Addiction Consultation

Reason for Referral

Referred by Dr. Sarah Jenkins (Internal Medicine) for management of severe opioid and alcohol withdrawal, OAT initiation, and acute pain management.

ID

38yo M with hx of severe OUD, severe AUD, HCV, and depression, admitted 23/10/2023 for R forearm cellulitis and abscess secondary to IVDU.

History of Presenting Illness

Pt presented to ED 23/10/2023 at 19:00 with worsening R forearm erythema, swelling, and purulent drainage at an injection site. Started on vancomycin IV and underwent bedside I&D. Developed worsening opioid withdrawal (diaphoresis, myalgias, GI distress) and alcohol tremors overnight. Requesting OAT optimization and symptom relief.

Substance Use History

1.) Nicotine: Started age 14. First cig within 5 mins of waking. Wakes 1-2x/night to smoke. Tried nicotine patch and varenicline (Champix®). Smokes max 40 cigs/day, min 15 cigs/day.

2.) Alcohol: Last use 23/10/2023 at 14:00 (2 L 7% cider). Hx of 2 withdrawal seizures (last in 2021), no DT. Drinks to blackout 3x/week. 1 prior arrest for public intoxication, no incarceration, no DUI. Tried naltrexone PO previously (non-adherent). Past withdrawal: severe tremors, diaphoresis, anxiety, seizures. Attended detox x2, occasional AA in the past.

3.) Opioids: Last use 23/10/2023 at 16:00. Started age 22 (oxycodone PO), progressed to unregulated fentanyl at age 30. Uses ~0.5 g (5 points, ~$50) daily, divided 4-5x/day via inhalation and IV. Hx of 3 overdoses requiring naloxone. High cravings currently. Withdrawal: severe bone pain, nausea, diarrhea, anxiety, piloerection. Goal: stabilize on methadone and cease IVDU. Longest abstinence: 6 mos in 2019 while on buprenorphine/naloxone (Suboxone®).

4.) Stimulants: Last use 22/10/2023. Started age 25. Crystal methamphetamine, ~0.1 g (1 point) 2-3x/week smoked/IV (often mixed with fentanyl). Mild cravings, withdrawal consists of fatigue/hypersomnia. No stimulant overdoses, no prior treatments. Goal: reduce use, not ready for abstinence. Longest abstinence: 6 mos in 2019.

5.) Cannabis: Last use 20/10/2023. Started age 13. Smokes dried flower (weed) 1 g PRN (2x/week) for sleep. No cravings or withdrawal, no prior treatments. Goal: continue PRN use. Longest abstinence: 1 yr.

6.) Benzodiazepines: Unintentional exposure via contaminated unregulated opioid supply over past 2 yrs ("benzo-dope"). Does not intentionally seek out or purchase prescribed/street benzodiazepines. Unsure if prior seizures were partially benzo-related. No prior specific benzo withdrawal tx. Goal: avoid use. Longest abstinence: unknown due to supply contamination.

7.) LSD, PCP, Solvents, MDMA, GHB, Ketamine: Hx of recreational MDMA and LSD use in 20s (1-2x/yr). Denies PCP, solvents, GHB, or ketamine use.

Social History

Unhoused, stays in shelters in Vancouver DTES. Income: PWD ($1,483.50/mo). Regularly accesses Insite OPS and obtains harm-reduction supplies. No hx of incarceration. Denies sex work. GP: Dr. M. Patel at Pender Community Health Centre.

Addiction Treatment History

On site detox (Harbour Light) x2 in 2020 and 2021. Completed 60-day inpatient treatment at Together We Can in 2019. Attended NA/AA in 2019, none recently. Prior trials of buprenorphine/naloxone, methadone, and slow-release oral morphine (Kadian®).

Pharmanet Summary

Carnegie Pharmacy. Daily witnessed ingestion (DWI) for methadone, prescribed by 1 physician (Dr. Patel). Missed 7 consecutive doses of methadone 80 mg PO daily (last dispensed 16/10/2023); prescription currently expired/cancelled. No dispensed benzodiazepines.

CIWA

CIWA-Ar score 16 at 06:00 (moderate withdrawal) and 11 at 09:00 (moderate withdrawal). Good response to diazepam 20 mg PO x2 given overnight, with reduction in tremor and agitation.

Medications in Hospital

Ordered: hydromorphone (Dilaudid®) 4-8 mg PO q3h PRN, hydromorphone 2-4 mg SC q3h PRN. Administered in past 24h: hydromorphone 16 mg PO total, hydromorphone 8 mg SC total.

Physical Exam

Vitals: T 37.2 °C, HR 104 bpm, BP 138/88 mmHg, RR 18/min, SpO2 98% on RA. General: Mildly diaphoretic, yawning frequently, moderate opioid and alcohol withdrawal, no signs of intoxication. HEENT: Pupils dilated (6 mm), reactive. Mild rhinorrhea. Resp/CV: Chest clear, HS dual, tachycardic, no murmurs. Derm/MSK: Piloerection noted on bilateral arms. R forearm dressed, surrounding erythema demarcated. Neuro: Fine resting tremor of bilateral outstretched hands. MSE: Alert, oriented x3, cooperative, anxious affect, linear thought process, no perceptual disturbances or SI/HI.

Investigations

Labs (23/10/2023): WBC 14.2, Hb 135, Plt 210, Na 137, K 3.9, Cr 78, ALT 65, AST 82, ALP 90, Bilirubin 12. UDS: Positive for fentanyl, norfentanyl, amphetamines, benzodiazepines, cannabinoids. Negative for opiates, methadone. Imaging: R forearm US shows 2x1 cm superficial collection (drained) and diffuse subcutaneous edema. ECG: Sinus tachycardia at 102 bpm. QTc is 435 ms (normal, safe for methadone initiation).

Assessment

38yo M referred for OUD, AUD, and acute pain management.

1. Opioid Use Disorder - Severe, active. High tolerance (fentanyl), currently in moderate withdrawal. Lost tolerance to methadone after missing 7 days.
2. Alcohol Use Disorder - Severe, active. High risk for withdrawal seizures given prior hx. Currently managed on CIWA protocol.
3. Sedative, Hypnotic, or Anxiolytic Use Disorder - Unspecified severity, active (unintentional via contaminated fentanyl supply). Contributes to seizure risk.
4. Stimulant Use Disorder (Methamphetamine) - Moderate, active.
5. Tobacco Use Disorder - Severe, active.
6. Acute R forearm cellulitis/abscess - Acute nociceptive pain complicated by opioid tolerance and withdrawal.
7. Depression - By history, stable.

Plan

1. OUD / Acute Pain:

• Restart methadone at 30 mg PO daily today (given > 5 days missed).
• Start slow-release oral morphine (Kadian®) 200 mg PO daily to bridge opioid requirements while titrating methadone, with plan to titrate daily.
• Increase short-acting opioid for acute pain and withdrawal: hydromorphone 8-12 mg PO q3h PRN and 4-6 mg SC/IV q3h PRN (hold for sedation).
• Provide take-home naloxone kit prior to discharge.

2. AUD / Benzo Exposure / Seizure Risk:

• Continue CIWA-Ar protocol with diazepam (Valium®) 10-20 mg PO q1h PRN for CIWA >= 10.
• Given hx of withdrawal seizures and concurrent street benzo exposure, add standing diazepam 10 mg PO QID x 48h, then taper by 10 mg/day.
• Thiamine 100 mg IV daily x 3 days, then 100 mg PO daily.

3. Stimulant Use Disorder:

• Monitor for crash/hypersomnia; supportive care.

4. Nicotine Use Disorder:

• Nicotine patch 21 mg transdermal daily, plus nicotine gum 4 mg PO q1h PRN cravings.

Thank you for involving me in this patient’s care; I will follow along while they are in hospital.