This site is intended for health professionals only

Do or do not, there is no try. Helping Paul find the Force

Janet Webb
BSc(Hons) RGN
DipN(Lond)
Practice Nurse Lindum Medical Practice
Lincoln

Paul is 28. He visited the GP at our practice, who has a special interest in substance misuse, to request treatment for his heroin addiction. He joined the methadone programme and was referred to the local unit to be listed for inpatient detoxification. He was also referred to me for management of his leg ulcers. He had not been seen before by a practice nurse despite having had the ulcers for about a year.
Paul has a long history of addictive behaviours. He has smoked tobacco, injected heroin and used alcohol and benzodiazepines in the past, all of which have contributed to occasional homelessness, a prison sentence, thrombophlebitis and repeated venous thromboemboli (VTE), for which he is now taking warfarin. He does not regularly attend the INR clinic. The varicose and thrombosed veins in his legs have led to two shallow but sloughy, heavily exudating and clinically infected ulcers on his right calf, which he estimates started about a year ago. He has had at least five courses of antibiotics but suffered steady deterioration. After his latest VTE, the hospital arranged a community nurse follow-up for dressings. He claims no visits were made, yet his case notes record repeated failure to find him at home. He has therefore been dressing the ulcers himself with Inadine (Johnson & Johnson) and Melolin (Smith & Nephew).

"Smackhead waste of space"
Paul had a long list of complaints about all aspects of his treatment by the police, the prison service, the
hospital, the ambulance service and the surgery. He had low self-esteem and said he had expected to be criticised, lectured and treated as a "smackhead waste of space". He held a dim view of general nurses, having had most contact with psychiatric nurses and prison nurses. He detailed his thoughts while I removed his dressings, cleaned the ulcers and surrounding skin, measured the ulcers, took swabs for culture and sensitivity, and applied emollient to the dry and flaky haemosiderin staining, typical of venous hypertension.(1) He included me in his complaints when he learned that I would not prescribe yet more antibiotics until I had the microbiology result.
With his rapid, repetitive speech and frequent changes of subject I wondered whether he was taking amphetamines as well as the prescribed methadone. Polydrug use is extremely common, and as part of the methadone programme he would need to abstain from opiates while awaiting residential treatment. Random urine testing detects heroin for one to three days and alcohol for 12-24 hours after consumption. Because methadone, heroin and alcohol are all respiratory depressants, even if all are taken at sublethal levels the cumulative effect can be fatal. Methadone is safe by itself, however, and is highly effective in preventing six out of seven heroin-related deaths.(2)
With a characteristic change of subject, Paul asked: "Am I doing your head in?" I replied in the affirmative and he grinned, then noticed a picture of Yoda, renowned Jedi Master from the Star Wars films, and asked why it was there. I explained that I find Yoda's quotation, "Do or do not, there is no try", motivational (see www.starwars.com).
I used Doppler ultrasound to establish that Paul's dorsalis pedis and posterior tibial pulses were present but monophasic, and I advised him to stop smoking. His foot and toes were pink and warm with normal capillary refill, so I dressed his ulcers with a nonadherent, an absorbent dressing, then layers 1 and 4 of the Profore compression system (Smith & Nephew). I did not measure Doppler pressures but referred him to the leg ulcer clinic for specialist advice. I was proceeding with gentle compression since Paul was in a great deal of pain from the ulcers, which seemed to be venous in origin. The need to avoid opiates and interactions with the warfarin would present problems with pain relief. He was currently taking indometacin, having had no relief from paracetamol or nefopam. To further complicate matters, lack of sleep is a feature of methadone maintenance and might further lower his pain threshold.(3)

"There is no try …"
By now Paul was telling me that he had twice before gone through detoxification, once successfully completing it only to relapse, and once having discharged himself midway through the programme. This time, he said, he was really going to try, and then he stopped and asked me to repeat the Yoda quote. I did so, explaining that Yoda had become annoyed with Luke, who had said he would try. He was told there is no "try": you either do or you don't. Sometimes motivation can come from an unexpected source, or perhaps when a person is ready to be motivated a source will be found.
The Stages of Change Model is often applied to addictive behaviour and the desire to change.(4) Describing a cyclical pattern of precontemplation, contemplation, action, maintenance, relapse and return to precontemplation, people enter or leave the cycle like a revolving door. Relapse is acknowledged to be common when changing addictive behaviour and is all part of the cycle; it is not regarded as failure since re-entry to the cycle is always possible. I feel Paul's encounter with Yoda helped him move from thinking about to committing to change - from the contemplation to action stage. He repeated the quotation to himself and seemed to like it.
Changing a behaviour that has been such a large part of one's life is not as simple as moving to the next stage of a model, however. Evidence suggests six requirements for successful change: the change must be self-initiated, timely and relevant, part of a new way of life and easier to maintain than the old behaviour; the old behaviour should not be a coping mechanism or "comfort blanket"; life should be stable and unproblematic; and social and/or family support should be available.5 Paul had requested the treatment; he was bored with the "getting stoned, getting nicked, getting sacked" scenario and now had a steady girlfriend with no interest in the drug scene. He had a flat near his mother's house and was having little contact with his old social circle. He had the promise of a job if he could prove himself reliable and sober. Things were beginning to look good for him.

Responsibility
Over the course of his appointments it was heartening to see his personality emerge as the drugs were left behind. He was given an admission date for detoxification; he had chosen diazepam after reducing the methadone and would be discharged on rapidly reducing doses of this. He was keen to take over his own wound care in preparation for this. The swabs had shown a heavy growth of group G Streptococcus and Staphylococcus aureus, for which I prescribed clarithromycin at a dose of 500mg 12-hourly for two weeks,6 and the ulcers were visibly improving, although still very painful. He would manage compression better by changing to a double elasticated tubular bandage, and quickly became proficient in aseptic technique, frequently muttering Yoda's quotation as he worked. He finished the antibiotics two days before admission. Repeated swabs showed a light growth of Staph aureus, and I prescribed flucloxacillin 250mg for a week.(6)
He had benefited enormously from being given the responsibility for his own care; teaching him aseptic technique, handwashing and the principles of cleaning surfaces before and after dressing meant working closely with him and interacting at a level that respected his intelligence while allowing space for his sense of fun that he had not expected. It also allowed for much more health promotion than he would probably have engaged otherwise, including the importance of healthy eating, recipes and snack suggestions that would increase his vitamin intake and promote healing, exercise and smoking cessation that would help his circulation, attention to hygiene and prevention of cross-infection in the home.
Addiction to opiates often becomes chronic, even for physically dependent users who have abstained for more than a year. Paul's problems would not be over once he had been through the detoxification process, but with his past experience he was well aware of this. He will undoubtedly need to use us again for various health needs, and he needs to know we will help.
Paul rang to arrange a dressing review after leaving the unit, almost a month after admission. He sounded upbeat, saying, "Me and Yoda. Hey!"

References

  1. Hopkins A. Leg ulcers: assessment and management plan. NiP 2005;25:78-83.
  2. Beaumont B, editor. Care of drug users in general practice. 2nd ed. Oxford: Radcliffe Publishing; 2004.
  3. Wolff K. Sleep management and methadone. Network 2006;15:15.
  4. Prochaska J, DiClemente C. In: Katz J, Peberdy A, editors. Promoting health: knowledge and practice. London: Macmillan; 1997.
  5. Naidoo J, Wills J. Health promotion: foundations for practice. London: Baillière Tindall; 1994.
  6. BNF 51. London: 2006. Available from http://www.bnf.org