Post-its from Practice:
Make no assumptions (May 2009)
Tony came to visit me a couple of months ago complaining of palpitations. He explained to me that the worst episode had been following a long night of drinking after a family celebration. I had known Tony for over 25 years, delivered two of his four children at home, supported him and the family through his wife's diagnosis of - and recovery from - breast cancer and many other family events. Such is the joys and privilege of old fashioned general practice.
I knew he drank too much and we had had many discussions about it including talking about his increased risk of heart disease, which was heightened due to a strong family history. But I had never asked him about, and he had never volunteered information about other drug use. Even when he presented with palpitations and "heavy night drinking" I didn't think of asking him about cocaine!
Tony returned to see me immediately after his appointment with the cardiologist to whom I had referred him after his ECG at the surgery had shown a slight abnormality. He said he thought he had better explain before I got the letter from the hospital. He informed me that he had been snorting cocaine on and off for four years. He had started using it when going through a difficult period with his wife but had managed to stop with the help of a counselor after one year.
This current episode had started nine months ago and he had been using about two grams per day. He had realised that he needed help again so after seeing me he had booked himself an appointment to go back and see the same counselor. Three weeks into counseling he was cocaine free and was motivated to stay that way.
People using cocaine can get a number of health problems including heart problems. Blood pressure can be increased and needs to be checked regularly. Cocaine use can lead to rhythm changes and/or arrhythmias, which if untreated can be fatal. The risk of arrhythmias increases greatly during binges, but reduces again during periods of low use/abstinence. Cannabis and cigarette smoking can increase these arrhythmias. Angina, myocardial infarct and congestive heart failure can result from reduced heart muscle function, increased heart size and arteriosclerosis of the arteries. Cocaethylene, formed by combination of cocaine and alcohol greatly increases the risk of heart problems, as well as sudden death, and increases the risk of suicide, accidents and the incidence of violence. Cocaine and alcohol can also both acts as disinhibiters and patients can find themselves in risky situations. When seeing patients with a combination problem both must be addressed (Ref 1).
After apologising for not asking him about drug use, I was interested to know and enquired why he had not previously told me about his cocaine use. For Tony it was all due to his shame and fear of what I might think of him, even although he knew I had an interest in working with people who have drug problems. From my side I was questioning whether I had made assumptions about his class and colour? Or had I just forgotten to think outside the box? Anyhow it was a good lesson for me to be reminded of, especially in the sex and drugs field, "make no assumptions"!
1. RCGP Guidance for working with cocaine and crack users in Primary Care by Chris Ford