published between 2020 and 2023
The enforcement of lockdown in the UK in March 2020 saw businesses shut up shop and most of the general population barricade themselves in the safety of their homes. NHS and community facilities had to implement downgraded versions of their services to comply with social distancing with a reduced workforce available to deliver these services. One such cohort affected by these measures is those who take recreational drugs, either socially or habitually.
The number of people who use recreational drugs regularly is unknown. NHS Digital data states that there were 14,053 patients admitted to hospital with ‘poisoning by illicit drugs’ in England in 2018. 53% of these patients were male and two-thirds fell into the 16-44yrs age bracket. Men were more than twice as likely to use cannabis or cocaine compared to women and older age groups were more likely to use opiates alone (1).
One in 12 adults were found to have taken an illicit drug between 2016 and 2017 (1). Whilst lockdown may have caused many inconveniences to the everyday lives of most of us, many habitual drug users have found themselves with additional stressors extending beyond contracting COVID-19 itself. This may not be someone’s chosen path in life but it is the reality that many are living with. This lifestyle is intertwined with medical and psychological difficulties which may necessitate NHS support.
If your first thought upon waking is how you are going to obtain your next fix, then how are...
If your first thought upon waking is how you are going to obtain your next fix, then how are you going to orchestrate daily life during lockdown? Although drug dealers are not exempt from social isolation, they are unlikely to have their usual presence on the street and drug-seeking may be more difficult. With international travel currently limited there is likely to have been adaptations to the mechanisms via which drugs are acquired and sold. Smaller drug packages are likely to be on offer to maintain transactions, especially to those who have lost usual sources of income. To address shortages of supply there may be more ‘cutting’ of active substance with other substances, potentially with toxic side-effects. These factors are likely to end up being the most detrimental to a vulnerable end-user.
Perhaps the paucity of supply of the usual drug abused by an individual forces them towards different, more easily available substances to which they go on to become addicted to. For those who have become addicted to prescribed medication, the cost of obtaining such drugs is likely to have sky rocketed.
Conversely, this scenario of desperation may not be replicated in those whom partake only in occasional recreational drug use. Staying at home may cause a decrease in social drug use from lack of opportunities to see friends, bans on festivals and parties, closure of nightclubs or because an individual is at home with their family. The rising use of video-based social gatherings could, however, trigger increasing drug use.
This complete disruption to normal life, however, could prove an opportunity for periods of abstinence and detox. There is an increased presence of information upon social media platforms reaching out to patients who may be suffering with drug addiction during this time. Many habitual drug users who are previously homeless have been accommodated in hotels, paid for by local councils, to protect them during COVID-19 pandemic (2). This has given many a well-needed source of stability with the opportunity to recuperate and achieve positive lifestyle changes. Community drug project workers have had an active presence in such hotels providing socially-distanced needle-exchange programmes, opiate substitute therapy, community naloxone provision and nursing staff to monitor those symptomatic of COVID.
This change in social circumstance may also have contributed to 56.6% fewer attendances to Emergency Departments (ED) in April 2020 compared to the same month in 2019 (3). High Intensity Users (HIUs), those whom attend ED more than five times per year, make up a significant proportion of this case load (4). Drug-related HIU attendances are likely are likely to have fallen in line with other non-COVID presenting complaints.
If analysis of current statistics proves a reduction in ED attendances related to drug use, including overdose, withdrawal, changes to mental health and death from drug toxicity, then there could be more evidence to increase funding and provision of services to this cohort of the population. And if that is the case, at least there is one small positive found at the end of the NHS rainbow.
1. https://digital.nhs.uk/data-and-information/publications/statistical/sta... ---- https://files.digital.nhs.uk/publication/c/k/drug-misu-eng-2018-rep.pdf
The courage with which emergency medicine specialists are responding to COVID19 crisis is admirable. They are in a situation similar to the battlefields of first World War. It is a protracted war unlike the disasters and tsunamis that we have faced in recent times. Lord Moran in his seminal book "The Anatomy of Courage" based on his WW1 experience of treating medical emergencies had noted that battle fatigue would set in the most courageous of soldiers after 30 days of trench warfare. This led to the deployment of battalions in formations, which provided relief to those in the front lines through planned rotation. This model may be useful in developing systems of rostering which provide planned periods of relief and recuperation for medics and paramedics manning the front lines of COVID 19 crisis.
Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an already extremely busy system, if those patients require acute attention it is important that they are appropriately referred. Similarly, there may be a number of patients with NEWS<5 who were unnecessarily referred to hospital; without outcomes data, conclusions about appropriateness of referrals cannot be drawn. In addition, in the West of England, where NEWS is used by GPs, admissions did not increase at any greater rate than elsewhere (3).
It is also suggested in the paper that a NEWS cut off of <5 could be used to reduce ‘low acuity admissions’; however, it is often appropriate to admit a patient irrespective of NEWS, for example someone with a stroke or crushing central chest pain. The Royal College of Physicians is clear that ‘NEWS should be used as an aid to clinical assessment- it is not a substitute for competent clinical judgement’ (4). Using NEWS promotes a full assessment of the patient and, if used at referral, is also a useful communication tool which helps the receiving hospital to recognise the patients that are deteriorating in the time frame between referral and arrival.
GPs have to make important and challenging decisions in a short time frame and formal actions should not be ascribed to NEWS in the community but instead there should be increased awareness that the higher the NEWS the more likely the patient is to be sick. Before NEWS, GPs would admit a patient and highlight the most extreme observations; perhaps the learning from this analysis could be that simply measuring observations is of limited value in identifying who needs admission and the aggregate nature of NEWS is better suited to identifying potential deterioration than high scores for a single vital sign(5).
1. Scott LJ, Redmond NM, Garrett J, et al. Distributions of the National Early Warning Score (NEWS) across a healthcare system following a large-scale roll-out. Emergency Medicine Journal 2019; 36:287-292.
2. Scott LJ, Redmond NM, Tavaré A, et al. National Early Warning Scores in primary care are associated with clinical outcomes. BJGP 2020, In press.
3. Pullyblank A, Tavaré A, Little H, et al System Wide Implementation of the National Early Warning Score Reduces Mortality in Patients with Suspicion of Sepsis. BJGP 2020, In press.
4. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. London: RCP, 2017.
5. Jarvis S, Kovacs C, Briggs J, et al. Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes. Resuscitation 2015, Volume 87, 75 – 80.
Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic d...
Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic dilatation, pericardial effusion or tamponade, and aortic valve regurgitation, warranting urgent definitive aortic imaging or transfer to expert centres(9). In particular, in the latter study "integration of[focused TTE] with D-dimer provided an exceptionally safe and fairly efficient rule-out criterion for AAS(acute aortic syndrome"(9).
I have no funding and no conflict of interest
(1) Greenslade JH., Sieben N., Parsonage WA
Factors influencing physicians' estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome
(2) Swan D., Hitchen S., Klok FA., Thachill J
The problem of underdiagnosis and overdiagnosis of pulmonary embolism
Thrombosis Research 2019;177:122-129
(3) Gimenez MR., Reiter M., Twerenbold R et al
Sex-specific chest pain characteristics in early diagnosis of acute myocardial infarction
JAMA Internal Medicine 2014;174:241-249
(4) Kukla P., Diugopolski R., Krupa E et al
How often pulmonary embolism mimics acute coronary syndrome?
Kardiologia Polska 2011;69:235-240
(5) Sandoval Y., Thgesen K
Myocardial infarction Type 2 and myocardial injury
Clinical Chemistry 2017;63:101-107
(6) Villablanca PA., Vlismas PP., Aleksandrovich T et al
Case report and systematic review of pulmonary embolism mimicking ST segment elevation myocardial infarction
(7) Amjad A., Ali A., Bashir A et al
Chest pain with raised troponin, ECG changes bu normal coronary arteries
BMJ case Reports 2014;doi:10.1136/bcr-2013-201975
(8) Yen K-H., Chang H-C
Massive pulmonary embolism with anterolateral ST segment elevation: electrocardiogram limitations and role of echocardiogram
Am J Emerg Med 2008;26:632.e1-632.e3
(9)Nazerian P., Mueller C., Vanni S et al
Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes
Eur Heart J 2019;40:1952-1960
PS please ignore my previous Rapid Response. This one is the definitive version