Post traumatic stress disorder with “street benzo” use

Background (age, sex, occupation, baseline function)

• 32-year-old male
• Currently unemployed

History of presentation/reason for review

• Requesting diazepam for ongoing sleep problems

Current medical history and relevant co-morbidities

• No mental or physical health comorbidities recorded in notes

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions: nil

• Currently no prescribed medication. Takes street benzodiazepines.
• Previously prescribed dihydrocodeine for pain related to injuries from assault (broken ankle). On discharge he received a further two weeks’ supply. He did not attend physiotherapy appointments

Over the counter medicines: Solpadeine Max® (codeine 12.8mg and paracetamol 500mg)

Lifestyle and current function

• Single, no dependents
• Lives alone
• Alcohol – current intake is around 30 units week, has been trying to reduce intake

“What matters to me” (ideas, concerns and expectations of treatment)

• Keen to have a safe option to control symptoms, reduce street benzos, and OTC co-codamol use

Observations, examinations and results 

Note: local laboratory reference ranges may vary

• No recent bloods or tests

Most recent relevant consultations

During the consultation:

• When discussing his sleep routine, he avoids going to bed because he has increased anxiety, with flashbacks and recurring nightmares related to a serious assault last year
• He states his emotions are “all over the place” making him feel “out of control” and that he has memory problems. He explains the assault has triggered memories of trauma earlier in his life.
• He confirms that he still experiences some pain from the assault and started to buy OTC co-codamol to help manage this
• By providing a safe place where his concerns are acknowledged, he discloses taking street benzodiazepines and Solpadeine Max® with alcohol, in increasing doses, which helps block out overwhelming thoughts and feelings. He visits various pharmacies to buy the co-codamol, as some refuse the sale due to the frequency of requests
• He reports that his mood is low with fleeting thoughts of suicide. However, he confirms he does not have any immediate suicidal plans and protective factors, include his family and friends
• He becomes more tearful and agitated when discussing polydrug use. He is aware of risks having witnessed a friend’s non-fatal overdose and thought a prescription might reduce the risks with street drugs and OTC medicines

Person specific issues to address

• Reduce avoidable harms from street drugs, OTC medicines and alcohol use
• Manage pain from previous assault-consider trauma informed approach

 

Person specific issues to address

• No drugs considered essential
• Although not essential, street benzodiazepines, alcohol and OTC co-codamol should not be stopped suddenly – see below for risks. He requires support to safely reduce his use. Referral to specialist service and/or third sector partner 

 

Person specific issues to address

• Having checked his understanding of the current risks, he is offered further harm reduction advice in relation to his benzodiazepine, alcohol and co-codamol use 

 

Person specific issues to address

• Work with specialist service to develop a shared care plan for him which may include prescribing for alcohol detox, relapse prevention and appropriate vitamins, diazepam detox and opioid substitution therapy (OST)
• Pain to be discussed in greater detail at follow up appointment, explaining the difference between acute and chronic pain 

 

Person specific issues to address

• Discuss increased overdose risk with the combination of benzodiazepines, alcohol and opiate (co-codamol)
• Need for appropriate harm reduction strategies including dose reduction. Advice includes:
  • avoid buying larger quantities of benzodiazepines to limit the risk of an overdose
  • splitting doses throughout the day to avoid discontinuation/withdrawal symptoms
  • keep a note of how much and how often he takes
• Opioids: supply take home naloxone kit 
• Benzodiazepines: discuss risk associated with street supply - purity and strength are unknown
• Alcohol: discuss risk associated with alcohol consumption.AUDIT score of 20 indicates specialist referral required
• Paracetamol: discuss the possible effects on his liver from co-codamol use above recommended doses for a prolonged period of time
• He must not drive if he is unfit to do so, because he has taken medication or street drugs

 

Person specific issues to address

• No prescribed medication

 

Agreed plan

• Gradual reduction of street benzodiazepines, OTC co-codamol, alcohol intake whilst considering specialist input
• Referral offered to specialist drug and alcohol service, discussed and encouraged, but reluctant to engage at this time. He agrees to attend a local third sector drop-in
• Naloxone trained and has a kit. Advise where friends and family can obtain a kit 
• Discuss worsening symptoms and possible increasing self-harm/suicide risk. Give out of hours telephone numbers, e.g. Breathing Space, Samaritans, NHS 24
• Written information provided to support discussions
• Follow-up appointment in seven days’ time for ongoing pain management, and check if attended third sector drop-in. Discuss specialist referral again