning PointsWide differential for fever in IVDUs
Screen for blood-borne viruses; blood cultures are mandatory
Opioid withdrawa
l is rarely life-threatening
Take time to confirm OST prescription or assess for signs of withdrawal
Risks
of initiating
OST must be balanced against risks of
self-discharge
Liaise with Dispensing Chemist,
hSMP
,
cSMS
, ward pharmacist
Opioid analgesia should not be withheld from patients with opiate-dependenceHigher / more frequent doses often required