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pinkshoes

Heroin wihtdrawal/methadone demands

18 posts in this topic

Hello fellow gluttons for punishment. After looking thro Slarty's amazing PMP collection, I have noticed that quite a few PMPs seem to have come up regarding substance misuse and I am particularly stuck with the following....

'26-yr-old heroin addict turns up at casualty at 2am, saying he's suicidal. Last fix was 12 hours ago. Says he will kill himself, if he doesn't get what he wants. Assess and manage. '

I know what I want to say but fear it would cause me a fail...! Aside form approaching  this in terms of finding out what he wants etc etc, what would people do when it comes to the crunch?

And why am I even worrying about this when the written results aren't out yet?

Thanks for your help....  :-?

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Key issues

1. The guys substance use... opiate withdrawal and dependence - assessment and management - including which phase of Prochaska's cycle he is in... I would guess he is in precontemplation... or he may actually be getting methadone, but topping up... which again means he is in precont stage.

2. Comorbid Axis I - Other substance use; Depression; psychosis; anxiety disorders - assess and manage

3. Comorbid Axis II - ASPD/ Borderline - assess and manage

4. Risk of self harm/ suicide - assess and manage

Immediate issues

Get as much h/o as possible - Notes/Treating Psychiatrist/GP/Family/Staff/Carecoordinator

'He will kill himself if he does not get what he wants.'

[highlight]Acknowledge that suicide is a recognised cause of mortality in Opioid use

At the same time, it is recognised that people come in crisis to obtain methadone/ feign symptoms/ manipulate...[/highlight]

So what does he want?

If he wants a fix to get high, he has come to the wrong place obviously...

If he wants to get rid of his withdrawals... and if he has severe withdrawals... then offer medical admission for management of withdrawals... in liaison with medics (most people will be willing to admit him if we say that we will follow him up in the morning with a plan)

We are not allowed to offer detox in emergency setting according to NICE...

the patient has to be referred to a DAT

About suicidal ideation...  management wiil depend on history of risk...

if it is related to the substance use... I will tell him that I cud offer to help him with withdrawal, but the management with methadone can be done only after consultation with the DAT... and that wud happen only in the morning (if it not a weekend)

If the suicidal ideation is secondary to another axis 1... then consider crisis team support/ admission/ section etc... in view of managing the axis 1 and the suicidal ideation

Long term

Management of everything axis 1, axis 2 etc

[highlight]

'I know what I want to say but fear it would cause me a fail...!'[/highlight]

Thats interesting... because if I dont say anything... I fail anyway... and the fact that we dont stop living for fear of death do we???  :)  ::)

I may fail with the above answer... but I can handle it ::) :'( :'( :'( :'( :'( :-X

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Hello fellow gluttons for punishment. After looking thro Slarty's amazing PMP collection, I have noticed that quite a few PMPs seem to have come up regarding substance misuse and I am particularly stuck with the following....

[highlight]'26-yr-old heroin addict turns up at casualty at 2am, saying he's suicidal. Last fix was 12 hours ago. Says he will kill himself, if he doesn't get what he wants. Assess and manage. '[/highlight]

I know what I want to say but fear it would cause me a fail...! Aside form approaching  this in terms of finding out what he wants etc etc, what would people do when it comes to the crunch?

And why am I even worrying about this when the written results aren't out yet?

Thanks for your help....  :-?

Issues are same what Dorian said......

1)Attend quickly and talk to the doctor and nurses to get a feel of the situation

2)Find out if previoue contact and review past few discharge summaries

3)Review if blood inv/physical/urine have been done so far since arrival

4)Ensure your and patients saftey before embark on the assessment and consider a chaperone

Explore the presenting complaints of killing if does not get what he wants...is it methadone/heroin he is after

Consider the dependence criteria/ICD10

Consider psychological sx of withdrawal

Consider risk (sharing needles etc)

Now consider suicidal ideation and screen for mental health issues,especially depression/ICD10

6)Usual psych history to follow, particular reference to social/forensic

7)mental state/physical state for signs of withdrawal

8)Decide if going home (?with lorazepam) to come back in the morning for support from addiction team OR admit to treat severe withdrawal/contain suicidal risk/treat mental illness

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You guys are fabulous! I wholly agree, but get a bit stuck with the admission thing: would we admit someone with opiate withdrawal? i am thinking not... the only reason would be it it were life threatening that he would be admitted to a medical ward, and this isn't. It could be life threatening from a suicide point of view, but my worry is that how do we conduct a proper MSE if he is withdrawing? And in the reality of home treatment teams, there is , in my experience, no way that he would get an admission or crisis support.... Anyway, I guess PMPs are all about exploring the issues and thinking laterally- I just don't know what I'd say if the examiners were forcing me to say admit or not....

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Pinkshoes, it is going to boil down to his suicidal intention. If he is depressed, hopeless, homeless, actively suicidal (esp if has taken recent deliberate ODs which may undisclosed), I'd admit. If he's in withdrawal and has come for a bed or a free fix, he goes back to wherever he came from to make his choice about his lifestyle with advice about how to obtain treatment (or a referral by yourself to substance misuse depending on area guidelines). For detox he needs proper assessment and preparation, ie in a new patient clinic. Substance misuse has a statutory obligation to treat drug users within 3 weeks of them requesting treatment, so it is really fast, but a complete waste of time and money if they are not ready.

I wouldn't want to damage my relationship with the medics by suggesting they admit someone in opiate withdrawal. It's unpleasant, but not dangerous.

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when we find it hard to make crisis teams accept substance misusers who r suicidal- I wonder how many medics would be happy to take him on really.

but otherwise I agree with most of what dorian and Ros say. Don't, however give Methadone to this chap under any circumstance- no matter what he says- whether it was stolen from his bag or his dog drank it. There is no way of confirming whether he is on Methadone.

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If the fellow is in severe withdrawal, as in shitting all over the place... he may need to be admitted and rehydrated... only in that case medical admission...

In PMPs, I think we have to think of ideal situations... where we have access to almost everything including medical cooperation...

In reality we know it is going to be dead difficult... but I think in the PMP we need to mention those...

Any thots?????

Sands... Post exam thots???

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You may need a reason for not giving Methadone in A&E and here is one for you.(not necceserily just for the exam)

Methadone is not a treatment for addiction- it is only an aid that provides the patient with space to address his problem via PSYCHOLOGICAL intervention. Withdrawing, shaking, going out to find a dealer, the gear to inject etc and then a few hours later the same circle again) does not allow for meaningful work with even the most committed keyworker.

What makes NHS different for from a dealer is providing this 'space' in addition to the 'real' treatment, rather than giving a drug alone. As Methadone is a long-acting substance that cumulates in the body, it requires supervised titration. The patient needs to be seen daily, or twice daily if two doses are planned. Therefore treatment needs to take place in specialist unit rather than ad-hoc in A&E. A key worker needs to be available for a longer treatment. One dose in A&E will not treat the patient and what's more will not help pt access treatment (what for if he can get a one-off freebie as soon as he runs out of cash).

Also giving one-off Methadone we might in fact increase the risk- say the pt meets a 'friend' on the way from A&E and they score together on-top etc.

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I guess most aspects arecovered in your discussion but please dont forget symptomatic management.

Mebeverine for abdominal cramps

Loperamide for diarrhoea

Diclofenac for pain

Insomnia is another withdrawal symptom which might need addressing with Zopiclone.

Be very wary about using prochaska's cycle of change in this case, might make the examiners uneasy.

It will make you look very practical if u can add these points. They repeatedly ask you about methadone and you can add these points.

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The pregnant woman, 18 weeks if I remember correctly, heroin user wanting detox/stabilisation- another college favourite.

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[be very wary about using prochaska's cycle of change]

What do u mean by prochaska's cycle of change???

 

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I meant to say that an emergency at 2 pm would not warrant an assessment of the cycle of change, that all. I am sure most of you chaps and chappies wouldnt do that but just to warn u lot.

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I meant to say that an emergency at 2 pm would not warrant an assessment of the cycle of change, that all.

Agree with that bit- whatever the stage he is in all one can do in A and E is signpost him to DAT.

dorian- yes PMP is discussing about ideal situation, which should also be realistic. while all the points u have discussed r very comprehensive- some of that u would never do in A and E situation . The PMP gives a hint- a chap who is demanding Methadone, or he would kill himself( in other words he is blackmailing u)- and while u do have to mention things like assessing mental state for suicidality, I am sure the examiners would want to know what u would do with regard to mehadone- would u agree to give him some or not.

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Alright.. I get your point Sands...

Adding to the whole thing... NICE guidelines do not recommend detox anyway in the A and E... leave alone decide on maintainence treatment...

12.2.1 Opioid detoxification should not be routinely offered to people:

• with a medical condition needing urgent treatment

• [highlight]in police custody[/highlight], or serving a short prison sentence or a short period of remand; consideration should be given to treating opioid withdrawal symptoms with opioid agonist medication

who have presented to an acute or emergency setting; [highlight]the primary emergency problem should be addressed and opioid withdrawal symptoms treated[/highlight], with referral to further drug services as appropriate.

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The pregnant woman, 18 weeks if I remember correctly, heroin user wanting detox/stabilisation- another college favourite.

This question has an answer in superegocafe, search.

kc24

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Really useful discussion. I think the point about symtpomatic treatment is really important too- will I be able to remember to think so laterally on the day??? Hope everyone got on ok with the results...

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