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164

Name (street names)

junk, brown, stag, scag, jack)

(E, XTC, doves, disco

biscuits, echoes, scooby doos)

Chemical name:MDMA

(acid, trips, tabs, dots, blotters,

Magic mushrooms

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164

CHAPTER7 Healthyliving

Dependence/ tolerance

Overdose— can lead to coma and death

Sharing injecting equipment brings risk of HIV/ hepatitis

infection

Dependence, restlessness, paranoia

Damage to nasal membranes

As for cocaine but, because of the intensity of its eects,

crack use can be extremely hard to control

Additionally causes lung damage (‘crack lung’)

Nausea and panic

Overheating and dehydration— if dancing can be fatal

Use has been linked to liver/ kidney problems

Long- term eects are not clear but may include mental

illness and depression

There is no way of stopping a bad trip which may be a

very frightening experience

i risk of accidents

Can trigger long- term mental health problems

As for LSD, with the additional risk of sickness and

poisoning

Insomnia, irritability, panic

Drowsiness, sense of warmth and

well- being

Sense of well- being, alertness, and

How usually taken Eects sought Harmful eects

Injected, snorted, or

smoked

Table7.5 Commonly misused substances inthe UK

Heroin (smack, horse, gear, H,

Cocaine (coke, charlie, snow, C) Snorted in powder form,

condence

injected

Smokable form of cocaine Similar to those of snorted cocaine

Crack (freebase, rock, wash,

but initial feelings are much more

intense

stone)

Alert and energetic, but with a

calmness and a sense of well- being

towards others. Heightened sense of

sound and colour

Swallowed, usually in tablet

form

Ecstasy

Hallucinations, including distorted/

mixed- up sense of vision, hearing,

and time. LSD trip can last 8– 12h

Swallowed on a tiny square

of paper

LSD

microdots)

Similar eects to those of LSD, but

the trip is often milder + shorter

Eaten raw or dried, cooked

in food, brewed into tea

(shrooms,

mushies)

d sleep

Khat (quat, chat) Chewed as leaves Stimulant,

Amphetamines

uppers, billy, sulph, amp)

ganja, weed, shit, pu, marijuana)

Tranquillizers

Anabolic steroids

(alkyl nitrates, including

amyl nitrate with trade names such

(including lighter gas rells,

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Dependency/ tolerance

Overdose can lead to coma or death

Severe withdrawal symptoms

Insomnia, mood swings, irritability, panic

The comedown (hangover) can be severe and last for

several days

Calm and relaxed state, larger doses

produce a drunken eect

Stimulates the nervous system,

wakefulness, feeling of energy and

condence

Impaired coordination and i risk of accidents

Poor concentration, anxiety, depression

i risk of respiratory diseases, including lung cancer

Dependency/ tolerance

i risk of accidents

Relaxed, talkative state, heightened

sense of sound and colour

Prescribed for the relief of anxiety

and to treat insomnia, high doses

ASSESSMENT OFDRUGSMISUSE

Overdose can be fatal

Severe withdrawal symptoms

♂:erection problems, risk of MI or liver disease

♀:development of male characteristics

Injecting equipment:brings risk of HIV or hepatitis

infection

Hypotension/ fainting

Headaches

Nausea

Skin burns

cause drowsiness

With exercise, can help to build

up muscle. Some debate about

whether i muscle power and athletic

performance

Brief and intense head- rush caused

by a sudden surge of blood through

the brain

165

‘Sudden sning death syndrome’— due to arrhythmia

Nausea, blackouts, increased risk of accidents

Fatal arrhythmias can cause instant death

Short- lived eects similar to being

drunk, thick- headed, dizziness,

possible hallucinations

capsules; injected

In powder form, dissolved

in drinks, injected, snied

or snorted

Rolled with tobacco into a

spli, joint, or reefer and

smoked; smoked in a pipe;

or eaten

(speed, whizz,

Barbiturates (barbs, downers) Swallowed as tablets/

Cannabis (hash, dope, grass, blow,

Swallowed as tablets or

capsules, injected

Injected or swallowed as

tablets

(moggies),

(include:Valium

, Mogadon

Ativan

temazepam (wobblies, mazzies,

jellies))

(many trade

names)

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Vapours from small bottle

of liquid are breathed in

through mouth or nose

Poppers

as Ram, TNT, Thrust)

Snied or breathed into

the lungs

Solvents

aerosols, glues). Some painter

thinners and correcting uids

166

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166

CHAPTER7 Healthyliving

Management ofdrugsmisuse

Management aims to help the patient stay healthy until a drug- free life is achieved. In particular by d the risk of infectious diseases, drug- related deaths, and criminal activity to nance drug habits. Care can be dicult due to chaotic lifestyle and drug- seeking behaviour. Set clear rules of engagement.

0 GPs interested in working in specialist drug misuse treatment centres or providing substitute prescribing in the community should obtain specialist training. The RCGP Substance Misuse Unit provides certicate courses in management of drug and alcohol misuse (M www.rcgp.org.uk).

Role oftheGP

Important role in identifying drug misuse (including prescription drugs) and assessing willingness to modify drug behaviour (see Figure 7.8). GPs can also provide:

Information and advice as appropriate about:

• Safe injecting, overdose prevention and specic risks of drugs (Table7.5, E p. 164)— including local risks, e.g. contaminated street drugs

• Safe sexual practices (E p. 711)

• Driving and drug misuse (E p. 99)

• Other sources of support/ information

Medicalcare

• Routine medical care, including treatment of complications of drug misuse, e.g. infected injection sites

• Routine preventive care (e.g. cervical screening, contraception)

• Blood- borne viruses (hepatitis B/ C, HIV)— testing as needed; hepatitis B vaccination to injecting drug misusers not already infected/ immune, and close contacts of those infected— use an accelerated regimen— immunization at 0, 7, and 21d, and a booster after 12mo

Patient is unaware that

Relapse

Can occur at any stage. Not a failure

but a learning experience to improve

chances the next time around

Maintenance

Needs to consolidate gains to avoid

relapse

Figure7.8 Stages of change in addiction

Precontemplation

there is a problem

Contemplation

Ambivalence, might acknowledge a

problem and need for change

Decision

Hypothetical point at which a decision

is made whether to change or not

Action

Patient seeks help

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MANAGEMENT OFDRUGSMISUSE

• Referral for specialist assessment/ treatment of drug misuse. 0 Patients

requiring substitute prescribing (e.g. with methadone/ buprenorphine for heroin misuse) should be referred to a specialist treatment centre

Prescription benzodiazepineaddiction E p. 169 Prescription opioidmisuse Suspect if taking long- term opioid medi-

cation for any non- cancer condition, particularly if drug- seeking behaviour (e.g. early requests/ requests for replacement medication), refusal to see a GP for reviews, or reluctance/ refusal to d the dose of opioids.

Action Discuss your concerns with the patient directly. Oer patients the option of referral to a specialist drug treatment centre for substitute prescribing with methadone/ buprenorphine, or detoxication.

Detoxication Convert patients on patches to long- acting oral medication. Agree a gradually d dose of opioid, e.g. 10– 25% of the dose/ mo. 0Patients who detoxify should be warned of the risk of overdose if they relapse and restart opioids again at the same dose. Monitor frequently.

Opioid withdrawalsymptoms

• Within 24h muscle aches; restlessness/ anxiety; watering eyes/ runny

nose; excessive sweating; yawning; inability to sleep

• Later Diarrhoea; abdominal cramps; goosebumps (‘cold turkey’); nausea/ vomiting; blurred vision and dilated pupils; tachycardia; i BP

Safe injectingadvice Provide information about safer routes of drug

administration, e.g. smoking/ rectal administration for heroin abusers. Discourage IM/ subcutaneous administration. Advise:

• Safe injecting— never inject alone; always inject with the blood ow; rotate sites— avoid neck, groin, penis, axilla, foot and hand veins, and any infected areas/ swollen limbs. 0 Poor veins indicate poor technique— nd out what the patient is doing

• Drugs/ equipment— sterile injecting equipment with small- bore needle; dispose of equipment safely after use; avoid unsuitable preparations, e.g. crushed tablets and/ or drug cocktails

• First aid— learn basic principles of rst aid/ CPR; encourage calling for an ambulance. Suggest a naloxone kit (available from drug treatment centres)— d deaths from opioid overdose

Opioid overdose riskfactors

• Injecting heroin

• Longer injecting career

• Depression, suicidal thoughts

• Lowered tolerance through detoxication/ imprisonment

• Multiple drug use— particularly CNS depressants

• Sharing equipment/ other high- risk injecting behaviour— may indicate low concern about personal risk

• Not being on/ premature exit from a methadone treatment programme

• Recent non- fatal overdose

• High levels of use/ intoxication

• High levels of alcohol use

Further information

DH (2017) Drug misuse and dependence:UK guidelines on clinical management. M https:// www.gov.uk/ government/ publications/ drug- misuse- and- dependence- uk- guidelines- on- clinical- management Faculty of Pain Management Identication and treatment of prescription opioid dependent patients. M https:// www.rcoa.ac.uk/ faculty- of- painmedicine/ opioids- aware/ clinical- use- of- opioids/ identication- and- treatment

167

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168

CHAPTER7 Healthyliving

Insomnia

From the Latin meaning ‘no sleep’: describes a perception of disturbed or inadequate sleep. ~1:4 of the UK population (♀ > ♂) are thought to suer in varying degrees. Prevalence:i with age, rising to 1 in 2 amongst the over 65s.

Causes Numerous— common examples include:

• Minor, self- limiting— travel, stress, shift work, small children, arousal

• Psychological ~½ have mental health problems:depression, anxiety,

mania, grief, alcoholism

• Physical— drugs (e.g. steroids), pain, pruritus, tinnitus, sweats (e.g.

menopause), nocturia, asthma, obstructive sleep apnoea

Denition of‘a good night’s sleep’

• <30min to fall asleep

• Maintenance of sleep for 6– 8h

• <3 brief awakenings/ night

• Feels well rested and refreshed on awakening

Management ofinsomnia

Careful evaluation. Many do not have a sleep problem themselves but a relative feels there is a problem, e.g. the retired milkman continuing to wake at 4 a.m. Others have unrealistic expectations, e.g. they need 12h sleep/ d. Reassurance alone may be all that is needed.

For genuine problems withinsomnia

• Eliminate physical problems preventing sleep, e.g. treat asthma/ eczema;

give long- acting painkillers to last the whole night; consider HRT or clonidine for sweats; refer if obstructive sleep apnoea is suspected (E p. 308)

• Treat psychiatric problems, e.g. depression, anxiety

• Sleep hygiene— see Box 7.2

• Relaxation techniques— podcasts; relaxation classes (often oered by

local recreation centres/ adult education centres); many physiotherapists can also teach relaxation techniques

• Consider drug treatment only as a last resort. Benzodiazepines should

be prescribed for insomnia ‘only when it is severe, disabling, or subjecting the individual to extreme distress’

0 Only prescribe a few weeks’ supply at a time due to potential for dependence and abuse. Never put benzodiazepines or z- drugs on repeat prescription for sleeping problems. Beware the temporary resident who has ‘forgotten’ his/ her night sedation.

Drug treatment Benzodiazepines (e.g. temazepam), zolpidem, zopiclone, and low- dose TCA (e.g. amitriptyline 10– 75mg) nocte are all commonly prescribed for patients with insomnia. Side eects include amnesia and daytime somnolence. Most hypnotics do aect daytime performance and may cause falls in the elderly. Warn patients about their eect on driving and operating machinery

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INSOMNIA

Box 7.2 Principles of‘sleep hygiene’

• Don’t go to bed until you feel sleepy

• Don’t stay in bed if you’re not asleep

• Avoid daytime naps

• Establish a regular bedtime routine

• Reserve a room for sleep only (if possible). Do not eat, read, work,

or watch TV in it

• Make sure the bedroom and bed are comfortable, and avoid extremes

of noise and temperature

• Avoid caeine, alcohol, and nicotine

• Have a warm bath and warm milky drink at bedtime

• Take regular exercise, but avoid late night hard exercise (sex is OK)

• Monitor your sleep with a sleep diary (record both the times you

sleep and its quality)

• Rise at the same time every morning regardless of how long

you’ve slept

Complications ofinsomnia

• Reduced quality of life

• Reduced concentration/ memory— may aect performance of daytime tasks

• Relationship problems

• Risk of accidents— 10% of motor accidents are related to tiredness

Obstructive sleep apnoea E p. 308 Sleepwalking E p. 891 Night terrors E p. 891 Restless legs E p. 552

Addiction to prescription benzodiazepines and z- drugs

Common in primary care. Regular use of hypnotics for insomnia rapidly leads to tolerance (in <1mo). Long- term use results in decline in cognitive functioning and blunting of emotions. In older people, hypnotic use is also associated with i falls and associated injuries. However, stopping the drugs results in rebound insomnia and other eects which may be severe including anxiety, panic attacks, muscle pain, and rarely seizures.

Stopping hypnotics Discuss stopping hypnotics with any patient who has had regular prescriptions for >3mo. Explain long- term risks of taking these drugs. Switch to an equivalent dose of diazepam and agree a schedule for reduction— usually 1mg every 2wk, although can be slower if necessary. Withdrawal symptoms tend to occur 2– 10d after reduction in dose.

Dose equivalence 5mg diazepam is approximately equivalent to 10mg temazepam, 5mg nitrazepam, 500mcg lorazepam, 15mg chlordiazepoxide, 15mg oxazepam, 7.5mg zopiclone, or 10mg zolpidem.

Patient information and support

Benzodiazepine addiction M www.benzo.org.uk Royal College of Psychiatrists (2015) Sleeping well. M https:// www.

rcpsych.ac.uk/ mental- health/ problems- disorders/ sleeping- well? www. rcpsych.ac.uk/ healthadvice/ problemsanddisorders/ sleepingwell

169

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170

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Chapter8

Chronic disease and elderlycare

Chronic disease management 172 Multimorbidity 174 Genetics and genomics 176 Medically unexplained symptoms 178 Assessment of pain 180 Principles of pain control 182 Pain- relieving drugs 184 Morphine and other strong opioids 186 Neuropathic pain 188 Normal ageing 190 Falls in the elderly 192 Prescribing for older people 194 Elderly care and disability management 196 Maintaining independence 198 Carers 200

0 In other sections of this book, where management diers from the norm for elderly patients, the text is highlighted in a box marked with this symbol.

171

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172

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172

CHAPTER8 Chronic disease and elderlycare

Chronic diseasemanagement

The predominant disease pattern in the developed world is one of chronic or long- term illness. In the UK, 41% of adult ♂ and 43% of adult ♀ report a long- term illness. This gure is increasing as our population ages. People with long- term conditions are very intensive users of services; they account for 52% of GP appointments, 65% of outpatient appointments, and 77% of hospital bed days.

Long- term conditions frequently managed in general practice include:

• Back pain

• Cancer

• DM

• Dementia

• Chronic neurological conditions, e.g. Parkinson’s disease, MS

• Psychiatric illness, e.g. depression, psychosis

Although details of chronic illness management depend on the illness, people with chronic diseases of all types have much in common with each other. They all have similar concerns/ problems and must deal not only with their disease(s) but also its impact on their lives/ emotions.

Common patientconcerns

• Finding and using health services

• Finding and using other community resources

• Knowing how to recognize/ respond to changes in a chronic disease

• Dealing with problems and emergencies

• Making decisions about when to seek medical help

• Using medicines and treatments eectively

• Knowing how to manage stress/ depression that goes with chronic illness

• Coping with fatigue, pain, and sleep problems

• Getting enough exercise

• Maintaining good nutrition

• Working with your doctor(s) and other care providers

• Talking about your illness with family and friends

• Managing work, family, and social activities

• HIV

• Arthritis of all types

• Chronic lung disease

• Cardiovascular disease, e.g. i BP, heart disease, stroke

• Renal or liver failure

• Irritable bowel syndrome

• Inammatory bowel disease

Common elements ofeective chronic illnessmanagement

• Involvement of the whole family Chronic diseases do not only aect the

patient but everyone in a family

• Collaboration between service providers, patients, and carers

Negotiate and agree a denition of the problem; agree targets and goals for management; develop an individualized self- management plan

• Personalized written care plan Take into account patients’/ carers’ views

and experience and the current evidence base

• Tailored education in self- management Apatient with diabetes spends 7 3h/ y with a health professional— the other 8757h he or she manages his/ her own condition. Helping patients with chronic disease understand and take responsibility for their conditions is vital

• Planned follow- up Proactive follow- up according to the care plan— use of disease registers and call– recall systems is important

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CHRONIC DISEASEMANAGEMENT

• Monitoring of outcome and adherence to treatment Use of disease/

treatment markers; monitoring of concordance, e.g. checking prescription frequency; medicine management programmes— E p. 116

• Tools and protocols for stepped care Provide a framework for using

limited resources to greatest eect; step professional care in intensity— start with limited professional input and systematic monitoring, then augment care for patients not achieving an acceptable outcome

• Targeted use of specialist services For those patients who cannot be

managed in primary care alone

• Monitoring of process Continually monitor management through clinical governance mechanisms (E p. 52)

Multimorbidity E p. 174

Depression and chronic disease

people with chronic disease. It is reported to aect 30– 50% of those with epilepsy, CVD, dementia, cancer, type 2 DM, and arthritis.

Interaction betweendepression and chronic physicalillness Depression in those with chronic medical illnesses adversely aects prognosis. Conversely, treatment of depression can improve prognosis.

Depression is associated with:

• i mortality, i morbidity, i disability, and poorer quality of life

• i prevalence of smoking and sedentary lifestyles

• Poorer chronic disease outcome measures, e.g. higher HbA1c levels

• i use of services and i healthcare costs

• Poor concordance with medication and management plans

Detection of depression Use NICE depression screening questions:

• During the last month, have you often been bothered by feeling down, depressed, or hopeless?

• During the last month, have you often been bothered by having little interest or pleasure in doing things?

A positive response to either of these questions should prompt further assessment with the following 3 questions:During the last month have you often been bothered by:

• Feelings of worthlessness? • Thoughts of death?

• Poor concentration?

Further assessment and management E p. 978

Depression is common among

Residential care homes 220,000 people live in residential care in

England; 77% are elderly with long- term health conditions. Of younger residents, 61% have learning disabilities, 21% have mental illness, 17% have physical disability, and 2% have substance misuse problems. Chronic disease management for residents of care homes is frequently neglected. Ensure that chronic disease management checks take place including routine blood monitoring, physical health checks, and medication review.

Deprivation of Liberty Safeguards (DoLS) E p. 1106

Further information

NICE (2009) Depression in adults with a chronic physical health problem.

M www.nice.org.uk/ guidance/ cg91

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