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Complications of Substance Abuse

Karen McDonough MD. Complications of Substance Abuse. Spring quarter pharmacology. Lecture by addiction psychiatrist, Dr. Saxon Intoxication Withdrawal Treatment. Complications of substance abuse. Direct effect Methamphetamine – paranoia Opiates – respiratory depression Withdrawal

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Complications of Substance Abuse

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  1. Karen McDonough MD Complications of Substance Abuse

  2. Spring quarter pharmacology • Lecture by addiction psychiatrist, Dr. Saxon • Intoxication • Withdrawal • Treatment

  3. Complications of substance abuse • Direct effect • Methamphetamine – paranoia • Opiates – respiratory depression • Withdrawal • Infectious • Viral – needle sharing • Bacterial – altered flora, breaching skin barrier • Behavioral • Stimulants: hypersexual, poor impulse control • Heroin: TB, hepatitis A

  4. Which is more common? • Heroin • Cocaine • Nonprescription use of pain meds • Methamphetamine

  5. Illicit drug use in past year: 2007 • Marijuana 10.1% • Nonprescribed pain meds 5.0% • Cocaine 2.3% • Nonprescribed tranquilizers 2.3% • Hallucinogens 1.5% • Ecstasy 0.9% • Inhalants 0.9% • Methamphetamine 0.5% • Heroin 0.1% 2007 National Survey on Drug Use & Health

  6. Case #1: Stupor and decreased respiratory rate A 31 year old man is dropped off in the ER by a friend, barely arousable. On your initial assessment, he is sedated and responds with a grunt to sternal rub. He has a RR of 8, O2 sat of 93% on RA.

  7. Which drugs would you suspect? • Heroin • Benzodiazepines • Cocaine • GHB • Methamphetamine

  8. Gammahydroxybutyrate (GHB) • CNS depressant • Sedation • Coma common • RR, HR, temperature • Colorless liquid, generally taken by mouth • Can cause initial euphoria • Steep dose response curve • Variable response person to person

  9. What if you found this? From drugrecognition.com 3.29.2010

  10. Confounders • Coingestion • Stimulants • Anticholinergics • Certain opioids have less effect on pupils • Meperidine • Propoxyphene

  11. “Doctor, his RR is 6” • Order a urine tox screen • Order an ABG • Naloxone 0.2 mg IV • Naloxone 4 mg IV • Flumazenil 0.2 mg IV

  12. Opioid Overdose • Clinical diagnosis • No need to wait for a tox screen • Decreased RR is the best clue, followed by pinpoint pupils • Goal of therapy is normal ventilation not complete reversal of sedation, which can cause acute withdrawal

  13. Urine tox screens • Standard • Immunoassay • Common drugs of abuse + acetaminophen, alcohol, tricyclics, methadone • Comprehensive • More accurate - GCMS • 3 pages of drugs • At Harborview: bedside testing

  14. Case #2 • A 29 year old man calls 9-1-1 because of substernal chest pain x 20 minutes • Medics find him with HR 128, BP 184/96, uncomfortable, mildly agitated and diaphoretic.

  15. Methamphetamine Oxycontin Cocaine Propofol Alcohol withdrawal 0% 0% 0% 0% 0% What substances could cause this hypersympathetic picture?

  16. Chest pain and cocaine • Most common reason for ED visit related to cocaine • Potent sympathomimetic • Usually within hours of use via any route • ~ 6% have myocardial infarction • Sympathomimetic – increased myocardial demand • Promotes thrombus formation • Vasospasm

  17. Which of the following would NOT be appropriate for a patient with cocaine induced CP? 1. Aspirin 2. Nitroglycerin 3. Morphine 4. Metoprolol

  18. Other CV effects of cocaine • Cardiomyopathy • Arrhythmia • Malignant or difficult to control hypertension • Aortic dissection • Accelerated atherosclerosis • Stroke

  19. Methamphetamine & the heart • Now the 2nd most widely abused drug in the world (after marijuana) • Causes myocardial ischemia and other cardiac complications but less literature than cocaine • Similar mechanisms to cocaine • Also can cause pulmonary hypertension

  20. Would patients tell you? • Study of ED patients at UC-Davis • Screened lab records for patients with both a urine tox screen + for cocaine or meth AND cardiac enzymes • 357 patients had chest pain and a positive urine tox • 51% “self reported” their drug use in the ED

  21. Case #3 A 44 year old man with a history of injection drug us (IDU) presents to the ER with fever and cough of one day duration. PMHx: Hepatitis C, on interferon and ribavirin Multiple episodes of cellulitis Methadone maintenance T =38.8 Other VS normal Crackles at R base

  22. Endocarditis in IDU • Estimated 2-5 cases/1000 patient years IDU • Murmur present in half or less of patients • Other physical exam signs are rare • No clinical features reliably predict endocarditis • Febrile injection drug users often admitted to “R/O endocarditis”

  23. Febrile IDU in the ED: Obvious Major Illness (180/283)

  24. No obvious major illness (103/283)

  25. Endocarditis in Febrile IDU • Overall, 9% of patients were ultimately diagnosed with endocarditis • Diagnosis was made in the ER only 60% of the time • Patients with “major illness” diagnosed in ER were very rarely found to have another major illness

  26. Why do IDUs get endocarditis? • Endothelial damage from injected material, pulmonary HTN or vasospasm • Contamination of injected drugs • Nasal and skin carriage of S. aureus • More common in HIV infected • Structural heart disease in 6-40%

  27. Blood cultures • First blood culture positive in 96% of streptococcal and 82% of other causes • 1/first 2 positive in ~ 98% • …assuming patient has not been on antibiotics prior to cultures

  28. When should I get an echo? • Moderate or high clinical suspicion • Positive blood cultures • New regurgitant murmur • New conduction abnormality on ECG • Septic emboli on CXR

  29. Case #4: Back Pain • A 42 year old man with a long history of IV heroin use, multiple MRSA abscesses, and R ankle osteomyelitis presented with 1 week of worsening back pain. • Admission for abscess 2 weeks prior. Blood cultures (-) but those drawn on 2nd to last day turned positive afer discharge. Discharged on 14d of TMP-SMX. • He used black tar heroin on a daily basis • “Social chaos” – lived in a trailer that had recently burned down, on disability, an aunt but no other family support

  30. Case #4: Exam • Afebrile, normal vital signs • Normal cardiac and lung exams • MSK - Moderate tenderness to palpation at lumbar, sacral spine • Neuro – • A/Ox3 • CN II-XII intact, • Strength with flex / ext at ankle bilaterally is 5/5, flex/ext knee 5/5, left hip flex is 4+/5, ext is 5/5, right hip flex / ext 5/5. Normal sensation to light touch bilateral thighs. • 2+ symmetric reflexes throughout, toes downgoing

  31. Case #4: MRI

  32. Musculoskeletal complications of IDU Back pain Vertebral osteomyelitis and/or discitis Epidural abscess SI joint arthritis Septic arthritis (including unusual joints) Sternoclavicular Sacroiliac Knee, hip, elbow

  33. Prevention of Withdrawal • For heroin, methadone 15 mg q 12 is a reasonable starting point • Hold for sedation • Reassess and increase as needed

  34. Pain Management • Pain often undertreated, because of both tolerance and mistrust • Clear and consistent message from team • Oral pain meds preferable • Slower onset and offset • Patients often request IV dilaudid • IV pain meds post major surgery or trauma

  35. What problems can you expect? • Struggles over pain meds • Being present for antibiotics and other therapies • Illegal substance use in hospital • Limited access to post-discharge care

  36. Other interventions to consider • Assess readiness for change • HIV testing • Hepatitis vaccination if not immune • Harm reduction • Clean needles • Safe injection

  37. Case #7 • A 31 y.o. man with a 9 month history of IV heroin use presented with R leg swelling of 2 weeks duration.

  38. DVT in IDU • Injection into femoral vein • Trauma to vessel • Stenosis • Infection • Internal jugular • Can also affect superficial veins (in which case it is called superficial thrombophlebitis)

  39. Injection sites: • Intravenous • Subcutaneous • “Skin popping” • Intramuscular • “Muscling” Source: http://dermatlas.med.jhmi.edu

  40. Skin and Soft Tissue Infections Cellulitis Abscess Skin necrosis and ulceration Necrotizing fasciitis Myonecrosis Pyomyositis

  41. Case #5 A 22 y.o. man with a 3 year history of heroin use is admitted with buttock cellulitis. His admission exam was notable for T 38.3 and a 6X6 cm area of erythema and induration of the right buttock, with a 12 X12 cm area of surrounding edema with a “peau d’orange” appearance. A CT of the buttock showed no abscess. WBC was 20.

  42. Peau d’orange

  43. Pain was initially well controlled with methadone and oxycodone. The following day, he was still febrile and WBC was still 20 but the erythema had decreased.

  44. By the 4th hospital day, pain was severe despite methadone and oxycodone. A bulla had formed on the buttock, with surrounding dusky skin. WBC had increased to 40,000.

  45. Clinical Clues in Necrotizing Fasciitis & Myonecrosis • Severe pain, extending beyond involved area • Many patient afebrile on presentation(80% in one series) • Tachycardia in ~3/4 • Bullae or brawny edema in ~ half • Hyponatremia in ~ half • Soft tissue gas in ~1/4 • Elevated lactate level, very high WBC

  46. Case #6 A 31 y.o. injection drug user presents with three days of increasing weakness and one day of diplopia and difficulty swallowing. PMH: large, chronic undermined ulcers on B legs Meds: none Exam: T 38 large, undermined, foul smelling ulcers both legs

  47. Wound botulism • Clostridial species, including botulinum, can grow in the relatively anaerobic unhealthy soft tissue • Clinical syndrome similar to food-related botulism – weakness, diplopia, change in voice, difficulty swallowing

  48. Fever 96% Adenopathy 74% Pharyngitis 70% Rash 70% Myalgia 54% Diarrhea 32% N/V 27% Remember Primary HIV Infection

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