SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
Tuberculosis unmasked (Jul 2009)

Angie bounced into my room yesterday with a large smile on her face. She had recently "escaped" hospital after being admitted with pulmonary tuberculosis. Angie has been a patient for years and has multiple medical problems, recently compounded by homelessness.

Her first drug of choice had been alcohol from the age of 14 years, which she discovered helped numb the traumas of her abused childhood. She moved on to include heroin aged 18 years. She always smoked drugs and never injected. Then five years ago, she "found" crack.

Angie first presented to us in a dreadful state having been picked up by the outreach team in the area. She had refused to go to any drug services but agreed to give general practice a go! She arrived very underweight (BMI 15.1) with multiple burns on her fingers and lips and with a dreadful chest infection. We got her stabilised on methadone, treated her chest and gave harm reduction advice about how to smoke crack e.g. by using glass pipes.

She soon stopped all heroin, reduced her alcohol dramatically but continued with crack binges when she was offered or had the money. Angie described crack as the drug that she "couldn't live with, but couldn't live without". We continued to work with her on this and she had periods of minimal use, when she felt well and put on weight but then relapsed. We had her housed a couple of times but she always got asked to leave for simply not following the rules, so she preferred either the street or friends' sofas where rules didn't apply. She is an amazing and vibrant person who will have lots of friends.

Her chest remained a problem as she continued with at least 20 roll-ups a day and frequently smoking crack - but her chest X-ray was largely normal. Her weight improved with the help of food supplements and her energy returned.

There is a range of chest problems including breathing difficulties, developing or worsening of asthma, and "crack lung" when smoking crack, all made worse by cigarette or cannabis smoking. As cocaine has anaesthetic properties Angie could have been unaware of the damage being done due to fumes, the heat and foreign bodies. The action of the lung cilia can be reduced, leading to worsening lung function. This effect can make the crack user more susceptible to tuberculosis.

Tuberculosis (TB) has re-emerged as a public health problem in London, and people who use drugs, particularly crack smokers, are at high risk of contracting and spreading the disease. Angie's homelessness and poor nutrition put her at increased risk. TB is a bacterial infection; it is spread by inhaling tiny droplets of saliva from the coughs or sneezes of an infected person. Mycobacterium tuberculosis is the bacteria responsible for TB and is very slow moving, so a person may not experience any symptoms for many months, even years, after becoming infected. TB primarily affects the lungs (pulmonary TB). However, the infection is capable of spreading to many different parts of the body, such as the bones or nervous system. Typical symptoms of TB include a persistent cough, weight loss and night sweats.

Angie became acutely breathless one night and was rushed to hospital and TB was diagnosed. It is vital for people with TB to take medication daily to kill the infection and prevent resistance to the drugs developing. Angie was happily able to take the drugs daily with her methadone under supervision. Angie's pharmacist and the TB nurses have been amazing; frequently going the extra mile and Angie is well on the way to recovery. She has given up crack she says for good, saying "life is too precious to lose".

- Dr Chris Ford