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  4. Solution -final Answer: Although a typical patient with mild to moderate alcohol withdrawal and no history of complications from alcohol withdrawal can safely go through medically supervised withdrawal as an outpatient with daily monitoring visits, this patient’s problematic opioid use makes that potentially risky. He will need to be placed in a controlled setting where his alcohol withdrawal can be carefully monitored with the Clinical Institute Withdrawal Assessment (CIWA) and medication, either gabapentin or a benzodiazepine can be provided in symptom triggered fashion. The patient enters a treatment unit and completes a course of alcohol withdrawal treated with gabapentin. During the withdrawal he is maintained on his usual dosage of oxycodone. However, mild pathognomonic opioid withdrawal signs emerge including piloerection, yawning, and sneezing. Upon further assessment the patient acknowledges that he was obtaining extra oxycodone off the street and using it motivate himself to get through a day’s work or when he felt bored on the weekends. What is the next step? The patient appears to have co-occurring DSM-5 opioid use disorder and alcohol use disorder, a very common co-morbidity. He will need both medication and behavioral interventions for these disorders, and it is not safe to continue him on oxycodone. What are the medication options? One option is to complete medically supervised opioid withdrawal now that alcohol withdrawal is complete. In that case the mu-opioid antagonist, extended release naltrexone injection, could be used which is FDA approved to treat both disorders. A second option, if the patient does not want to go through full opioid withdrawal, is to start the partial mu-opioid agonist, buprenorphine, for treatment of opioid use disorder after 12-24 hours off oxycodone with ongoing evidence of opioid withdrawal signs and then choose an FDA approved pharmacotherapy that is safe in conjunction with opioids (which naltrexone is not). The choices are acamprosate or disulfiram. Disulfiram requires a commitment to total alcohol abstinence because of the disulfiram-alcohol reaction if alcohol is consumed.
  5. Thank you for all your comments. The patient was using Kratom. For this patient, kratom use appears to be related to self-management of opioid withdrawal and pain without indication of euphoria seeking. In moving forward with the session, counseling could include discussion about potential pros/cons of kratom, regulatory issues, and a lack of clinical evidence. One could explore further in a non-judgmental way whether he has an opioid use disorder and, if so, discuss potential options for treatment. Below are links to the FDA press announcement as well as a couple links from recent Medscape articles on Kratom. I’ve also including a picture of Kratom used by a patient who presented seeking treatment of an opioid use disorder. In recent years, a wide array of both plant-based and synthetic new psychoactive substances have proliferated. Many such substances are readily available over the Internet and act neurochemically in multifaceted ways. Kratom is one such product that recently has received increased attention given the national opioid epidemic and recent weighing-in by the FDA. Kratom is a botanical product derived from the leaves of the kratom tree (Mitragyna speciosa). The primary psychoactive alkaloids, myrtrigine and 7-hydroxymitragynine, act in part via an opioid agonist mechanism. Many individuals are using kratom as an opioid medication substitute, including for managing pain as well as emergent withdrawal symptoms when coming off prescription opioids or heroin. Much remains unknown regarding kratom epidemiology and clinical effects. However, as kratom use has appeared to expand, adverse effects have increasingly been identified, such as potential addiction to kratom itself and serious health consequences, including death. In February 2018, the FDA released a press announcement expressing concern about kratom use and potential toxicity, as well as describing new analytical approaches to characterize the opioid agonist effects of the substance. There has been much controversy about DEA scheduling of the product, with calls by some to enact policy changes to restrict use. Others have called for deregulation to enable access for withdrawal mitigation among those trying to cease opioid use and who are unable to access effective pain or opioid use disorder treatment. LINKS: FDA on evidence of opioid compounds in kratom, underscoring its potential for abuse www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm595622.htm Kratom Now an Opioid, FDA Says https://www.medscape.com/viewarticle/892375 FDA Issues Kratom Warning, Cites 36 Deaths https://www.medscape.com/viewarticle/888593 Kratom Association Hits Back at 'Unsubstantiated' FDA Advisory https://www.medscape.com/viewarticle/888686
  6. Thank you all for your comments. The diagnosis is as follows:Cannabinoid Hyperemesis Syndrome (CHS):CHS: Diagnostic Criteria:1. Chronic Heavy Cannabis Use2. Cyclic Episodes of Severe Nausea and Emesis3. Learned Behavior of Hot Bathing for Relief4. Resolution after Stopping Cannabis UseCHS: Treatment:1. IV Fluids: Electrolyte Abnormalities2. Overall Supportive Therapy Not Effective3. Nausea and Emesis: 5HT3 antagonists, H1 receptor antagonists, PPI, caution on opioids for pain n & v, endoscopy4. Hot Showers Most Effective5. Topical Capsaicin6. Treat Cannabis Use DisorderThe mechanism of action of both the hot showers and Capsaicin are unknown. There is involvement of the endocannabinoid system, and a balance between the CNS antiemetic effect of cannabis, and the pro-emetic effect of cannabis, secondary to decreased gastric motility and emptying.In summary, the CHS is uncommon. Occurs in patients who use large daily amounts of cannabis for years prior to the onset of CHS. Patients discover that hot showers provide temporary relief. Discontinuing cannabis results in resolution.
  7. Since there is no mention of abdominal pain in the vignette (THC usually causes crampy abdominal pain + N/V), and "GI workup and blood work were normal" ( no detail on these investigations ), I was thinking of a CNS cause for the N/V. Would engage the patient in another conversation about frequency of THC or K2 use, whether he/she had headaches, as possible cause for the N/V. Head CT would be recommended. LP if CT negative, would be recommended.
  8. I missed the mention of "no medications". If workup is negative, Cannabis is known to cause N/V, but but before settling on that diagnosis would get a non-contrasted CT head, & if normal get an LP.
  9. What was performed in the GI workup? (KUB?, Endoscopy? Abd sono? LFT's and CBC included in the blood work?) What about prescription meds? K2 use? Previous needle use for illicit drugs?
  10. I would suspect he is using Kratom, and inquire as to which "botanical" he is taking. If it is Kratom, I would caution him that it has opioid properties, could cause dependence, and has been reported to result in fatalities.
  11. I would take him off of the oxycodone. The American College of Occupational and Environmental Medicine has said that people shouldn’t take opioids if the work in a safety sensitive position. I assume that his construction job would be considered safety-sensitive. Also, the American Academy of Neurology has said that opioids usually result in worse outcomes if given for back pain. I agree with the w/u for the LFTs. You also may want to send a urine off for EtS and EtG to look for alcohol use. Franklin, G. M. (2014). Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology, 83(14), 1277–84. https://doi.org/10.1212/WNL.0000000000000839 Hegmann, K. T., Weiss, M. S., Bowden, K., Branco, F., DuBrueler, K., Els, C., … Harris, J. S. (2014). ACOEM Practice Guidelines. Journal of Occupational and Environmental Medicine, 56(7), e46–e53. https://doi.org/10.1097/JOM.0000000000000237
  12. A 35-year-old man with chronic low back pain presents to primary care office for high blood pressure, which was 160/90 on a home monitor. No history of elevated blood pressure in the past. Symptoms of anxiety, hot flashes/cold chills, and diaphoresis began after prior physician tapered him off the opioid medication he was receiving for back pain. He had been prescribed 3-4 oxycodone/acetaminophen (5/325mg) tablets per day, corroborated on the Prescription Monitoring Program. Seems he was taking extra medication and running out early. Other history includes alcohol use disorder (sustained full remission for over 5 years) and tobacco use disorder (1 pack per day). Blood pressure currently is 120/76 and exam is unremarkable. Urine drug testing in the office was negative for any prescribed or illicit substances, including an opiate test. He reported he started a natural, botanical product picked up from a supplement store and is now buying online. The product alleviated his acute symptoms and he said “I don’t need these pharmaceuticals anymore.” What could he be using/how to counsel him about such products?
  13. A 30 yo rock musician presents to emergency appointment with severe nausea and vomiting. GI workup and bloodwork were normal, except for minor electrolyte abnormalities. He is on no medications and does not have a significant past medical history. No hematemesis or coffee grounds. The patient relates that he has had similar, but less severe episodes in the past. He had taken a variety of anti-emetics with minimal improvement. History includes smoking approximately 10 cigarettes per day, social alcohol use, smokes cannabis a few times a week. Denies any use of opioids or stimulant drugs. He thought that smoking cannabis, since it is used for nausea and improved appetite, would help during the episodes, but the cannabis seemed to worsen the nausea and emesis. Diagnosis/treatment?
  14. This patient was initially on oxycodone for pain, but your comments make sense as a way to gather additional information. Also, your suggestions for working up the transaminitis are good ones.
  15. I would probably increase the frequency of visits- obviously diversion is a possibility- you didn't say how often he is seen, but if he is seen monthly, it is possible he is using less than prescribed and just making sure to save some so he will test positive on the day of the visit. The other possibility is that he is taking more than prescribed and then running short and saying he "lost" the medication. I would ask about cravings, ongoing pain and then about adherence- i might say "are you ever tempted to take more than prescribed?" or "have you ever taken an extra strip?" It may be that he needs a higher dose...that said, I would still start by scheduling more frequently so that there is less opportunity to either divert or run through it too quickly. As for the elevated transanimases, I might do an INR or platelet count to make sure there is no severe liver dysfunction and I would do a hepatitis screen but otherwise would just recheck in 3 months.
  16. Thank you for your question M. Chaplin. You have pointed out a flaw in my writing of the case. My intention in saying the urine drug screens were negative was to indicated that they were negative for any illicit or non-prescribed substances, not negative for oxycodone. The next part of the case suggests a workup for all causes of transaminitis which would include Hepatitis C antibody screen as you suggest. I agree that one would want to know other medications the patient is taking. In this case he was not on any other medications.
  17. can you clarify what is meant by uds "negative"- does that mean oxycodone is present and nothing else is? or does it mean there is no oxycodone? Also has he been tested for hepatitis C? i would be curious if he had EVER injected drugs and if his physical exam showed any injection marks or track marks...also would want to know if he is taking any other medication.
  18. A 47 year old, married Caucasian male works in construction and receives oxycodone 5 mg q 4 h for back pain after an unsuccessful surgery. He has had several urine drug screens which were negative, and the state prescription drug monitoring program indicates that he is not receiving controlled substances elsewhere. In general, the patient has been very adherent to the treatment plan, but twice in the past 4 months he has lost part of his prescription and come in for an early refill. On routine blood work the following transaminase results were obtained: AST 68 IU ALT 111 IU GGT 127 IU. He denies any regular alcohol use. What is the next step?
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