Substance use disorders: diagnosis and management for hospitalists

Figures & data

Table 1. Differential diagnosis of acutely intoxicated patients [7,8].

Substance abuse intoxication of other alcohols-methanol/isopropyl alcohol cocaine, amphetamine, cannabis, opiates Metabolic Electrolyte abnormality (hypo or hypernatremia) Hypoglycemia Hepatic encephalopathy Hypertensive encephalopathy Uremia Diabetic ketoacidosis Hyperosmolar non-ketotic coma Infections Sepsis Meningitis Encephalitis Trauma Subarachnoid hemorrhage Subdural hematoma Neurologic Post ictal state Cerebrovascular accident (ischemic or hemorrhagic) Alcohol withdrawal

Table 2. Symptom triggered benzodiazepine dosing and benzodiazepine sparing dosing in alcohol withdrawal syndrome.

Symptoms triggered dosing of lorazepam (Intravenous or Oral) [14]		*Gabapentin dosing schedule [18, 19]
CIWA-Ar Score	Lorazepam dose	300-400 TID for 3days, then 400 BID on day 4.
0-7	No medication required
8-10	1-2mg
11-15	2-3mg
16-19	3-4mg
20 or above consider transferring the patient to ICU
		*Gabapentin has renal excretion requiring dose adjustment in renal failure

Table 3. Summary of opioid use disorder.

Mechanism of action	Act on opioid receptors including μ, κ, δ. [23–25]
Modes of use	Ingestion, inhalation, injection [32]
Diagnosis	Urine, blood, saliva, sweat, hair assays [28]
Symptoms of intoxication	Miosis, respiratory depression, depressed mental status [24]
Symptoms of withdrawal	Nausea, diarrhea, piloerection, diaphoresis, myalgias, arthralgias, restlessness, mydriasis, rhinorrhea, lacrimation fever, hypotension and tachycardia [30]
Treatment of intoxication	Supportive, opioid antagonist therapy when appropriate, management of comorbid conditions, intoxications [24,26]
Treatment of withdrawal	Supportive, use of opioid agonists or clonidine if indicated [30]

Table 4. Summary of cocaine use disorder.

Cocaine Common routes of administration  Smoking  Insufflation  Intravenous injection Adverse effects  Cardiac  Myocardial ischemia  Cardiomyopathy  Prolonged QTc interval  Arrhythmias  Sinus bradycardia  Pulmonary  Reactive airway disease  Tracheal stenosis  Pneumothorax  Pneumomediastinum  Pulmonary edema  ‘Crack lung’  Neurologic  Seizures  Transient loss of consciousness  Stroke, ischemic and hemorrhagic  Renal  Rhabdomyolysis  Acute renal failure  Gastrointestinal  Gastrointestinal bleeding  Ischemic colitis  Obstruction and perforation in ‘body packers’  Psychiatric  Transient hallucinations  Paranoia  Aggression  Agitation  Stereotyped behavior  Other  Chronic rhinitis  Erosion dental enamel  Perforated nasal septum Management  Supportive  See Table 5for cocaine-induced acute coronary syndrome Withdrawal  Rarely medically serious  Depression  Anxiety  Inability to concentrate  Increased appetite

Table 5. Management of cocaine-related acute coronary syndrome.

Recommend against beta-blocker usage to avoid unopposed alpha-stimulation. Combination of nitroglycerin and benzodiazepines can be used for the management of hypertension and tachycardia. Other than above, management is same as in patients without cocaine use. Similar management recommended for methamphetamine-induced coronary events as well.

Table 6. Summary of methamphetamine use disorder.

Methamphetamine Common routes of administration  Ingestion  Inhalation  Insufflation  Anal suppository Adverse effects  General  Hypertension  Tachycardia  Hyperthermia  Cardiac  Arrhythmias  Acute heart failure  Pulmonary  Pulmonary edema  Pulmonary hypertension  Respiratory failure  Neurologic  Seizures  Ischemic/Hemorrhagic strokes  Cognitive impairment  Renal  Rhabdomyolysis  Acute renal failure  Gastrointestinal  Acute liver failure  Ischemic colitis  Mesenteric infarction  Dermatologic  Skin and soft tissue infection  Psychiatric  Anhedonia  Depressed mood  Anxiety  Psychosis  Agitation  Other  Suicide  Accidents Management  Largely supportive  Benzodiazepines and anti-psychotics as needed for controlling agitation and psychosis  Avoid beta-blockers for hypertension, tachycardia or methamphetamine associated cardiac complications Withdrawal  Depression  Inability to concentrate  Paranoia

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