cocaine guidance - Royal College of General Practitioners

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13Guidance for working with cocaine and crack users in primary careUsers of cocaine/crack and alcoholWhen a patient uses alcohol with cocaine, cocaethyleneis produced. This is dangerous as it is toxic and canincrease the risk of liver and heart disease, fits andepilepsy. The risks of sudden death, suicide, accidentsand violence are all increased. When seeing patients witha combination problem both must be addressed. Cocaineand alcohol can also both act as disinhibiters and patientscan therefore place themselves in dangerous situations.Users of cocaine/crack and cannabisHeavy cannabis use, particularly high content THC variants,such as skunk, may exacerbate the tendency of crackto produce paranoid ideation.Users of other drugs such as ketamineand sildenafil (Viagra)Ketamine and sildenafil can complicate the effects ofcrack on the central nervous system. Users usually knowthe short-term effects of the drugs they are using but areoften less careful about long-term effects. Using crackwith ketamine, which is a disassociate anaesthetic, is agood example of a poorly researched problematiccombination. Sildenafil and crack may be less rewardingfor users than it promises, and may also causecardiovascular problems. Crack has aphrodisiac qualitiesand promotes disinhibited sexual behaviour in bothgenders. However, in males it can act as a performanceinhibitor, as well as reduce vaginal secretions in women.Sildenafil promotes and prolongs erection but the mix ofdrugs can frustrate orgasm. This may result in violencedirected at a person selling sex.Different types of user communitiesBlack and minority ethnic groupsCrack use is often associated in the media particularlywith black people and the stereotype of a crack user issteeped in historical racism. In reality many differentpeople from all communities use cocaine/crack.Even so, concerns about the spread of crack useand its impact on the communities have been expressedby many African Caribbeans, as well as concerns overthe patchy coverage of services that can meet the needsof these users. It is crucial to develop services to meetthe needs of diverse communities. It is also important tounderstand how a combination of factors that characterisethe lives of many BME people, in particular, risk factorsthat revolves around social exclusion and deprivation,means that the context within which drug use existsprovides an environment in which it can be particularlyproblematic.The basics of treatment in primary care are the same forany patient but those primary care services treating usersfrom different cultural backgrounds need to be aware ofthis issue and how it may impact upon the user, staffand the service itself. It is not an issue that can beadequately addressed unless there is understanding, andservices will need to give consideration to serviceaccessibility, appropriateness of service and potentialbarriers to service utilisation.Specific black and minority ethnic groups health issuessuch as sickle cell anaemia can also be exacerbated bythe use of crack and cocaine.Young peopleThere is a changing image of cocaine among youngerpeople with a new trend towards mixing drugs,particularly in the dance drug culture. As with all patients,when a young person presents, it is important to addressthe individual and not solely the drug(s). Confidentialityand respect are essential.If the young person is under 16 years, they should bereferred to a specialist young person’s service. If they areunlikely to attend, then it is reasonable to use the FraserGuidelines. These allow treatment to be provided to ayoung person if he/she understands the advice, hassufficient maturity to understand what is involved, andthe doctor cannot persuade the young person to informparents or allow the doctor to inform them. 16When seeing a young person alone, take a history,and assess and discuss harm reduction in the same wayas with other patients. Provide written advice that isappropriate. Be aware that they may use languagethat you don’t understand, so ask them to explainwhat they meanOther patients who are using the drug safely can behelpful in explaining the safer use of cocaine, but careis needed to avoid young people being introduced intocircles that may cause them further harm.
Guidance for working with cocaine and crack users in primary care 14Women, pregnancy and childprotection issuesWomenLike any chaotic drug use, crack can disrupt the menstrualcycle mainly through poor general health and chaoticlifestyle. Offer contraception and remember to explainthat some drug-using women may not be having periodsor be eating well, and could be under the impressionthat they cannot or are unlikely to get pregnant. This isuntrue and needs to be made clear. Many women mayalso have drug-using partners who need treatment andit is always better to provide help and treatment to bothat the same time.Women are likely to use primary care services for supportand advice, so we are well placed to provide guidanceon safer drug use and good sexual health.Use in pregnancyPregnant women need good information about crackand its effects to allow them to make choices.Confidentiality is essential and outcomes improve withconsistent advice, support, reassurance, integrated careservices and consistency of attendance.There is quite a lot of information but most of it is oflimited value and can be conflicting but there is a risk,especially compared to opiates in pregnancy, and sufficientreason for concern. 17There is some evidence that suggests there is a linkbetween stillbirths, miscarriages through placentaldetachment (placenta abruptio), premature labour anddelivery and low birth weight and small-for-dates babies,though this may reflect lifestyle and smoking rather thana direct effect. Placental abruptio and pre-term ruptureof membranes are the only confirmed problems associatedwith cocaine use. Placenta abruptio, if it occurs after 24weeks would result in pre-term labour not miscarriage.Abruption does not inevitably result in delivery at the time;this depends on the extent of the abruption and may ormay not result in the death of the fetus.Approximately one quarter to one third of the cocainewill pass across the placental barrier to the foetus, whichmay lead to agitation and apnoea initially at birth. Mostof these symptoms will settle by comforting the babyand avoiding loud noises or bright lights. The ‘crack’baby image is a myth.Heavy cocaine use is likely to be incompatible withsuccessful breast-feeding so, if breast-feeding is successful,cocaine use will not be too high to allow it. Consequentlythere is no reason why cocaine using women should notbe encouraged to try breast-feeding since their morevulnerable babies have most to gain from it.A review in 2002 showed little evidence of damage inbabies and children aged up to 6 years, 18 but otherstudies show subtle but consistent changes in childrenaged 6 to 7 years. 19 A controlled study published in 2002found cocaine-exposed children were twice as likely toshow delay in cognitive development by theage of two as a control group. 20Some children born to crack-using mothers havedisplayed seizures or strokes, cerebral palsy, mentalretardation, vision and hearing impairments, urinary tractabnormalities, autism and learning disabilities. These areall rare and it is unhelpful to frighten mothers. Forcingpeople into abstinence rarely works. However, it is awoman’s right to have this information.Child and family issues and child protectionThe Advisory Council on the Misuse of Drugs report‘Hidden Harm’ includes much valuable information andadvice about the problems faced by children of drugusingparents. 17 GPs and other primary care workers canplay an important part in providing professional supportto parents and should apply the normal criteria in decidingwhether a child might be at risk. Cocaine use per se isnot a reason for assuming a child is at risk, but the lifestyleand problems associated with such use may be.Extensive crack use can disrupt the relationship andbonding between the mother and infant, as attention isprimarily on the drug rather than the child and can leadto development and emotional problems.Primary care can work with Social Services to providea package of care for the parents. Consult with allcolleagues involved with the family and identify any currentor potential problems. As always, it is important to behonest and open with parents, particularly about socialservices role and involvement.What we do know is that childcare is improved if parentsare in appropriate drug treatment. Stability in the familyis important and child protection is paramount.Early involvement of Social Services may prevent thelater need for care proceedings. Also lack of accessby a parent to their children may trigger problems andbreakdown in relationships. There is also increasedfrustration if parents are referred for help, and none isthen forthcoming.Remember that our responsibilities to the children of ourpatients, in the family environment are the same as ourresponsibilities to our patient.All women should be encouraged to breast-feed except,currently, those who are HIV positive.
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cocaine guidance - Royal College of General Practitioners

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