Admitted to inpatient rehab following alcohol “detox” with chlordiazepoxide Sept 2016

Never felt happy—anxious, low self esteem

Father physically abused pt and brother: mother ignored

Raped on street by stranger while intoxicated with EtOH: age 20

EtOH, THC in H.S.: IN cocaine D/C’d 10 yrs ago: heroin IN X4 did not like: never IV. EtOH preferred: Benzos last few years

I year community college: wanted RN: too many drugs

Estranged from family: homeless; ¾ houses

Has never worked regularly: Thinks she could be an office manager

FH of alcohol in grandparents on either side; Italian/Polish

No Children: Never been in long term healthy relationship

Rehab is a locked unit, with visitors 1xweek. Pt. had

Started on Gabapentin 300mg tid

On 4th day of rehab, 9AM, patient had altered mental status, and rapid response called. Patient was somnolent: O2 Sat=91%, Glu=64. After DW50 and IV hydration MS improves. Remains on Rehab unit.

UDT: Negative –opiate, cocaine, THC, benzo

What Happened??

Blood Alcohol Level: 312mg/dl

~ $16

62.5% Ethanol125 Proof

50% 100 Proof

13% 25 Proof

5% 10Proof

140 Proof

~ 25% Alcohol: 50P 35% Alcohol 70P

Denatured Alcohol: Additional Ingredients

5 year hx of drinking sanitizer in health care facilities; like Vodka—but stronger

Would drink Sanitizer to alleviate withdrawal

No hangovers

Also drank Listerine

Required ICU and intubation in the past

Critical Care Medicine. 40(1):290-294, January 2012.

Coercing customers to open credit card accounts to use as overdraft protection for their checking accounts when they were already struggling to keep their checking accounts balanced

Witnessing other bankers and being pressured by management to add credit defense onto new credit applications without the customer’s knowledge, which led to unnecessary monthly fees

Closing and opening new accounts for customers by convincing them that there had been fraud on their existing accounts

Quotation of the Day:NYT, 10/21/16

The FDA is particularly interested in gathering additional data on the long-term safety of daily, repeated exposure to these ingredients by consumers, and on the use of these products by certain populations, including pregnant women and children, for which topical absorption of the active ingredients may be important. Emerging science also suggests that for some antiseptic active ingredients, systemic exposure (full body exposure as shown by detection of antiseptic ingredients in the blood or urine) is higher than previously thought, and that more information is needed about the effects of repeated daily human exposure to some antiseptic active ingredients.

Complicated Vignette for NYSAM

R. Jeffrey Goldsmith MD, DFASAM, DLFAPAPresident, ASAM

Department of Veterans AffairsCincinnati VAMC

Professor of Clinical Psychiatry

First Appointment

• 37yo W D male living with GF x 12 months

• 12 yo daughter out of town

• opioid use since age 24 by ex-wife and heroin since age 31 IV

• past hospitalization for overdoses x2

• one suicidal

• heroin and benzodiazepines

• past residential treatment for 2 months, a year earlier

• not engaged in outpatient counseling, unable to get into Buprenorphine Treatment nor Methadone Maintenance Clinics

• past buprenorphine/naloxone and methadone maintenance

• opioid use, sedative use, alcohol use, tobacco use, marijuana use in remission, PTSD, Bipolar II, Hep C, chronic pain low back and knees

• bupropion, citalopram, gabapentin21

Complications at First Appointment

• Across town methadone clinic 50mg/day

• spoke to that doctor in couple of days and discussed tapering and transfer to VA BTC

• GF worked in Criminal Justice setting and doesn't always agree with the patient

• overdoses and suicide attempts, he is threatening when intoxicated

• has AA sponsor and goes to some AA meetings

• tries to meditate daily and does compassion meditation per Dalai Lama

• not clear if he has PTSD diagnosis, teenage trauma with MVA and friend hurt badly. Past diagnosis, unclear about current symptoms.

• Initial Plan: see weekly and do taper —transition to buprenorphine as slow as necessary, keep collaboration with methadone and GF, see if anxiety and tension improves after transition

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Transition Visits

• met 8/31, 9/12, 9/19

• patient not meet with methadone doctor as planned and had to wait two weeks to meet again since tapering group qowk.

• 10/12 patient decided tapering too slow and he wanted to stop methadone Friday and see me Monday in withdrawal, inducting buprenorphine/naloxone

• 10/17 inducted: in some withdrawal- gooseflesh, headaches, achey, sweats, insomnia, poor appetite

• not show more withdrawal with 2mg/0.5mg dose, given total of 16mg/4mg for the day and next day, felt better.

• Saw me in two days, called me the next day after induction

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Psychosocial Crisis

• Saw me 10/31 since I was out of town one week, did see therapist when I was gone

• Crisis with GF regarding payments to his daughter out of town• moved out, overtook buprenorphine/naloxone and ran out,

took opiates briefly

• GF brought him and he didn’t allow her in room. His story and hers were different.

• They have been back together doing well since• GF not in the room for appointments and he is more animated

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TBI and Psychiatric Dx

• Silver et al N=5000 from NIMH showed sig more dep and anxiety and suicide attempts

• Timonen et al N=11,000 0-31 prospective, child TBI doubled onset of psych d/o

• Post-TBI dep can persist for years

• TBI and Axis II significant co-occurring

Addiction and TBI

• Among adolescents and adults in TBI Rehab, 2/3 premorbid substance use d/o

• OSU found 58% of 350 admitted to TBI rehab had prior SUD

• UW found 61% of 142 admitted to TBI rehab had prior at risk alc or drug use

• Gordon et al. 63% of 243 admitted to SUD programs in upstate NY had TBI

• 48% of 404 screened in 12 NYC programs

• OSU found 53% of 119 in residential SUD tx had loss of cs and almost 1/3 had at least one mod-sev TBI

• Early substance use associated with early TBI

Traumatic Brain Injury

Mild TBI• GCS 13-15• LOC <31min• MS change

<24h• PT Amnesia

<1d

Moderate TBI• GCS 9-12• LOC 1/2-24h• MS change

24+• PTA 1-7

Severe TBI• GCS 3-8• LOC >24h• MS change

depends on other items

• PTA >7d

Admitted to inpatient rehab for SUD of IN Xdrug.

Lives at home with father and sister. Mother died when patient was 21 yo.

Xdrug use started age 20, quickly daily, episodes of not using and relapsing.

Drug use limited to IN Xdrug

Medical history is negative, except for urinary complaints: frequency, burning, gross hematuria, & suprapubic pain. Has had similar in the past. No discharge or lesions. Sexually active. Heterosexual. HIV-

Tobacco: 1ppd since age 17

Urine culture negative, CMP- WNL, CBC-WNL

UDT: negative-- opiates, cocaine, methadone, amphetamine, THC, benzo,

GC, Chlamydia, RPR all negative

Want to know his Ethnicity?

Chinese American: Which Drug?

KETAMINE CYSTITIS

Most common illicit drug in Taiwan. HK, Singapore, Malaysia

Frequency, urgency, suprapubic pain, dysuria, hematuria

Urothelial ulceration, inflammation, bladder wall fibrosis

~26% in regular users—dose/frequency related M:F=

Pathophysiology: local bladder, autoimmune, vascular damage

Sterile pyuria, Bladder Capacity

Treatment: D/C ketamine--most improve. Hyaluronic acid, Chondroitin sulfate, Botulinum toxin instillation.

NSAIDS, Steroids, Anticholinergics (oxybutynin): ± efficacy

Urinary diversion, Augmentation Cystoplasty

Patient improved over one week: Urological f/u. D/C ketamine

Fig. 1. Intravenous pyelography in a man with ketamine cystitis reveals bilateral hydronephroureters and contracted urinary bladder.

Yao Chou Tsai, Hann-Chorng Kuo

Urological Science, Volume 26, Issue 3, 2015, 153–157http://dx.doi.org/10.1016/j.urols.2014.11.003

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MMTP: 210 mg daily

Admit 8/12/15 2/2 multiple episodes of weakness, syncope last 24 hours

Rx: Clonazepam 1mg tid

FH: negative for cardiac disease, syncope

PE: unremarkable

Initial Labs: normal

UDT: +THC, +PCP, +amphetamines

Head CT: normal

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EKG: Prolonged QTc interval . Was told about this a few months ago in MMTP

CCU: Episode of TdP, defibrillated

QTc: 595msec

Refused Bupe—tried in the past

Medical Service: Hold Methadone: 1 Dose MS-Contin60mg

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Methadone to 30mg q6hour 8/14/15

Patient Agrees

Minimal withdrawal

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Discharged 8/18/15 on 120mg MMTP

Re-Admitted 12/15—prolonged QTc

Methadone dose 110mg

Occurred while taking Azithromycin

Copyright restrictions may apply.

Al-Khatib, S. M. et al. JAMA 2003;289:2120-2127.

Measuring the QT Interval in Different Clinical Scenarios

What Clinicians Should Know About the QT Interval

Congenital LQTS vs. Acquired LQTS(often medication related)

Copyright restrictions may apply.

Wedam, E. F. et al. Arch Intern Med 2007;167:2469-2475.

Percentage of study population exceeding the cutoff value for Bazett's corrected QT of 470 milliseconds for males and 490 milliseconds for females at the different "on-drug" points in the study

Methadone/QT--Multifactorial

Electrolyte Abnormalities—Hypokalemia, HypoMg++Bradycardia, Intracranial Bleed, 3A4 inhibitorsDrugs whichQT interval qtdrugs.org

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Sept 2014: Perforated Toxic Mega-Colon

Ileostomy: Discharged on Methadone 15mg tid—for pain and physical dependence—pain clinic Rx.

No family Hx of addiction

Works in Finance

Tobacco:1ppd age 18

Family moved to Israel: pt age 7; disaster for pt: in and out schools, friends

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Baltimore age 12: Father nicknamed him “Mr. Restless” Angry kid—mother remote

Did not think he would go to college

Opioids for dental as teenager: “calm me down”

Finance job age 21 NYC—felt unworthy

Hydrocodone illicit to calm down at night

Friends taking during the day: he starts also

Within 6 mos 150—200mg daily oxy. Never IN/IV

28 day Rehab 2011: 90 day OPR Psych—no MAT

Few AA meetings 3 yrs no opioids

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Relapse to oxy Jan 2014 with friends from Rehab

Abdominal pain, constipation June 2014: does not reveal to anyone: ashamed

Acute Abdomen: Colon Resection: Ileostomy

Pain mgt. and psych both not comfortable prescribing methadone

Referred to me

PDMP - POC urine +methadone: - all else

Brought in correct number of methadone tablets

Patient to have reanastomosis in Future—can’t wait: February 5, 2015

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Do you feel you can manage this pain/addiction case?

Will you taper the methadone before the re-anastomosis?

Will you transfer to buprenorphine? When?

Is it all legal?

Methadone maintained and dose increased prior to 2nd

surgery; patient c/o chronic incisional pain

Post –op methadone 30mg tid +short course of hydromorphone

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Do you feel you can manage this pain/addiction case?

Will you taper the methadone before the re-anastomosis?

Will you transfer to buprenorphine? When?

Is it all legal?

Methadone maintained and dose increased prior to 2nd

surgery; patient c/o chronic incisional pain

Post –op methadone 30mg tid +short course of hydromorphone

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Methadone tapered to 40mg by June 1

Had some hydromorphone IR: bridge

Home Induction went well

Maintenance Dose 16 mg Bupe/Nal

Plastic surgery revision of scar soon: Acute pain mgt on Bupe maintenance

On Vyvanse by Psych with 4+ efficacy

On prn propranolol by me 4+ efficacy

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Does not like taste of Film product

Feels the 16mg “not holding” as before

Trial of branded tablet (Zub-Solv) 5.7mg bid

Positive Response

All UDTs negative

All PDMP checks negative