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CASE CONFERENCE: CLINICIANS AT WORK Richard Rosenthal, MD, St. Luke's-Roosevelt Hospital Center, New York, NY; Richard Ries, MD, Harborview Medical Center, Seattle, WA; and Christopher Pelic, MD, Medical University of South Carolina, Charleston, SC Abstract Case conferences provide an opportunity for clinicians to share experiences from their practices. The question of how do addiction psychiarists go about their clinical work is examined. The tasks of evaluation, considering, talking, suggesting, prescribing, and consulting were explored. A case was presented, and two highly respected clinicians offered their comments on how each approaches treatment. Dr. Pelic presented the case of a 45-year-old woman he recently treated. Dr. Ries raised questions regarding the acute care needs of the patient. Dr. Rosenthal addressed the need to know what changed in the patient’s life that caused her to present herself now. Audience members participated in the case analysis and shared their knowledge. Case Conference Chair: Michael M. Scimeca, MD, Mount Sinai Medical School, and Bronx VA Medical Center, New York, NY
Presentation of the Case Dr. Pelic: The patient, a 45-year-old white female, was transferred to the Psychiatric Unit and presented with the chief complaint of withdrawal and depression. She was transferred from the neurology service at the main hospital. The patient had a known history of approximately three years of opiate (OxyContin) and alcohol use. The Neurology Department felt the patient would be "best served on the psych unit" secondary to her questionable polysubstance dependence as well as depression. Three years ago, the patient had two surgeries to remove a cholesteatoma, a middle-ear growth that can erode away the bones of the ear, and it resulted in her having occipital neuropathy on the right side. She was prescribed a variety of medications starting with basics such as ibuprofen, to which she developed an allergic reaction of tongue swelling. Other drugs included neurontin, Elavil, teretol, and darvoset; finally OxyContin worked for her. She was started with 20mg BID; it was pushed it up to 40mg BID. The patient admitted she had been taking much more than that, as much as 80mg BID and sometimes as much as 160mg in one dose. She described her pain as approximately 10 out of 10 after the two surgeries—sharp, shooting, burning pain. In late summer before coming to our hospital, she had surgery to remove the compressed occipital nerve; the surgery was effective. Her pain was now better controlled with a value of 2 out of 10. However, she presented to her neurologist two days ago expressing the desire to get off the OxyContin now that the pain was well controlled; however, she felt she was hooked. She had engaged in drug-seeking behavior by contacting other physicians to try to get prescriptions for the pain. She had tried to buy it from friends, admitting to significant craving. She had terrible occupational problems as a vice president of a trucking company and had been demoted. She was divorced in the last three years, which she attributed to OxyContin use. The patient admitted to tolerance of OxyContin, which is why she was increasing the dosage. She had attempted to stop "cold turkey" the day she presented to the neurologist. The patient also admitted she was a social drinker prior to surgery and began heavy drinking after the surgeries. Her last drink was 1½ days ago. She had a DUI prior to the surgeries, has attended AA in the past, and has had a recent DUI and was in danger of losing her license. She had some tremors when admitted to Neurosurgery in April for the decompression surgery; while in the hospital she had tremors and was treated with Ativan. She never had DTs or seizures; she admitted to some blackouts and tolerance to the alcohol use. She had a desire to quit the alcohol as well as the OxyContin. She admitted also to depressed moods for several months, fleeting sensory integration (SI), she wasn’t suicidal on our discussion, but according to the neurologist she was. She had anhedonia, decreased energy, and guilt, as her marriage was ended secondary to this. Her physical complaints were consistent with certain types of withdrawal—anxiety, nausea, vomiting, headaches, blurred vision, and abdominal cramping. She denied any auditory or visual hallucinations, any manic symptoms, nicotine or illicit drug use. She admitted to all the CAGE questions for both OxyContin and alcohol. The past medical history is mainly non-contributory; she was treated for depression by internists during this whole ordeal. She had good results from Paxil; however, she stopped it due to weight gain. This was a big concern of hers. When presenting to the neurologist 1½ days ago, she was on 5mg PO BID of Valium as prescribed by her PCP for her nerves. She was on Tylenol prn as well as the OxyContin. The neurology service started her on Trileptal (oxcarbazepine, a derivative of Tegretal) 300mg PO qd to address the two out of 10 pain she was still experiencing. Her social history included divorce shortly after heavy OxyContin use, denial of drug use and smoking, and admittance to six drinks a day. She lives with her 21-year-old son and has two daughters to whom she is not close. She grew up without father from an early age; she handled many responsibilities in the childhood home and was under much stress. As vice president of the trucking company, she was demoted after she missed several days of work and for poor performance. The family history was significant for a maternal uncle’s alcoholism. The mother and sister had no alcoholic or substance abuse problems. On mental status examination, her affect was congruent with mood and topic even though she was sad at times. She wasn’t suicidal. On physical examination her vital signs were within normal limits. Her laboratory findings included: AST 60, GGT 120, UDS positive for opiates. In summary, the assessment is a 45-year-old Caucasian female with likely opiate withdrawal with +/- alcohol withdrawal, with depressive symptoms who presented secondary to withdrawal symptoms. The diagnosis included: opiate withdrawal, rule out alcohol withdrawal, opiate dependence, alcohol dependence, and rule out substance-induced mood disorder both from the opiates and the alcohol. She did have poor social support—living with the 21-year-old son and having unsupportive daughters. The treatment plan included admission to the Psychiatric Unit, antidepressants were considered and Celexa was chosen because of the patient’s concerns about weight gain. She was put on a CIWA-Ar protocol which included Ativan for various clinical parameters. She did not get any Clonidine as her pressures were on the low side; she tolerated the Flexeril and Bentyl. She was given Acetaminophen 325-650mg PO q6hr prn for the pain. The plan was to increase the Trileptal to a higher dose of 300mg two times a day. Vital signs were stable throughout her hospital course; Valium was tapered off; Celexa was started at 20mg. Also, she was given auricular acupuncture, a procedure commonly offered in our unit. She attended several group meetings during her five days on the unit. When discharged she was on Celexa 20mg, Trileptal 300mg PO BID, and Tylenol. Her pain seemed to be under control; she expressed weight gain concerns from the Celexa. Community follow-up opportunities were arranged. We felt this was a success story since she did not present for readmission.
Case Discussion Dr. Ries: The questions I will address are on acute care needs in patients such as this. My first question would be how much alcohol was the patient really drinking? When the patient admits to taking alcohol and that it is a problem, is on Valium and OxyContin, and clearly admits to taking significantly more OxyContin than had been prescribed, the immediate danger is acute alcohol and benzodiazepine withdrawal. This is an emergency. We need to clarify how much risk exists for the patient to go into withdrawal; if we get behind on this then seizures and other problems arise. Another question is "what is a drink?" There is recent research in Addiction by Kaskutas1 about questions asked patients in an OB clinic. When asked to describe a "drink" and shown pictures of "scientifically-defined" drinks, the participants thought for beer/wine the drink was less than two times the volume of the scientifically-defined drink. However, for hard liquor, it was four to five times less. So taking six drinks of a hard drink by a female attending an OB clinic in the San Francisco area may actually be as many as 20-24 drinks. Deciding what six drinks are and how much withdrawal potential exists can be complex. The benzodiazepines confound the problem. Drug screens used for typical general care hospitals don’t do a good job of picking up benzodiazepines. They miss Alprazolam and Clonazepam; there is research literature on this2. The kinds of drug screens in most drug abuse treatment programs that have chain-of-custody and automatic testing of positive screen results do better with those. However, Abbott AXIM and other typical drug screens typically administered in the ER will screen negative for benzodiazepines; we get the patients in our service and they begin benzodiazepine withdrawal. Another issue to examine is how accurate are opiate histories. In a recent study by Cologne in the International Journal of Epidemiology3 hair samples were used to compare accuracy of self report to what the hair analysis was for the last month. One hundred fourteen people’s hair samples were tested; when results were compared to the original history provided, an underrepresentation of taking opiates was found to be about 300% and for taking cocaine 1300%. We have to ask how accurate is using the CIWA-Ar for somebody undergoing simultaneous opiate and alcohol withdrawal. There are many reasons to suspect that this test might not be accurate and decisions should not be based solely on this test. Vital signs may be masked by PRN clonidine. We need to examine pain medicines and addiction. The anticonvulsants in this case are a good approach; this is an agent that may be treating the benzodiazapine withdrawal, the alcohol withdrawal, and the pain. The question of using Trileptal versus another medication in this case should be considered. If the patient gained weight on Paxil, Topamax might be a better suggestion for someone really concerned about weight gain. At this point the patient does not need treatment for opiate withdrawal, it sounds like she is through that. However, opiate relapse is a concern. What is going to happen after this hospital stay? The patient has serious markers for opiate and alcohol dependence; a long-term recovery plan is needed.
Dr. Rosenthal: I am going to ask more questions than I answer. My first question was why did this patient get admitted to Neurology in the first place? Why now? What changed in her life that she is being admitted to the hospital? What is behind her story and how do you think about it? What are the vulnerabilities she carries biologically and in terms of her development that render her more likely to fall prey to addiction? Why aren’t there protective factors? What do you do about pain? What changed? Is this the course of her addiction that she showed up now? Is this an example of the Jellinek Curve? We need to play detective. We need to say that the approach may be overly simplistic and gives too much weight to the addiction. There are other factors at work not asked about. Things that mitigate are interesting. For example, her pain is better, not worse, since the second surgery. She stated that she was feeling better, so the pain was not driving this. However, she is out of control with her use of alcohol and opiates. We need to ask what her additional stressors are that provide a contextual base to understand the current presentation. She had significant losses—the job demotion is one, and we don’t know what that means to her. What does it mean for her social status? What is the financial impact? The lack of support system is also a stressor—who is there for her? The daughters are distant. Why is she living with the college-age son? Is the relationship close? When does he graduate? Is he leaving the house soon? Looking at this case as a substance-induced mood disorder makes sense. There is good evidence for the existence of alcohol-induced mood disorder; research as far back as the 1980s shows that in methadone-maintained patients, greater than 50% met lifetime criteria for major depression, but most of those occurred after the onset of the opiate dependence. So, perhaps that codifies substance-induced mood disorder secondary to opiates. We know that major depression is rampant in methadone maintained patients. However, another way to look at this is the lack of history of a diagnosable mood disorder. We don’t know what it meant when the primary care doctor gave her some medication after the surgery. Is this a response to chronic pain syndrome? Is the depression not necessarily or solely due to the abused substances, but also due to the fact that she had unremitting chronic stress secondary to her pain syndrome? We need to try to find out from the patient what underlying vulnerabilities might exist around mood reactivity, sensitivity to loss, or actual syndromes (i.e., dysthymia) prior to the onset of the mood disturbance/surgery/chronic pain problem. She had a good response to the internist-prescribed Paxil. There is now some evidence to show that even if it is a substance-induced mood disorder, there may be a positive response to SSRI treatment. One component that usually is not addressed is that some of her mood disturbance may be more situational than categorical, that is, demoralization. Demoralization is essentially the experience of the loss of self-efficacy, i.e., a low mood with a drop in self-esteem, and the attribution is that there is an external locus of control over your situation. This is commonly seen in addicts; they externalize—"nobody ever cuts me a break," "life isn’t fair," etc. Addiction-generated losses in a patient’s life cause a state of helplessness with the combined attribution of external locus of control, and it perpetuates the state. When people are demoralized, they don’t try. There isn’t much self-motivated behavior; people experience their lives as if it were happening to them rather than as the author of their own experience. We don’t know how the break up of the marriage contributed to her situation. How significant was this in her life? We assume this was a 22-23 year marriage (she has a 21-year-old son). We don’t know what role the hysterectomy and tubal ligation had as contributory factors. What happened to her body? What was the impact of the opiate dependence in the marriage? Was there a change in their sexual behavior? Was there a change in their intimacy and emotional relatedness? Why did he leave? What is the context? What is keeping her addictive problem in place? I believe her demoralization is a major factor; her own experience of not knowing what to do. With the loss of her support system, she is floundering. A second possibility is that there is buy-in; there may some "sick role" identification where she has basically learned to be a patient and now can’t get out of the role. Part of the addiction may be her attempt to avoid being driftwood; she may be anchoring herself by attaching herself to the medical system. We may want to evaluate if there is some type of secondary gain for her in the medical system. What are the vulnerabilities? She has a family history of an uncle with alcohol dependence, which may provide the genetic component. But, is there any interpersonal component? Does she have any history of atypical depressive factors? What is her history of tolerating loss—boyfriend, educational performance, and job? What is the timing of the marital problems—is this systemic, i.e., feeling bad from the surgery led to withdrawal from her partner, the husband reacts by withdrawing, she self-medicates in reaction, etc. Pain appears to be a major trigger to cope with her drinking. Remember, she had the DUI before the onset of the pain problem. Pain is a potential liability for her future capacity to maintain her sobriety. The role of pain control in patients with addiction needs to be clarified; providing another narcotic must be carefully considered. References:
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