Psychiatric, Behavioral & Substance Use Disorders > Substance Use Disorder

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Academic Level: Undergrad. (yrs 3-4)

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Question

A 20-year-old woman who is a college student is brought to the emergency department (ED) 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 emergency medical services in route to the ED and received morphine on her arrival at the ED. The patient is accompanied by her roommate, who mentions 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 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 °F (38.3 °C), pulse is 119 beats/min, respiratory rate is 24 breaths/min, blood pressure is 165/90 mm Hg, oxygen saturation is 97% on room air, height is 60 inches, and weight is 100 lb. Eye examination reveals dilated pupils bilaterally with sluggish light reflex, along with occasional twitching of her right eye. Extraocular movements are 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 distention. Distal extremity pulses are brisk and symmetrical. The remainder of her examination is unremarkable.

Questions

What is the differential diagnosis for this case?

What is your first diagnostic step?

What is the next step in management of this patient?

Answers to Case 41: Substance Use Disorder

Summary: A 20-year-old woman presents with

No significant past medical history
Symptoms of coronary ischemia and other symptoms that signify increased sympathetic activity (substernal chest pain, 10/10 in intensity, radiating to her jaw, and associated with headache, sweating, nausea, and palpitations)
Report of drinking alcohol, smoking “a few joints,” and ingesting unknown substances
Fever, tachycardia, and hypertension
Dilated pupils bilaterally with sluggish light reflex, along with occasional twitching of her right eye

Differential diagnosis: Cocaine-induced myocardial ischemia; cocaine- and ecstasy-induced mental status changes (eg, anxiety, paranoia); panic attack; cardiac arrhythmia; and pulmonary embolism.

First diagnostic step: 12-lead electrocardiogram (ECG); markers of myocardial damage, including serum troponin I, creatine kinase, and creating kinase 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.

Next step in management: Telemetry, oxygen, assessment of ABC’s, aspirin, sublingual nitroglycerin, and morphine. Beta-blockers should be avoided initially, especially if cocaine intoxication is suspected, rule out acute coronary syndrome with serial ECG and cardiac enzymes.

Analysis

Objectives

Be able to state the definition and epidemiology of substance use disorders (SUDs). (EPA 12)
Be able to state the most commonly used illicit and prescription drugs, as well as their adverse and toxic effects. (EPA 2)
Be able to name the components of a validated ambulatory care screening protocol, history taking, physical examination, and laboratory findings in patients consistent with substance intoxication and SUDs. (EPA 1, 3)
Be able to name the medications available to control alcohol use disorder (AUD). (EPA 4)

Considerations

This is a healthy young woman 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. 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. Beta-blockers should be avoided initially, especially if cocaine intoxication is suspected, due to risk of unopposed alpha constriction, which 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. 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 should be performed to detect the most commonly abused illicit substances.

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 a 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.

Definitions

DETOXIFICATION: A process that enables the body to rid itself of a drug.
RELAPSE: Resumption of illicit drug use after an attempt or multiple attempts to quit.
SUBSTANCE USE DISORDER: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) no longer uses the terms substance abuse and substance dependence. Instead, the term substance use disorder is used, with SUD defined as mild, moderate, or severe to indicate the level of severity. SUDs occur when the recurrent use of alcohol and/or drugs causes clinical and functional impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. A diagnosis of SUD is based on evidence of the craving of a substance, failure to be able to control use, social impairment, risky use, and pharmacological criteria.

Clinical Approach

Pathophysiology

Primary care providers are well positioned to identify patients at risk for drug abuse early in the course. Since addiction and dependence are equal opportunity afflictions, clinicians should screen all new patients for substance abuse. Abrupt changes in behavior or functioning of the patient should also prompt the provider to screen for substance use. As with many other chronic illnesses, early recognition and management of the substance abuse leads to better outcomes. The most common SUDs in the United States are AUD, tobacco use disorder (see Case 7), cannabis use disorder, stimulant use disorder, hallucinogen use disorder, and opioid use disorder (see Case 59).

Vulnerability and affinity to addiction differs 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. Table 41–1 includes the most commonly abused substance categories, street names, route of administration, intoxication effects, and potential health complications.

Screening. The United States Preventive Services Task Force (USPSTF) recommends adults 18 and above be screened both for AUD (grade B) and for illicit drug use (grade B). Screening, brief intervention, and referral to treatment (SBIRT) is broadly recommended by multiple federal agencies, the USPSTF, and all of the primary care physician groups. The National Commission on Prevention Priorities ranked SBIRT among its top five priorities, ahead of 20 other effective services, including colorectal cancer screening, hypertension screening and treatment, and influenza immunization.

Clinician offices can integrate annual tobacco, alcohol, and substance use screening. Tobacco and alcohol screening and brief interventions are measures for the Merit-Based Incentive Payment System (MIPS) used for reimbursement for value-based population health medicine. Annual SBIRT screens are reimbursed by all major insurers. If an individual is identified as having an SUD, the history should be geared to determine what, how, and when the patient is using the drug; the level of counseling and treatment should be based on the pattern and severity of use. 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.

COMMONLY ABUSED ILLICIT AND PRESCRIPTION DRUGS

Table 41–1COMMONLY ABUSED ILLICIT AND PRESCRIPTION DRUGS

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Alcohol Use Disorder. Excessive alcohol use can increase a person’s risk of developing serious health problems in addition to those issues associated with intoxication behaviors and alcohol withdrawal symptoms. According to the Centers for Disease Control and Prevention, excessive alcohol use causes 88,000 deaths a year. Data from the National Survey on Drug Use and Health show that in 2017, slightly more than half of Americans ages 12 and up drank alcohol. Most people drink alcohol in moderation, but an estimated 16.7 million are considered heavy drinkers and are at high risk for AUD. The definitions for the different levels of drinking include the following:

Moderate drinking: Up to one drink per day for women and up to two drinks per day for men.
Binge drinking: Drinking four to five or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days. Binge drinking produces blood alcohol concentrations of greater than 0.08 g/dL. This usually occurs after four drinks for women and five drinks for men over a 2-hour period.
Heavy drinking: Drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days.

Cannabis Use Disorder. Marijuana is the most-used drug after alcohol and tobacco in the United States. In 2017, there were 26 million people ages 12 and up who reported using marijuana during the previous month. In 2014, based on marijuana use, 4.2 million people ages 12 and up met criteria for an SUD. Cannabis use disorder is defined as continued use despite impairment in psychological, physical, or social functioning. About 10% of users experience addiction. As adult use increases due to state legalization, the use increases in children and adolescents.

Stimulant Use Disorder. Stimulants increase alertness, attention, and energy, as well as elevate blood pressure, heart rate, and respirations. They include a wide range of drugs that have historically been used to treat conditions such as obesity, attention deficit hyperactivity disorder, and depression. Like other prescription medications, stimulants can be diverted for illegal use. The most commonly abused stimulants are amphetamines, methamphetamine, and cocaine. Stimulants can be synthetic (eg, amphetamines) or can be plant derived (eg, cocaine). They are usually taken orally, are snorted, or are delivered intravenously. In 2017, an estimated 1.8 million people ages 12 and older misused stimulants, and 2.2 million were users of cocaine. Withdrawal symptoms that occur after stopping or reducing use include fatigue, vivid and unpleasant dreams, sleep problems, increased appetite, and irregular problems in controlling movement.

Hallucinogen Use Disorder. Hallucinogens can be chemically synthesized (as with lysergic acid diethylamide, also known as LSD) or may occur naturally (as with psilocybin mushrooms, peyote). These drugs can produce visual and auditory hallucinations, feelings of detachment from one’s environment and oneself, and distortions in time and perception. In 2017, approximately 1.4 million Americans had recent hallucinogen use.

Clinical Presentation

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 signs such as damage to nasal mucosa, septum perforation due to nasal inhalation, or injection “track marks.” Sequelae of cirrhosis, including spider angiomas, caput medusa, hepatomegaly, and/or ascites, due to viral hepatitis or alcohol abuse, may also be found.

Laboratory Values. Several laboratory tests are available for determining the presence of alcohol and other drugs in body fluids and other substances, such as urine, hair, and blood. Urine drug toxicology tests measure recent substance use rather than chronic use or dependence. These tests can have false negatives since synthetic substances ingested are often not detected in point-of-care urine drug toxicology tests. These tests can also have false positives and should be interpreted with caution. There is no conclusive test to determine SUDs. Useful laboratory tests may include breath or blood alcohol tests, urine toxicology, liver enzymes, electrolytes, renal function, CBC, PT/INR and PTT, and vitamin-deficiency screening.

Treatment

Substance use disorder is challenging and requires an understanding of the natural history of recovery, including high rates of relapse with the need for multiple long-term interprofessional interventions to achieve optimal outcomes. 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, and it often requires many behavioral changes and multiple attempts to quit.

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 relapse is to minimize the withdrawal symptoms, which is often the first step of treatment in a patient who acknowledges addiction. Tapering doses of long-acting agents for the abused drugs is frequently 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.

Collaboration With Patients. 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 provider 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.

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. Medication helps make patients more receptive to the behavioral treatment and to avoid drug-seeking and related criminal behavior. See Table 41–2 for substance withdrawal symptoms, medications used to treat withdrawal symptoms, long-term treatment, and relapse prevention.

ADDICTION: WITHDRAWAL SYMPTOMS AND PHARMACOLOGY FOR DRUG WITHDRAWAL AND RELAPSE PREVENTION

Table 41–2ADDICTION: WITHDRAWAL SYMPTOMS AND PHARMACOLOGY FOR DRUG WITHDRAWAL AND RELAPSE PREVENTION

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Behavioral Therapies. Behavioral treatment is an important adjunct to addiction treatment. Clinicians help by providing motivational interviewing to encourage behavior change, reduce relapse, modify lifestyles related to drug abuse, and help develop coping mechanisms to handle stressful situations. Additional behavioral therapy models include group therapy, cognitive behavioral therapy, and the 12-step model, which is used by organizations such as Alcoholics Anonymous and Narcotics Anonymous.

Case Correlation

See Case 7 (Tobacco Use and Cessation) and Case 59 (Opioid Use Disorder and Chronic Pain Management).

Clinical Pearls

No single treatment for SUD is appropriate for all individuals.
Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for SUD.
Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
Individuals with SUD with coexisting mental disorders should have both disorders treated in an integrated way.
Medical detoxification is only the first stage of SUD treatment and by itself does little to change long-term drug use.
Recovery from SUD is often a long-term process and frequently requires interprofessional care management and multiple episodes of treatment.

Question 1 of 3

An 18-year-old young woman who is captain of her high school cheerleading squad presents to the clinic with her mother, who is concerned about her daughter’s 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 the physical examination is unremarkable. She consents to a urine toxicology screen, which is positive for methamphetamine. The patient admits she last used about 1 week ago and has only used twice in her life. What is the most appropriate next step in managing this patient?

Confront the patient in the presence of her mother about her addiction problem.

Refer the patient for an immediate psychiatry evaluation.

Prescribe oral propranolol to prevent withdrawal symptoms.

Offer behavioral therapy and drug rehabilitation to the patient alone.

Obtain an ECG, comprehensive panel, and CBC.

The correct answer is D. You answered D.

Explanation:

This patient should be presented with the results of the urine toxicology screen and options about substance abuse treatment. This should be done with the patient alone and not in the presence of her parent (answer A). She appears reasonable and psychologically stable during the appointment and thus does not require an immediate psychiatry evaluation (answer B). An ECG and serologic evaluation (answer E) will not likely add to the investigation of this patient since 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 (answer C).

Question 2 of 3

A 40-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 use, 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 an elevated blood pressure of 140/90 mm Hg. A comprehensive metabolic panel reveals an alanine aminotransferase (ALT; also known as SGPT) of 30 U/L (normal 10-40) and an aspartate aminotransferase (AST; also known as SGOT) of 84 U/L (normal 10-30). The remaining laboratory studies are negative. There is no family history of liver disease. Which one of the following pharmacologic agents could help reduce this patient’s alcohol consumption and increase abstinence?

Acamprosate

Amitriptyline

Paroxetine

Promethazine

Venlafaxine

The correct answer is A. You answered A.

Explanation:

Pharmacological treatment is used as an adjunct in treatment of alcohol dependence. Naltrexone, disulfiram, and acamprosate are approved by the Food and Drug Administration (FDA) for this indication. Consistent, good-quality, patient-oriented evidence has found naltrexone or acamprosate to be the most effective treatment of alcohol dependence when used in conjunction with behavioral therapy. Antidepressants (answer C, paroxetine; answer B, amitriptyline; and answer E, venlafaxine) may be beneficial in patients with coexisting depression. The antiemetic ondansetron (not promethazine, answer D) may also help decrease alcohol consumption in patients with AUD. An AST to ALT ratio greater than 2:1 suggests alcoholic liver disease, and a ratio of 3:1 or higher is highly suggestive of alcoholic liver disease. With most hepatocellular disorders, including nonalcoholic fatty liver disease, viral hepatitis, and iron overload disorder, the patient will have an AST to ALT ratio < 1.

Question 3 of 3

Which one of the following is effective in preventing seizures associated with alcohol withdrawal syndrome?

Carbamazepine (Tegretol)

Chlordiazepoxide

Clonidine (Catapres)

Gabapentin (Neurontin)

Phenytoin (Dilantin)

The correct answer is B. You answered B.

Explanation:

Benzodiazepines can prevent alcohol withdrawal seizures. Anticonvulsants such as carbamazepine (answer A), gabapentin (answer D), and phenytoin (answer E) have less abuse potential than benzodiazepines but do not prevent seizures. Clonidine (answer C), an alpha-adrenergic agonist, reduces the adrenergic symptoms associated with withdrawal but does not prevent seizures.