Immunizations:

Because Barry has not been seen by a regular medical care professional for 10 years, and we are seeing him in November, I would recommend that he receive:

-Influenza vaccine – one annual dose

-Tdap booster – Barry is due for a booster, as he has not received regular medical care since he finished college at age 20, 10 years ago

-Hepatitis A – Due to Barry being transiently homeless, a man that has sex with men, and an injection drug user

-Hepatitis B – For the same reasons as Hepatitis A

However, Barry states that he received “a bunch of shots” from a free clinic a year or two previously, so we can assume he received some of these vaccines. It would be advisable to see if it’s possible to contact the clinic and see which vaccines he was given before proceeding.    

Screenings:

The USPSTF recommends the following screenings:

-Hypertension

-Obesity

-Tobacco Use and Cessation

– Depression

-HIV infection

-Alcohol Misuse

-Chlamydia and Gonorrhea infection – due to inconsistent condom usage and exchanging sex for drugs

-Hepatitis B infection – being an MSM, intravenous drug user

-Syphilis infection – exchanging sex for money, being an MSM

-Tuberculosis infection – being homeless or formerly homeless

-Hepatitis C infection – high risk sexual behavior, intravenous drug use

-Sexually Transmitted Infection Risk Factors – due to history of risky sexual behavior, exchanging sex for drugs, inconsistent condom usage

Health Promotion / Disease Prevention

Injury Prevention:

-Safe sleep environment

-Choking – Can be a risk when using heroin

Diet:

Barry seems to have a problem with unintentional weight loss and has not talked about what he typically eats every day. We can assume based on his lifestyle that most of his money is spent on drugs and not on quality food. He has mentioned that his clothes seem to be looser on him than before and on physical inspection his clothes seem too large for his frame. His BMI is 15.8 which is underweight, and so we should try to get him to focus on ways that would help him maintain a healthy weight. Barry’s drug dependence is almost certainly the cause of these problems, and so long-term solutions may not be viable unless he manages his drug usage. For Barry, I would recommend that he start by looking at the nutritional labels and content of the food that he eats, so that he can look for things that are more calorie-dense that might help him keep weight on. Because money and living conditions are a large obstacle in this case, I would recommend that he try and spend money on low-cost foods like rice, lentils, potatoes and broccoli, that are typically less than a dollar per pound. These can make a very filling and high calorie soup with some important micronutrients that he may be missing in his typical diet. The protein from the lentils can also help prevent muscle wasting¹ if he is spending a lot of time on the street or if he is incapacitated because of his drug use. If he is unable to cook food because of his living situation, I would try and direct him toward several of the soup kitchens and food charities around NYC, and if he has to consume fast food I would suggest that he try a place like Subway², that has a decent selection of meats and grains while avoiding many of the fried foods that one would find at other establishments. Most of all, I would recommend he try to be consistent with having meals two or three times per day, if he is using heroin first thing in the morning and then at night, this can create issues with meal timing, so it is important to remember to stay consistent.

Outline of a Typical Day’s Meal:

Breakfast: 8:30 AM – Oatmeal w/ banana – bananas are usually around 60 cents per pound, and oatmeal can be prepared with a microwave or just boiling water.

Lunch: 12:00 PM – Subway sandwich with turkey, cheese, and spinach, or the balanced meal at a place like Holy Apostles Soup Kitchen in Chelsea.³

Dinner: 6:30 PM – Soup with red lentils, potato, onion, rice, and broccoli with a tin of sardines or tuna– the total cost for all of these items should equal less than $5 and can make several portions.

1. Galvan, Elfego et al. “Protecting Skeletal Muscle with Protein and Amino Acid during Periods of Disuse.” Nutrients vol. 8,7 404. 1 Jul. 2016, doi:10.3390/nu8070404
2. Kirkpatrick, Sharon I et al. “Fast-food menu offerings vary in dietary quality but are consistently poor.” Public health nutrition vol. 17,4 (2014): 924-31. doi:10.1017/S1368980012005563
3. https://holyapostlessoupkitchen.org/meal-service-and-outreach/

Exercise:

Because Barry does not work a regular job, his ability to exercise consistently can be unpredictable. As of now he is underweight and typically spends his days shooting up heroin either alone or with friends, and if he earns money, it is sometimes by singing in the subway station which is not especially physically demanding. Because he likely leads a very sedentary lifestyle, I would recommend that he start his morning by taking a long walk around the block before he decides to use heroin. There are also public parks that have outdoor fitness equipment where he can do calisthenic exercises like pullups, dips, chin-ups and ab crunches. This can help him maintain some muscle mass and prevent further weight loss¹. Even moreso, exercising can create pharmacological effects in the brain that mimic drugs, like the release of endorphins² that can lead to feelings of relaxation and contentment. With a lot of and counseling, Barry may be able to channel his urge to use drugs away from heroin and may find that exercising can fulfill that need. I would recommend he continue to work at the garage more often and try and seek steady employment where he can be physically active, and if he is more occupied with work there will be less opportunities for him to abuse drugs.

Exercise Regimen:

Beginner progression of walking several blocks, and then walking to the park and  progressing to calisthenic training like:

-3 pull ups

-5 pushups

– 5 chin ups

– 5 ab crunches

From there, Barry can add more repetitions as he gets stronger. Some evidence suggests that as Barry exercises more frequently, his appetite will increase which will hopefully make him eat more and reach a healthier weight.

1. Effect of Progressive Calisthenic Push-up Training on Muscle Strength and Thickness

Kotarsky, Christopher J.¹; Christensen, Bryan K.¹; Miller, Jason S.²; Hackney, Kyle J.¹

The Journal of Strength & Conditioning Research: March 2018 – Volume 32 – Issue 3 – p 651–659

• Vina, J et al. “Exercise acts as a drug; the pharmacological benefits of exercise.” British journal of pharmacology vol. 167,1 (2012): 1-12. doi:10.1111/j.1476-5381.2012.01970.x

• Dorling, James et al. “Acute and Chronic Effects of Exercise on Appetite, Energy Intake, and Appetite-Related Hormones: The Modulating Effect of Adiposity, Sex, and Habitual Physical Activity.” Nutrients vol. 10,9 1140. 22 Aug. 2018, doi:10.3390/nu10091140

Harm Reduction:

I would recommend that Barry continue to try and use the needle exchange program if he continues to use heroin. Keeping needles in an iced tea container does not necessarily prevent them from becoming contaminated, and he should not be using drugs around other people that may use his paraphernalia without him realizing. I would also counsel him about safe sex practices, based on his history of inconsistent protection usage and having risky sex with strangers in exchange for drugs. I would then talk to Barry about overdose protection programs because of the frequency of his drug use, which is twice a day. I would ask him to try and limit the amount of cigarettes he smokes a day, typically 4-5, as much as is possible for him, perhaps only 3 per day. Lastly, I would ask him if it’s possible to cut back on his drug usage; instead of twice a day maybe once a day or every other day.

Brief Intervention:

Substance Use – I would conduct a brief intervention on Barry for his substance of choice, which is heroin. I would try going through the 5 A’s of substance use to try and determine if he is considering changing his habits and start working toward abstinence of drugs. The 5A’s are as follows:

Ask – I would ask Barry if he’s willing to discuss drug treatment options or the possibility of quitting. I could also ask him the CAGE screening questions to get him to start thinking about his lifestyle. “Would it be alright if we talked about your heroin use?”

Advise – If the answer is yes, I can recommend some therapy options, like cognitive behavioral therapy or family therapy, as well as drug treatment centers that can provide buprenorphine or methadone. “Do you want to have a discussion about some of the benefits of abstaining from heroin?”

Assess – “Okay, I see that you’re contemplating quitting, would you be ready to start today?”

Assist – “What do you feel like is stopping you from quitting and how can I help?”

Arrange – “I know some clinics that can provide you with medication if you’re willing to try it.”  

Smoking Cessation – These 5 A’s can also be adapted to smoking cessation, and I would ask him similar questions about whether he would consider quitting, what barriers might exist to him quitting, then we can discuss various treatment options like a nicotine patch.