Management strategies for IDU-related HIV

There are a number of strategies which may be adopted in order to cope with IDU-related HIV admissions, including higher staffing levels, avoidance of high occupancy levels and continuity of care by both nursing and medical staff.

Box 11.4 Social effects — physical and mental slowing

• More vulnerable to exploitation from peers

• More likely to get caught by the law

• Reduced income — “criminal unemployment”

• Increased demands on NHS to replace the missing funds

pressure for prescribed drugs pressure for access to state benefits

Box 11.5 Initiatives for initiation and maintenance of contact with drug users

• Needle exchange

• Methadone prescribing

• Social provisions such as helping with housing

• Medical care

Box 11.6 Specific problems of IDU-related HIV for a health service

• Mixture of physical and psychological dependency

• Frequent security and fire incidents

• Increased need for cubicles

• Need for increased staffing levels

Box 11.7 Management strategies for IDU-related admissions

• Continuity of care from medical and nursing staff

• Increased number s of nur sing and medical staff

• Response to violence is to call police

• Tight control on drug prescribing

• A written smoking policy which is given to every patient on admission

• Coordination of drug prescribing between different agencies around admissions and discharges

• Increase contact with healthcare system gradually

• Clear guidelines and policies which all staff sign up to

• Such policies to be supportive and caring and based on health and safety principles

• Avoid situations leading to confrontation

• Avoid withdrawals in ward area but make it clear that no guarantee of increases on discharge

• Awareness of need for relief of pain and psychological distress

Box 11.8 Strategies for coping with IDU-related HIV admissions

• Violent activities, assaults, etc.

• Treatment in the community is often arranged in order to avoid long spells in hospital. Increased drug taking in hospital or difficult behaviour is often a symptom of boredom and much can be done to avoid this, for instance by providing satellite TV or computer games.

• There is tight control of prescribed drugs early on in the disease process with accompanying harm reduction messages. The message concerning prescribing is that its function is to provide a safety net for the physical discomfort of addiction rather than to provide a free buzz or “stone”.

• There is a gradually increasing level of contact between hospital and patient over time which allows the service to get used to the behaviour of patients and for them to get used to the hospital’s routines. This is one form of re­socialisation for the individual with problem drug use.

• The aim is to provide a supportive and caring environment associated with firm discipline over misbehaviour and illegal activities. Wherever possible the rules are based on health and safety principles rather than moral or legal ones. Injecting in the hospital is forbidden because of the dangers to staff. Similarly being stoned is discouraged because of the increased risks of hypostatic pneumonia or fire hazards from concomitant smoking.

• Coordination of substitute prescribing with other carers is very important to avoid double prescribing via hospital admissions. Careful prescribing on discharge is also required to avoid similar problems in the community.

• Illegal drug use in the ward requires careful discussion in order to arrive at a compromise over the amount of drugs prescribed and the amount of drugs used illegally.

• On occasions, in order to deliver inpatient care, illegal or extra drug use needs to be covered. In such situations the patients are warned that this does not imply any sort of contract or obligation for increased doses on discharge. If the admission is prolonged then an offer of detoxification to the doses prescribed would be made.

• A written smoking policy is provided to every patient on admission. It is based on health and safety principles and the need to reduce the danger of fires for everyone’s sake.

• The regime for outpatient appointments is reasonably flexible (anytime on a set day) in order to allow for missed appointments. However the patients are made aware of the need for some structure in the system by making the patient aware of the hospital’s limitations.

• The law relating to the prescribing of drugs such as methadone is explained in verbal and written instructions.

• Confrontation is generally avoided in situations that cannot be resolved. This means adapting the regime or removing the patient from the environment that they find difficult; this may require us either to allow the patient to self­discharge or if necessary to discharge the patient from the unit. The patients are always offered an outpatient appointment if they leave the hospital or are discharged.

• Obvious withdrawal symptoms (alcohol or opiates) during a physical illness would be covered with extra doses of opiates or short courses of benzodiazepines (diazepam or chlodiazepoxide). Agitation from recent stimulant use would also be covered for inpatients. The prime aim would be to reduce the chance of agitation and disturbed behaviour in the wards.

• Fear of pain may be a major problem for drug-using patients. We have generally used either a subcutaneous infusion of opiate over and above maintenance drugs or the use of oral slow-release morphine preparations. Provided observation reveals that the patients are not excessively sedated from a health and safety point of view there is no upper limit on the doses employed to relieve pain.

• There may be concern amongst the staff over the level of prescribing of sedative drugs. The nursing staff need to have confidence in the medical management policy relating to sedative and pain control prescribing. A number of patients, particularly drug users, request high levels of sedation prior to death and this may cause concern amongst a number of staff, medical and nursing as well as relatives.