Managing drug abusers in primary care involves not only treating patients who admit to their dependency but also recognising the signals in those who are reluctant to share this information. Not infrequently, you will also be approached by temporary patients attempting to obtain drugs by deception. GPs need to be alert to the following clues:
- Temporary residents just passing through the area.
- Patients with an overly familiar knowledge of the pharmacopoeia, demanding analgesia for renal colic, sickle-cell crises, etc.
- Patient giving evasive answers.
- Signs of heavy smoking, strange smoke smells (cannabis, cocaine, heroin).
- Acetone or glue smell on breath (solvent abuse).
- Small pupils (opiates).
- Needle tracks on arms, groin, legs, between toes; intravenous access difficult.
- Abscesses and lymphadenopathy in nodes draining injection sites.
- Signs of drug-associated illnesses (eg, endocarditis, AIDS, chronic viral hepatitis).
Medical conditions presenting in drug abusers
Patients may present with a variety of medical conditions but the doctor may not be aware of the history of drug dependency. The following is a list of scenarios:
- Patient found unconscious - consider narcotics, barbiturates, solvents and benzodiazepine (see also separate articles Opiate Poisoning and Coma).
- Psychosis - consider methylenedioxymethamfetamine (MDMA, or 'ecstasy'), lysergic acid diethylamide (LSD), amfetamine, anabolic steroids.
- Agitation - common with benzodiazepines.
- Asthma/dyspnoea - consider opiate-induced pulmonary oedema, asthma (may follow the smoking of heroin).
- Reduced lung density, lung cysts and chronic bronchitis - may be related to cannabis use.
- Lung abscess - may be a complication of right-sided staphylococcal endocarditis (common in intravenous drug abusers).
- Airway burns, pneumothorax, pneumomediastinum - these can all be complications of crack cocaine, due to its method of delivery.
- Fever/pyrexia of unknown origin (PUO)/shivering - may be the only sign of endocarditis.
- Shivering and headache - due to chemical/organism contamination of intravenous drug. If suspicious, outline risks and offer immediate referral to secondary care - may need blood cultures, and antibiotics - eg, gentamicin.
- Hyperpyrexia - consider 'ecstasy'; be wary of associated myoglobinuria, disseminated intravascular coagulation, renal failure.
- Abscesses - if over an injection site, then often of mixed organisms.
- Deep vein thrombosis - may result from injecting suspension of tablets into a groin; consider acute compartment syndrome; organise a creatinine kinase test.
- Pneumonia - pneumococcus, haemophilus, tuberculosis, pneumocystis.
- Tachyarrhythmia - in young patients consider cocaine, amfetamines, endocarditis.
- Jaundice - hepatitis B, C, or D, anabolic steroids (cholestasis).
- Glandular fever - may actually be HIV seroconversion illness.
- Pain in a limb or back pain with fever - consider osteomyelitis.
- Severe constipation - unusual in a young patient, and may be sign of opiate abuse.
- Cystitis - ketamine abuse can cause inflammation of the bladder lining leading to frequency, urgency and nocturia (ketamine bladder syndrome).
- Blindness - may be secondary to fungal or bacterial endophthalmitis with or without endocarditis, or talc or other particulate emboli.
- Rhinitis - consider opiate withdrawal; other features may be colic/diarrhoea, lacrimation, dilated pupils, insomnia, piloerection, myalgia, low mood; (rhinitis may also be a sign of cocaine use).
- Signs of sensory or motor neuropathy - consider solvent abuse.
- Myocardial infarction - may be associated with:
- Stroke or transient ischaemic attack (TIA), spinal infarction - consider:
- Myocarditis, hypertrophic cardiomyopathy, dilated cardiomyopathy, aortic dissection - all noted in cocaine users.
- Mental health conditions (principally anxiety and depression) and physical effects, such as hypertension and arthritis, are more common in older patients who abused drugs in the 1970s compared with individuals with no history of dependence.
The general management of substance misuse was extensively revolutionised with the release of consensus guidelines in 2007.These guidelines take on board the National Institute for Health and Care Excellence suite of guidance on substance misuse as well as other evidence-based studies.[15, 16, 17, 18, 19] The guidelines were built upon in 2012 with the publication by the National Treatment Agency for Substance Abuse of the document Medications In Recovery: Re-Orientating Drug Dependence Treatment.As with the previous guidelines, the 2012 document covers a wide range of issues and needs to be read in detail by health professionals who come into contact with people requiring care for substance misuse. Essential components include:
- The prevalence of drug misuse in the UK.
- Drug-related morbidity and mortality.
- The impact of drug misuse on families and communities.
- Models of drug treatment.
- Clinical governance principles.
- Non-medical prescribing (ie prescribing by health professionals other than doctors or dentists).
- Confidentiality, information sharing and child protection.
- Patient and carer involvement.
- Assessment, planning care and treatment.
- Drug testing.
- General health assessment.
- Psychosocial components of treatment.
- Pharmacological interventions.
- Assessing and responding to progress and failure to benefit.
- Opioid maintenance prescribing.
- Opioid detoxification.
- Naltrexone for relapse prevention.
- Preventing drug-related deaths.
- Alcohol misuse.
- Specific clinical situations - for example, prisoners, mental health issues and older current and ex-drug users.
In addition, the revised guidance shifts the emphasis from maintenance therapy towards treatment methods and objectives that can aid recovery. The review was instituted as a result of the Government's Drug Strategy 2010 which declared the ambition to re-balance local services so that prominence was given to recovery as well as to harm reduction.
Further reading and references
Murray-Thomas T, Jones ME, Patel D, et al; Risk of mortality (including sudden cardiac death) and major cardiovascular events in atypical and typical antipsychotic users: a study with the general practice research database. Cardiovasc Psychiatry Neurol. 20132013:247486. doi: 10.1155/2013/247486. Epub 2013 Dec 26.
Drugs and Alcohol; Public Health England
Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP; British Association for Psychopharmacology (May 2012)
Wisdom JP, Manuel JI, Drake RE; Substance use disorder among people with first-episode psychosis: a systematic review of course and treatment. Psychiatr Serv. 2011 Sep62(9):1007-12. doi: 10.1176/appi.ps.62.9.1007.
Devlin RJ, Henry JA; Clinical review: Major consequences of illicit drug consumption. Crit Care. 200812(1):202. Epub 2008 Jan 8.
Reece AS; Chronic toxicology of cannabis. Clin Toxicol (Phila). 2009 Jul47(6):517-24.
Prendergast BD; The changing face of infective endocarditis. Heart. 2006 Jul92(7):879-85. Epub 2005 Oct 10.
Gourgiotis S, Villias C, Germanos S, et al; Acute limb compartment syndrome: a review. J Surg Educ. 2007 May-Jun64(3):178-86.
Ghuran A, Nolan J; The cardiac complications of recreational drug use. West J Med. 2000 Dec173(6):412-5.
Colebunders B, Van Erps P; Cystitis due to the use of ketamine as a recreational drug: a case report. J Med Case Reports. 2008 Jun 262:219.
Safneck JR; Endophthalmitis: A review of recent trends. Saudi J Ophthalmol. 2012 Apr26(2):181-9. doi: 10.1016/j.sjopt.2012.02.011. Epub 2012 Mar 3.
Kaye S, Darke S, Duflou J; Methylenedioxymethamphetamine (MDMA)-related fatalities in Australia: Drug Alcohol Depend. 2009 Oct 1104(3):254-61. Epub 2009 Jul 14.
Westover AN, McBride S, Haley RW; Stroke in young adults who abuse amphetamines or cocaine: a population-based study of hospitalized patients. Arch Gen Psychiatry. 2007 Apr64(4):495-502.
Schreiber AL, Formal CS; Spinal cord infarction secondary to cocaine use. Am J Phys Med Rehabil. 2007 Feb86(2):158-60.
Restrepo CS, Rojas CA, Martinez S, et al; Cardiovascular complications of cocaine: imaging findings. Emerg Radiol. 2009 Jan16(1):11-9. Epub 2008 Sep 5.
Rosen D, Smith ML, Reynolds CF 3rd; The prevalence of mental and physical health disorders among older methadone Am J Geriatr Psychiatry. 2008 Jun16(6):488-97.
Drug misuse and dependence UK guidelines on clinical management; Dept of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive (2007)
Substance misuse interventions for vulnerable under 25s; NICE Public Health Guidance, March 2007
Methadone and buprenorphine for the management of opioid dependence; NICE Technology Appraisal Guidance, January 2007
Naltrexone for the management of opioid dependence; NICE Technology Appraisal Guidance, January 2007
Drug misuse in over 16s: opioid detoxification; NICE Clinical Guideline (July 2007)
Drug misuse in over 16s: psychosocial interventions; NICE Clinical Guidance (July 2007)
Strang J; Medications in Recovery Re-orientating Drug Dependence Treatment, National Treatment Agency for Substance Abuse, 2012
May T; Drug Strategy 2010, HM Government
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