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Guest khuram

Junkie

22 posts in this topic

Heroin addict demands methadone at early morning in A&E ---- OR will commit suicide.

Last dose was 12 hours ago.

Will you admit him in your unit?

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Not bloody likely! Get him liifted by the police. He last had methadone 12 hours ago for god's sake!

But for the sake of PMPs...

Issues to clarify with referrer:

Any immediate risk to patient or to others in the department,

What is his mental state?

Why has he presented now?

Sources of info:

A+E staff's assessment of mental state -depressed/manic/psychotic, is he intoxicated, is he appearing to be withdrawing? Did he get his morning dose of methadone? If not why? Any other medical risks to be aware of from notes? Anyone with him? Why suicidal? Will he remain in dept to speak to a psychiatrist? If not consider emergancy detention to allow assessment by psych. If will stay then chase notes/GP/drug worker/local drug service/chemist's if possible (although out of hours may not be possible). Check for previous psych illness and level of substance misuse, current regime for reduction/maintenance, any recent drug screens? Check for any forensic hx/hx of violence.

Go and see patient ensuring safety to yourself, ask security to be involved if any hostility. Take history and assess reasons and precipitants to presentation. Check when he says he last got methadone. Ask about recent drug and alcohol use, mood, sleep, etc. Ask about suicidality and conduct risk assessment, ask about previous self harm attempts and degree of planning involved in this threat. Ask about harm to others. Assess mental state and try to rule out psychosis, affective disorder, anxiety. Request physical ix: bloods FBC, U+E, LFT, haematinics, request urine drug screen. Breathalyse if suspicious of alcohol intoxication. Obtain any corroborative history if accommpanied to department by any one, with his consent.

Diff dx:

Missed methadone and withdrawing

Acute intoxication

Depressive illness

Acute stress reaction

Psychosis

Organic??? - infection, encephalopathy, head injury, but unlikely

Management:

Depends on situation. If depressive illness apparent then would consider offering admission for treatment with antidepressant and psychological input, at same time as restabilizing on methadone reduction regime, involving outreach CPN, drugs worker, etc.

If no apparent mental illness, and no medical concerns then discharge. Advise that he should attend to get his methadone from his local chemist's in a few hours when it opens. If further problems or if refusing to leave the department then contact police and ask for their assistance in removing the gentleman.

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good chris

i think u didnt mention youd look for signs of methadone withdrawal features.? or did u?

hate those ones!

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Hell, if it'll get me a job after August then why not?   :lol:

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Few points:

- According to the text, the man is a 'heroin addict'. Don't assume he's on a methadone programme

- This man is likely to be withdrawing from heroin, because of the short half life of the drug. Methadone has a longer half life (wouldn't have withdrawal symptoms 12 hours after his last dose)

- Mention withdrawal from opiates may be very uncomfortable, but not life threatening

- Which one is this man's stage of change? Is he asking for methadone just to fix him until he gets more heroin in the morning? Or does he want to enter detox/methadone maintenance programme? Consider refering to substance misuse team (if he's willing).

- Would it be appropriate to start him on a detox programme there and then?

- This man is threatening suicide if methadone is not given. What would happen if you didn't give him methadone and he harmed himself or even killed himself? Whose responsibility is it? What's the risk that he'll kill himself? Would the risk change if he was intoxicated with alcohol? Is that enough reason to admit him to hospital?

- Is he likely to attack you/staff/premisses if you refuse to give methadone? How can you minimize this?

- What are the social circumstances of this man? Does he have a house, a job, family...? How does he finance his drug habit? (all this many not be so relevant in this case, but worth keeping in mind)

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would u give him codeine? in case thats a probe and there are signs of heroin withdrawal and hes got no money for a fix.

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I think dicussions are excellent.

but if this patient is found to be of high risk of harming himself,but no underlying mental illness would we condider using mental health act.......(I am aware we have to bring in consultants & and possibly trust legal advisor,unlikely to be available early in the morning)

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. Heroin withdrawal is not life threatening.

. I would have to consider the pros and cons of codeine prescribing. On one hand, it may calm him down sufficiently to leave A+E without causing any more problems. However, this would be a means to avoid aggression rather than treating the individual.

. Giving codeine may reward his aggressive behaviour (if pressed hard enough, you'll get something), and this would encourage the drug user to come back to A+E for drugs (operant conditioning).

If at all possible, I would avoid prescribing any drugs.

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but if this patient is found to be of high risk of harming himself,but no underlying mental illness   would we condider using mental health act

The Mental Health Act can be used if the individual has a mental disorder as defined by the Act. This is something that needs assessed.

Self harm does not necessarily equal mental illness/disorder.

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I agree that mental health act has to be used to treat mental disorder.but if the risk is high how to deal with the situation

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Questions related:

1. Probably the role of us here is liasion psychiatrist. Should we suggest for further observation of patient's physical withdrawal status at

- psychiatric ICU (under MHA section 2) or

- A+E observation ward or

- acute medical ward?

2. What sources we can assess at 2am in the morning (usually the scenario sets like this).

I thought of past medical / psychiatric notes may be immediately accessible. What others?

3. Just want to ask methadone control at A+E setting in UK. Is that available? At what circumstances it would be prescribed?

4. I think Chris' formulation is nearly perfect, just add other monetary / social gains may got from methadone re-selling and (suppose Chris knows) a list of physical withdrawal; and other (poly)drug +/- EOH abuse is great.

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This man is threatening suicide if methadone is not given. What would happen if you didn't give him methadone and he harmed himself or even killed himself? Whose responsibility is it? What's the risk that he'll kill himself? Would the risk change if he was intoxicated with alcohol? Is that enough reason to admit him to hospital?

If he chose to harm or kill himself then it's absolutely nothing to do with me. If he does not have a mental illness, and choses to act in a self destructive way then he will have to accept the responsibility for his actions. The risk would not change if he was intoxicated with alcohol (in the same way that if you commit a crime while intoxicated you still go to jail), but it would make assessment more difficult. I would be reluctant to admit this man to hospital.

To use the MHA then he needs to have a mental illness. I don't think he would be detainable.

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i think in this pmp they want to know your abilities to deal with manipulative behaviour

and i do,nt know how can you provide him methadone in a&e. you should have the courage to say that it could possibly be manipulative behaviour and by going with his wishes i may do more harm except if there are s/s of some psychiatric illness

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How about just talking about admission in terms of physical withdrawal?

(Of course it is obvious that this PMP is handling a manipulative case)

I know that opioid withdrawal don't kill but patient may feel somatic discomfort and agitate. Is that okay to have in-hospital observation for his physical state?

And I think it would be less argumentative for alcohol / BZD withdrawal for the possible lethal consequence of withdrawal.

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This man is threatening suicide if methadone is not given. What would happen if you didn't give him methadone and he harmed himself or even killed himself? Whose responsibility is it? What's the risk that he'll kill himself? Would the risk change if he was intoxicated with alcohol? Is that enough reason to admit him to hospital?

If he chose to harm or kill himself then it's absolutely nothing to do with me. If he does not have a mental illness, and choses to act in a self destructive way then he will have to accept the responsibility for his actions. The risk would not change if he was intoxicated with alcohol (in the same way that if you commit a crime while intoxicated you still go to jail), but it would make assessment more difficult. I would be reluctant to admit this man to hospital.

To use the MHA then he needs to have a mental illness. I don't think he would be detainable.

That's my view too

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How about just talking about admission in terms of physical withdrawal?

Would you admit somebody to a psychiatric ward because of physical withdrawal? I can't see how you can justify this.

If there are physical concerns and his mental state is stable, I'd pass him back to the A+E team.

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I think in this situation establishing opoid dependence is reqd. - urine drug screen and objective s/s of withdrawal. If this man is genuinely withdrawing at that hour of the night we have to do something about it - either give methadone mixture if available in a&e or give buprenorphine or prescribe something symptomatic or lofexidine and along with that he does not have any mental illness then just follow up his case in the morning either with his gp or the specialist subs abuse team or his key worker who are prescribing him methadone to titrate his dose against withdrawal to prevent his future appearances in a&e demanding this stuff.

If on assessment he does have mental illness and suicidal - then admit informal or formal.

If urine drug screen negative and no objective sign of withdrawal - then we can refuse opioids on grounds of making him opioid toxic and offer to treat him symptomatically.

If despite him being negative for opioids and no mental illness at that assessment but suicidal - still offer to admit him because of that - safe for pmp purpose to err on the side of caution

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ive turned away lots of heroin addicts pretending to be suicidal.

in a/e

when they got aggressive hospital security thru them out.

sometimes the royal college need a reality check.

idiots

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if this patient was distressed with his wiothdrawal symptoms persoanlly i think it would be wrong to  send him away with out a bit of codeine a  referral to the drug and alcohol team.

'do no harm' comes to mind

sending away a distressed junkie is wrong.

so mr examiner  put that in your pipe and smoke it.

saying hes suicidal might be his only way if getting attention and his needs met.

who knows

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