Psychiatry · Year 3 · from Psychiatry
Case 2: Opioid Use Disorder - Overdose and Treatment Initiation
Patient Demographics
- Age: 28 years old
- Sex: Female
- Occupation: Server at restaurant (recently terminated)
Chief Complaint
"They said I overdosed. I just want to feel normal again."
History of Present Illness
The patient is a 28-year-old female brought to the ED by EMS after being found unresponsive by her roommate. She was successfully resuscitated with naloxone 2 mg intranasal by paramedics, with rapid improvement in mental status. She reports a 4-year history of opioid use that began with a prescription for oxycodone following a motor vehicle accident. After her prescription ended, she transitioned to buying pills on the street, and 18 months ago began using intravenous heroin due to lower cost and greater availability. She currently uses approximately 1 gram of heroin daily, injecting 3-4 times. She reports that fentanyl contamination in the heroin supply has made her using increasingly unpredictable. This is her third overdose in the past year. She has had two prior detoxifications but relapsed within days each time. She lost her job last month after missing work due to withdrawal symptoms. She is ambivalent about treatment, stating "Nothing has worked before."
Mental Status Examination
Appearance: Thin young woman, track marks visible on bilateral arms, appearing fatigued, mild diaphoresis
Behavior: Cooperative but restless, rubbing arms, frequent yawning
Speech: Normal rate and rhythm, soft volume
Mood: "Sick and hopeless"
Affect: Dysphoric, constricted, tearful at times
Thought Process: Linear and goal-directed
Thought Content: Preoccupied with avoiding withdrawal; passive suicidal ideation ("Sometimes I think it would be easier if I didn't wake up") but denies active plan or intent; no homicidal ideation
Perceptions: No hallucinations
Cognition: Alert and oriented x4; attention intact; memory intact
Insight: Partial - recognizes addiction as a problem but ambivalent about ability to change
Judgment: Impaired - continued IV drug use despite overdoses
Physical Examination
Vital Signs (Post-Naloxone):
- Blood pressure: 138/86 mmHg
- Heart rate: 98 bpm
- Temperature: 99.1°F
- Respiratory rate: 18
- Oxygen saturation: 97% on room air
Pertinent Findings:
- Track marks bilateral antecubital fossae
- Pupil size: 4 mm bilaterally (post-naloxone)
- COWS (Clinical Opiate Withdrawal Scale): 18 (moderate withdrawal)
- Early withdrawal signs: rhinorrhea, lacrimation, piloerection, yawning
Psychiatric and Medical Workup
Screening Tools:
- COWS: 18 (moderate withdrawal)
- PHQ-9: 14 (moderate depression)
- Columbia Suicide Severity Rating Scale: Passive ideation present, no plan or intent
Laboratory Studies:
- Urine drug screen: Positive for opiates, fentanyl
- CBC: Within normal limits
- CMP: Within normal limits
- Hepatitis panel: HCV antibody positive, HCV RNA pending
- HIV: Negative
- RPR: Non-reactive
- Pregnancy test: Negative
Diagnosis
Opioid Use Disorder, Severe (F11.20)
DSM-5 Criteria Met (9 of 11):
- Opioids taken in larger amounts than intended
- Persistent desire or unsuccessful efforts to cut down (multiple detox attempts)
- Great deal of time spent obtaining, using, recovering
- Craving
- Failure to fulfill major role obligations (lost job)
- Continued use despite social problems
- Important activities given up
- Continued use in physically hazardous situations (IV use, overdoses)
- Tolerance
- Withdrawal
Comorbid Diagnoses:
- Major Depressive Disorder (requires reassessment in sustained recovery)
- Hepatitis C infection
Treatment Plan
Acute Management - ED-Initiated Buprenorphine:
- Initiate buprenorphine/naloxone (Suboxone) in ED using low-dose initiation protocol
- Starting dose: Buprenorphine 2-4 mg SL when COWS ≥8
- Titrate to 8-16 mg on day 1 as tolerated
- Target maintenance dose: 16-24 mg daily
Rationale for Buprenorphine:
- Mortality reduction of 50% compared to abstinence-based treatment
- Reduces illicit opioid use
- Allows outpatient management
- Patient preference (does not want methadone clinic)
Safety Planning:
- Suicide risk assessment: Low-moderate
- Safety plan completed
- Naloxone kit prescribed for home (Narcan nasal spray)
- Education on overdose prevention
Psychosocial Interventions:
- Warm handoff to outpatient addiction treatment program
- Individual counseling referral
- Harm reduction education (never use alone, fentanyl test strips, safe injection)
- Peer recovery support specialist
Medical Follow-up:
- Hepatitis C treatment referral (DAA therapy highly effective)
- Primary care establishment
- Infectious disease consultation if needed
Discharge Planning:
- Bridge prescription: Buprenorphine/naloxone 16 mg daily x 7 days
- Addiction medicine appointment within 72 hours
- NA meeting schedule provided
- Crisis line numbers
Image Attribution
Image: Diagram showing the effects of alcohol on various organ systems. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.