Substance use disorder in the anaesthetist: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists.

Anaesthetists have a higher incidence of substance use disorder when compared with other doctors. This might be due to the ease of access to intravenous opioids, propofol, midazolam, inhalational agents and other anaesthetic drugs. Alcohol use disorder continues to be the most common problem. Unfortunately, the first sign that something is amiss might be the anaesthetist's death from an accidental or deliberate overdose. While there are few accurate data, suicide is presumed to be the cause of death in approximately 6-10% of all anaesthetists. If we are to prevent this, substance use disorder must be recognised early, we should ensure the anaesthetist is supported by their department and hospital management and that the anaesthetist engages fully with treatment. Over 75% of anaesthetists return to full practice if they co-operate fully with the required treatment and supervision.

Guidelines on suicide amongst anaesthetists 2019.

Anaesthetists are thought to be at increased risk of suicide amongst the medical profession. The aims of the following guidelines are: increase awareness of suicide and associated vulnerabilities, risk factors and precipitants; to emphasise safe ways to respond to individuals in distress, both for them and for colleagues working alongside them; and to support individuals, departments and organisations in coping with a suicide.

Validation of two survey diagnostic interviews among primary care attendees: a comparison of CIS-R and CIDI with SCAN ICD-10 diagnostic categories.

BACKGROUND: The most widely used survey measures in psychiatry, the Composite International Diagnostic Interview (CIDI) and the Clinical Interview Schedule-Revised (CIS-R) have generated estimates of psychiatric morbidity that show considerable variation. Doubts have been raised regarding the validity of these structured lay interviewer assessments. There have been no direct comparisons of the performances of these instruments against a common, established criterion. METHOD: A total of 105 unselected primary care attendees were each interviewed with CIDI, CIS-R and SCAN in a single sitting with random order of administration. SCAN was administered by a SCAN trained psychiatrist, and CIDI and CIS-R by a public health doctor. Concordance was estimated for all ICD-10 neurotic disorders. We assessed the overall discriminability of the CIS-R morbidity scale using a receiver operating characteristic (ROC) analysis. RESULTS: The concordance for CIDI for ICD-10 diagnoses was moderate to excellent (kappa= 0.58-0.97). Concordance for CIS-R ranged between poor and moderate (kappa = 0.10-0.65). The area under the ROC curve for the CIS-R morbidity scale with respect to any ICD-10 disorder [0.87 (95% CI 0.79-0-95)] indicated good overall discriminability, but poor sensitivity (44%) and high specificity (97%) at the usual CIS-R cut-point of 11/12. CONCLUSION: Among primary care attendees the CIDI is a highly valid assessment of common mental disorders, and the CIS-R is moderately valid. Previous studies may have underestimated validity. Against the criteria of all ICD-10 diagnoses (including less severe depressive and anxiety disorders) a much lower CIS-R cut-point is required than that which is usually advocated.

Factors contributing to the cause of a community outbreak of tuberculosis.

The diagnosis of pulmonary tuberculosis (TB) in a nursery teacher led to a total of 282 adults and children being screened for TB, and 67 of these contracted the condition. Latent and active factors mitigated against earlier diagnosis of the disease during the multiple contacts by the teacher with the healthcare system over 18 months. A series of barely inter-linked events meant that the system failed the patient and consequently the contacts who contracted the disease. The system errors were widespread and render possible a similar occurrence elsewhere.

Maternal drug use and length of neonatal unit stay.

AIMS: Infants with neonatal abstinence syndrome (NAS) may require a prolonged neonatal unit admission, which has implications for both their families and bed occupancy. The aim of this study was to test the hypothesis that the duration of neonatal unit stay would be influenced by the type of maternal drug use and particularly prolonged for the infants whose mothers had taken methadone with other substances. DESIGN: The medical records of infants born at term who were admitted consecutively to a neonatal unit because of NAS were reviewed. Data were collected regarding antenatal and neonatal factors likely to affect neonatal stay. Comparisons were then made between three groups of infants: those whose mothers took methadone alone, methadone plus other drugs or non-methadone opioids. SETTING: Level three neonatal intensive care unit. PARTICIPANTS: Forty-one infants with a median gestational age of 39 (range 37-42) weeks. FINDINGS: The 41 infants had a median duration of admission of 30 (range 3-68) days. Thirty-six of the infants required treatment for NAS; their median duration of treatment was 29 (range 6-68) days. The duration of stay and requirement for treatment were greater in the infants exposed to methadone and other drugs compared to those exposed to non-methadone opiods only (P = 0.0212, P = 0.0343, respectively). The duration of stay without requirement for treatment was also longest in the methadone plus other drugs group (P = 0.0117). CONCLUSIONS: Prolonged treatment and neonatal unit stay are influenced by the type of maternal drug abused.

Treatment of neonatal abstinence syndrome.

Neonatal abstinence syndrome (NAS) is suffered by infants withdrawing from substances on which they have become physically dependent after in utero exposure. They may require prolonged treatment and spend weeks or even months in hospital. A wide range of drugs have been used to treat NAS. The efficacy of few, however, have been adequately investigated. Evidence suggests that opioids are the most appropriate, at least in infants exposed to diamorphine or methadone. In all "head to head" trials, diazepam has been shown to be ineffective. Morphine and methadone are currently the most commonly prescribed opioids to treat NAS, but randomised trials have not been undertaken to determine which is the more beneficial. Many infants with NAS have been exposed to multiple substances in utero. Further research is required into whether a single opiate or a multiple drug regimen is the best option for such patients.

Hyperphagia, weight gain and neonatal drug withdrawal.

UNLABELLED: Hyperphagia, a classical feature of neonatal drug withdrawal, has been reported not to lead to excessive weight gain, but this is contrary to our clinical experience. The aim of this study was to determine whether infants with neonatal drug withdrawal suffered excessive weight gain because of hyperphagia and, if so, to determine the risk factors. The study population comprised 48 infants consecutively admitted to the neonatal intensive care unit, 11 of whom gained weight by more than 20 g kg(-1) d(-1) for at least 10 d (excessive weight gain). All 11 infants were hyperphagic (>200 ml/kg) for at least part of the excessive weight gain period. During the perinatal period, the 11 infants had a greater fluid intake (p < 0.01) but similar weight gain to gestational-age-matched, neonatal drug-withdrawal infants who did not suffer any excessive weight gain. Compared to the rest of the cohort, the infants with excessive weight gain were more likely to require treatment with morphine/chlorpromzaine (p < 0.05) and had a higher maximum withdrawal score (p < 0.01). CONCLUSION: Hyperphagia can lead to excessive weight gain in infants with neonatal drug withdrawal. Our results suggest that hyperphagia occurs in those who require treatment for severe withdrawal.

A review of shared care protocols for the treatment of problem drug use in England, Scotland, and Wales.

In 1995, the Department of Health instructed health authorities to establish protocols for the shared care of problem drug users. Response to this has been disappointing: 26 out of 120 health authorities have shared care arrangements in place, with the content of these differing widely.

A controlled evaluation of small-group education of general practitioners in the management of drug users.

We evaluated the effectiveness of small-group education of general practitioners (GPs) in the management of drug users. A total of 40 doctors were trained. Some 28 doctors who were unable to attend and 30 who did not want training participated as comparison groups. Sixteen months after the education, trained doctors notified significantly more drug users to the British Home Office database and more often prescribed methadone at first consultation with a drug user.

Characteristics of drug misusers and their perceptions of general practitioner care.

BACKGROUND: Little is known about drug misusers' views of the care they receive from general practitioners. AIM: This study set out to determine drug users' views about primary health care and their relationship with their general practitioners. METHOD: A semi-structured interview was conducted with 180 drug users who were consecutive attenders at five treatment services in north east London--a general practice with a special interest in treating drug users, a private drug clinic, a community drug team, a drug dependence unit and a street agency for drug users. RESULTS: The majority of the 145 London-based drug users attending the four treatment centres other than the general practice with a special interest were registered with a general practitioner (88%). Forty-two per cent of users sought out a general practitioner prepared to treat them, rather than register with a local or the family doctor. Most drug users reported that their general practitioners were aware of their drug problems (88%) but half of the general practitioners were not prescribing replacement drugs with almost 20% of the users not receiving prescriptions claiming that this was due to lack of knowledge or trust on the part of the doctor. Sixty per cent of the drug users attending the four centres perceived that their general practitioners held negative or neutral views about them. However, 34 of the 35 drug users interviewed in the specialist general practice believed their doctors had a positive view of drug users. CONCLUSION: Most drug users were registered with general practitioners but the relationship between doctor and patient was not always easy or productive. There is a need to clarify the role of general practitioners in this field and provide them with better educational opportunities.