MEDICAL PRESENTATIONS OF

SUBSTANCE USE DISORDERS

February 2, 2009

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

Amphetamines

Complications similar to cocaineCognitive changesDermatologic lesions

Skin picking

Photo: Robert G. Hendrickson

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 Lab Burns

Photo: Ameri-Chem

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!

QUESTIONS?