Elsevier

The Lancet

Volume 374, Issue 9697, 10–16 October 2009, Pages 1284-1293
The Lancet

Review
Management of injecting drug users admitted to hospital

https://doi.org/10.1016/S0140-6736(09)61036-9Get rights and content

Summary

General hospital clinicians frequently deal with injecting drug users because substance use has diverse medical and psychiatric complications. Non-specialist clinicians often initiate management when specialist consultation is not available or accepted by the patient. Here, we summarise evidence for the management of hospitalised injecting drug users. The first challenge is to engage a drug user into medical care. A non-judgmental approach towards patients and acceptance of their lifestyle choices facilitates engagement. Pragmatic clinical goals can be negotiated and achieved. We also describe common conditions of injecting drug users. Accurate diagnosis and appropriate management focus on common issues such as intoxication, withdrawal, pain management, drug seeking, psychological comorbidity, behavioural difficulties, and pregnancy. Effective management can reduce the medical and social effect of these conditions and is not difficult.

Introduction

Injecting drug use is a major public health problem in many countries, with an escalating burden of social,1, 2, 3, 4 economic,5, 6, 7, 8, 9 physical,10, 11, 12, 13, 14 and psychiatric15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 complications. Addiction is now regarded as a treatable chronic condition comparable to other chronic conditions such as hypertension and asthma.26 The ultimate aim of addiction treatment is to reduce mortality and morbidity related to substance use by decreasing the risk and severity of relapse. Treatment needs long-term commitment from individuals, their families, and the multidisciplinary teams involved in their care. Short-term interventions can be effective for some immediate goals but are often insufficient for long-term behavioural change.

Injecting drug users are admitted to hospital for various reasons—typically direct consequences of substance use (eg, intoxication, overdose, or withdrawal) or its medical complications. These include soft-tissue infections, endocarditis, injuries sustained while intoxicated or from substance-use-related violence, or psychiatric complications such as substance-induced psychosis or suicidal ideation. Marginalised injecting drug users might need to be admitted for treatment that more socially stable people could access as outpatients.

Specialised drug and alcohol consultative services that manage these patients are evolving in many hospitals but are not always available. Here, we focus on hospital-based physicians who care for injecting drug users without specialist support, and describe the epidemiology, medical complications, and clinical problems of hospital-admitted drug users, with recommendations for managing their issues.

Section snippets

Epidemiology

Of the world population aged 15–64 years, an estimated 16 million (range 11–21 million) people inject drugs regularly.27 Data for the Caribbean and sub-Saharan Africa are incomplete and the real number might be even greater.

According to UN Office on Crime and Drugs, the most commonly injected drugs are amphetamine-type stimulants, opiates, and cocaine.28 Patterns of drug use vary across jurisdictions, and are influenced by many factors including availability, social stability, and law

Hospital presentation

Injecting drug users present to hospital and emergency departments more frequently than does the general population,33 and are admitted more often.34 A Canadian study35 found that, of 598 injecting drug users, 265 presented to emergency three or more times, and 118 were admitted two or more times over 39 months.

Case reports from different parts of the world consistently indicate that the most frequent presentations to emergency departments were soft-tissue infections, overdose, intoxication,

Diagnosis and assessment

Doctors often do not identify patients who use drugs,38 which might have serious consequences such as unexpected drug withdrawal syndromes and failure of the patient to remain in hospital for treatment. Therefore, the opportunity to initiate treatment or provide harm reduction advice for drug users could be missed. Failure to detect substance misuse might be kept to a minimum by routine screening questions and examination for injection marks. Detailed assessment is indicated if drug use is

Complications of injecting drug use

Medical complications from injecting drug use could be related to the mode of delivery, the toxic effect of co-administered substances or of the drug itself (table 1). Therefore, physical examination is indicated.

Transmission of blood-borne infectious diseases is a major complication of sharing injecting equipment. Patients should be screened for hepatitis B, hepatitis C, and HIV/AIDS. Those at risk of sexually-transmitted diseases should be also tested. Many other infections are associated

Management

Doctors might express disapproval of people with drug dependence, and patients might feel stigmatised,38 which can discourage engagement in a therapeutic relationship. Key skills in engagement with drug users include acceptance of patient autonomy, empathic communication, a non-judgmental approach, collaborative attitude, and maintenance of confidentiality, all of which improve treatment outcomes in substance treatment settings.52 Private interviews, away from relatives and other patients,

Recognition and management of intoxication and overdose

Treatment of intoxication (table 2) is generally supportive and symptomatic, with regular assessment for cardiorespiratory safety. Non-fatal overdose of illicit or prescribed opioids—often in combination with alcohol, benzodiazepines, and other drugs—presents various consequences including aspiration pneumonia, pressure nerve palsies, and rhabdomyolysis due to prolonged immobility, hypotension, and hypoxia.13

The initial management priorities for opioid overdose are airway protection, correction

Management of withdrawal syndromes

Short-term interventions, such as detoxification, are not successful in the management of opioid dependence. By contrast, the effectiveness of opiate substitution treatment is clear.65, 66, 67 Acutely-ill, medically-compromised patients with pain and distress respond poorly to attempts at detoxification. The recommended treatment in these situations is stabilisation on opioids to prevent withdrawal.65 Nonetheless, this decision should be made in consultation with the patient, explaining any

Pain management in opioid-dependent patients

Pain is a common problem for all admitted patients89, 90 but injecting drug users might experience issues accessing adequate analgesia. Prescription of opioid analgesia in adequate doses for pain is sometimes avoided inappropriately, especially for patients with current or previous opioid dependence. Requests for analgesia might be interpreted as drug-seeking.91 Long-term use of, or treatment with, opioids can result in tolerance to opioid effects, hyperalgesia, or both.91, 92 The decision to

Management in pregnancy and lactation

European and North American household surveys indicate that illicit substance use is reported by at least 4–5% of pregnant women.97, 98 Data for injecting drug use during pregnancy are scarce. All women presenting to antenatal clinics should be clinically screened for drug use.99, 100 If evident, early referral to specialised drugs and pregnancy services will keep the harms associated with injecting drug use to a minimum and facilitate engagement in antenatal and postnatal care.101

Pregnant

Management of difficult behaviour in hospital

The general principles of managing difficult behaviour of injectors in hospital are similar to those of non-injectors. Common difficult behaviours include anger and illicit drug use while in hospital. Clear behavioural boundaries should be negotiated with the patient and staff with consistency, fairness, and compassion. These behaviours can be exacerbated by attitudinal problems, potentially relating to stigma or previous experiences of the patient, staff, or both. The origin of such behaviour

Conclusion

Substance misuse is common, and it is likely that most medical practitioners will be required at times to assess and manage patients who inject illicit substances and have associated complications. Management involves adopting a non-judgmental and problem-solving approach for both psychosocial and medical issues, with pharmacotherapy where appropriate. While these disorders can be challenging, management is often relatively straightforward and rewarding.

Search strategy and selection criteria

We searched PubMed, Cochrane Library, and Embase with no time limit (up to May, 2008); and Medline (from 1950 to May, 2008), Cinahl (from 1982 to May, 2008), and PsychINFO (from 1806 to May, 2008), with no language restrictions. Database searches were done with one or more of the following keywords: “injecting drug user”, “intravenous drug user”, “inpatient management”, “management”, “hospitalised”, “social”, “medical”, “complications”, and “psychiatric”. Because of scarcity of relevant

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