# Clinical Cases: Substance Use Disorders

## Case 1: Alcohol Use Disorder with Complicated Withdrawal

### Patient Demographics
- **Age:** 52 years old
- **Sex:** Male
- **Occupation:** Construction foreman (currently on disability leave)

### Chief Complaint
"I've been shaking and seeing things since I stopped drinking two days ago."

### History of Present Illness
The patient is a 52-year-old male presenting to the emergency department with tremors, diaphoresis, and visual hallucinations that began 48 hours after his last drink. He has a 30-year history of heavy alcohol use, currently drinking approximately one liter of vodka daily. He attempted to quit "cold turkey" after his wife threatened to leave him. Within 12 hours of his last drink, he developed hand tremors, anxiety, and nausea. Over the past 24 hours, symptoms have progressed to include visual hallucinations of insects crawling on the walls, which he recognizes are not real. He has not slept since stopping drinking. He denies seizure history but reports a prior hospitalization 5 years ago for alcohol withdrawal that required ICU admission. He has had multiple failed attempts at sobriety, with his longest period of abstinence being 3 months. He reports drinking to manage stress and to avoid withdrawal symptoms.

### Mental Status Examination

**Appearance:** Diaphoretic middle-aged man, tremulous, flushed face with telangiectasias, appears older than stated age

**Behavior:** Restless, picking at bedsheets, frequent position changes, visible coarse tremor of hands

**Speech:** Normal rate, slightly slurred, coherent

**Mood:** "Terrified"

**Affect:** Anxious, fearful, appropriate to content

**Thought Process:** Linear but with intermittent confusion and difficulty maintaining focus

**Thought Content:** Preoccupied with withdrawal symptoms, fear of seizures, regret about drinking; denies suicidal ideation; insight that visual disturbances are not real

**Perceptions:**
- Visual hallucinations: Seeing insects on walls (recognized as not real)
- Tactile hallucinations: Intermittent sensation of bugs crawling on skin
- No auditory hallucinations

**Cognition:** Alert but disoriented to date; attention impaired; short-term memory impaired; oriented to person and place

**Insight:** Fair - recognizes alcohol problem and need for treatment

**Judgment:** Fair - sought help appropriately when symptoms worsened

### Physical Examination

**Vital Signs:**
- Blood pressure: 168/102 mmHg
- Heart rate: 112 bpm
- Temperature: 100.4°F (38°C)
- Respiratory rate: 22

**Pertinent Findings:**
- Diaphoresis
- Coarse bilateral hand tremor
- Hepatomegaly
- Spider angiomata on chest
- Palmar erythema
- CIWA-Ar score: 24 (severe withdrawal)

### Psychiatric and Medical Workup

**Screening Tools:**
- CIWA-Ar: 24 (indicates high risk for complicated withdrawal)
- AUDIT: 32 (severe alcohol use disorder)

**Laboratory Studies:**
- Blood alcohol level: 0 mg/dL (abstinent 48 hours)
- Urine drug screen: Positive for alcohol metabolites only
- CBC: WBC 11.2, MCV 108 fL (macrocytosis), platelets 98,000
- CMP: AST 186, ALT 92 (AST:ALT ratio >2:1 classic for alcohol), albumin 2.8 g/dL, glucose 68 mg/dL
- GGT: 342 U/L (elevated)
- INR: 1.4
- Ammonia: 68 mcg/dL (elevated)
- Magnesium: 1.2 mg/dL (low)
- Phosphorus: 2.0 mg/dL (low)

### Diagnosis

**Primary Diagnosis:**
1. **Alcohol Use Disorder, Severe (F10.20)**
2. **Alcohol Withdrawal with Perceptual Disturbances (F10.232)**

**DSM-5 Criteria for Alcohol Use Disorder - Severe (6+ criteria met):**
- Alcohol taken in larger amounts/longer than intended
- Persistent desire or unsuccessful efforts to cut down
- Great deal of time spent obtaining, using, or recovering from alcohol
- Craving
- Continued use despite social/interpersonal problems
- Important activities given up due to alcohol
- Continued use despite physical health problems (liver disease)
- Tolerance
- Withdrawal

**Risk Factors for Complicated Withdrawal (Delirium Tremens):**
- Prior complicated withdrawal
- Current severe withdrawal (CIWA-Ar >15)
- Age >40
- Concurrent medical illness (liver disease)
- Heavy, prolonged drinking
- Elevated vital signs

### Treatment Plan

**Acute Management - Medical Admission:**
- ICU monitoring given high risk for delirium tremens
- Symptom-triggered benzodiazepine protocol (lorazepam preferred given liver disease)
- CIWA-Ar monitoring every 1-2 hours
- IV fluids with dextrose (after thiamine)
- Thiamine 500 mg IV x 3 days, then 100 mg daily (Wernicke prophylaxis)
- Folate 1 mg daily
- Multivitamin
- Electrolyte repletion (magnesium, phosphorus, potassium)

**Pharmacotherapy for Withdrawal:**
- Lorazepam 2-4 mg IV/PO for CIWA-Ar >10
- Maximum: lorazepam 8 mg/hour for severe withdrawal
- If refractory, consider phenobarbital loading

**Post-Withdrawal Treatment:**
- Naltrexone 50 mg daily OR Acamprosate 666 mg TID (choose based on liver function)
- Consider disulfiram if highly motivated
- Gabapentin 300 mg TID for residual symptoms and craving

**Psychosocial Interventions:**
- Motivational interviewing during hospitalization
- Referral to inpatient rehabilitation (28-day program recommended)
- Alcoholics Anonymous introduction
- Family therapy referral
- Social work consultation for occupational and financial concerns

**Follow-up:**
- Addiction psychiatry within 1 week of discharge
- Primary care for liver disease monitoring
- Consider hepatology referral

---

## 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

![Alcohol Effects on the Body](case_01_image.jpg)

*Image: Diagram showing the effects of alcohol on various organ systems. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*