Resident Version
Drug Addiction, Withdrawal, and Overdoses
Created by Dr. Simson and Dr. Davis
Objectives:
1. Recognize the cost of drug abuse.
2. List two signs and symptoms of opiate and benzodiazepine withdrawal.
3. List four complications of cocaine overdose and their management.
References:
1. Palepu A, Tyndall MW, Leon H, et al. Hospital utilization costs in a cohort of
injection drug users. Can Med Assoc J 2001; 165(4):415-20.
2. Adolescent Abuse of Other Drugs Adolescent Medicine Clinics - Volume 17, Issue
2 (June 2006)
Kosten TR, O'Connor PG: Management of drug and alcohol withdrawal. N Engl J
Med 2003 May 1; 348(18): 1786-95
3. Nephrotoxicity of over-the-counter analgesics, natural medicines, and illicit
drugs Adolescent Medicine Clinics - Volume 16, Issue 1 (February 2005)
4. Haim D.Y., Lippmann M.L., Goldberg S.K., et al. The pulmonary
complications of crack cocaine: a comprehensive review. Chest (1995) 107 : pp 233240
5. Robinson M., Turnipseed S., Glatter K.: Methamphetamine-associated
caridoyopathy: A previously unrecognized cause of heart failure. American Heart
Association Annual Scientific Sessions, 2004.
6. The Association of Methamphetamine Use and Cardiomyopathy in Young
Patients
The American Journal of Medicine - Volume 120, Issue 2 (February 2007)
7. Cerebrovascular and Cardiovascular Complications of Alcohol and
Sympathomimetic Drug Abuse
8. Medical Clinics of North America - Volume 89, Issue 6 (November 2005).
9. Warren, JD, Blumbergs, PC, Thompson, PD. Rhabdomyolysis: a review. Muscle
Nerve 2002; 25:332.
Discussion Outline:
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According to a report issued by the Office of National Drug Control policy released
in 2002, the cost of drug abuse (not including alcohol or tobacco) was $180 billion
dollars in 2002. Approximately 10% of this was related specifically to direct medical
costs. The remainder was societal costs related to loss of productivity (50%) and
criminal losses or damage (40%).
The medical complications of drug abuse are varied and depend in large part on the
type of drug and route of administration.
This module will present an overview of the spectrum of complications focusing on noninfectious complications. It is by no means exhaustive.
1.
Overview of Addiction and withdrawal
According to DSM-IV addiction is characterized by 3 phases – anticipation, intoxication
and withdrawal. This provides a psychological as well as physiologic dependence on the
substance. Drugs typically associated with addiction/withdrawal are: benzodiazepines,
opiates, stimulants (cocaine, methamphetamines), alcohol, and tobacco. Acute
withdrawal syndromes requiring medical intervention are possible with most of these
substances, but this module will focus primarily on opiates and benzodiazepines.
A. Opiates
 Dependence usually develops with three weeks of daily usage.
 Highly lipophilic drugs (e.g. heroine) which cross the blood brain barrier the easiest
have the highest potential for development of dependence.
 Withdrawal usually begins within 1 half-life of the last dose and is characterized
initially by anxiety, restlessness, insomnia, yawning, rhinorrhea, lacrimation,
diaphoresis, and stomach cramps. This is followed by muscle spasms, vomiting,
diarrhea, hypertension, tachycardia, fever, chills, and piloerection.
 Acute opiate withdrawal is rarely life threatening, but can complicate management of
coexisting medical conditions.
Management of opiate withdrawal
1. Methadone: typically not administered in an acute setting, unless the patient is on a
maintenance program in which case the patient’s usual dose of methadone can be
administered.
2. Buprenorphine: a partial agonist, may be administered in typical starting doses of 4
to 8 mg. This can be administered in an acute setting, even if the patient is not in a
treatment program, if the patient’s withdrawal will complicate management of coexisting
medical problems during a hospitalization.
3. Clonidine: reduces catecholamine release and may be used to reduce symptoms in
patients who take low doses of opiates.
All of these may be supplemented by antiemetics, anxiolytics, or NSAIDS to treat
specific withdrawal symptoms.
B. Benzodiazepines
 Withdrawal symptoms are usually evident on discontinuation of medications after 6
weeks of steady usage.
 27 to 45% of patients who are taken off benzodiazepines develop significant
withdrawal symptoms causing them to seek medical attention.
 Withdrawal symptoms range from tremors, anxiety, and panic attacks, to muscle
cramps, delusions, hallucinations and seizures. They are similar to symptoms seen
with alcohol withdrawal.
 Withdrawal may be precipitated by administration of flumazenil.
Management of Benzodiazepine withdrawal
 Supportive treatment is similar to the treatment for alcohol withdrawal, though the
syndrome may last longer and take up to 2 to 3 weeks of tapering benzodiazepine
doses to resolve.
2. Overdose
Overdoses are characterized by the expected effects of the drug exaggerated by dose or
route of ingestion resulting in potentially deadly consequences. The US Centers for
Disease Control reported there were over 19,000 deaths from drug overdoses in 2004.
This represents accidental overdoses only, not those ruled to be suicides. Any drug can
be taken in excess and result in harm. This module will focus on the most common
recreational drug overdoses requiring medical attention:
A. Cocaine
 The classic signs of cocaine overdose are: tachycardia, hypertension, tachypnea,
irritability, hyperthermia, agitation, confusion, arrhythmias, and chest discomfort.
 Labs/diagnostic tests: ECG, CPK, Troponin, Chem-10, LFTs, UA, chest x-ray.
 Acutely cocaine overdose can cause MI and cocaine use is associated with
development of early coronary artery disease. 25% of nonfatal MIs in patients 18 to
45 are attributable to cocaine.
Treatment
 Generally the treatment of cocaine intoxication is supportive.
1. Sedation:
 Administration of benzodiazepines (diazepam, 10 mg IV q 5 min until the patient is
sedated) may help to sedate the patient.
2. Hypertension:
 In patients with hypertension beta-blockers are contraindicated. Labetolol has not
been shown to be effective. Again, sedation with benzodiazepines may be helpful.
 Nitroglycerine or nitroprusside may be used. The drug of choice is phentolamine – 1
to 5 mg IV, reassessed every 5 minutes.
 Blood pressure may generally be titrated back into the normal range if the patient
does not have a history of HTN.
3. Chest pain:
 For patients with chest pain sedation is indicated.
 Aspirin is useful since cocaine promotes platelet aggregation.
 Nitrates are indicated.
 Phentolamine, 1 mg slow IVP may be given, monitoring the patient’s BP closely.
This may be repeated as long as the blood pressure remains stable.
4. Arrhythmias:
 Arrhythmias secondary to cocaine intoxication may be either atrial or ventricular.
 Atrial arrhythmias are treated with sedation and calcium channel blockers can be
considered.
 Ventricular arrhythmias are best treated initially with sodium bicarbonate 1 to 2
meq/kG, while closely monitoring the rhythm. If sodium bicarb and sedation do not
resolve a wide complex arrhythmia, lidocaine can be considered, though it may lower
seizure threshold and should only be given after a patient has received
benzodiazepines.
5. Hyperthermia:
 Cocaine induced hyperthermia should be treated with aggressive fluid hydration,
sedation, and external cooling.
 If adequate cooling is not possible with these measures, neuromuscular blockade and
intubation are indicated.
6. Fluid status:
 Most patients with cocaine intoxication are salt and water depleted so crystalloid
infusion is usually indicated.
B. Amphetamines
 The toxic effects of amphetamines are nearly identical to cocaine.
Treatment
 Follows the same guidelines as cocaine, though the duration of toxicity with
amphetamines tends to be longer.
C. Opiates
 The predominate cause of morbidity and mortality from opiate intoxication is
respiratory compromise – either by direct respiratory compromise or through
aspiration secondary to altered mental status.
 The primary role in treating opiate overdose is to protect the airway and maintain
ventilation.
 Patients who have recently started or restarted opiates (tolerance is lost after about 1
week of abstinence) are at high risk for intoxication. Also, patients who have a
history of “skin popping” who are provided with IV access, such as when hospitalized
are at higher risk.
 Labs/Diagnostic tests: Glucose, Chemistry, ABG, CXR, CPK
Treatment
 The primary focus should be on maintaining ventilation.
 Naloxone 0.1 to 0.4 mg can be administered every 1 to 2 minutes. If the patient
responds, repeat doses may be required.
 Naloxone has a half life of 20 to 60 minutes. So, intoxication with longer acting
opiates may require multiple doses of naloxone, or possibly a naloxone drip.
 Typically a drip can be instituted at 2/3 of the initial effective dose of naloxone given
hourly as a continuous infusion.
D. Benzodiazepines
 As with opiates the predominate feature of benzodiazepine intoxication requiring
medical intervention is respiratory depression.
 Prolonged intoxication may lead to immobility predisposing the patient to
rhabdomyolysis.
Treatment
 Aimed at maintaining the patient’s airway and ventilation.
 Reversal of intoxication with flumazenil is usually not indicated since this may
precipitate acute benzodiazepine withdrawal and seizures.
CASE
You are called to see Mr. G., a 47 yo male who is brought to the ED by ambulance. The
EMT’s went to his home after his sister called 911. He was found in his bedroom by his
sister who asked a friend to take her to his house when he had not answered his phone for
about 8 hrs. He was intubated and suctioned in the field and received IV thiamine,
glucose, normal saline, narcan and oxygen. The EMT notes say he was unresponsive,
cyanotic with shallow, infrequent respirations, barely palpable pulse with bile emesis on
his chest. He awoke somewhat after the medications, became combative, and was
restrained. No injection paraphernalia was found at the home.
His sister says that he was jailed for 10 days in Santa Fe after being arrested there on a
warrant issued for outstanding speeding tickets. They had released him the night before
and he had taken a bus home to Belen. He told her he was going to get a friend to take
him back to Santa Fe to get his impounded truck so he could return to work and would
call her when he got back. She came by when he did not return her calls. When she
discovered him in bed she gave him nasal Narcan after calling 911 but was afraid to do
rescue breathing.
PHM:
1. IV heroin dependency from age 16 to 32.
2. Methadone maintenance beginning age 32 until present; dose about 130mg/d. None for
about 2 weeks.
3. Chronic hepatitis C; genotype 2; treated with 24 weeks of interferon and ribavarin at
age 42 with undetectable antigen since then. Annual CEA’s normal.
4. Hepatitis B
MEDS: 13 empty methadone bottles correctly labeled from local methadone clinic in
medicine cabinet at 130mg daily dose. Last dated bottle is day after recent arrest. Only
other meds were typical OTC’s and no empty Tylenol or ASA bottles.
SH: Divorced. Lives alone and shares custody of 3 kids ages 16,17,19. Technical welder
earning $42,000 last year. Hobbies: fishing, stainless steel art fabrication. Smokes ½ ppd
x 30 yr. Drank ~6 pack of beer daily from ages 22-36 and then none since
FMH: Brother and 2 cousins died of heroin overdoses. Father with stable CAD and DM.
Mother in remission from breast CA x 8 yrs. Sister’s son with ADHD and her daughter
smokes heroin and marijuana.
PE:
BP 138/92 P122 RR 20 T 96.8 rectal O2 100% on rebreather attached to ET tube
IV with D5NS at 125cc/hr running well in rt forearm
General: Muscular male, agitated, in restraints, intubated and breathing well on own.
Does respond to commands appropriately.
HEENT: pupils 2mm, EOM’s appear intact without nystagmus, ET tube in mouth well
secured. No blood in mouth. TM’s obscured by cerumen. Supple neck, no adenopathy or
thyroid felt.
Lung: coarse rhonchi; decreased sounds rt base
Cor: regular tachy no m/r/g. Nl JVP supine. Periph pulses 2+ symmetrical, no edema or
cyanosis
Abd: liver felt at rt costal margin; firm but not hard. No bruits or ascites. Lap choly scars.
Genit: nl uncirc male phallus. Nl scrotum. Neg OB on rectal
Ext: extensive tattoos on arms and calves, all old. Antecubital scarring bilat.
Neuro: agitated; follows commands mostly; moves all 4’s with 5/5 strength; DTR’s seem
¾. No clonus. Toes downgoing. Unable to see fundi due to meiosis.
LAB:
WBC 12.8 with nl diff and indices Hgb 14 Hct 42 plts 344K
Na 142 K 5.6 CL 102 CO2 12 BUN 67 CR 6.4
Glu 155 Ca 8.0 PO4 6.6
CK 24,000 97%MM
TP 7.0
alb 3.6 AST 72 ALT 84
LDH 650 GGT 87
AlkP 45
INR 1.1 PTT 28
ammonia 22
UA dark red ; SG 1.030 +ketones, tr blood, +myoglobin ; no WBC, no Bact
Tox screen: pos methadone, opiates; neg cocaine, THC, amphetamines, alcohol, PCP,
benzodiazepines, barbiturates, TCA, salicylates, acetaminophen
Portable CXR: atalectasis rt base; Ghon complex lt hilum; nl cardiac shadow; metallic
piece in rt neck consistent with needle.
What are the working diagnoses and explanations for the metabolic abnormalities?
How would you treat the patient?
Hospital course: The patient awakens completely with the 3rd Narcan dose and
extubates himself. His creatinine drops quickly to 2.0 over 2 days and his other
metabolic abnormalities improve as well. He tells you that when he got home from jail
he had only 1 dose of methadone left and took it because he was still “pretty sick” from
his acute withdrawal. The “friend” who came over to take him to pick up his truck was a
previous injecting partner and gave him some heroin to inject since he seemed so ill. The
next thing he remembers were the EMT’s at his house.
What happened?
Review Questions:
1. A 48-year-old white man arrives at the emergency department obtunded. He is
accompanied by his wife, who states, “He took a lot of pills, trying to hurt himself.” She
also reports that he drinks a pint of whiskey every day and more on the weekends and
that he has prescription pain pills for chronic back pain. The patient is taken to an
examination room; a brief clinical assessment reveals a patent and protected airway. The
patient has pinpoint pupils.
Which of the following medications is NOT appropriate for this patient?
A.
B.
C.
D.
25 g of 50% dextrose
100mg of vitamin B1 (thiamine)
Nalaxone, 0.2 to 0.4 mg
Flumazenil
2. A 33-year-old man who suffers from depression and chronic pain attempts suicide by
overdosing on the collection of pain killers he has accumulated from multiple physicians.
He is in the emergency department with stupor, pinpoint pupils, and hypotension.
Which of the following tests should you order for this patient?
A.
B.
C.
D.
E.
Electrocardiogram
Benzodiazepine level
Acetaminophen level
Aspirin level
Electrocardiogram, acetaminophen level, and aspirin level
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
Medical student