15 y.o . male with “behavioral problems”

1. Lausanne Orendain, M.D. January 30, 2009 Adolescent Medicine 15 y.o. male with “behavioral problems”

2. HPI • Patient’s CC – “I don’t know” • Mom’s CC: Behavioral problems • HPI: 15 year old Filipino male brought in by mom for behavioral problems that began with drug use on Halloween (3 mos PTP) • Problems consist of drug use, failing grades, running away, skipping school.

3. Transitioning • Pt admits to having a hard time with transitioning to 9th grade at new school: Bishop Gorman • Friends • Peers • Drug tested twice: negative • Grades started to decrease

4. Timeline • Halloween: Patient drank unknown quantity and type of alcohol, ate pizza and then felt “weird.” • Denies knowingly taking drugs by ingesting, drinking, or smoking • At home, experienced visual and auditory hallucinations • He called his mom

5. Timeline… continued • Stayed home for next 2 days • Brought to U.C. on day 3 post-ingestion • UDS positive for marijuana • Was discharged from U.C. • November: Patient insisted on switching to public school • Lost relationships with friends and family • Began failing all classes • Ran away for 3 days • Stayed at friend’s house.

6. Timeline • December: Patient was switched to public high school • Began skipping school • 1st week of January: Was found at home high on marijuana with friend • 2nd week of January: Continued to miss school for 13 days • Sent home after finals because teacher believed he was intoxicated with alcohol

7. Intervention • Mom grounded patient over Christmas break • Mom brought him to 4 sessions with a counselor • No meds were taken/given

8. Past Medical History • BHx: FT, NSVD, + PNC • Mom denies drugs, alcohol, tobacco while pregnant • No complications • Broken left wrist, right forearm, right elbow from skateboarding & snowboarding • No surgeries

9. Past Medical History • Diagnosed with ADHD in 7th grade treated with Adderall • Stopped by mom because it made him feel “slow” • Meds: None • ALL: NKDA, no food allergies • Development: Doing well (grades As-Bs) until Fall 2008 • FHx: • Mom has arthritis, migraine headaches • No substance abuse, depression, or other psychiatric diagnoses

10. Social History • Home: Lives with mom. “Latch-key kid” since 11 years old. • Education: Currently failing 9th grade. Goal is to finish high school and become stunt double in movies. • Activity: Inolved in Lacrosse teams and has been showboarding x 4 years

11. Social History • Drugs: • First substance use on Halloween • Admitted to alcohol but denies knowing how he had marijuana in his system • Smoked marijuana knowingly for first time 1st week of January • Denies any other drug use

12. Social History • Suicide: Denies ever having suicide ideation/plans. Admits to feeling a little sad • Sex: First intercourse last summer. Has had 2 female partners total, vaginal sex only, condom use 100% of the time. • Safety: Feels safe at home and at school.

13. CRAFFT • C – Has not ridden in car with someone who was under the influence • R – Does not use to relax • A – Does not use when alone • F – Did forget events at Halloween • F – Family has told him to stop using • T – Has gotten into trouble while using * Has > than 2 positive responses

14. Physical exam • Vitals: T-98 P-65 RR-16 BP-104/66 • Wt 64kg (75%) Ht 174.5cm (50-75%) • Gen: WN, WD, Alert, NAD • Rest of exam normal and non-contributory including HEENT and skin exam

15. Plan • Mom wanted “resources” for her son and drug testing. • Patient refused any further counseling. • Patient plans to attend school and get better grades this semester • Wants to get his driving license this summer. • Patient agreed to return to clinic in one month and submit to urine drug testing

16. Substance Abuse Criteria • Substance abuse: maladaptive pattern of substance use leading to clinically significant impairment or distress as manisfested by 1 or more episodes in a 12 month period • Symptoms do not meet dependence criteria

17. Substance Abuse Criteria • Recurrent substance use resulting in failure to fulfill obligations at work, school, home • Recurrent use in situations where it is physically hazardous • Substance-related legal problems • Continued use despite social/personal problems

18. Substance Dependence Criteria Three or more occurring at any time in same 12 months: • Tolerance – need for increased amounts • Withdrawal symptoms • Taking substance over longer time period or increased amounts • Cut Down – persistent desire & efforts • Time spent in obtaining substance • Social, work, recreational activities are given up • Continues substance use despite knowing problems are likely caused by substance

19. Hallucinogen • Derived from Latin term “Alucinari” which means “to wander in mind” • Hallucinogen causes distortion of perceived reality vs. a true hallucination when a person has experiences that do not happen • “Synethesias” = mixing of senses • Hearing colors or seeing smells

20. Percentage of High School Students Who Reported Lifetime Hallucinogenic Drug Use,* by Sex** and Race/Ethnicity,*** 2007 * Used hallucinogenic drugs (e.g., LSD, acid, PCP, angel dust, mescaline, or mushrooms) one or more times during their life. ** M > F *** W, H > B National Youth Risk Behavior Survey, 2007

21. Percentage of High School Students Who Reported Lifetime Hallucinogenic Drug Use,* 2001 – 2007 * Used hallucinogenic drugs (e.g., LSD, acid, PCP, angel dust, mescaline, or mushrooms) one or more times during their life. 1 Decreased 2001-2007, p < .05 National Youth Risk Behavior Surveys, 2001 – 2007

23. LSD • d-lysergic acid diethylamide • Originally derived from ergot fungus that grew on rye & wheat • Street Names: acid, dragon, white lightning, sorcerer’s apprentice, dots, microdot, battery acid, lucy in the sky with diamonds • Mechanism : serotonin and dopamine receptors like a serotonin agonist – increased glutamate

24. LSD • Forms: snorted, smoked, liquid, eye drops, blotter sheets • Onset: few minutes • Flush, mydriasis, pilorection, chills, tachycardia • Peak: 30-90 minutes • Visual and auditory illusions, synesthesia, see themselves or others aging, feel competent • Paranoia, confusion, depression, panic, anxiety • Duration: 8-12 hours

25. LSD • Acute toxicity: Coma, respiratory arrest, hypertension, tachycardia, hyperthermia, seizures • Chronic reactions: • personality changes • psychosis • ~50-60% will present with spontaneous flashbacks • may occur weeks to 1 year after last use, triggered by stress, illness, exercise

26. LSD • Hallucinogen Persisting Perception Disorder (HPPD) – DSM IV diagnosis • After few months to 5 years after stopping LSD use, continue to have: • geometric hallucinations • false perceptions of movement in the peripheral visual fields, • flashes of colors, intensified colors • trails of images of moving objects, afterimages, halos around objects

27. LSD • Urine tox screen: Not included • Have to specifically screen for it • Tolerance: Yes • Produces tolerance of psilocybin and mescaline, but not PCP and marijuana • Dependence: possibly psychological

29. Morning Glory • Lysergic acid amide • Forms: Eaten whole or ground to flour and mixed in drinks

31. Psilocybin • Psilocybin Cubensis • Mushrooms grown in northwest and southeast of US • Found in South America, Mexico

32. Psilocybin • Street Names: “shrooms,” magic mushrooms, liberty cap • Mechanism : Serotonin agonist • Forms: eat raw, dried, stewed • Average “dose” = 2-6 mushrooms • 1/3 of mushrooms sold contain psilocybin, many are laced with LSD or PCP • Onset: 20-30 minutes • Mydriasis, Facial flushing, dysphoric, hyperreflexia, paresthesia, ataxic, nausea

33. Psilocybin • Peak: 1.5 hours • visual hallucinations, inappropriate laughter, altered perception of time • Cannot tell fantasy from reality • Panic reactions and psychosis with larger doses • Duration: 6 hours • Acute toxicity: chills, myalgia, rarely hyperthermia or seizures or coma

34. Psilocybin • Urine tox screen: No • Need to specifically screen • Tolerance: Yes • Dependence: None

37. Mescaline • Peyote cactus found in Southwest US, North/Central Mexico • Disc shaped buttons at crown of cactus that are dried • Street names: Mescal buttons, Mexc, cactus • Mechanism: Serotonin agonist

38. Mescaline • Forms: Ingested by chewing or soaking in water to produce tea • Average “dose” = 6-12 peyote buttons • Ground into a powder and smoked. • Onset: 30 minutes • Nausea, vomiting, diaphoresis, dizzyness, ataxia • Peak: 4 hours • Mydriasis, visual and auditory hallucinations, euphoria, paranoia, sense of increased physical power • Duration: 8-12 hours

39. Mescaline • Acute toxicity: nausea, vomiting, muscle weakness • Urine tox screen: No • Tolerance: Yes • Dependence: None

41. PCP • Phencyclidine • Originally developed as an anesthetic • Street Names: angel dust, loveboat, peace weed, super grass, elephant tranquilizer, rocket fuel, hog • Mechanism : Inhibits norepinephrine and dopamine reuptake • Some cholinergic and anticholinergic effects

42. PCP • Forms: powder - smoked, mixed with liquid, IV • Onset: 2-5 minutes • Unpredictable symptoms: calm or wild, violent or disoriented. • Peak: 15 minutes • Bizarre and psychotic behaviors • Dissociative drug – feel minimal pain • Tachycardia, hypertension, miosis with a blank stare, nystagmus (rotary)

43. PCP • Duration: 16 hours  48 hours • Acute toxicity: Delusions, paranoia, anxiety, Muscle rigidity, myoclonus • Complications: severe agitation and muscle rigidity rhabdomyolysis and myoglobinuric renal failure. Violent behavior & decreased sense of pain  law problems

44. PCP • Long term: memory loss, difficulties with speech, thinking, depression can persist up to 1 year after stopping • Utox screen: Yes, 3-8 days after • Tolerance: Yes • Dependence: Yes, psychological. Repeated abuse leads to addiction and craving.

46. Jimson Weed • Originally derived from poisonous plant native to North America • Street Names: Jamestown weed, Angel’s trumpet, Loco weed • Mechanism : anticholinergic, has atropine • Forms: kidney shaped seed which can be ingested, smoked

47. Jimson Weed • "red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare.“ • Urine tox screen – no • Need to specifically screen for it • Symptoms: flushing, dry mouth, urinary retention, mydriasis and blurry vision, hyperthermia, • tachycardia, decreased GI motility, confused, hallucination, restless, irritable

49. MDMA • 3,4-methylenedioxymethamphetamine • Synthetically made by accident, initially recommended during marriage counseling • Street Names: ecstasy, XTC, Adam, E, X, clarity, Stacy, hug drug • Mechanism: massive serotonin release • Forms: tablet, powder, liquid

50. MDMA • Onset: 30 minutes • anxiety, tachycardia, mydriasis • Peak: 1-1.5 hours • Relaxation, empathy, euphoria, disinhibition, increased sensuality • See halos, sense of touch is enhanced, not really hallucinogenic, however may be mixed with other hallucinogenic drugs • Duration: 4-8 hours