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General Principles – drug users
• Entitled to same quality of healthcare as we are
• Characteristics / challenge stereotyping?
• Addiction – the defining criteria
• Morbidity and mortality
• Prescribing
• Prison specifics
Drug users
• Social exclusion
• Abusive upbringing
• Children in care
• School exclusion - poor educational achievement
• Illiteracy
• Unemployment
• Low self-esteem
• Criminal justice system
Addiction
• Persistent use despite problems related to that use
• This may be drugs or behaviour (eg gambling / sex)
• Development of tolerance
• Withdrawal syndrome
• Craving and drug seeking behaviour
• Primarily a disorder of the brain’s reward system
Addiction - continued
•Relapsing – remitting pattern
•Treatment is dependent on patient’s motivation
•Avoid complicity in prescribing
•Avoid judgemental management
•Importance of therapeutic alliance (mutual trust)
•Psychosocial management – MI, Life mapping etc
• Morbidity and Mortality• Approx 1,500 drug related deaths/yr 2001-2005• Overdose• Hepatitis B and C; HIV; • DVT; venous insufficiency; leg ulceration• Endocarditis• Septic arthritis
Prescribing analgesia to Drug Users
• Accurate assessment / diagnosis of pain causation
• Learned behaviour – eg “shooting pains, Doc!”
• Non-pharmacological pain management
• WHO Pain ladder
• Awareness/abuse of non-opioid popular among drug users
• Gabapentin, pregabalin, benzo’s, tricyclics, quetiapine
• Regular review of dosages / need for medication
Prescribing analgesia to Drug Users (cont)
• Encourage other coping strategies
• ?Need to co-prescribe substitute and analgesic Rx
• Eg Methadone and dihydrocodeine / tramadol
• Split dose methadone – all supervised
• Supervised slow release preparations - MXL
• Urine testing to monitor compliance
• Opiate hyperalgesia? Low pain tolerance levels
Prison specifics
• 83,000 in custody
• Increasing numbers of elderly patients
• Long sentences, sex offenders caught long after the crime eg using DNA
• Socio-economic factors – higher morbidity rate, smoking
• Cost of escorts and bed-watches
Palliative care in prison• Gold standards framework (prison version pilot)• Medication• Syringe driver security• MacMillan nurses• Patient choices?? – place of death• Dignity• ROTL• Public protection