Medical care systems
The difficulties of engaging drug users for medical care should not be underestimated. There are some particular characteristics of IDU that it may be helpful to be aware of, and the details will vary with geographical location (Box 11.1).
Drug users usually require a substantial supply of money to fund their addiction ‘habit’, which in itself results in other problems.
Not surprisingly the problems and illegality associated with the use of recreational drug use is associated with a number of difficulties for any health service in delivering medical care for drug users. For the health service these numerous crises, whether social, financial, legal, etc., lead to the impression of a chaotic lifestyle; in reality hospital appointments usually have a fairly low priority because of the enormity of their problems.
The social effects of HIV infection are similar for all risk groups — the infection effectively impoverishes the patient; however in the case of drug users these effects may be a little more dramatic.
More importantly the inability to fund a drug habit can have important consequences for a health service which are often not appreciated:
• A need to find additional sources of income — benefits fraud, drug dealing, hospitalisation (save money on food, etc.) — all of which increase the pressure on the NHS to prescribe addictive drugs (which may be greater than actual habit in order to provide additional funds).
• The physical weakness and mental slowing leads to peer victimisation.
• Practical problems such as problems with visitors, unexplained absences from ward, frequent self-discharge,
Box 11.1 General characteristics of IDU in UK
• Mainly an illegal activity
• Male dominated (10-30% females)
• Usually involves the young and initially healthy — 2 years before any contact with NHS
• Do not seem to be particularly health conscious
• Have often spent time in prison (up to 70%)
• Tend to have a crisis lifestyle
• Are often associated with violent or unpredictable behaviour, which in part is related to an excess of or withdrawal from recreational drugs and is more often than not related to problems with their peers
Box 11.2 Specific problems relating to drug addiction
• Expensive to maintain (£100—£200/day) and may be funded by a variety of means such as:
theft — car crime, burglary fraud — credit and cheque cards, DSS benefits drug dealing prostitution — male or female
• Are often short of money
• May need to avoid police “warrants”
• Live for today (shortened “future time perspective”)
• May require 3—4 shots per day for opiates and every hour for cocaine
Box 11.3 Recreational drug use and health care
“Unreliable” individuals with chaotic type of lifestyle
• Irregular attendances — missed appointments, wrong day, frequent self-discharges from ward
• Suspect motives for many of symptoms
• Unexplained absences from wards
• Disruptive visitors
• Day/night reversal
• Self-medication and drug dealing
• Theft from other patients and staff
• A threat for patients and staff
• Attention seeking, demanding of time and often noisy
• Aggressive behaviour both verbal and physical
• Utilise a number of offensive weapons — knives, guns Come with a variety of staff “attitudes”
• “Others more deserving” of care
• “Manipulative” of staff
• “Dangerous”
• “Frightening”
• “Upset other patients”
• “Not enough time”
• “Never change”
day/night reversal, theft of hospital property (related to a falling income), noise, manipulation of staff or other patients and attention-seeking behaviour.
• Increased frequency of verbal and physical abuse of both staff and other patients.
The net result may be an inability to cope in the community or the hospital, resulting in frequent precipitous admissions and discharges — “revolving door” type admissions with considerable frustration for patients, relatives and staff.
Without a modified healthcare system which understands and considers these problems, drug users have a tendency to record a high default rate in terms of attendance or frequent discharges from hospital units. The aim of an IDU service should be to initiate and maintain contact primarily in order to deliver health care and health education. The initiation and maintenance of that contact may require a variety of initiatives as described in box 11.5.
A system of providing both drug services as well as medical care from the same site by the same doctors seems to be an efficient model of care for drug users, whereas a system of delivering care via two distinct physical sites (one for drugs and one for physical care) is less efficient and seems to provide either a poor medical and/or a poor HIV service.
The dependency needs of IDU-related HIV are both physical and psychological. The physical care varies from mildly ill to high dependency, whilst on the psychological side it may vary from being entirely well to toxic confusional states, obsessive-compulsive states, anxiety and agitation as well as frank psychosis. The differential diagnosis is extensive and admission is commonly required to exclude the diagnosis of an organic psychosis. The time that patients may remain in a medical unit varies from a few days to over a month and this mixture of serious physical and mental ill health is rarely found in other areas of medicine. There is also the danger of fire from careless cigarettes, since the majority of patients smoke heavily and consume excessive amounts of sedative drugs. Because addiction to cigarettes seems to be greater or at least equal to opiates, it appears impossible to enforce a total no smoking policy for the inpatient areas if the policy of maintaining contact with patients is to be followed. In addition to the difficulties described above, there are also the problems of nursing individuals in some form of isolation. The requirement for cubicles is high as a consequence of an increased risk of infectious agents associated with HIV and IDU, such as tuberculosis. There is also an increased need for privacy because of mixed sexes (one third are female), mixed risk groups (homosexuals and drug users) and disturbed patients.