Barry Anderson is a 30 year old man who has been injecting heroin for 10 years.  He has no medical diagnoses that he’s aware of, but has not had regular medical care since he finished college at age 20.   When he finished college, he worked in an online news company as a writer and reporter.  He had a drug habit while in school – mostly prescription pain killers taken orally –  but it became worse over the next 3 years as he moved on to sniffing and then injecting heroin.  He finally lost his job and eventually his apartment.   He now lives in a residence hotel a few blocks away when he can scrape enough money together to pay a week’s rent.  Sometimes he sleeps on the street or in an abandoned building that is also used by other people with nowhere else to go.  He is able to wash up in a bathroom in the local Dunkin Donuts, library or community based organization where he gets new, sterile syringes.  In really cold weather he sleeps at the local Salvation Army shelter, but he doesn’t like to go there because “they make you listen to a sermon – it could drive you nuts”.  He supports himself by doing odd jobs at a local garage or by performing on the street or in the subway station – he says, “I’m actually a pretty good singer so people give me money”.

 

He smokes cigarettes – “however many I can bum on the street” (he estimates 4 or 5 a day).  He drinks alcohol at times, “but my drug of choice is heroin”.  You ask him about his immunization history and he says he’s not sure, “I got a bunch of shots from a free clinic” last year or the year before, but he’s not sure which ones.  When asked about his heroin use, he explains that he tries to use clean syringes when he can get to the local syringe exchange program, but that he doesn’t always manage to get there on time so he usually saves one or two used ones “just in case”.  He keeps them in a wide-mouthed iced tea bottle “so they don’t get dirty or bent.”  He shoots up alone or with friends “depending on the day”, but says that he never shares needles or “works” (the cottons or cookers) with anyone.  He typically uses 2 times a day – “Once when I first get up and then in the evening before I go to sleep.”

 

He thinks that he’s lost some weight over the past year – he notes that his pants don’t fit as well as they used to and that when he got a new pair at the thrift shop, he needed to get a smaller size.  When asked about cardiorespiratory symptoms, he admits that he has a chronic cough and that he coughs up greenish phlegm most mornings.  He doesn’t think he has a fever.

 

He says he is sexually active mostly with women, but occasionally with men especially when he needs money for drugs.  He uses a condom when he has one, but says that he only gets them when he goes to the syringe exchange program for supplies or at the health department office.

 

 

Immunizations

• Inactivated Influenza Vaccine or Recombinant Influenza Vaccine – one dose annually until age 20, then possibly one vaccine per year at age 28 and 29.
• DTap, Tdap or Td: one dose of DTap as an infant, then one Td or Tdap booster @ 10 y/o, another one Td or Tdap booster @ 20 y/o, possibly another Td or Tdap booster @ 30y/o.
• Measles, Mumps, Rubella (MMR): 1 or 2 doses Varicella (VAR): 2 doses Zoster Recombinant (RZV): 2 doses Human papillomavirus (HPV): 2 or 3 doses
• Pneumococcal conjugate (PCV13): 1 dose Pneumococcal polysaccharide (PPSV23): 1, 2, or 3 doses Hep A: 2 or 3 doses
• Hep B: 2 or 3 doses
• Meningococcal A, C, W, Y (MenACWY): 1 or 2 doses
• Meningococcal B (Men B): 2 or 3 doses
• Haemophilus influenzae type b (Hib): 1 or 3 doses Screening

 

Screening Tests

• Blood Pressure Screening – Hypertension can be asymptomatic and people may not be aware of having high blood pressure. Smoking temporarily raises blood pressure because it is vasoconstrictive but overtime can lead to chronic hypertension.
• Cholesterol Screening – Smoking raises LDL levels and increase the risk of plaque buildup. Furthermore, it lowers HDL levels which is responsible for removing lipids from arterial walls.
• Diabetes Screening – About a third of diabetics are unaware that they have diabetes. Furthermore, Barry is a smoker which puts him at a higher risk of developing Type 2 diabetes compared to nonsmokers.
• Sexually Transmitted Infections – Mr. Anderson is sexually active with both men and women. He uses condoms only when its available.
• Bloodborne Infectious Disease Screening – Bloodborne infectious diseases like HIV, Hepatitis B, Hepatitis C, etc. should be screened. With the addition of being sexually active with men/women and using condoms occasionally, Mr. Anderson is a drug abuser and injects heroin into his system. He claims that he sometimes reuses syringes if he does not have a clean one available.
• Lung Cancer / COPD Screening – Mr. Anderson is a smoker. He reports having chronic cough and productive cough (green phlegm) in most mornings but no fever. Also, over the past year, he indicates notable weight loss.

 

Injury Prevention

• Safer Sex Education
• Needle Exchange Program
• Overdose Protection Programs
• Suicide Prevention

 

Harm Reduction

• Safer Sex Education – Mr. Anderson is involved in some risky sexual behavior which includes intercourse with multiple partners of both genders. Furthermore, he only uses condoms when they are available. Proper safer sex education is strongly recommended so that he may learn about the risks of contracting sexually transmitted infections (STIs), which are more susceptible when intercourse is with multiple partners. Condoms are effective at preventing certain STIs like herpes, chlamydia, and gonorrhea but they are not full proof against HIV and syphilis. The goal of educating Mr. Anderson on safer sex is to make him more aware of the health consequences of risky sexual behavior and encourage him to take steps to effectively avoid them.
• Syringe Service Programs – Mr. Anderson acquires his needle from the local syringe exchange program. However, he sometimes reuses his needles that are stored in an iced tea bottle. This is also a risky behavior because storing needles in non-sterile environments and reusing them will expose the needles to contaminants and can cause serious infections. It is recommended that Mr. Anderson engages more with the Syringe services programs because they offer so much more than just new, sterile needles. These programs offer “screening, care and treatment for viral hepatitis and HIV / education about overdose prevention and safer injection practices / referrals to social, mental health and other services” etc.
• Overdose Protection Programs – Mr. Anderson abuses heroin daily for 10 years. Overdose Protection Programs are great because they connect drug (opioid, heroin, etc.) users to get naloxone treatment which is used to reverse the effects of opioid abuse.

 

Brief Intervention

• Substance Use –  The course of the brief intervention for substance abuse will follow the Stages of-Change Model. Motivational interviewing will be used to help the transition from the precontemplation state to contemplation stage. This involves informing the patient that he is capable of slowly overcoming is heroin abuse with the help of intervention. Moving forward, preparing him for assistance by introducing him to helpful resources such as therapy and Overdose Protection Programs will be done. Afterwards, regular weekly to biweekly meetings will be conducted, once he participates in the resources and attempts to reduce his substance use, in order to follow up with his progress. Hopefully the brief intervention is successful and fewer follow-ups will be done for maintenance and to prevent relapse.

 

References

• “Safer Sex Guidelines.” Johns Hopkins Medicine, 0AD, www.hopkinsmedicine.org/health/wellness-and-prevention/safer-sex-guidelines.
• “Syringe Services Programs (SSPs) FAQs.”
• Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 23 May 2019, www.cdc.gov/ssp/syringe-servicesprograms-faq.html.
• “Useful Resources on Opioid Overdose Prevention.”
• SAMHSA, 0AD, www.samhsa.gov/homelessness-programs-resources/hpr-resources/useful-resourcesopioid-overdose-prevention.
• “Health Screenings for Men Ages 18 to 39: MedlinePlus Medical Encyclopedia.” MedlinePlus, U.S. National Library of Medicine, 0AD, medlineplus.gov/ency/article/007464.htm.
• “Safer Sex Guidelines.” https://www.hopkinsmedicine.org/health/wellness-andprevention/safer-sex-guidelines Center for
• Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Rockville (MD): Substance Abuse and
• Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 34.) Chapter 2—Brief
• Interventions in Substance Abuse Treatment. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64942/