# Clinical Cases: Addiction Medicine

## Case 1: Opioid Use Disorder — Medication-Assisted Treatment

### Patient Presentation
**Demographics:** 29-year-old female registered nurse (license currently suspended)

**Chief Complaint:** "I need help — I've been using fentanyl and I'm going to lose everything"

**History of Present Illness:**
This 29-year-old female registered nurse presents voluntarily to the addiction medicine clinic seeking treatment for opioid use disorder. She reports a 3-year history of escalating opioid use that began with diversion of hydrocodone and oxycodone from her workplace. She initially started taking leftover patient medications for back pain following a lifting injury at work. Over time, she began diverting medications more frequently and in larger quantities to manage worsening withdrawal symptoms.

Six months ago, she transitioned to using illicitly obtained fentanyl (snorting pressed pills) after she was caught diverting controlled substances and her nursing license was suspended pending investigation by the state board of nursing. She currently uses approximately 4-6 pressed fentanyl pills daily at a cost of $100-150/day. She has depleted her savings and recently pawned her grandmother's jewelry. She experienced one non-fatal overdose 3 weeks ago that was reversed with naloxone by a friend.

She presents today 14 hours after her last fentanyl use and is in moderate opioid withdrawal. She has not eaten in 2 days and has been vomiting and having diarrhea. She reports strong cravings and is motivated to enter treatment, stating she wants to get her nursing license back, repair her relationship with her family, and "get her life back." She has no prior addiction treatment history.

**Past Medical History:**
- Lumbar strain (work-related injury, 3 years ago)
- Hepatitis C (recently diagnosed, genotype 1a, untreated)
- Depression (untreated)
- No prior psychiatric hospitalizations
- No prior addiction treatment

**Medications:**
- None prescribed
- Active fentanyl use (illicit pressed pills, 4-6 daily)

**Social History:**
- Registered nurse (license suspended 6 months ago)
- Unmarried, in a relationship with a partner who also uses opioids
- No children
- Estranged from parents and siblings who are aware of her substance use
- Lives in a rented apartment, behind on rent
- History of sharing snorting equipment
- One prior naloxone reversal (3 weeks ago)
- No IV drug use (snorting route only)
- No alcohol or benzodiazepine use
- Denies suicidal ideation

**Family History:**
- Father with alcohol use disorder (in recovery for 10 years)
- Paternal uncle died of heroin overdose at age 42
- Mother with generalized anxiety disorder
- No siblings with substance use disorders

### Physical Examination
- **Vital Signs:** BP 148/92 mmHg, HR 102 bpm, RR 20/min, Temp 37.4°C, SpO2 98% on room air, BMI 21.2, Weight 56 kg
- **General:** Thin-appearing female, visibly uncomfortable, restless, yawning frequently. Appears anxious and tearful
- **HEENT:** Dilated pupils (6 mm bilaterally, reactive). Rhinorrhea. Lacrimation. No nasal septal perforation on anterior rhinoscopy
- **Cardiac:** Tachycardic, regular rhythm, no murmurs
- **Lungs:** Clear to auscultation bilaterally
- **Abdomen:** Hyperactive bowel sounds, mild diffuse tenderness without guarding or rebound. No hepatomegaly
- **Skin:** Piloerection ("gooseflesh"). Diaphoretic. No track marks. No abscesses. No rashes
- **Musculoskeletal:** Diffuse myalgias reported, muscle twitching in lower extremities
- **Neurologic:** Alert, oriented x3. Restless. Tremor of hands. No focal deficits
- **COWS (Clinical Opiate Withdrawal Scale) Score: 22 (moderate withdrawal)**
  - Resting pulse >100: 2
  - Sweating: 2
  - Restlessness: 3
  - Pupil size dilated: 5
  - Bone/joint aches: 2
  - Rhinorrhea/lacrimation: 2
  - GI upset: 2
  - Tremor: 1
  - Yawning: 2
  - Anxiety/irritability: 1

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 12.4 g/dL | 12.0-16.0 g/dL |
| WBC | 8,200/μL | 4,500-11,000/μL |
| Platelets | 210,000/μL | 150,000-400,000/μL |
| AST | 58 U/L | 10-40 U/L |
| ALT | 72 U/L | 7-56 U/L |
| Albumin | 3.6 g/dL | 3.5-5.0 g/dL |
| Total Bilirubin | 0.9 mg/dL | 0.1-1.2 mg/dL |
| Creatinine | 0.8 mg/dL | 0.6-1.2 mg/dL |
| HCV RNA | 2.4 million IU/mL | Undetectable |
| HCV Genotype | 1a | -- |
| Hepatitis B surface Ag | Negative | Negative |
| HIV 1/2 Ab/Ag | Negative | Negative |
| RPR | Non-reactive | Non-reactive |
| β-hCG | Negative | Negative |
| Urine Drug Screen | Positive: fentanyl, norfentanyl | -- |
| Urine Drug Screen | Negative: opiates, benzodiazepines, cocaine, amphetamines, THC | -- |
| TSH | 2.8 mIU/L | 0.4-4.0 mIU/L |
| Vitamin D | 18 ng/mL | 30-100 ng/mL |

**Imaging/Additional Studies:**
- ECG: Sinus tachycardia, QTc 410 ms (normal, relevant for methadone consideration)
- FibroScan (liver elastography): 7.8 kPa (F1-F2, mild fibrosis)
- PHQ-9: Score 16 (moderately severe depression)
- GAD-7: Score 12 (moderate anxiety)
- Columbia Suicide Severity Rating Scale: No current suicidal ideation

### Clinical Image

![Opioid use disorder medication-assisted treatment diagram](case_01_image.jpg)

*Diagram illustrating the three FDA-approved medications for opioid use disorder (methadone, buprenorphine, naltrexone) and their mechanisms of action at the mu-opioid receptor as full agonist, partial agonist, and antagonist, respectively. Source: Educational illustration.*

### Diagnosis
**Opioid Use Disorder, Severe (DSM-5), with Physiologic Dependence — Currently in Moderate Withdrawal**

**Key Diagnostic Criteria (DSM-5 — meets 8 of 11 criteria, Severe):**
- Opioids taken in larger amounts over longer period than intended
- Persistent desire or unsuccessful efforts to cut down
- Great deal of time spent obtaining, using, or recovering from opioids
- Craving or strong desire to use opioids
- Recurrent use resulting in failure to fulfill major role obligations (loss of nursing license)
- Continued use despite social/interpersonal problems (family estrangement)
- Important activities given up or reduced
- Tolerance (escalation from hydrocodone to fentanyl)
- Withdrawal symptoms when not using
- Additional: continued use despite physical problems (hepatitis C)

### Treatment Plan
1. **Immediate withdrawal management and buprenorphine induction:**
   - Given fentanyl use (long-acting lipophilic synthetic), standard buprenorphine induction carries high risk of precipitated withdrawal; use a **micro-dosing (Bernese method) induction protocol:**
     - Day 1: Buprenorphine/naloxone 0.5 mg sublingual twice daily (continue fentanyl use)
     - Day 2: 1 mg twice daily
     - Day 3: 2 mg twice daily
     - Day 4: 4 mg twice daily (begin reducing fentanyl)
     - Day 5: 8 mg twice daily (stop fentanyl)
     - Day 6-7: Consolidate to 16-24 mg daily
   - Adjunctive comfort medications: clonidine 0.1 mg every 8 hours PRN (for autonomic symptoms), loperamide for diarrhea, ondansetron for nausea, dicyclomine for abdominal cramps, trazodone 50-100 mg for insomnia
2. **Maintenance buprenorphine therapy:** Target dose 16-24 mg/day buprenorphine/naloxone sublingual. Once stabilized, consider transition to monthly buprenorphine extended-release injection (Sublocade 300 mg x2, then 100 mg monthly) to eliminate daily medication adherence burden
3. **Hepatitis C treatment:** Refer to hepatology. Initiate HCV treatment with sofosbuvir/velpatasvir 12-week course after stabilization on buprenorphine (timing does not need to wait for sobriety). Check for drug-drug interactions with buprenorphine (none significant with sofosbuvir/velpatasvir)
4. **Psychiatric care:** Start SSRI for depression (sertraline 50 mg daily, titrate as needed). Continue monitoring with PHQ-9 and GAD-7. Individual psychotherapy (cognitive behavioral therapy for substance use disorders)
5. **Psychosocial treatment:**
   - Individual counseling (weekly): motivational enhancement therapy transitioning to CBT
   - Group therapy: process group 2-3 times/week
   - 12-step facilitation or SMART Recovery referral
   - Peer recovery support specialist
6. **Harm reduction:** Naloxone (Narcan) nasal spray prescribed for patient and identified contacts. Education on overdose prevention. Fentanyl test strips provided
7. **Professional recovery program:** Referral to state professional recovery program for healthcare professionals. This program monitors recovery, facilitates nursing license reinstatement, and provides workplace monitoring upon return to practice
8. **Follow-up:** Weekly visits for first month (COWS scoring, urine drug screens, medication management), then biweekly, then monthly. Urine drug screens at each visit (confirm buprenorphine and norbuprenorphine present, fentanyl absent)

### Key Learning Points
- Buprenorphine micro-dosing (Bernese method) induction is increasingly used for patients using fentanyl, as traditional induction requiring 12-24 hours of abstinence frequently fails due to fentanyl's lipophilicity and prolonged tissue redistribution, leading to precipitated withdrawal even at 48-72 hours of abstinence
- Medication for opioid use disorder (MOUD) with buprenorphine or methadone reduces all-cause mortality by 50% and overdose mortality by 70-80%; it is first-line treatment for OUD and should be offered to all patients
- Standard urine immunoassay drug screens test for morphine/codeine metabolites (natural opiates) and will NOT detect fentanyl; specific fentanyl immunoassays or confirmatory testing (LC-MS/MS) must be ordered separately
- Healthcare professionals with substance use disorders have excellent recovery outcomes (75-90% sustained recovery at 5 years) when enrolled in structured professional monitoring programs that include workplace monitoring, random drug testing, and contingency management
- Hepatitis C treatment should not be delayed until completion of addiction treatment; concurrent treatment is safe and effective, and HCV treatment during MOUD has similar SVR rates to the general population

---

## Case 2: Alcohol Use Disorder with Withdrawal Management

### Patient Presentation
**Demographics:** 48-year-old male divorced accountant

**Chief Complaint:** "I had a seizure at home and my roommate called 911"

**History of Present Illness:**
This 48-year-old male is brought to the emergency department by EMS after a witnessed generalized tonic-clonic seizure at his apartment. His roommate reports the seizure lasted approximately 2 minutes and was followed by a 5-minute postictal period. There was no tongue biting, urinary incontinence, or head trauma. The patient regained full consciousness en route to the hospital.

His roommate reports the patient has been drinking heavily for the past 3 months following a job loss. He estimates the patient has been consuming approximately one fifth of vodka (750 mL, approximately 17 standard drinks) daily. The patient's last drink was approximately 18 hours ago when he ran out of vodka and was unable to obtain more due to financial constraints.

The patient has a 20-year history of heavy alcohol use with two prior hospitalizations for alcohol withdrawal: the first was 5 years ago (treated with benzodiazepines, no seizure, no delirium) and the second was 2 years ago (complicated by withdrawal seizure). He has never completed a formal alcohol treatment program and has not tried any medications for alcohol use disorder. He has had several unsuccessful attempts at self-directed quitting.

He reports his drinking escalated significantly after his divorce 3 years ago and again after losing his accounting position 3 months ago. He acknowledges drinking has caused his divorce, job loss, a DUI conviction, and estrangement from his two teenage children.

**Past Medical History:**
- Alcohol use disorder, severe (20-year history)
- Two prior alcohol withdrawal hospitalizations (one with withdrawal seizure)
- Hypertension
- Alcoholic fatty liver disease
- Gastritis
- Peripheral neuropathy (alcohol-related)
- DUI conviction (1 year ago)
- Depression
- No prior seizure disorder

**Medications:**
- Lisinopril 20 mg daily (has not taken in 2 weeks)
- Pantoprazole 40 mg daily (has not taken in 2 weeks)
- No psychiatric medications

**Social History:**
- Divorced 3 years ago
- Two teenage children (limited contact)
- Former senior accountant (lost job 3 months ago)
- Lives with a roommate in a rented apartment
- Currently unemployed, running out of savings
- Drinking one fifth of vodka daily (~17 standard drinks/day) for past 3 months
- 10-pack-year smoking history (1/2 pack per day, current smoker)
- No illicit drug use
- No prior completion of addiction treatment
- DUI 1 year ago (license restricted)

**Family History:**
- Father with alcohol use disorder (died of alcoholic cirrhosis at age 58)
- Mother with depression and anxiety
- Brother with alcohol use disorder (in recovery)
- Paternal grandfather died of alcohol-related causes

### Physical Examination
- **Vital Signs:** BP 168/102 mmHg, HR 118 bpm, RR 22/min, Temp 38.0°C (100.4°F), SpO2 97% on room air, BMI 26.4
- **General:** Diaphoretic, tremulous, anxious-appearing male. Alert and oriented x3. Agitated, pacing in the room
- **HEENT:** Injected sclera. Moist mucous membranes. No tongue laceration. Mild facial flushing
- **Cardiac:** Tachycardic, regular rhythm, no murmurs
- **Lungs:** Clear to auscultation bilaterally. Tachypneic
- **Abdomen:** Soft, mild epigastric tenderness. Liver edge palpable 2 cm below right costal margin (smooth, non-tender). No ascites. No splenomegaly
- **Neurologic:** Alert, oriented x3. Bilateral hand tremor (coarse, large-amplitude, worse with intention). Hyperreflexia (3+ patellar and Achilles bilaterally). No clonus. Decreased vibration sense in bilateral feet (stocking distribution). No focal motor weakness. No nystagmus at this time
- **Skin:** Diaphoretic. No spider angiomata. No palmar erythema. No jaundice. No signs of chronic liver disease
- **Psychiatric:** Anxious, hypervigilant. No visual or auditory hallucinations at this time. No paranoid ideation. Denies suicidal ideation
- **CIWA-Ar Score: 24 (severe withdrawal)**
  - Nausea/vomiting: 3
  - Tremor: 5
  - Paroxysmal sweats: 4
  - Anxiety: 4
  - Agitation: 3
  - Tactile disturbances: 0
  - Auditory disturbances: 0
  - Visual disturbances: 0
  - Headache: 3
  - Orientation/clouding: 2

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 13.8 g/dL | 13.5-17.5 g/dL |
| MCV | 104 fL | 80-100 fL |
| WBC | 12,400/μL | 4,500-11,000/μL |
| Platelets | 128,000/μL | 150,000-400,000/μL |
| AST | 148 U/L | 10-40 U/L |
| ALT | 82 U/L | 7-56 U/L |
| GGT | 385 U/L | 9-48 U/L |
| Alkaline Phosphatase | 112 U/L | 44-147 U/L |
| Total Bilirubin | 1.4 mg/dL | 0.1-1.2 mg/dL |
| Albumin | 3.4 g/dL | 3.5-5.0 g/dL |
| INR | 1.1 | 0.8-1.2 |
| Sodium | 132 mEq/L | 136-145 mEq/L |
| Potassium | 3.2 mEq/L | 3.5-5.0 mEq/L |
| Magnesium | 1.4 mg/dL | 1.7-2.2 mg/dL |
| Phosphorus | 2.0 mg/dL | 2.5-4.5 mg/dL |
| Glucose | 72 mg/dL | 70-100 mg/dL |
| Blood Alcohol Level | 0 mg/dL | 0 mg/dL |
| Ammonia | 42 μmol/L | 15-45 μmol/L |
| Urine Drug Screen | Negative (all panels) | -- |
| Lipase | 45 U/L | 10-140 U/L |
| CDT (Carbohydrate-Deficient Transferrin) | 4.8% | <1.7% |
| Thiamine level | Low (not quantified in stat labs) | -- |
| Folate | 3.2 ng/mL | >3.0 ng/mL |
| Vitamin B12 | 310 pg/mL | 200-900 pg/mL |

**Imaging/Additional Studies:**
- CT Head (non-contrast): No acute intracranial pathology. No subdural hematoma. No mass lesion. Mild diffuse cerebral atrophy
- Chest X-ray: Clear lung fields. No cardiomegaly
- ECG: Sinus tachycardia 118 bpm. QTc 440 ms. No ST-T wave changes
- Liver ultrasound: Hepatomegaly (17 cm). Diffusely echogenic liver consistent with fatty infiltration. No focal lesions. No ascites. Patent hepatic and portal vasculature
- AUDIT Score: 32 (out of 40, indicates severe alcohol use disorder)
- PHQ-9: Score 18 (moderately severe depression — to be reassessed after withdrawal management and sobriety)

### Clinical Image

![Alcohol withdrawal timeline and CIWA-Ar management diagram](case_02_image.jpg)

*Diagram illustrating the timeline of alcohol withdrawal symptoms (6-72+ hours), CIWA-Ar scoring system, and symptom-triggered benzodiazepine therapy protocol. Source: Educational illustration.*

### Diagnosis
**Alcohol Use Disorder, Severe (DSM-5), with Alcohol Withdrawal Seizure and Severe Alcohol Withdrawal (CIWA-Ar 24)**

**Key Diagnostic Criteria:**
- Severe alcohol use disorder meeting >=6 DSM-5 criteria (tolerance, withdrawal, larger amounts/longer than intended, unsuccessful efforts to cut down, craving, social/occupational impairment, continued use despite consequences)
- Alcohol withdrawal seizure (generalized tonic-clonic, 18 hours after last drink)
- CIWA-Ar score 24 indicating severe withdrawal requiring pharmacologic management
- Prior history of complicated withdrawal (kindling effect increases severity with each successive withdrawal episode)

### Treatment Plan
1. **Acute withdrawal management (ICU or monitored bed):**
   - **Symptom-triggered benzodiazepine protocol:** Diazepam 10-20 mg IV/PO every 1 hour for CIWA-Ar >=10 (or chlordiazepoxide 50-100 mg if stable for oral). Reassess CIWA-Ar every 1 hour during active withdrawal. Given prior withdrawal seizure, consider front-loading with diazepam 20 mg IV every 2 hours x3 initial doses, then symptom-triggered
   - **Seizure precautions:** Padded side rails, suction at bedside, no seizure prophylaxis with phenytoin (ineffective for alcohol withdrawal seizures; benzodiazepines are both treatment and prophylaxis)
   - **Thiamine:** 500 mg IV three times daily for 3 days (high-dose protocol for Wernicke encephalopathy prophylaxis — ALWAYS give thiamine BEFORE glucose), then 100 mg IV/PO daily
   - **Electrolyte correction:** IV magnesium sulfate 2 g, oral magnesium oxide 400 mg BID. IV potassium chloride 40 mEq. Phosphorus repletion. Monitor and replete every 6-12 hours
   - **IV fluids:** D5NS with multivitamins and folate at 125 mL/hr (avoid overhydration)
   - **Monitoring:** Continuous telemetry, CIWA-Ar every 1 hour until score <10 for 24 hours, then every 4-8 hours. Monitor for delirium tremens (typically onset 48-72 hours after last drink)
2. **If delirium tremens develops (48-96 hours):** Escalate to IV diazepam or midazolam infusion in ICU. Consider phenobarbital 130-260 mg IV as adjunct for benzodiazepine-resistant withdrawal. Propofol and mechanical ventilation for refractory cases
3. **Nutritional rehabilitation:** Thiamine, folate, multivitamin. High-calorie, high-protein diet when tolerating oral intake. Monitor for refeeding syndrome (phosphorus, magnesium, potassium)
4. **Medications for alcohol use disorder (initiate before discharge):**
   - **Naltrexone** 50 mg daily (first-line) — reduces heavy drinking days and craving. Check LFTs first (contraindicated if AST/ALT >3-5x ULN; reassess when liver enzymes improve). Alternatively, start with 25 mg x3 days, then 50 mg daily
   - Alternative: Extended-release naltrexone injection (Vivitrol 380 mg IM monthly) for improved adherence
   - Consider adding **acamprosate** 666 mg three times daily (renally cleared, safe with liver disease) for craving reduction, particularly if naltrexone contraindicated
   - **Gabapentin** 300 mg three times daily (titrate as needed) for residual insomnia, anxiety, and craving (evidence-based adjunct)
5. **Psychosocial treatment (arrange before discharge):**
   - Referral to intensive outpatient program (IOP): 3 hours/day, 3-4 days/week for 8-12 weeks
   - Individual counseling: motivational interviewing transitioning to CBT/relapse prevention
   - 12-step facilitation: AA meeting attendance (90 meetings in 90 days recommendation)
   - Consider residential treatment given unemployment, social instability, and prior failed quit attempts
6. **Psychiatric follow-up:** Reassess depression after 2-4 weeks of sobriety (alcohol-induced depressive disorder vs. independent major depression). Initiate antidepressant if symptoms persist
7. **Discharge planning:** Ensure safe living situation, sober support network, outpatient appointment within 1 week, prescription for naltrexone and gabapentin, naloxone kit (in case of polysubstance exposure), smoking cessation resources

### Key Learning Points
- Alcohol withdrawal seizures typically occur 12-48 hours after the last drink and are generalized tonic-clonic; they are effectively prevented and treated with benzodiazepines (phenytoin is NOT effective for alcohol withdrawal seizures)
- The "kindling" phenomenon means each successive alcohol withdrawal episode tends to be more severe; patients with prior withdrawal seizures or delirium tremens are at significantly higher risk for complicated withdrawal
- Symptom-triggered benzodiazepine therapy (using CIWA-Ar scores) is superior to fixed-schedule dosing: it results in lower total benzodiazepine doses, shorter treatment duration, and fewer cases of oversedation
- Thiamine must be given BEFORE or concurrently with glucose-containing fluids to prevent precipitation of Wernicke encephalopathy; high-dose IV thiamine (500 mg TID) is recommended for patients at high risk
- FDA-approved medications for alcohol use disorder (naltrexone, acamprosate, disulfiram) are significantly underutilized — fewer than 10% of patients with AUD receive any pharmacotherapy; they should be offered to all patients as part of a comprehensive treatment plan

---

## Case 3: Stimulant Use Disorder with Contingency Management

### Patient Presentation
**Demographics:** 36-year-old male restaurant line cook

**Chief Complaint:** "I can't stop using meth no matter how hard I try — I've lost my apartment and my girlfriend left me"

**History of Present Illness:**
This 36-year-old male restaurant line cook presents to the addiction medicine clinic after being referred by an emergency department social worker. He was seen in the ED 3 days ago for chest pain and hypertension (BP 192/110, HR 130) while intoxicated on methamphetamine. Cardiac workup was negative for acute coronary syndrome, and he was discharged with a referral to addiction services.

He reports a 5-year history of methamphetamine use, initially smoking crystal methamphetamine on weekends at parties. Over the past 2 years, his use has escalated to daily smoking, with binges lasting 3-5 days ("runs") followed by 1-2 day crashes where he sleeps 18-20 hours. During binges, he does not eat or sleep and reports consuming 1-2 grams of methamphetamine daily.

His most recent binge ended 4 days ago, and he is currently in the "crash" phase. He reports profound fatigue, hypersomnia (sleeping 16 hours/day for the past 3 days), increased appetite, dysphoria, and anhedonia. He denies current suicidal ideation but reports passive death wishes during the crash ("I wouldn't care if I didn't wake up"). He has experienced methamphetamine-induced psychotic symptoms during binges, including paranoid delusions (believing people were following him) and visual hallucinations (shadow people), which resolve within 24-48 hours of cessation.

He has tried to quit multiple times on his own, with his longest period of abstinence being 3 weeks. He has never received formal addiction treatment. He is currently homeless, staying in a shelter, after being evicted from his apartment 1 month ago for non-payment of rent.

**Past Medical History:**
- Methamphetamine use disorder, severe
- Methamphetamine-induced psychotic disorder (during binges, resolved with abstinence)
- Hypertension (untreated, likely stimulant-related)
- Dental caries (multiple, "meth mouth")
- Unintentional weight loss (20 lbs over 6 months)
- No prior addiction treatment
- No prior psychiatric hospitalizations
- STI history: chlamydia (treated 1 year ago)

**Medications:**
- None prescribed
- Active methamphetamine use (smoking, 1-2 g/day during binges)

**Social History:**
- Restaurant line cook (at risk of losing job due to absences during binges and crashes)
- Currently homeless (staying at a shelter for 1 month)
- Former girlfriend ended relationship 2 months ago due to his drug use
- No children
- High school graduate
- Some college (dropped out after 1 year)
- No current partner
- Smokes cigarettes (1 pack/day)
- Occasional alcohol (2-3 beers on non-binge days)
- Sexual risk behaviors during binges (unprotected sex with multiple partners)
- No IV drug use
- Limited social support (most friends are also users)

**Family History:**
- Mother with bipolar disorder
- Father with alcohol use disorder
- Maternal uncle with methamphetamine use disorder
- No family history of cardiovascular disease

### Physical Examination
- **Vital Signs:** BP 142/88 mmHg (improved from ED, still elevated), HR 68 bpm (bradycardic during crash phase), RR 14/min, Temp 36.6°C, SpO2 99% on room air, BMI 20.8, Weight 65 kg (down from 74 kg 6 months ago)
- **General:** Thin male appearing older than stated age. Fatigued appearance, psychomotor retardation. Oriented x3. Flat affect
- **HEENT:** Multiple dental caries and areas of tooth decay ("meth mouth"). Gingival recession. Dry, cracked lips. No oral lesions. Pupils 4 mm, equal, reactive
- **Cardiac:** Bradycardic (crash phase), regular rhythm, no murmurs. No S3 or S4
- **Lungs:** Clear to auscultation bilaterally
- **Abdomen:** Thin, soft, non-tender. No hepatosplenomegaly
- **Skin:** Multiple excoriations on forearms and face (from skin picking/formication during binges). Some with secondary infection (crusted, erythematous). No track marks. Dry skin. Poor wound healing
- **Neurologic:** Alert, oriented x3. Psychomotor retardation. Flattened affect. Speech is slow but coherent. No tremor. No hallucinations or paranoid ideation at this time. No focal deficits
- **Musculoskeletal:** Generalized muscle wasting. No joint swelling
- **Psychiatric:** PHQ-9: 20 (severe depression — reassess after abstinence). No active suicidal ideation. No homicidal ideation. No current psychotic symptoms. Insight: fair. Motivation: ambivalent but presenting voluntarily

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 14.2 g/dL | 13.5-17.5 g/dL |
| WBC | 7,800/μL | 4,500-11,000/μL |
| BMP | Within normal limits | -- |
| Creatinine | 0.9 mg/dL | 0.7-1.3 mg/dL |
| AST | 32 U/L | 10-40 U/L |
| ALT | 28 U/L | 7-56 U/L |
| TSH | 3.1 mIU/L | 0.4-4.0 mIU/L |
| HIV 1/2 Ab/Ag | Negative | Negative |
| Hepatitis B surface Ag | Negative | Negative |
| Hepatitis C Ab | Negative | Negative |
| RPR | Non-reactive | Non-reactive |
| Urine Drug Screen | Positive: methamphetamine, amphetamine | -- |
| Urine Drug Screen | Negative: opiates, benzodiazepines, cocaine, fentanyl, THC | -- |
| BNP | 42 pg/mL | <100 pg/mL |
| Troponin I (from ED visit) | <0.04 ng/mL | <0.04 ng/mL |
| Fasting glucose | 88 mg/dL | 70-100 mg/dL |
| Vitamin D | 14 ng/mL | 30-100 ng/mL |
| Prealbumin | 14 mg/dL | 20-40 mg/dL |

**Imaging/Additional Studies:**
- ECG: Sinus bradycardia 62 bpm (crash phase). Normal QTc (420 ms). No LVH. No ST changes
- Echocardiogram (ordered from ED): LVEF 55%, mild concentric LVH. No regional wall motion abnormalities. No valvular disease
- Chest X-ray: Clear. Mild cardiomegaly
- Dental panoramic X-ray: Multiple carious lesions, periapical abscess at tooth #19, generalized periodontal disease
- Montreal Cognitive Assessment (MoCA): 24/30 (borderline, deficits in attention, delayed recall, and executive function — expected in early abstinence, reassess at 3 months)
- Columbia Suicide Severity Rating Scale: Passive death wish present during crash, no active suicidal ideation, no plan or intent

### Clinical Image

![Stimulant use disorder dopamine reward pathway diagram](case_03_image.jpg)

*Diagram illustrating the mesolimbic dopamine reward pathway affected by methamphetamine, showing the ventral tegmental area, nucleus accumbens, and prefrontal cortex, and the principle of contingency management reinforcement. Source: Educational illustration.*

### Diagnosis
**Methamphetamine Use Disorder, Severe (DSM-5), with Methamphetamine-Induced Psychotic Disorder (in remission), Methamphetamine-Induced Depressive Disorder, and Stimulant-Related Cardiovascular Complications**

**Key Diagnostic Criteria (DSM-5 — meets 9 of 11 criteria, Severe):**
- Stimulant taken in larger amounts/longer than intended
- Persistent desire or unsuccessful efforts to cut down (multiple failed quit attempts)
- Great deal of time spent in stimulant-related activities (binge-crash cycles)
- Craving or strong desire to use stimulant
- Recurrent use resulting in failure to fulfill role obligations (job at risk)
- Continued use despite social/interpersonal problems (girlfriend left, homeless)
- Important activities given up
- Use in physically hazardous situations (driving, risky sexual behavior)
- Continued use despite physical/psychological problems
- Tolerance (escalating doses and frequency)
- No physiologic withdrawal per DSM-5 criteria, though "crash" symptoms are recognized

### Treatment Plan
1. **Contingency management (CM) — primary evidence-based behavioral intervention:**
   - Enroll in a structured CM program: urine drug screening 2-3 times per week for 12 weeks
   - Reinforcement schedule: earn vouchers or prizes for each stimulant-negative urine specimen. Escalating reinforcement (increasing voucher value with consecutive negative specimens: $1 first specimen, $1.50 second, $2 third, escalating up to $20 per specimen). Reset to $1 if positive specimen, with bonus for return to negative
   - Target: 12-week CM program with potential earnings of $300-600 in total incentives
   - Evidence: CM is the ONLY intervention with consistent, robust evidence for treatment of stimulant use disorders (NNT=4-5 for achieving sustained abstinence)
2. **Cognitive behavioral therapy (CBT):** Weekly individual CBT sessions focused on:
   - Functional analysis of stimulant use (triggers, consequences)
   - Coping skills training (managing cravings, high-risk situations)
   - Relapse prevention planning
   - Sleep hygiene and routine establishment
   - Pleasurable activity scheduling (behavioral activation for depression)
3. **Pharmacotherapy (limited evidence for stimulant use disorder, but adjunctive use):**
   - **Mirtazapine** 30 mg at bedtime: dual benefit for depression and methamphetamine use reduction (some evidence for reduced use in clinical trials). Also addresses insomnia and appetite stimulation
   - **Bupropion SR** 150 mg twice daily: may reduce methamphetamine craving and has antidepressant properties. Weak norepinephrine-dopamine reuptake inhibitor that may partially address dopamine depletion
   - **Naltrexone** 50 mg daily: emerging evidence for reducing methamphetamine use and craving
   - Monitor cardiovascular status: lisinopril 10 mg daily for hypertension. Repeat echocardiogram in 6 months to monitor for stimulant cardiomyopathy
4. **Psychotic symptom monitoring:** Methamphetamine-induced psychotic symptoms typically resolve with sustained abstinence. If psychotic symptoms recur during abstinence, consider independent psychotic disorder and initiate antipsychotic medication. Avoid typical antipsychotics if possible (dopamine system sensitivity in stimulant users)
5. **Nutritional rehabilitation:** High-calorie, high-protein diet. Vitamin D 50,000 IU weekly x8 weeks then 2000 IU daily. Multivitamin daily. Oral nutritional supplements. Dental referral for comprehensive treatment
6. **Housing and social services:**
   - Referral to transitional sober housing program
   - Case management for housing assistance, food stamps, Medicaid enrollment
   - Vocational support to maintain current employment
   - Healthy social network development (sober recreational activities, community groups)
7. **Harm reduction:** STI/HIV screening every 3-6 months. PrEP counseling if ongoing sexual risk. Condom distribution. Hepatitis A and B vaccination
8. **Follow-up:** Clinic visits 2-3 times/week for CM specimen collection and brief check-ins. Weekly CBT sessions. Monthly psychiatry for medication management. Cognitive reassessment (MoCA) at 3 months of sustained abstinence to evaluate for persistent neurocognitive effects

### Key Learning Points
- There are NO FDA-approved medications for stimulant (methamphetamine or cocaine) use disorder; contingency management is the most effective evidence-based treatment, with consistent superiority to all other interventions in randomized controlled trials
- Contingency management works by providing immediate, tangible reinforcement for objectively verified abstinence (negative urine specimens), leveraging the same operant conditioning principles that maintain addiction but redirecting behavior toward prosocial outcomes
- Methamphetamine-induced psychotic symptoms (paranoia, auditory/visual hallucinations, ideas of reference) occur in 25-40% of chronic users and typically resolve within 1-2 weeks of sustained abstinence; however, they represent a vulnerability marker for future psychotic episodes with resumed use
- Chronic methamphetamine use causes significant neurotoxicity including dopaminergic and serotonergic terminal degeneration, with neuropsychological deficits in attention, memory, executive function, and processing speed; these deficits partially recover with sustained abstinence (6-12 months) but may not fully normalize
- Stimulant-related cardiovascular complications include acute coronary syndrome, aortic dissection, cardiomyopathy, arrhythmias, and stroke; all patients with stimulant use disorder should receive cardiovascular screening and ongoing monitoring even after achieving abstinence