Substance Abuse Case File
Eugene C. Toy MD, Donald Briscoe, MD, FA AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA AFP, FACG
Case 41
A 20-year-old female college student is brought to the emergency room complaining of chest pain that started 45 minutes ago. She describes the chest pain as substernal, 10/10 in intensity, radiating to her jaw, and associated with headache, sweating, nausea, and palpitations. She was given oxygen, aspirin, and nitroglycerin by the emergency medical services (EMS) in route to the emergency department (ED) and received morphine on her arrival to the ED. The patient is accompanied by her roommate who mentioned that the patient came back from a concert about an hour ago and complained of feeling nauseated, anxious, and somewhat paranoid. The patient has no history of health problems and has not had similar episodes in the past. She is currently sexually active with one male partner and takes oral contraceptive pills (OCPs) for birth control. She reports drinking alcohol and smoking cigarettes occasionally. On questioning about use of illicit drugs, she hesitates, then says that she drank"a few beers,' smoked "a few joints;' and "took a capsule" at the concert. She swears that this is the first time she has used any illicit substances.
On examination, she is anxious and restless with heightened alertness. Her temperature is 101.0°F (38.3°C), pulse is 119 beats/min, respiratory rate is 24 breaths/min, blood pressure is 165/90 mm Hg, oxygen saturation of 97% on room air, height is 60 in, and her weight is 100 lb. Eye examination reveals dilated pupils bilaterally with sluggish light reflex along with occasional twitching of her right eye. Extraocular movements were found to be normal. Her heart examination reveals tachycardia with no murmurs. Respiratory examination reveals tachypnea with shallow breathing but lung fields are clear to auscultation. Neck is without carotid bruit or jugular venous distension. Distal extremity pulses are brisk and symmetrical. The remainder of her examination is unremarkable.
⯈ What are the differential diagnoses for this case?
⯈ What is your first diagnostic step?
⯈ What is the next step in management of this patient?
ANSWER TO CASE 41
Substance Abuse
Summary: A 20-year-old female college student with no significant past medical history presents to the ED with symptoms of coronary ischemia and other symptoms that signify increased sympathetic activity after drinking alcohol and smoking and ingesting unknown substances.
- Differential diagnosis: Cocaine-induced myocardial ischemia, cocaine- and ecstasy-induced mental status changes (eg, anxiety, paranoia), panic attack, cardiac arrhythmia, and pulmonary embolism.
- Next diagnostic step: 12-lead electrocardiogram (ECG), markers of myocardial damage including serum troponin I, creatine kinase (CK), and MB isoenzyme (CK-MB) performed STAT, urine toxicology screen, blood alcohol level, comprehensive metabolic panel (electrolytes, glucose, kidney and liver function tests), complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), and a chest x-ray (CXR).
- Next step in management: The initial management of this patient will be the same as for any other patient presenting with acute chest pain, as she should be placed on telemetry and oxygen. Airway, breathing, and circulation should be ensured followed by administration of aspirin, sublingual nitroglycerin, and morphine. β-Blockers should be avoided initially, especially if cocaine intoxication is suspected, due to risk of unopposed α-constriction that can induce ischemia. Ruling out acute coronary syndrome with serial ECG and cardiac enzymes should occur every 8 hours over three intervals. She should be monitored closely for mental status changes, and withdrawal symptoms of potentially ingested illicit drugs.
ANALYSIS
Objectives
- Know the etiology and epidemiology of substance abuse.
- Know the most commonly used illicit and prescription drugs, their adverse and toxic effects, and the amount of time they remain in a patient's system.
- Know the screening tools available, history taking, physical examination, and laboratory findings in patients with suspected illicit substance intoxication and substance abuse disorder.
- Know the medications available to control acute toxicity and withdrawal symptoms, as well as treatment and relapse prevention.
- Know the different behavioral therapies available for treatment of substance abuse.
Considerations
This is a healthy, young female who presents with acute chest pain unrelated to respiration and position but associated with nausea, fever, tachycardia, tachypnea, anxiety, heightened alertness, paranoia, and mydriasis. The events preceding her arrival include ingestion of alcohol and other likely illicit substances that might have caused her to have chest pain. After ruling out the cardiac causes of chest pain, it is very important to screen for signs and symptoms of acute illicit drug intoxication and drug abuse in this patient. Urine toxicology screening is performed to detect the most commonly abused illicit substances and if found positive, is an indication of recent substance use. When people consume two or more psychoactive drugs together, such as cocaine, ecstasy, and alcohol, the danger of experiencing adverse effects of each drug is compounded. In this patient, the history and physical examination suggest that she may have used combination of cocaine and alcohol which may have led to the formation of a third substance, Cocaethylene, which intensifies cocaine's euphoric effects. Cocaethylene is associated with a greater risk of coronary vasospasm than cocaine alone, resulting in myocardial ischemia and sudden death.
Approach To:
Substance Abuse
DEFINITIONS
SUBSTANCE ABUSE: A maladaptive pattern of substance use leading to clinically significant impairment and ongoing use in spite of professional ( eg, poor work or school performance), legal (eg, driving under the influence [DUI]), or interpersonal (eg, erratic behavior, fights, relationship losses) consequences.
SUBSTANCE DEPENDENCE: A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by the development of drug tolerance, withdrawal symptoms, inability to cut down on use and use despite the development of physical or psychological problems caused by the substance.
RELAPSE: Resumption of illicit drug use after an attempt or multiple attempts to quit.
DETOXIFICATION: A process that enables the body to rid itself of a drug.
CLINICAL APPROACH
Every year, the abuse of illicit drugs and alcohol rises. In 2012, drug overdose was the leading cause of injury death among people aged 25 to 64, causing more deaths than motor vehicle accidents. The drug overdose rate has more than doubled from 1999 to 2013. In 2013, 81.1 % of the nearly 44,000 drug overdose deaths in the United States were unintentional, 12.4% were linked to suicide, and 6.4% were of undetermined intent. In 2011, drug abuse accounted for 2.5 million emergency department visits, with over 1.5 million of these cases attributable to prescription drugs. As of 2012, the percent of US persons of age 12 or older with illicit drug use in the past month (9.2%) or marijuana use in the past month (7.3%) was greater than previous years.
Primary care physicians are well positioned to identify patients at risk for drug abuse early in the course. Since addiction and dependence are equal opportunity afflictions, physicians should screen all new patients for substance abuse. Abrupt changes in behavior or functioning of the patient should also stimulate the physician to screen for substance abuse. As with many other chronic illnesses, early recognition and management of the substance abuse leads to better outcomes.
ASSESSMENT
Expectations From Substance Abuse and Reward Pathway
Several survey-based studies have shown that people abuse drugs to feel good, to get energy, to do better in school and work, and in some cases, due to curiosity. A feeling of euphoria is associated with all commonly abused drugs. The initial euphoric phase is followed by other effects, which differ with the type of the drug abused. With stimulants such as cocaine, ecstasy, and phencyclidine (PCP), the "high" is followed by overexcitement, and feelings of power and self-confidence. On the other hand, relaxation and satisfaction follow the euphoric phase in individuals abusing opiates. Thrill seeking, risk taking, and curious behavior, especially in the adolescent population, play a key role in initial experimentation and continued substance abuse.
The presence of a reward-reinforcement pathway is thought to be the cause of repeated self-administration of drugs to achieve the desired effects. The ventral tegmental area, nucleus accumbens, and frontal cortex of the brain form the stimulant, alcohol, sedative, and hypnotic reward pathway. The periaqueductal gray area, arcuate nucleus, amygdala, and locus coeruleus form the opioids reward system. These pathways are mediated by dopamine, y-aminobutyric acid (GABA), and certain other peptides.
Etiology and Risk Factors
Vulnerability and affinity to addiction differ from person to person and is considered multifactorial in origin. Factors include gender, ethnicity, developmental stage, and socioeconomic environment. Genetic susceptibility accounts for between 40% and 60% of a person's vulnerability to addiction. Populations at increased risk of drug abuse include adolescents and persons with psychiatric disorders.
Epidemiology
According to the 2009 National Survey on Drug Use and Health, marijuana was the most commonly abused drug followed by psychotherapeutic medications. Marijuana is now legal in several states for medicinal or recreational purposes, which may increase the likelihood for abuse and dependence. Daily marijuana use has increased to 8.1 million Americans in 2013. The highest rate of use was among 18- to 25-year olds and males were more likely than females to be users of several different drugs. The highest rates of use were seen among American Indians or Alaska Natives followed by African Americans, Caucasians, Hispanics, and Asians. The rate of drug use was lower for college graduates than for those who did not graduate from high school. However, adults who had graduated from college were
more likely to have tried illicit drugs in their lifetime than adults who had not completed high school. The rate of illicit drug use was higher for unemployed persons compared to those who were employed. The rate of current illicit drug use was approximately nine times higher among youths who smoked cigarettes than who did not. Among youths who were heavy drinkers, 69.9% also were current illicit drug users. Table 41-1 includes the most commonly abused substance categories, street names, route of administration, intoxication effects, and potential health complications.
History
Currently, the United States Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. This statement does not imply that clinicians should not screen patients for illicit drug use, but that there is a lack of evidence to determine the utility of screening. A few brief, standardized questionnaires have been shown to be valid and reliable in screening adolescent and adult patients for drug use/misuse.
Most clinicians perform alcohol and drug abuse screening as part of their routine social history. Electronic medical records often require this data to meet meaningful use criteria. If an individual is identified as having a substance abuse disorder, the history should be geared to determine what, how, and when the patient is using the drug. Information about co-occurring psychiatric or medical conditions and a personal or family history of substance abuse should be obtained. The clinician should ask open-ended questions and should remain nonjudgmental, respectful, and empathetic at all times. Information should also be elicited about health, family, social, career, financial, and legal impacts of the drug use.
Physical Examination
Some findings on the physical examination may aid in the diagnosis of illicit drug use. Eye examination is crucial, especially in an unconscious patient suspected to be under the influence of drugs. Dilated pupils may indicate stimulant or hallucinogen use or withdrawal from opioids. Constricted pupils are a hallmark of opioid use. Physical examination can also reveal damage to nasal mucosa or septum perforation due to insuffiation, injection "track marks;' or sequelae of cirrhosis due to viral hepatitis or alcohol abuse including spider angiomas, caput medusa, hepatomegaly, and/or ascites.
Laboratory Examination
Several laboratory tests are available for determining the presence of alcohol and other drugs in body fluids such as urine and blood. Laboratory tests measure recent
National Institutes of Health. Med line Plus. Toxicology Screen.
substance use rather than chronic use or dependence. Table 41-2 highlights how long illicit substances can be detected via urine toxicology screening. There is no conclusive test to determine substance dependence. Useful laboratory tests in those suspected of substance abuse include breath or blood alcohol tests, urine toxicology, liver enzyme tests, electrolytes, renal function, CBC, PT/INR and PTT, and vitamin deficiency screening.
INTERVENTION
Treatment Approach
Substance abuse is a difficult-to-treat disorder and requires an understanding of natural history of recovery from addiction. Although, initial symptoms from withdrawal may not be very different from one class of drug to another, there are significant differences in complications and management of withdrawal from different substances. Therefore, it is crucial to identify the abused substance early in the treatment. The treatment is a long-term process regardless of the substance being abused that often requires many behavioral changes and multiple attempts to quit.
In the United States, treatment of drug addiction is provided in various settings with different medication and behavioral therapy options, which should be discussed with the patient at the initiation of the treatment. Considering the wishes and readiness of the patient to acquire treatment, the physician should recommend a comprehensive plan, preferably including both medication and behavioral therapy. General categories for drug treatment programs include detoxification and medically managed withdrawal, long-term residential treatment, short-term residential treatment followed by long-term outpatient treatment, or exclusively outpatient treatment. A one-time intervention in primary care settings with phone call follow-up demonstrated no significant benefit in decreasing substance abuse.
Medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic process that often begins with detoxification. This includes management of the withdrawal symptoms, followed by treatment and relapse prevention. A key to preventing relapses is to minimize the withdrawal symptoms, which is often the first step of treatment in a patient who acknowledges his addiction. Tapering doses of long-acting agents for the abused drugs are often used to treat drug withdrawal. Antidepressants, anxiolytics, mood stabilizers, and antipsychotic medications may be critical for treatment success when patients have co-occurring psychiatric disorders.
Pharmacotherapy
Detoxification is an important first step in substance-abuse treatment with three goals: initiating abstinence, reducing withdrawal symptoms and severe complications, and retaining the patient in treatment. Ongoing treatment is needed thereafter to maintain abstinence. The aims are to restore normal cognitive and emotional function, to diminish cravings, and to prevent relapse. The medication also helps to make patients more receptive to the behavioral treatment and to avoid drug seeking and related criminal behavior. See Table 41-3 for substance withdrawal symptoms, medications used to treat withdrawal symptoms, long-term treatment, and relapse prevention.
Behavioral Therapies
Behavioral treatment is an important adjunct to addiction treatment. It helps to provide positive reinforcement to remain abstinent, to modify lifestyles related to drug abuse, and to help develop coping mechanisms to handle stressful situations. Common behavioral therapy models include cognitive behavioral therapy and the 12-step model, which is used by organizations such as Alcoholics Anonymous and Narcotics Anonymous.
COMPREHENSION QUESTIONS
41.1 An 18-year-old woman who is captain of her high school cheerleading squad presents to the clinic with her mother, who is concerned about her erratic behavior and emotional outbursts. She states that her daughter rarely sleeps on the weekends but sleeps heavily at the beginning of the week and is frequently late for school. She has no significant medical or psychiatric history. Her mother states that she has tried to discuss these issues, but her daughter gets angry and leaves home. She wants to have her daughter tested for drug use. You speak to the patient alone, and she endorses the symptoms her mother reports. Her vital signs are within normal limits and physical examination is unremarkable. She consents to a urine toxicology screen that is positive for methamphetamine, then she admits that she last used over a month ago and has only used twice in her life. What is the most appropriate next step in managing this patient?
A. Confront the patient in the presence of her mother that she has an addiction problem.
B. Refer the patient for an immediate psychiatric evaluation.
C. Prescribe oral propranolol to prevent withdrawal symptoms.
D. Offer behavioral therapy and drug rehabilitation to the patient alone.
E. Obtain an ECG, comprehensive panel, and CBC.
41.2 A 67-year-old man is brought to the ED by ambulance with altered mental status. His physical therapist accompanies him and states that he found the patient semiconscious on his bed. He mentioned that the patient had a femoral neck fracture secondary to fall 4 weeks ago. He went through inpatient rehab and was discharged last week. He has been receiving home physiotherapy three times a week. He has a history of hypertension, diabetes mellitus type 2, and depression. His current medications include lisinopril, metformin, glyburide, Prozac (fluoxetine), and MS-Contin (morphine sulfate). Examination revealed a semiconscious man with temperature of 98.4°F, blood pressure of 135/87 mm Hg, respiratory rate is 8 breaths/min, and pulse of 59 beats/min. Further examination revealed pin point pupils on eye examination and sinus bradycardia with no murmur, rubs, or gallops on heart examination. Lung examination revealed shallow breathing and decreased breath sounds on both sides. He was immediately placed on bag-mask ventilation. What is the most appropriate next step in managing this patient?
A. Obtain neurology consult.
B. Computed tomography (CT) scan of the brain without contrast.
C. Give IV naloxone.
D. STAT echocardiogram.
E. Transfer to intensive care unit (ICU).
41.3 A 30-year-old woman presents to the clinic complaining of feeling depressed and jittery. She has been feeling this way on and off for the last year, since her husband passed away in a car accident. She reports a recent increase in headaches, insomnia, loss of appetite, and increased irritability. When asked
about substance abuse, she says she drinks wine at night to help her sleep. Further questioning leads her to disclose that she started drinking more after her husband's death and she currently drinks, on average, 1.5 bottles of wine each evening. She denies previous history of psychiatric disorder. The patient's physical examination is unremarkable with the exception of elevated blood pressure 140/90 mm Hg. You diagnose and counsel the patient about alcohol dependence. Which of the following statements regarding available treatments for alcohol dependence is most accurate?
A. Naltrexone and acamprosate are recommended as FDA-approved options for treatment of alcohol dependence in conjunction with behavior therapy.
B. Disulfiram is the first-line treatment to decrease relapse.
C. Admission to the hospital for inpatient detoxification is the next best step in management.
D. Fluoxetine (Prozac) and other selective serotonin reuptake inhibitors (SSRIs) are recommended for patients with comorbid depressive disorders.
ANSWERS
41.1 D. This patient should be presented with the results of the urine toxicology screen and options about substance abuse treatment while not in the presence of her parent. She appears reasonable and psychologically stable during the appointment, thus does not require an immediate psychiatric evaluation. An ECG and serologic evaluation will not likely add to the investigation of this patient, as she is asymptomatic upon presentation. Similarly, she does not appear acutely intoxicated, and propranolol has no role in the prevention of withdrawal symptoms for methamphetamine intoxication.
41.2 C. The treatment of choice for the acute opioid intoxication is the administration of an intravenous opioid antagonist (ie, nalaxone). This patient has been taking oral morphine for pain control after his surgery and is now presenting with classic symptoms of acute opioid intoxication. A useful mnemonic to remember the sign and symptoms of opioid agents is MORPHINE-ABC (ie, Miosis, Out of it/sedation, Respiratory depression, Pneumonia/ aspiration, Hypotension/hypothermia, Infrequency includes constipation, decreased bowel sounds, and urinary retention, Nausea, Emesis/euphoria, Analgesic, Bradycardia, Coma/altered mental status).
41.3 A. The pharmacologic treatment is used as an adjunct in treatment of alcohol dependence. Naltrexone, disulfiram, and acamprosate are FDA approved for this indication. Consistent, good-quality, patient-oriented evidence have found naltrexone or acamprosate to be the most effective treatment of alcohol dependence when used in conjunction with behavioral therapy. Limitedquality patient-oriented evidence is available for use of fluoxetine or other SSRIs for patients with comorbid depression disorder.
CLINICAL PEARLS
⯈ No single treatment for illicit substance abuse is appropriate for all individuals.
⯈ Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction .
⯈ Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
⯈ Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
⯈ Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.
⯈ Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.
REFERENCES
Center for Substance Abuse Treatment. (n.d.). Incorporating alcohol pharmacotherapies into medical practice. Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. (SMA) 09-4380. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2009. (Retrieved from Agency for Healthcare Research and Quality).
Commonly Abused Drugs. (Revised October 2010). Retrieved from The National Institute on Drug Abuse (NIDA).
Diagnosis & Treatment of Drug Abuse in Family Practice. (2003 ). Retrieved from The National Institute on Drug Abuse (NIDA).
Drugs, Brains, and Behavior The Science of Addiction. (Revised August 2010). Retrieved from The National Institute on Drug Abuse (NIDA).
National Center for Biotechnology Information, US National Library of Medicine. (Bookshelf ID: NBK25909). Appendix B Assessment and Screening Instruments.
National Center for Biotechnology Information, US National Library of Medicine. (Bookshelf ID: NBK25606). Specialized Substance Abuse Treatment Programs.
National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD. 2014.
Principles of Drug Addiction Treatment: A Research-Based Guide. 2nd ed. NIH Publication No. 09-4180. (Revised April 2009). Retrieved &om The National Institute on Drug Abuse (NIDA).
Screening for Illicit Drug Use. (January 2008). Retrieved &om US Preventive Services Task Force.
Substance abuse and mental health services administration. Results from the 2009 National Survey on Drug Use and Health: Mental Health Findings. Center for Behavioral Health Statistics and Quality, NSDUH Series H-39, HHS Publication No. SMA 10-4609. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2010.
Thomas R, Kosten M. Management of drug and alcohol withdrawal. N Engl J Med. 2003; 348:1786-1795.
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