A Nurse with Pethidine Addiction

Pethidine is a synthetic opioid substance with high addiction potential. It is commonly used in medicine pre and postoperatively to relieve the pain. A Pethidine addiction generally starts as iatrogenic and may be a problem for the clinicians when there is a real pain. Its opioid analgesic usage is legal, yet it is possible that it can be abused by the health care workers and addiction may become a frequent case. In order to attract attention to this issue a case of a nurse who was given pethidine after an operation to ease her pain and whom addiction is developed was presented. When the medicines with high addiction potential are given for the treatment, the patients must be followed closely in terms of addiction and drug abuse.


INTRODUCTION
Pethidine is a synthetic opioid substance with high addiction potential.It is a weak µ receptor agonist with clear anticholinergic and local anesthetic effects.Half life time is approximately three hours.Abstinence syndrome starts quickly and reaches the highest point at 8-12 hours (1).It is commonly used in medicine pre and postoperatively to relieve the pain.Pethidine, a narcotic analgesic, is beneficial especially for crisis with pain in sickle-cell anemia, trauma, in acute pains related to kidney and gallbladder colic (1)(2)(3).A Pethidine addiction generally starts as iatrogenic and may be a problem for the clinicians when there is a real pain (3).Although the effect of opioid analgesics in pain treatment is known, there are very few presentations about the psychiatric problems of these drugs and the fact that they can develop addiction (2,4,5).
Especially pethidine abuse by the health care workers is encountered commonly.The usage frequency among nurses and physicians is more than expected due to the easiness of prescribing the medicine (2,5).In a study conducted in our country, the most frequent addiction type among the doctors hospitalized for addiction was alcohol addiction and following it pethidine addiction was the second (5).
Its opioid analgesic usage is legal, yet it is possible that it can be abused by the health care workers and addic-tion may become a frequent case.In order to attract attention to this issue a case of a nurse who was given pethidine after an operation to ease her pain and whom addiction is developed was presented.

CASE
A 37 years old high school graduate widow nurse with two children applied to our clinic with pethidine abuse complaints.In the psychiatric interview it was found that the patient was given pethidine a few times to relive pain after a gynecologic operation postoperatively at the age of 31.She stated that she has used pethidine since then and she herself took it intravenously.She stated that she had no problems at first in finding the medicine.Since worked in general surgery department she asked the doctors prescribe it for her.However, at the end of that year, as she stated, she had problems in finding the medicine and she had to buy take the medicine since she had abstinence crisis at work place and stole pethidine from the clinic.She was punished by the hospital management for that reason.She said that at the second year of pethidine usage she was dismissed from her job and had to divorce from her husband due to problems.After leaving work, she tried to take pethidine illegally.A few times during visits to her friends she stole red prescription from clinic and had pethidine.Sometimes she lied that she had ovarian cancer and was hospitalized in various clinics and given pethidine.She has been using 500 mg daily for the last few months.She has not gone out of home and she could eat very little lately.In the first mental examination; conscious was open, co-operated and orient.She seemed older than real age.She appeared cachectic.Her self interest and care was low.Her speech was a little faster.Affection was dysforic.No psychotic finding was defined.
In the physical examination; height was 165 cm, weight 42 kg, echymoses related to injections done earlier were seen on the arms and venous veins in the legs.TA: 85/60 mmHg, Pulse: 135/min measured.She had light perspiration and shivering.These findings were evaluated as abstinence indications.She was hospitalized with the diagnosis of pethidine addiction.
Her blood biochemistry and hormonal examinations were normal.Hb: 9g/dl was defined in hemogram.There was sinus tachycardia in EKG.EEG was normal.30 mg/day diazepam was started and gradually decreased in two weeks and stopped.30 mg /day Mirtazapin was started.Blood pressure and pulse values, eating and drinking, sleeplessness were healed during clinic observation.At the fourth week of hospitalization she was discharged from hospital recovered.She did not come for the follow up after she was discharged.We learned that she started to use pethidine again and we learned that 6 months after she was discharged from the hospital, she died of overdose of pethidine.

DISCUSSION
Addiction and abuse of opioid analgesics is quite frequent (2).Pethidine abuse is generally iatrogenic (3,4).In addicted patients , it has been proposed that some factors such as cronic pain, bad relations between patient and treatment team, low threshold of pain, low tolerance due to anxiety and depression, inappropriate analgesic usage and abuse history may be effective (1).Another risk is groups like doctors and nurses that can easily reach the opioid analgesics thanks to their profession.It has been stated that health care professionals can find pethidine at work place, this was sometimes realized by their colleagues or managers and it has been also reported that sometimes without attracting the attention of the people they could abuse the drug at work place (2).It has been reported that since our case was a nurse, she could easily reached the medicine, had problems at work place and she was dismissed from work.
In researches when the usage of pethidine was compared to other illegal drugs, it was seen that pethidine usage is more frequent among women than men, frequently seen among middle aged, and more frequently seen among those married with children, and their education level was found to be higher.The reason of this is attributed to the fact the pethidine can be obtained with prescription, yet the other illegal drugs cannot.(2).Our case we presented was married, middle aged and had high education level.
Findings obtained from the studies by Hang et al. summarizes the things to be followed as follows: 1) suicide risk should be considered, 2) psychiatric disorders that accompany should be treated, 3) factors that cause vicious circle in pain control should be defined, 4) misconceptions on opioid analgesics among treatment team should be discussed 5) bad relation between the patient and treatment team should be recovered, 6) "addiction" is a critic diagnose that, if it is possible, should be avoided (6).There are presentations on Detoxification treatment (1,5).On the other hand further studies are needed that include long term treatment results.The case we presented only completed detoxification period, did not come to follow up later and started to use the medicine again.Though her death is tragic, it also reminds us commit suicide.
Consequently, abuse and addiction of opioid analgesics is frequent.Most of the cases that use pethidine generally start iatrogenically.Since health care professionals can reach the medicine easily, they have higher risk of addiction.When medicine that are potentially addictive and given for the treatment, the patients should be followed closely in terms of abuse and addiction.