Patient Management Exercise for Substance Abuse: Diagnosis and Treatment

You are an attending psychiatrist on an adult inpatient unit. You receive a call from the hospital's intensive care unit asking you to admit a 22-year-old man 4 days after the patient overdosed on an unknown quantity of psychoactive medications plus an unclear amount of acetaminophen. The college roommate who found him unconscious estimated that the patient probably ingested the pills between 5 and 8 hours before admission; the patient was intubated for 24 hours at the beginning of the hospitalization but was soon able to breathe on his own. His serum acetaminophen level was 225 μg/ml, his aspartate aminotransferase (AST)/alanine aminotransferase (ALT) levels were 1,220/700 IU/L, and his urine toxicology screen was positive for opiates and cannabis. His blood alcohol level on admission to the emergency room was 0.28. His pupils were pin-point, suggesting opiate intoxication, and naloxone was administered. The medical team ordered that he be NPO and treated him with activated charcoal with gastric lavage and then began N-acetylcholine treatment over the next 72 hours and monitored him closely for the following 2 days. Normal saline, thiamine, and lorazepam, 1 mg i.v. every 2 hours, were administered during day 2 as the patient began to exhibit signs of acute alcohol withdrawal, including clouded consciousness, an inability to sustain attention, disorientation, and a core temperature of 39°C. He was treated for acute fulminant liver failure and responded quickly. According to the consultation-liaison (C/L) psychiatry resident who was called to see the patient on day 2, the patient continued to be delirious, irritable, agitated, and refused to speak, although he “kicked me out of the room.” He noticed, however, a pack of cigarettes in the patient's belongings bag.

According to the patient's mother, whom the C/L psychiatry resident was able to reach by telephone on the opposite coast, the patient made two prior suicide attempts, both by overdose of medications, and had two subsequent inpatient psychiatric hospitalizations. She suggested checking his thighs for cut marks as he had engaged in self-mutilation off and on since he was at least 12 years old. He spent 2 weeks at an outpatient alcohol and substance abuse rehabilitation program in California when he was 16 after he was caught smoking marijuana at home. He attended 90 Alcoholics Anonymous meetings, attending daily for 3 months (“90 in 90”) and then stopped going. He saw a psychotherapist sporadically from the age of 16 until he was 18 and was treated by a psychiatrist for major depression with fluoxetine 40 mg daily. He was accepted to a university in New York City.

When he was 6 years old he was sent by elementary school staff for a psychiatric evaluation because of inattentiveness and disruptive and impulsive behaviors. He was diagnosed with attention deficit hyperactivity disorder (ADHD). Methylphenidate was prescribed. However his mother said she and his father refused to give it to him because they were afraid it would cause him to become addicted to the drug. He continued to struggle in school, but managed to earn good marks because of his “natural intelligence.” “He never had to study much,” his mother told the resident. According to his mother, she is not sure if he is still using street drugs or if he still takes his fluoxetine because he does not call home more than two or three times a year, “and only when he needs money.” She and her husband say their son does well in college and is due to graduate 1 year late after taking a year off to travel in Europe.

The lorazepam was slowly tapered beginning on hospital day 3 by 10%–15% per day. An antiemetic, non-opiate antidiarrhea formulation and fluids were administered or offered to help control the patient's withdrawal from opiates.

On hospital day 6 the medical team reports that the patient's vital signs have normalized, his acetaminophen level is 0, and his liver enzyme levels are moving toward normal limits, so you accept the transfer. The patient arrives several hours later, somewhat lethargic after he was given haloperidol 2 mg i.m. and lorazepam 1 mg i.m. by the treatment team after he learned he would be transferred to the psychiatry inpatient unit, had pulled out his intravenous lines, and leave the hospital against medical advice. Six hours later, the patient is still lethargic, but his heart rate is 110 and blood pressure is 160/100 mm Hg. To control the patient's withdrawal symptoms, he was initially titrated to lorazepam 2mg every 4 hours. Prior to arrival on the inpatient psychiatric unit, the patient's lorazepam regimen had been tapered to 1.5mg every 4 hours, for a total of 9mg/day. The patient's vital signs normalize for approximately 4 hours, but he again becomes tachycardic and hypertensive.

You obtain consent from the patient to speak with his parents, his psychiatrist, and therapist in California. The patient is still refusing to speak with you about the suicide attempt. He asks repeatedly for “something to mellow me out” because “I'm really stressed and I'm going to explode.” You explain that he is being carefully monitored for withdrawal symptoms, discomfort, and his lorazepam is being tapered. He becomes irate and screams, “Get out of my room! Get me a doctor who knows what he's doing. You are trying to torture me because that is what you get paid to do.” Using a calm voice you explain again that the staff is carefully monitoring him, but you are unable to finish your sentence because he throws a shoe at you, which fortunately misses and hits the wall instead.

You contact the patient's mother who explains that she and the patient's father divorced 6 years ago after she caught him cheating with his legal secretary. She has one other child, a daughter, 20 years old, who attends a private college in northern California. The daughter briefly saw a therapist during the divorce. She was also diagnosed with ADHD when she was between 6 and 7 years of age; like her brother, she was never given the methylphenidate she was prescribed. She is not doing well in school, has a history of running away from home, using drugs, and underwent an elective abortion at the age of 15 after a rape.

The patient's mother suffers from depression and takes escitalopram. Her depression was diagnosed 1 year before the divorce. The patient's father allegedly has alcohol dependency that is untreated, but has not yet interfered with his ability to function as a malpractice attorney. She is not certain whether her parents had any psychiatric problems, but her father-in-law died of pancreatic cancer related to heavy drinking. She warns you not to call her ex-husband because he remarried, and has two young children and does not want to be involved.

The patient's former psychiatrist and therapist inform you that the patient's two previous suicide attempts, at ages 16 and 17, were probably related to his parents' divorce when he turned 16. They recall that the patient was diagnosed with ADHD by history that was not treated, but say he was lucky that he maintained good enough grades to move on to a university in New York. He had at least five episodes of major depression, beginning when he was 10 years old when he claimed that his father sexually molested him. The family was investigated by Child Protective Services, and no charges were made.

He again exhibited symptoms of depression at 12 and 15 years of age, the longest lasting 4 months, but his depression became disabling when he was 16, lasting more than 6 months and leading to his first suicide attempt. In between bouts of depression he says he felt “normal.” During his depressions, however, he had anhedonia, was isolative, and ignored his friends. He typically lost 10% of his already lean body mass, had difficulty with sleep, and poor energy. After he was 16, he felt the divorce was his fault and continually ruminated with intrusive negative thoughts about himself. He never exhibited psychotic symptoms, homicidal ideation, or paranoid delusions. His mood was never elevated or euphoric, although he says it can change rapidly from “normal” to “really depressed.” The mood switching can happen several times in a day and last a day or up to several months. There is no history of aggression toward people or animals, destruction of property, deceitfulness or theft, or serious violations of rules. He abused alcohol by binge drinking on weekends with friends beginning at the age 15. By the time his parents divorced, he was drinking by himself during the week as well.

His psychiatrist diagnosed him with “strong cluster B symptoms,” but explains that he feels the patient's personality structure has taken on borderline personality disorder characteristics. By the time the patient was 12 it was noticed that he had begun cutting his thighs with a razor. The cuts were superficial, but there were numerous scars from his self-mutilation efforts and during visits typically six to eight fresh marks. None ever required sutures.

His friendships were of a fleeting nature. He would come to therapy or to see the psychiatrist extolling the virtues of his closest friends, but by the next month or two these friends had become enemies. Romantically, the patient seemed ambivalent about whether he preferred women or men and seemed to struggle with his own sexual identity. He often slept with strangers he met at bars, although he reported that he always used a condom. Even when he was in a better mood, he still complained of feeling empty, that his life was ruined, and he repeatedly blamed himself for his parents' divorce. He felt they may have set him up, to be the scapegoat for their decision to divorce by continually punishing him for alleged misconduct and poor grades, despite his “being the best son anyone could possibly want.”

Therapy was started with fluoxetine 20 mg, which was increased to 60 mg over the next 4 months. He stopped taking the medication and seeing his therapist because he said he “felt fine” but again became depressed and made the second suicide attempt approximately 4 months later. He returned to the psychiatrist and therapist after a week-long hospitalization, and fluoxetine was restarted but was quickly titrated back to 60 mg. Again, once he felt better he quit coming to appointments and stopped the medication. He called the therapist one last time before leaving for New York.

His mother reported that he was excited to start at the university, felt good about his academic achievements, and seemed to have put the events surrounding his parents' divorce into better perspective. He acknowledged that their divorce had nothing to do with him or his sister; his father had cheated on his mother, and although he still harbored resentment toward his father, he told the therapist that he wanted to concentrate on his studies. She gave him referrals for a psychiatrist and therapist in New York City, but apparently he never followed up on them.

On hospital day 8 the patient has calmed down considerably and decides to speak with you. You ask him what precipitated the overdose. “I could not take it anymore,” he tells you. “I have been lying to everyone to the point where I do not know which way is up. I am tired. I cannot handle all of the pressure anymore. I do not know what I'm going to do.” His eyes become glassy and he grabs a few tissues. He tells you he is “pissed off” that his suicide attempt failed. When he sleeps he wakes up every hour or so and feels overwhelmed by his problems. He says he feels hopeless, helpless, and worthless. He cannot focus on anything, not even TV, and he has not been eating well. He apologizes for his behavior then blames the nursing staff for not helping him with PRN [as needed] medications. “You should fire half this staff,” he tells you. “I've seen them do things to other patients that would get them arrested.” You ask about his alcohol consumption. He tells you that he has been drinking on and off since the age of 12. “I can put away a fifth if I want.” He began drinking by stealing sips of his father's drinks. He liked the way it felt and began stealing bottles from what he describes as “a huge bar.” By the time he was 13 he was drinking 5 shots of vodka per night before bedtime. He would binge drink on the weekend and often blacked out, and “I ended up in some pretty odd places doing some very odd things.” He does not want to tell you about those incidents. He managed to maintain sobriety for 6 months when he started college, but this situation quickly deteriorated and he was again binge drinking. “My parents do not know this, but I was kicked out of school after my sophomore year.” You ask what he has been doing for money and he replies that his parents send him large checks periodically “because I figure they owe me” and he also does “things” for money he prefers not to discuss.

You tell him you found evidence of opiates and marijuana in his urine toxicology screen. He admits to smoking marijuana infrequently, perhaps once per 1–2 months, only if someone “shoves a joint in my mouth.” He does not use opiates, but overdosed on “a couple of handfuls of Vicodin” that his roommate had hidden because he sold the pills. “I do not get into that either,” he says. “But I needed pills and they were around.”

Regarding his general health, he reports that he is healthy, has had recent tests for sexually transmitted diseases including HIV infection, all of which were negative. In the past he contracted a chlamydial infection that was treated successfully with antibiotics. He says “the one thing I do right is practice safe sex.” He says he smokes one pack of cigarettes per day and has smoked since he was 15 years old.