MEDICAL PRESENTATIONS OF SUBSTANCE USE … use disorders ... 20 yo college student ... Headache...
Transcript of MEDICAL PRESENTATIONS OF SUBSTANCE USE … use disorders ... 20 yo college student ... Headache...
ObjectivesReview epidemiology of alcohol/substance use disordersReview importance of these disorders in medicineGeneral overview of medical complications of alcohol/substance use disordersDiscuss complications specific to alcohol and other substances
Epidemiology2/3 ever consumed alcohol~40% ever used illicit drugs20% use tobaccoLifetime prevalence
Alcohol use disordersMen - 15-20%Women - 8%
Drug use disordersMen – 8%Women – 5%
A Few StatisticsOne million ER visits per year
Drug use primary problem20-40% of hospital admissions20% of primary care visits50-75% of trauma visitsUp to 200,000 deaths per year~40% of suicides involve drugs/alcoholAlcohol decreases life expectancy by ~15 yrsEconomic cost in US - >$400 billionAdvice, counseling, brief interventions in primary care and ER settings is important!
Societal Costs – Alcohol Use Disorders
Total: ~$185 Billion
Source: Harwood, H. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism; 2000. National Institutes of Health, NIH Publication No. 98-4327. Rockville, MD.
http://www.niaaa.nih.gov
†FAS = fetal alcohol syndrome.
47%
20%
2%
9%4%13%
5%
1%
Specialty Alcohol Services*Medical Consequences (except FAS†)Medical Consequences of FASLost Future Earnings Due toPremature DeathsLost Earnings Due toAlcohol-Related IllnessLost Earnings Due to FASLost Earnings Due to Crime/VictimsCrashes, Fires, Criminal Justice, etc
Medical ConsequencesDirect Effects
Toxicity of substance of abuseToxicity of contaminants
Indirect EffectsInfectious diseasesTraumaNutritional deficienciesConsequences of intoxication/withdrawal statesConsequences of behaviors associated with substance use
Case #1
43 yo woman c/o dyspepsia, epigastric burning and anxietyPMH – hypertensionMeds: Atenolol 25mg qdHPI, ROS – unremarkableLabs in past year – all WNL
Case #1PE:
Looks anxiousHands are cold,clammy, slightly shakyWearing strong perfumeP: 102 regularBP: 155/101Temp, respirations – normalRemainder of PE only remarkable for mild tachycardia
What’s Your Diagnosis?Differential – substance use disorders
Mild intoxication – stimulantsWithdrawal – alcohol, opioids,
sedative/hypnotics
Clues GI symptoms – gastritisHypertensionSymptoms of alcohol withdrawalUse of perfume, aftershave, mouthwash to cover
smell of alcohol
Chronic Alcohol Use
Liver DiseaseCirrhosis
Coronary Artery DiseaseCardiomyopathyArrhythmiasHypertension Stroke
Duodenal ulcers
Cognitive disordersCVAPsychosis
PancreatitisDiabetes
Head, Neck, GI cancers
Stomach ulcersGastritis
Adapted from: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566.
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NeuropathiesAnemias Nutritional Deficiencies
Nutritional ConsequencesHeavy drinkers – up to 50% of daily caloric intake
>25% - ↓significant decrease in necessary nutrients
MalnutritionVitamin deficienciesImpairs activation and utilization of nutrientsMaldigestion (GI complications)
Specific DeficienciesThiamine
Wernicke-Korsakoff’sNeuropathies
FolateMegaloblastic anemia
Vitamin C – with high alcohol intakeVitamin D
Decreased intake, poor absorption, insufficient sunlightDecreased bone mass, densityIncreased osteoporosis, bone fractures
GI ComplicationsLiver
ETOH toxic to hepatocytesAST>ALTAccelerates liver damage in hepatitis C infectionIncreases risk of acetaminophen toxicityRange of disease
Fatty liverAlcoholic hepatitisFibrosisCirrhosis
GI Complications
PancreatitisGenerally after 10-15 years of heavy ETOH
GI bleedingGastritisPeptic ulcer diseaseEsophageal varicesDuodenitisEsophagitis
Neurologic ComplicationsWernicke’s encephalopathy
Delirium, ataxia, ophthalmoplegiaThiamine deficiencyNecrosis of mammillary bodies and thalamus50-85% → Korsakoff’s psychosisFew regain cognitive function
Korsakoff’s Psychosis
Common pathology and etiology as Wernicke’sSevere memory impairment
Recent and ongoing eventsConfabulation, lack of insightOther intellectual functions may be intactTreat with thiamine
Alcoholic Dementia
Prominent effects – frontal cortex, putamenExtreme variabilityEtiology
NeurotoxicEffects on neurotransmittersDecreased cerebral blood flowVitamin deficiencies
Alcoholic Dementia
ImpairmentsAbstract thinkingProblem solvingVisual, spatial, motor abilitiesNew learningRemote memoryPersonal care
Other Neurologic Complications
“Blackouts” – transient anterograde amnesia↑risk of CVA↑risk of cerebral traumaCerebellar degenerationMetabolic encephalopathiesPeripheral neuropathies
Sensory, motor or autonomic“Stocking-glove” distribution
Other Organ SystemsHematologic
Anemias – Fe deficiency, folate deficiencyPancytopenia – alcohol toxic to bone marrow
MusculoskeletalRhabdomyolysisOsteopenia/osteoporosis, fracturesMyopathy
CardiovascularCardiomyopathyHypertension
DermatologicFacial edema, rosacea, rhinophyma
Metabolic/endocrineGoutDecreased testosteroneMenstrual abnormalities
Case #239 yo man presents to ER with crushing substernal chest painPMH, Meds – noneSxs – 10/10 pain, SOB, diaphoresisFH – no CADPE – P:126 BP: 178/115 T:38Lab – CPK = 6000; Creatinine = 3.5EKG – Sinus tachycardia; ST elevations in anterior leads
What’s Your Diagnosis?Clues
Sympathetic hyperactivityHypertensionTachycardiaHyperthermia
Organ systems involvedCardiac?RhabdomyolysisRenal failure
No medical or family history of similar problems
Cocaine ToxicitySeizuresCVAs
AnginaMIArrhythmiasCardiomyopathy
Perforated nasal septum
GI Ischemia
RhabdomyolysisMyoglobinuriaAcute Renal Failure
Sympathetic hyperactivityHypertensionTachycardiaHyperthermia
Pulmonary toxicity
Case #320 yo college studentDepressed, irritable, anhedonic, insomnia, new erythematous skin lesions – pruriticNo PMH, no meds, no relevant FHPE: remarkable for skin lesions, otherwise normalMSE: unremarkableYou refer patient to dermatologist
Methamphetamine Abuse
From: “Faces of Meth” – the Oregonian – December 28, 2004Photos courtesy of Bret King, Multnomah County Sheriff’s Department
ED presentationsAcute effects/overdose
Tachycardia/palpitationsHypertensionHyperthermiaHeadacheChest pain/MICVATachydysrhythmiasAnxiety, psychomotor agitationSeizuresBurns
Meth Mouth
Tooth decayDry mouthPoor hygieneSugar-laden dietVasospasmContaminants or caustics?
Photo: flapsblog.com/?cat=22
Case #428 yo man brought to ER after witnessed grand mal seizureFemur fracture 1 year ago - painNo known medications, other PMH, no known head traumaNo known use of ETOH, tobacco, drugsRecent rx of fluoxetine for depressionPE: post-ictal otherwise normalLabs: unremarkable; CT scan: unremarkable
What’s Your Diagnosis?Questions?
Any history of medication for pain?What pain medication(s) might cause seizures?
Meperidine – normeperidine causes seizuresTramadol – high doses may cause seizures
Any drug interactions with fluoxetine that may be significant?
Fluoxetine is an inhibitor of CYP 450 2D6
Opioids Relatively nontoxic when used as prescribedMay impair gonadotropin releaseHeroin
Noncardiogenic pulmonary edemaGlomerulonephritisComplications from overdose
Neurologic, respiratorySeizures
NormeperidineTramadol (doses >400mg day)
Other problemsAdverse effects from intoxication/withdrawal states
Case #518 yo brought to ER at 3AMBecame confused, disoriented at partyETOH/drugs available at partyShe usually doesn’t smoke, drink, use drugs; good student; well-liked; PE: T:40 BP:150/110 P:140 Delirious; skin warm and dry; otherwise WNLLab: Na = 129 Cr = 2.0 CPK = 600 SGOT = 755 SGPT = 886BAL = 20 mg/dl UDS - negative
What’s Your Diagnosis?Clues
Age of patientAt partyHyperthermia, hypertension, tachycardiaHyponatremiaEvidence of rhabdomyolysis, elevated creatinineLiver damageCocaine, amphetamines not detected
MDMA ToxicityDelirium“Serotonin syndrome”Serotonin depletionCerebral infarct/hemorrhage? Neuronal damage/loss
TachycardiaC-V collapse
RhabdomyolysisMyoglobinuriaAcute Renal Failure
HypertensionHyperthermia
↑LFTsFulminant hepatic failure
MarijuanaPulmonary toxicity
COPDHead, neck cancersCognitive deficits
Attention, short term memoryInformation processingMotor impairment
↓ Immune response↓ Testosterone levelsMenstrual abnormalities
Other SubstancesNicotine
PulmonaryMalignanciesCardiovascular disease
InhalantsWide range of adverse effectsNeurotoxicity, CV, pulmonary, renal, etc.
ID ComplicationsRoute of administration
Use of needlesIntranasal
High risk sexual practicesHIV
~25% of IVDU infectedHepatitis
65-90% of IVDU infected with HCV50-70% exposed to HBV
Local and systemic infectionsCellulitis, abscessesEndocarditis, osteomyelitis
Case #1 – Follow-upPatient admitted to 3-4 drinks/dDenied problemListened carefully to discussion of health effects of alcoholReturns 4 weeks later
Has been seeing a counselor, wants to stop drinking but has cravingsAsked you about “medications”
DisulfiramNaltrexoneAcamprosateTopiramate
Case #1
She also wants to quit smokingAsks your opinion about
Nicotine replacementBupropion “Zyban”Varenicline – “Chantix”
Case #4 – Follow-upPatient recovers uneventfullyAdmits to “Doctor shopping”Has multiple prescriptions for tramadol which he has been using in large amountsAlso buys opioids on the streetMotivated for treatment, has been struggling with stoppingAsks about:
Methadone maintenanceBuprenorphine
SummaryCommon disordersMany medical complicationsPatients frequently present to ERs, general medical settings
Counseling, advice in these settings can be important!
Important to assess all patients for alcohol, tobacco, other substance use
Complaints may caused/exacerbated by substance use
Don’t forget about treatment!