Guidance for working with cocaine and crack users in primary

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Guidance for working with cocaine and crack users in primary

Transcript Of Guidance for working with cocaine and crack users in primary

Royal College of General Practitioners
Guidance for working with cocaine and crack users in primary care
RCGP Drug & Alcohol Misuse Training Programme RCGP Sex, Drugs and HIV Task Group SMMGP
1st Edition 2004
Written by: Chris Ford Edited by: Harry Shapiro

Guidance for working with cocaine and crack users in primary care
Written by Chris Ford
Edited by Harry Shapiro
Available at www.smmgp.co.uk
Contributions and co-authors: Judy Bury, Tom Carnwath, Frances Davies, Clare Gerada, Cathie Gillies, Aidan Gray, Erin O'Mara, Matthew Southwell, Gary Sutton, Jez Thompson, Monique Tomlinson and Nat Wright.
Thanks to: The RCGP National Expert Advisory Group, the RCGP Drug Clinical Regional Leads, SMMGP Advisory Group and the Crack Squad.
Supported by: RCGP Drug Training Programme, SMMGP, RCGP Sex, Drugs & HIV Task Group, Conference on Crack and Cocaine (COCA), Traffasi, the Alliance and Black Poppy.
Completed September 2004 For review 2006

Guidance for working with cocaine and crack users in primary care

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Contents

Executive summary

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Introduction

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The drug

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What is cocaine?

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How is it used?

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What are the main physical and psychological effects?

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The users

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Caring for the user in the surgery

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Overview

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First presentation

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Assessment for first presentation

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Examination

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Ongoing care in the surgery

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Treatment options in the surgery

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Sharing care outside the surgery

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Psychological interventions

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Formal drug treatment settings

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Group specific issues

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Users of different drugs

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Different types of user communities

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Women, pregnancy and child protection issues

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Cocaine and the sex industry

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Cocaine and the criminal justice system

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Information for patients

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Appendix 1: Cocaine and health

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Appendix 2: Review health check for cocaine users

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Appendix 3: Prescribing

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Appendix 4: Harm reduction

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Appendix 5: Developing protocols for shared care

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Appendix 6: Patient information

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Appendix 7: Additional reading

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Appendix 8: Useful organisations and websites

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References

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Guidance for working with cocaine and crack users in primary care

Executive summary

Introduction
I The use of cocaine in the UK has been rising steadily over the past decade. As the price has fallen, all the other indicators of use have been rising including the number of those coming forward for treatment.
I The drug comes in two main forms: cocaine hydrochloride powder which is usually snorted, but also injected – and crack, which is usually smoked, but also injected.
I Cocaine is a powerful stimulant whose effects wear off quickly, prompting the user to repeat the dose. However, those who use cocaine powder on an occasional basis are unlikely to come to serious harm or seek medical treatment. But high dose users, especially of crack, are likely to need treatment for a large range of physical and psychological problems.
I This guidance focuses particularly on crack cocaine, because it has the potential to cause the most serious problems for the individual, families and the community at large.
I This guidance is aimed at all primary care workers.
I It is important that GPs and other primary care practitioners have a working knowledge of the problems faced by crack users, while at the same time not working in isolation or outside their level of competence.
I This guidance is underpinned as far as possible by the published clinical evidence base. Where there is none, it draws on the experience of users and of staff working in the field. Users have an important role in building up the evidence base for effective interventions, as they are often very knowledgeable.
I Crack users have been especially demonised by the media, but successful treatment outcomes are possible, and usually stem from a positive and empathetic practitioner / patient relationship.

The drug
I Cocaine is extracted from the leaves of the coca plant, which grows mainly in the mountainous regions of South America. The leaves are processed into cocaine hydrochloride powder.
I To transform cocaine into crack, the powder is heated up in a microwave with bicarbonate of soda and water. Crack is easily melted and vaporised, so can be smoked, but it can also be injected by adding an acid.
I Cocaine is most commonly snorted in its hydrochloride powder form. Crack is most commonly smoked through a pipe. This is the quickest way to get the drug to the brain. Glass pipes, tin cans or plastic water bottles are used as conduits.
I Cocaine is a stimulant drug. Users feel more alert and energetic, confident and physically strong, and frequently believe that they have enhanced mental capacities.
I When smoked as crack, it has more intense and immediate effects because in this form the drug is delivered to the brain much quicker.
I Excessive doses can cause severe medical problems, and even death, from pulmonary oedema, heart failure, myocardial infarction, cerebral haemorrhage, stroke and hyperthermia.
I The after-effects of crack use may include fatigue, depression, paranoid ideation and depersonalisation as people ‘come down’ from the high.
I Chronic high-dose crack use can result in some physical, and marked psychological dependence.

Guidance for working with cocaine and crack users in primary care

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Executive summary

The users
These ‘user’ categories are very generalised and often overlap.
I Recreational users will take the drug infrequently and in small amounts at social occasions with friends. However, if use increases, they then move on to binge use.
I Binge or problematic users actively seek cocaine and will buy increased quantities, plan social activities to involve cocaine and establish a recognisable pattern of use, isolating themselves from others and using large quantities at one time. This pattern of use is potentially life threatening and such users often present for help.
I Chronic high dose or dependent users will consume as much as possible and may demonstrate a lifethreatening pattern of use. Relationships and work are affected or are non-existent and there tends to be psychological and physical signs of use. These users may also present looking for help.
Caring for the user in the surgery
First presentation of crack problem
I Patient may present in a medical crisis.
I Receptionists and other staff should be made aware that these users may need to be seen as an emergency. They might be experiencing the after-effects of an overdose or be agitated and confused and need calming down.
I Less acutely – they might be presenting with a specific set of symptoms such as asthma, chest pains and/or weight loss, which turn out to be a result of their crack problem.
I Patient may already have another drug problem e.g. opioid dependence, and be currently in treatment at the surgery and present with symptoms of crack use as a new problem.

Assessment for first presentation I On the first visit, the patient should receive an initial
assessment to identify problems and assess immediate needs. This should cover: I Current drug and alcohol use. I Method and route of drugs used. I Drug and alcohol history including
previous treatment. I Current and past medical history. I Psychological and mental health. I Social situation and forensic history.
Examination Patient should undergo a physical and mental health examination.
Screening Patient should be offered screening for drugs, hepatitis, HIV and sexually transmitted infections (STIs), after appropriate pre-test discussions.
Notification Drug users should be notified to the relevant agencies in the four UK countries for the purpose of monitoring drug use and highlighting trends. (User information to be reported anonymously and in accordance with the Data Protection Act).
Ongoing care in the surgery It is recommended that regular health checks, including monitoring of weight, nutrition, blood pressure and peak flow rate, take place to monitor progress and provide appropriate interventions, (e.g. on a 3 to 4 monthly basis).

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Guidance for working with cocaine and crack users in primary care

Executive summary

Treatment options in the surgery
Prescribed medication Prescribed medication should never be used in isolation from a whole package of care, including relapse prevention. Drug therapy is only effective for the most part in short-term treatment of symptoms such as depression or insomnia. Do not attempt pharmacological treatment where there is little or no evidence base for such an intervention.
Harm reduction
I Patients may well present with a problem needing support even though they plan to continue their drug use. It would be unhelpful to exclude them, although continued use can be more challenging, especially as there is no easy substitute medication but it can also be extremely rewarding.
I There is accumulating experiences in providing harm reduction advice and a number of principles and safer practices that can be discussed with the patient in order to reduce crack-related harm.
I It is possible to use self-control techniques and a range of other interventions, although there is little evidence base as yet.

Sharing care outside the surgery
I Most surgeries will not be able to offer the full range of possible treatments.
I It is crucial to know about the local relevant resources and where people can be referred on to quickly, while at the same time avoiding any feeling in the patient that you are trying to get rid of them.
I There should be locally agreed integrated care pathways as well as a clear system of assessment and care coordination.
I Always ask users and local user groups for help. National drug user groups can also provide assistance to set up a local group, if there isn’t one already.
I It is becoming increasingly important to recognise that many drug users are using a combination of drugs rather than just opioids alone. Therefore if you are part of a shared care scheme which is predominantly opioid focused, you need to consider increasing the flexibility of the scheme to reflect current trends.
Psychological interventions
I Arguably this is the most useful of the treatments, but will for the most part be conducted outside of the surgery or by a worker attending the surgery from an outside agency.
I All psychological interventions are improved by a positive relationship with a key person, whether doctor, drug worker or therapist. This needs to be patientcentred and a strong empathic engagement with patients is the key to success.
I Quality drug counselling can be at least as effective as professional psychotherapy.
I The main interventions are:
I Cognitive behaviour therapy.
I Motivational interviewing.
I Minnesota method (12-step).
I Relapse prevention.
Complementary and alternative therapies There is some experience of benefit using complementary therapies on an individual basis, but evidence on a population base is not convincing.

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Executive summary

Formal drug treatment settings The National Treatment Agency (NTA) in England has introduced ‘Models of Care’, a framework for drug services to ensure that there is consistency and equity in the provision of services across the country.
This framework also provides a tiered categorisation of treatment types, so that drug treatment services are classified in a way easy to understand.
Non-specific (general) (Tier 1)
I Primary Health Care Teams and General Practitioners providing General Medical Services.
I Probation and housing services.
Open access services (Tier 2)
I The patient can access the range of Tier 2 services such as drop-in street agencies for advice and support as well as cocaine specific agencies. Tier 2 is a key area of provision for stimulant users as they should be able to just drop in when they are in crisis.
I Needle exchanges are also part of Tier 2 services. When injecting cocaine, a large number of needles and syringes are needed (much more than with heroin), because of cocaine’s shorter half-life and the quantities of acid and water required.
Community Prescribing Services (Tier 3)
I Many Tier 3 community prescribing services are geared towards opioid users and are not meeting the needs of cocaine users.
I These services need to be encouraged to look at the needs of the individual person using drugs rather than just the drug itself.
Structured day programmes (Tier 3)
I These programmes tend to provide education about the drug, help with identifying the triggers for use, life and work skills training and general practical issues.
Residential care (Tier 4)
I There are different systems in different areas for obtaining entry into residential care. Funding is usually through the Social Services Community Care Assessment Teams.

Group specific issues
Users of different drugs
Primary crack users It is important to advertise within your service that cocaine /crack users are welcome to access care.
Working with methadone and buprenorphine users who also use cocaine/crack Patients on a substitute medication may not see their cocaine use as a problem. But methadone/buprenorphine and crack users have the added complication of combining a short acting drug with a long acting one. This increases the risk of overdose.
Heroin and crack users and speedballing (injecting heroin and cocaine together)
I Speedballing is an increasing practice.
I There is a need to provide harm reduction advice on safer use, particularly how to inject frequently with safety, as well as information about the two drugs, how they work together and the full range of needle exchange and injecting paraphernalia.
I When cocaine is used with heroin, the risk of overdose is increased because it is much more difficult to assess the effect of either drug individually.
Users of crack cocaine and alcohol
I When a patient uses alcohol with cocaine, cocaethylene is produced which is dangerous and can increase the risk of liver and heart disease, strokes and epilepsy.
I When seeing patients with a combination problem, both must be addressed.
Users of cocaine/crack and cannabis Heavy cannabis use may exacerbate the tendency of crack to produce paranoid ideation.
Users of other drugs such as ketamine and sildenafil (Viagra) Ketamine and sildenafil can complicate the effects of crack on the cardiovascular and central nervous system. Sildenafil and crack can be a problematic mix.

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Guidance for working with cocaine and crack users in primary care

Executive summary

Different types of user communities
Black and minority ethnic groups
I Crack use is often heavily associated in the media with black people as the stereotype of crack users is steeped in historical racism. In reality many different people from all communities use cocaine/crack. However concerns about the spread of crack use and its impact on communities have been expressed by many African Caribbeans. There are also concerns about the patchy coverage of services that can meet the needs of these users.
I The basics of treatment in primary care are the same for any patient, but those primary care services treating users from different cultural backgrounds need to be aware of this issue and how it may impact upon the user, staff and the service itself.
I Specific black and minority ethnic groups health issues such as sickle cell anaemia can also be exacerbated by the use of crack and cocaine.
Young people (under 18 years old)
I When a young person presents, it is important to address the individual and not solely the drug(s). Confidentiality and respect is essential.
I If the young person is under 16 years, they should be referred to a specialist young person’s service. If they are unlikely to attend, then it is reasonable to use the Fraser Guidelines.
I When seeing a young person alone, take a history, assess and discuss harm reduction in the same way as with other patients. Provide appropriate written advice and be aware that young people may use language that you don’t understand, so ask them to explain what they mean.

Women, pregnancy and child protection issues
Women
I Crack use can disrupt the menstrual cycle mainly through poor general health and chaotic lifestyle.
I Offer contraception.
I Many women may also have drug-using partners who need treatment and it is always better to provide help and treatment to both at the same time.
I Primary care is well placed to provide guidance to women on safer drug use and good sexual health.
Use in pregnancy Pregnant women need good information about crack and its effects to allow them to make choices. Confidentiality is essential and outcomes improve with consistent advice, support, reassurance, integrated care services and consistency of attendance.
There is some evidence that suggests there is a link between stillbirths, miscarriages through placental detachment (placenta abruptio), premature labour and delivery and low birth weight and small-for-dates babies, though this may reflect lifestyle and smoking rather than a direct effect. Placental abruptio and pre-term rupture of membranes are the only confirmed problems associated with cocaine use.
Approximately one quarter to one third of the cocaine will pass across the placental barrier to the foetus, which may lead to agitation and apnoea initially at birth. Most of these symptoms will settle by comforting the baby and avoiding loud noises or bright lights. The ‘crack’ baby image is a myth.
Heavy cocaine use is likely to be incompatible with successful breast-feeding. If breast-feeding is to be successful, then cocaine use should be kept to a minimum. With the exception of HIV positive women, all mothers should be encouraged to breast-feed.
There is some evidence of later developmental problems, but research is conflicting.

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Executive summary

Child and family issues and child protection
I GPs and other primary care workers can play an important part in providing professional support to parents and should apply the normal criteria in deciding whether a child might be at risk. Crack use per se is not a reason for assuming a child is at risk, but the lifestyle and problems associated with such use may be.
I Consult with all colleagues involved with the family and identify any current or potential problems.
I Childcare is improved if parents are in appropriate drug treatment. Stability in the family is important and child protection is paramount. Early involvement of Social Services may prevent the later need for care proceedings.
Cocaine and the sex industry
I Many sex workers are providing sex for cocaine and have no time to access services.
I Unprotected anal and vaginal sex are common as they command a higher fee. There is a need to provide sexual health advice and safer sex/drug use information.
I There is also a new cohort of middle-aged men using cocaine/crack, introduced to it as a result of buying sex. These patients may not access traditional drug services and so primary care interventions are important.

Crack and the criminal justice system
I Increasing numbers of people who use crack are in contact with the criminal justice system.
I Doctors, including GPs in custody suites are often untrained in working with crack users.
I Crack users sometimes use short-term sentences as a form of respite care. Cravings can then disappear, leading to false minimisation of the problem by the user.
I Prison should be seen as a window of opportunity for treatment.
Information for patients
I It is vital to have a supply of good information for users of crack in a variety of appropriate formats and languages, according to local needs.
I The rights and responsibilities of a drug user should also be explained, and patient choice respected.

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Guidance for working with cocaine and crack users in primary care

Introduction
The use of cocaine in the UK has been rising steadily over the past decade. As the price has fallen, all the other indicators of use have risen such as: seizures of the drug by police and customs,1 numbers of people using the drug in the general population,2 numbers of those coming forward for treatment3 and deaths from cocaine use.4
Cocaine powder still retains its ‘champagne’ media image associated with the rich and famous, and it is probably still true that those with the most serious cocaine problems have significant amounts of disposal income. However, it has become an increasingly unremarkable adjunct to a ‘good night out’ in a bar, pub or club for a large cross section of the population. Most of these people will not come to any appreciable harm and will not find it necessary to present to a doctor.
The same is also true for some of those who indulge in crack – the smokeable form of the drug – but over all, they are more likely to run into serious physical and mental health problems, especially chronic high-dose users. Those with serious crack problems are likely to have other drug problems as well as a whole host of other social, legal and economic problems to cope with, and the crime and violence sometimes associated with selling of the drug is a cause of great concern for many communities across the country.
The cost varies but is upwards of £40 per gram for cocaine powder with wide regional variations. Crack sells for between £5 to £20 per rock, depending on the size of the rock and the location. Several dozen rocks can be used in one session. It is possible to smoke over a £1,000 worth of crack in a single sitting.
So while not wishing to underestimate the harms caused by a chronic cocaine powder habit, which are considerable, the focus of this guidance booklet will be on crack cocaine, although the reader will find general information on cocaine and suggestions for further reading.

Who is the guidance for? The guidance is aimed at all those involved in primary care working with adults using cocaine, including GPs and other team members. It will also be useful to all working in the community with drug users. Increasing numbers of cocaine/crack users are presenting to primary care, yet GPs have precious little guidance on how to manage and treat these patients. It is important that GPs have a working knowledge of the problems faced by cocaine users and ways of reducing the harms they face. At the same time practitioners of all levels are advised not to work in isolation and to work within their level of competence.
This guidance has arisen from the pooled experience of experts in the field, including a range of practitioners from different treatment and healthcare backgrounds, as well as the experiences of users. It demonstrates that primary care can offer a variety of useful interventions to people using cocaine in all its forms and that treating crack users is possible and does not demand totally new skills.
The evidence base and the role of users This guidance is based as much as possible on the available published research, primarily from the USA, but it also relies on experience gained in the UK. And here drug users themselves have a valuable part to play in building up the evidence base for effective interventions. Probably because of media tales of gangsters and Yardies, crack users are among the most ‘demonised’ group of drug users. But in keeping with many drug users, they are knowledgeable about their situation – both in terms of their needs at any given point (harm reduction, abstinence or just simply engagement) – and their specific knowledge about the drug and the circumstances of its use. If you don’t know something about the drug, ask someone who uses it. They will generally know more than you. Never underestimate the benefits of working together. Success usually stems from a positive and empathic practitioner/patient relationship.

Throughout this booklet, the term ‘cocaine’ is used to mean the drug in all its forms while ‘crack’ refers only to the drug in its smokeable form.
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