# Clinical Cases: Substance Use Disorders ## Case 1: Alcohol Use Disorder with Severe Withdrawal ### Patient Presentation **Demographics:** 52-year-old male **Chief Complaint:** "I'm shaking and I think I saw bugs crawling on the wall." **History of Present Illness:** A 52-year-old man presents to the emergency department with tremors, anxiety, and nausea. He reports drinking approximately one pint of vodka daily for the past 10 years. He has tried to quit multiple times but "always goes back." His last drink was 36 hours ago when he ran out of money. Since then, he has experienced progressively worsening tremors, profuse sweating, nausea with dry heaves, severe anxiety, and insomnia. Earlier today, he saw "bugs crawling on the walls" that he now realizes were not real. He has had two alcohol withdrawal seizures in the past, both occurring approximately 48 hours after his last drink. He has no other medical history and takes no medications. He has lost two jobs due to alcohol use and his wife left him last year. He wants help quitting this time "for real." **Physical Examination:** - Vital signs: BP 168/104, HR 118, T 38.1C, RR 22 - General: Diaphoretic, tremulous, anxious-appearing male - Neuro: Coarse tremor of outstretched hands, no asterixis - Skin: Spider angiomata on chest - Abdomen: Mild hepatomegaly, no ascites **Mental Status Examination:** - Appearance: Disheveled, diaphoretic - Behavior: Restless, tremulous - Mood: "Anxious, scared" - Affect: Anxious - Thought content: No SI/HI, worried about withdrawal - Perceptions: Reported visual hallucinations that have resolved; tactile sensation of "crawling" on skin - Cognition: Alert, oriented x3, mildly impaired attention **Workup:** - **CIWA-Ar score:** 24 (severe withdrawal; >15 indicates significant withdrawal) - **Blood alcohol level:** Undetectable - **CBC:** Mild thrombocytopenia (112k), MCV elevated (104) - **CMP:** AST 124, ALT 68, AST:ALT ratio 2:1 (suggestive of alcoholic liver disease), albumin 3.2 - **Magnesium:** 1.4 mEq/L (low) - **Phosphorus:** 2.3 mg/dL (low) - **GGT:** 285 (elevated) - **INR:** 1.2 **Diagnosis:** Alcohol Use Disorder, severe; Alcohol Withdrawal Syndrome, severe with history of withdrawal seizures **Treatment:** - Admitted to ICU for monitored withdrawal management - CIWA-Ar protocol initiated with symptom-triggered benzodiazepine dosing - Lorazepam 2-4 mg IV PRN based on CIWA score (preferable in liver disease due to glucuronidation metabolism) - Thiamine 500 mg IV daily x 3 days BEFORE any glucose administration (to prevent Wernicke encephalopathy) - Folate 1 mg daily, multivitamin - Magnesium and phosphorus repletion - IV fluids for volume repletion - Seizure precautions given history - On day 2: CIWA scores improved, no seizures occurred - On day 4: Withdrawal completed, CIWA consistently <8 - Started naltrexone 50 mg daily for craving reduction (after medical clearance) - Referral to addiction medicine and intensive outpatient program - Discussed maintenance options: naltrexone, acamprosate, disulfiram - Social work involved for housing and support services **Clinical Pearl:** Alcohol withdrawal follows a predictable timeline: tremor and anxiety at 6-12 hours, hallucinations at 12-24 hours, seizures at 24-48 hours, and delirium tremens at 48-96 hours. Prior withdrawal seizures significantly increase risk of future seizures. Thiamine MUST be given before glucose in malnourished alcoholic patients to prevent precipitating Wernicke encephalopathy. The CIWA-Ar protocol allows symptom-triggered dosing, reducing total benzodiazepine dose compared to fixed schedules. The AST:ALT ratio >2:1 is characteristic of alcoholic liver disease. --- ## Case 2: Opioid Use Disorder - Medication-Assisted Treatment ### Patient Presentation **Demographics:** 29-year-old female **Chief Complaint:** "I want to stop using. I'm tired of this life." **History of Present Illness:** A 29-year-old woman presents to an addiction medicine clinic seeking treatment for opioid use disorder. She began using prescription oxycodone at age 23 after a back injury and escalated to heroin use 2 years ago when pills became too expensive. She currently injects heroin 3-4 times daily, spending approximately $150-200/day. Her last use was 6 hours ago. She has tried to quit "cold turkey" multiple times but has never made it past 3 days due to severe withdrawal symptoms. She has overdosed twice in the past year, both times reversed with naloxone by bystanders. She is homeless, engaging in sex work to support her habit, and recently learned she is pregnant (approximately 8 weeks by LMP). She is terrified she will lose the baby. She has heard about "medication that can help" and wants to start today. **Physical Examination:** - Vital signs: BP 128/82, HR 78, T 37.0C - General: Thin female, track marks on bilateral arms - Pupils: 3 mm, reactive (not yet in withdrawal) - No signs of withdrawal currently (last use 6 hours ago) - Nasal septum intact **Clinical Opiate Withdrawal Scale (COWS):** Score 4 (no withdrawal yet - too early) **Workup:** - **Urine drug screen:** Positive for opioids, negative for others - **HCV antibody:** Positive with detectable viral load (chronic HCV) - **HIV:** Negative - **HBsAg:** Negative - **Pregnancy test:** Positive - **CBC:** Normal - **CMP:** Normal - **LFTs:** Mildly elevated (ALT 52, AST 48) **Diagnosis:** Opioid Use Disorder, severe; Pregnancy (8 weeks); Hepatitis C, chronic **Treatment:** - Discussed medication options: Buprenorphine vs. methadone - In pregnancy, both buprenorphine and methadone are standard of care - Methadone requires daily visits to OTP initially; buprenorphine allows office-based treatment - Patient prefers buprenorphine for flexibility - Explained need to be in mild-moderate withdrawal before buprenorphine induction (COWS ≥8-12) to avoid precipitated withdrawal - Instructed to return tomorrow morning after minimum 12-16 hours since last use - Day 2: COWS score 14 (moderate withdrawal) - Began buprenorphine induction with sublingual buprenorphine 4 mg - Additional 4 mg doses given every 2 hours as needed - Total day 1 dose: 12 mg - Day 2-3: Titrated to 16 mg daily for symptom control - Referred to high-risk OB clinic for prenatal care - Connected with hepatology for HCV treatment (can begin after pregnancy) - Social work referral for housing assistance - Urine drug screens weekly initially - At 4-week follow-up: No illicit opioid use, stable on buprenorphine 16 mg daily - Prenatal care ongoing, ultrasound shows normal fetal development - Plan for hospital delivery with communication to obstetrics about MAT **Clinical Pearl:** Buprenorphine and methadone are both standard of care for opioid use disorder in pregnancy - withdrawal attempts are associated with fetal distress and relapse. Buprenorphine induction requires the patient to be in mild-moderate withdrawal (COWS ≥8-12) to avoid precipitated withdrawal (the partial agonist displacing full agonist can cause acute withdrawal). Neonatal opioid withdrawal syndrome will occur with MAT but is manageable and preferable to untreated OUD in pregnancy. Harm reduction measures including naloxone prescription and Hepatitis C treatment are essential components of care. --- ## Case 3: Stimulant Use Disorder with Psychosis ### Patient Presentation **Demographics:** 35-year-old male **Chief Complaint:** Brought by police after found yelling at traffic, extremely agitated **History of Present Illness:** A 35-year-old man is brought to the emergency department by police after being found in the middle of an intersection, yelling about people trying to kill him. He is extremely agitated and paranoid, believing the police are part of a conspiracy. According to friends contacted later, he has been using methamphetamine heavily for the past 3 weeks during a "binge," sleeping only a few hours total. He has used methamphetamine intermittently for 5 years but increased use dramatically after losing his job 6 months ago. He has no prior psychiatric history and no psychotic symptoms when not using methamphetamine. He has been picking at his skin, believing there are "bugs under the skin." **Physical Examination:** - Vital signs: BP 182/110, HR 142, T 38.4C, RR 24 - General: Diaphoretic, extremely agitated male, appears emaciated - Pupils: 7 mm, reactive - Skin: Multiple excoriations on arms and face from picking - Cardiac: Tachycardic, no murmurs - Dental: Extensive decay ("meth mouth") **Mental Status Examination:** - Appearance: Disheveled, emaciated, multiple skin lesions - Behavior: Extremely agitated, combative, attempting to leave - Speech: Rapid, pressured, incoherent at times - Mood: "They're trying to kill me" - Affect: Terrified, agitated - Thought content: Paranoid delusions (conspiracy, being followed), formication (bugs under skin) - Perceptions: Tactile hallucinations (formication), possible visual hallucinations - Cognition: Unable to assess due to agitation - Insight/Judgment: Absent/Absent **Workup:** - **Urine drug screen:** Positive for amphetamines - **CMP:** Sodium 132, potassium 3.2, creatinine 1.4 (dehydrated) - **CPK:** 2,800 U/L (elevated - rhabdomyolysis risk) - **ECG:** Sinus tachycardia, no ischemia - **Troponin:** Negative - **CT head:** No acute abnormality - **Blood glucose:** 82 mg/dL **Diagnosis:** Stimulant Use Disorder (Methamphetamine), severe; Substance-Induced Psychotic Disorder **Treatment:** - IV access obtained with mild sedation - Lorazepam 2 mg IV for agitation (benzodiazepines first-line for stimulant intoxication) - Additional doses given PRN for continued agitation - Avoided antipsychotics initially due to hyperthermia and risk of lowering seizure threshold - Aggressive IV hydration for dehydration and rhabdomyolysis prophylaxis - Cooling measures for hyperthermia - Monitored on telemetry for arrhythmias - Day 2: Calmer after sleep, psychotic symptoms significantly improved - Day 3: Psychosis resolved with sleep and cessation of stimulant - Started supportive care for stimulant withdrawal (hypersomnia, depression) - No medications FDA-approved for stimulant use disorder - psychosocial treatment is primary - Referred to intensive outpatient program with contingency management - Dental evaluation for extensive decay - Dermatology follow-up for excoriation wounds - Discharged day 5, psychiatrically stable **Clinical Pearl:** Stimulant-induced psychosis typically resolves within days to a week of cessation with supportive care, distinguishing it from primary psychotic disorders. Formication (sensation of bugs crawling on or under the skin) is characteristic of stimulant-induced psychosis. Benzodiazepines are first-line for stimulant intoxication agitation. There are no FDA-approved medications for stimulant use disorder - treatment relies on psychosocial interventions, with contingency management having the strongest evidence. Stimulant withdrawal causes a "crash" with hypersomnia, hyperphagia, and depression. --- ## Clinical Image ![Effects of methamphetamine - facial changes](case_01_image.jpg) **Image Description:** Before and after photographs demonstrating the physical effects of chronic methamphetamine use, including dramatic facial aging, skin lesions from picking, dental decay (meth mouth), and weight loss. These images are used in public health campaigns to demonstrate the devastating physical consequences of methamphetamine use. **Attribution:** Public domain image from US Department of Justice, Faces of Meth campaign, used for educational purposes about substance abuse. **Image Source:** Wikimedia Commons - https://commons.wikimedia.org/wiki/Category:Methamphetamine - Search for "faces of meth" or "methamphetamine effects"