Pulse May 2019 issue - Page 34

34 Q For IV drug users (IVDUs), how often should we check for blood-borne viruses (BBVs)? Do you ever use pre-exposure prophylaxis (PrEP) for HIV in these patients? We can identify three BBVs: HIV, A hepatitis B and hepatitis C, which are mainly passed through contact with infected blood or bodily fluids, by: • Sharing equipment to inject or snort – even if only once. This includes needles, syringes, spoons, water, filters, acidifiers and straws. • Unprotected sex – vaginal, anal or oral. • Unsterile medical treatment or unsterile body piercing or tattoos – for example, home or prison tattoos. • Sharing razors or toothbrushes. • Receiving blood transfusions before 1991 or blood products before 1988. BBVs can also be passed from an infected mother to her baby. Treatment can greatly reduce the transmission risk of HIV and hepatitis B. The risk of a mother passing hepatitis C to her baby is very low. The presence of a BBV infection can go undetected for years so it is important to test those who are at high risk, such as sex workers and anyone who has injected drugs. The Centers for Disease Control and Prevention say PrEP is for people at very high risk of HIV to lower their chances of getting infected. It is highly effective if used as prescribed, reducing the risk of getting HIV from sex by more than 90%, and even more if condoms are used. Among IVDUs, it reduces the risk by more than 70%. 5 Q Do needle exchange schemes minimise harm, or do they perpetuate intravenous drug abuse? We should address the problem of A addiction in four stages. The first is prevention – we provide information to the public, which encourages individuals to stay away from harmful substance misuse. The second stage is harm minimisation for an individual who is misusing. The third is active treatment of addiction through replacement medication or detoxification. The fourth is support to maintain abstinence. Needle and syringe programmes are cost-effective harm minimisation interventions. They also encourage the return and safe disposal of used injecting equipment. Sharing needles and syringes is a key route by which BBVs are transmitted, and almost a quarter of IVDUs report sharing in the previous four weeks. Almost half of IVDUs share other injecting equipment. Hepatitis C is currently the most important infectious disease affecting IVDUs, with approximately 40% of IVDUs infected. In comparison, HIV prevalence rates are relatively low in IVDU populations. 6 Both the WHO and NICE recommend needle exchanges as an effective intervention with health benefit to the individual and society. Q If you uncover a history of drug abuse in a parent, which has never presented to health services, would you always make a referral to child protection? If not, what information would you seek to help you decide whether to refer? Safeguarding of children is A everyone’s business. We need to keep the child in focus when making decisions about their lives and work in partnership with them and their families. Parents’ alcohol and drug dependency can impact children’s physical and emotional wellbeing, development and safety. You would not make a referral for everyone, but become vigilant and proactive about any signs of safeguarding issues. You need multiagency collaboration with all the information co-ordinated by a lead practitioner who could be a GP, family support worker, school nurse, teacher, health visitor or special educational needs co-ordinator. Decisions about the lead practitioner should be informed by the child and their family. 7 You need to assess the impact of the drug use on the child and the risks if the use escalates. Consider a referral if you pick up any physical maltreatment or neglect, poor physical or mental health, poor school attendance and low educational attainment, involvement in antisocial or offending behaviour, being a young carer, and chaotic lifestyle of the parent with unknown adults in their homes. The aim should be to provide help and support at an early stage. Q Is there any circumstance where GPs should request urine drug screens, or should these always be done in specialist centres? If done in general practice, and if you can’t witness the sample being produced, how might we spot a patient who is using someone else’s urine to obtain a ‘clean’ result? This is tricky. The urine drug screen A can be either be a dipstick test, If you discover substance misuse in a parent, work in partnership with the child and the family Pulse May 2019 ONLINE Training for GPs on addiction. Go online for information on developing an interest in addiction pulse-learning. co.uk References 1 Nursing Practice Innovation Smoking Cessation. Very brief advice on smoking. Nursing Times 2012;108:23 2 Very Brief Advice training module. A short training module on how to deliver Very Brief Advice on Smoking. ncsct.co.uk/publication_ very-brief-advice.php 3 Cheatle M, Comer D, Wunsch M et al. Treating pain in addicted patients: recommendations from an expert panel. Popul Health Manag 2014;17:79-89 4 Mack A, Brady K, Miller S, Frances R. Clinical Textbook of Addictive Disorders. Fourth Edition Guilford Press. 2016;123-4 5 Centers for Disease Control and Prevention. cdc.gov/hiv/basics/prep. html date 6 National Institute of Clinical Excellence (NICE). Needle and Syringe Programme Ph 52. Published 26 March 2014 nice.org.uk/ guidance/ph52 7 HM Government. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. 2018. 8 Substance Misuse Management Good Practice. Guidance for the use and reduction of misuse of benzodiazepines and other hypnotics and anxiolytics in general practice 2014 smmgp-fdap.org.uk/ guidance-for-the-use- and-reduction-of-misuse- of-benzodiazepines which can be done at the surgery and gives results within five minutes, or you can send the sample to the lab for a full screen. I would not recommend urine testing for every patient, but both tests are useful for those at high risk of addiction because of past history, recent events or aberrant behaviour. Urine tests might also help establish whether a patient is using their prescribed medication or selling it on, particularly opioid analgesia and benzodiazepines. Some mental health problems, like anxiety and psychosis, are exacerbated by illicit drugs, so knowing what substances they are using helps to inform motivational discussions. Some individuals might not be forthright about drug use and even give urine samples that are not their own. Look for the 3Ts: • Time taken to produce the sample – if they are in and out of the toilet very swiftly, this should raise suspicion. • Temperature – in a physically stable individual the urine temperature is between 32⁰C and 38⁰C so the sample bottle will be warm to touch. • Tampered – the sample might be diluted (and pale) or adulterated with chemicals (perhaps with floating residues). Dr Yasir Abbasi is a consultant psychiatrist and clinical director for addiction services at the Mersey Care NHS Foundation Trust. Conflict of interest: Dr Yasir Abbasi has received honorarium or educational support from Indivior, Martindale, Mundipharma and Bite Medical For your appraisal folder Key points • Very brief advice for smoking addiction involves asking and recording smoking status, advising about quitting and acting on the response • A gradual reduction regime for long-term benzodiazepine use is 5% of the original dose every two to three weeks. For alcohol it is 5% every two to three days • Needle exchanges for IVDUs are an effective intervention • Gastrointestinal disturbance, sweating and yawning excessively can be signs of withdrawal from opioids 1.5 CPD HOURS Go to pulse-learning.co.uk to test your learning and download your certificate