The purpose of this post is to answer the question below from the opioid video.

Joe is a gentleman probably in the baby boomer age range who comes to see the MD because of chronic pain. He wants to discuss Percocet and oxycontin right off.

What symptoms of Substance Use Disorder (SUD) does the individual in the video present with?

His complaints of pain “all over my body” is a vague description without attributes of quality, quantity, severity, or timing. This description is also lacking in factors that relieve the pain or aggravate it (Bickley, 2017). Moreover, his affect and body language are not congruent with what I would expect to see in someone having significant pain levels. Third, he has been on oxycontin for a long time, the dosage was decreased 3 weeks ago, and he is now having trouble sleeping as well as “attacks” that begun approximately 1 week after this dosage decrease. This is consistent with sub-acute opioid withdrawal syndrome which can occur when there is a dosage reduction. Depending on the medication involved, withdrawal symptoms can be seen within 18-36 hours and can last up to 14 days. Some other symptoms that support opioid withdrawal are his dysphoria, irritability, and increased drug cravings (Strain, 2021). Joe also expresses the fact that he uses his wife’s Klonopin a form of drug abuse typical in SUD (Strain, 2021; Saitz, 2020).

What are other possible causes of his symptoms?

Often, SUDs co-occur with other psychiatric illnesses as well as medical illnesses. Some of the most common comorbid psychiatric conditions are depression, anxiety, attention-deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and antisocial disorders amongst others (National institutes of health, 2020). As such, some of Joe’s symptoms could be from any of the above conditions. Some medical conditions that could mimic some symptoms of SUD are hyperthyroidism, brain injury, brain tumors, etc (Bickley, 2017). 

What additional information would you like to have about this case?

I would like to have a complete comprehensive health history on the patient that includes any surgeries, childhood, or adult illnesses that he might have had. He mentions diabetes and high blood pressure in passing, I would like to know when he was diagnosed, does he take medication for these conditions, is he compliant with the treatment plan? Also, what kind of pain is he having, how long has he had it and when did he start taking opioids for pain management. I would like to know all the opioids he has taken in the past as well as his current opioid/s including doses as well as all other medications both over the counter and prescribed. I would like to have a family history because research has shown that childhood environments where a parent or caregiver has SUD are linked to higher rates of physical, emotional, and sexual abuse as well as impaired parent-child relationships which are SUD risk factors (Dugosh & Cacciola, 2019).

 Similarly, I would also like to have a more thorough social/personal history. Based on his attempts at a joke where he casually refers to his wife as “a chronic pain” there may be relationship issues. Also, it sounds like he does not work based on his statements, I would like to know if he is retired or he is on disability, what his social life looks like as well as any health maintenance activities that he engages in. According to Dugosh & Cacciola (2019), people with impaired social relationships, have partners with SUDs, or live in communities with high drug and alcohol availability are at increased risk for SUD.

Would you prescribe for this individual? Why or why not?

I would not prescribe anything at this point because based on the patient’s statements, he is switching providers because ‘Mark” his doctor lowered his opioid dose three weeks ago and he may have continued taking it as previously ordered and has no ran out. Also, the patient’s initial chief complaint is pain which is vague, but he also has other complaints of insomnia, ‘’the attacks”, and he is also abusing his wife’s Klonopin. Abuse is the inappropriate use of prescribed or over-the-counter medication in a manner that was not intended, this can include taking someone else’s prescription (Strain, 2021). Also, the patient discusses using alcohol frequently and using hallucinogens on weekends. Based on this assessment, the patient has SUD. Given his age, his potential diabetes, HTN, and polysubstance use, he is at high risk for increased drug-drug interaction, increasing SUD, morbidity, and death (Strain 2021). He needs detox and supportive care.

What would your next steps be for this individual? What would your treatment plan be?

The patient meets the Diagnostic and Statistical Manual of Mental Disorders-five (DSM-5) criteria for substance use disorder. Besides, he has between 4 and 5 of the listed symptoms within the criteria putting him at moderate SUD. The optimal target for moderate SUD is to join and participate in SUD specialty care (Saitz, 2020).  Therefore, I would discuss my findings indicating his SUD with him and educate him about the benefits of a medically supervised detox, risks involved with this plan as well as disadvantages and implications of continuing his current SUD. If he is agreeable, I would refer him for SUD specialty care which would probably include detox then initiation of a supportive medication like Buprenorphine which is a mu opioid receptor partial agonist (Stahl, 2017); usually, it is started after a Risk Evaluation and Mitigation Strategy (REMS) is conducted.

 Typically, the main aim of supervised withdrawal (detox) is to effectively and safely transition the patient to a state of medication-assisted treatment of SUD. However, this does not guarantee sustained abstinence nor address the reasons that caused SUD or the effects of SUD. As such, this patient will require further adjunct interventions like psychotherapy, individual, and family psychotherapy as well as connection to appropriate community-based support programs (Sevarino 2020; Saitz, 2020).

Hanging indent not retained.

References

 

Bickley, L. (2017). Bates’ guide to physical examination and history taking (12th ed.). New York: Lippincott, Williams & Wilkins. ISBN-13: 978-1469893419

 Dugosh, K. L., & Cacciola, J. S. (2019, February 25). UpToDatehttps://www.uptodate.com /contents/ clinical-assessment-of-substance-use-disorders?search=cormobis%20substance%20abuse %20disorders &source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4#H3654243859

 National Institutes of health. (2020, April). National institute on Drug Abuse. The Connection Between Substance Use Disorders and Mental Illness.https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness

Saitz, R. (2020, August 6). UpToDatehttps://www.uptodate.com/contents/screening-for-unhealthy-use-of-alcohol-and-other-drugs-in-primary-care?search=outpatient%20detoxification &topic Ref= 7799&source=see_link#H1052718

Sevarino, K. A. (2020, August 18). UpToDatehttps://www.uptodate.com/contents/medically-supervised-opioid-withdrawal-during-treatment-for-addiction?search=substance%20use%20disorder %20treatment&topicRef=7799&source=see_link#H292407430

Stahl, S. M. (2017). Stahl’s essential psychopharmacology: The prescriber’s guide (7th ed.). Cambridge, UK ; New York: Cambridge University Press.

Strain, E. (2021, March 3). UpToDatehttps://www.uptodate.com/contents/opioid-use-disorder-epidemiology-pharmacology-clinical-manifestations-course-screening-assessment-and-diagnosis?search=substance%20use%20disorder%20behavior&topicRef=7807&source=see_link#H134294385

 

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