3rd Friday Addiction Toxicology Case Conference

Cases discussed:

• A 60 year-old M presents to the ED with chest pain, restlessness, myalgias and yawning…
• A 31 year-old M presents to the ED with chest pain and is noted to be markedly tachycardic, tremulous and “just can’t settle down!”
• A 47 year-old F nurse presents to the ED with complaints of, “flank pain.” She’s slurring her speech and smells of alcohol.
   
• And a 41 year-old Male MVC victim is brought to the ED by ambulance (another car ran a stop sign à T-bone collision of driver’s side) has rib fractures, pelvic and other lower leg fractures and “the morphine is not touching him.”

Cases discussed:

• A 23 year-old female prescribed buprenorphine (Subutex) presents to the ED with pain and ‘dusky changes’ to the 2nd-4th digits of her L hand.
• A 62 year-old female with chronic pain and polysubstance dependence, who is prescribed opioids and alprazolam, overdoses and then develops withdrawal in the hospital.

Cases discussed:

• A 52 year-old M with cirrhosis and alcohol withdrawal is treated with a long-acting benzodiazepine. After initial good response he develops confusion and excessive sedation as well as swallowing difficulties. The order is left on for a scheduled dose of this benzodiazepines for several weeks until a psychiatry consultant recommends that the BZD be dc'd and that the team call toxicology to evaluate as well.
• 54 year-old F with recurrent opioid overdose presents with altered mental status and sedation along with 9 fentanyl patches in various places under her breasts. Tox is consulted to provide recs for withdrawal management as the patches are being removed.
• A 29 year-old M with recurrent mitral valve endocarditis is scheduled for valve replacement. He is currently on 8/2 mg Suboxone SL BID. Anesthesia calls to discuss perioperative management of pain.

Cases discussed:

• A heroin and cocaine dep 26 year-old F with IVDU presents with multiple sites of cellulitis and reports, “there is something funny with my neck…” 
• An elderly patient chronically taking 0.75 mg clonazepam at night presents with confusion and paranoia.

Cases discussed:

• “It just started with one but I couldn’t stop.”  Insufflation of bupropion and pregabalin in a Halfway House.
• A 32 year-old M with opioid use disorder is hospitalized for burns suffered while trying to light a campfire with gasoline.
• An attorney presents with agitation and fever while partying with friends using MDMA and amphetamine.
• A long-time stable patient on buprenorphine calls his provider reporting he’d just relapsed on cocaine after several years sober.

Cases discussed:

• An unexpected drug test result in a liver transplant candidate - presenter Stephanie Weiss, MD, PhD UTSW/Parkland Memorial Hospital Toxicology Fellow
• Gabapentinoid abuse in a patient receiving buprenorphine MAT 
• A body builder with an opioid OD and compartment syndrome
• An unexpected phenobarbital positive that persists, (and persists, and persists...) in a patient on buprenorphine

Cases discussed:

• 19 year-old M with anxiety and substance abuse who presents to the ED after sudden onset cessation of phenibut with insomnia agitation and palpitations. –Dr. Mike Keenan SUNY Upstate EM resident presenting.
• 38 year-old M with alcohol dependence being treated for withdrawal in the hospital discloses he also uses Kratom and thinks he’s withdrawing from that.
• A few cases of precipitated withdrawal…

Cases discussed:

• A patient complains of, "muscle spasms and my appetite is gone," after starting naltrexone tablets (while waiting for a Vivitrol(R) prescription to clear insurance) post incarceration.
• "Is it supposed to be this red? And it hurts..." A patient returns to clinic with redness and some swelling at the site of injection for Sublocade(R).
• Patient requests detox for IV methamphetamine and injection buprenorphine/naloxone dependence. How do you proceed with withdrawal management and treatment after detox?

Cases discussed:

• Is there a role for another micro induction?  Discussion of buprenorphine initiation for a patient on ECMO with ARDS unable to wean from high dose hydromorphone (10 mg/hr) and ketamine (3.5 mg/kg).
• Bupropion abuse after a cocaine binge -an interesting case and sequelae for the patient.
• A pregnant benzodiazepine and opioid-dependent patient is admitted for scheduled termination but is terrified of withdrawal -what are the options?
• Interesting urine toxicology results in an opioid-court referred patient.  How do you proceed?

Cases discussed:

• Buprenorphine microinduction performed in an opioid dependent patient unable to wean from a continuous fentanyl infusion (a 'modified' Bernese method induction).
• In the depths of an ether binge...' Discussion and review of an interesting case involving ether huffing and addiction
• How soon is too soon? rapid buprenorphine initiation in an ICU patient with iatrogenic dependence.

Cases discussed:

• It was going to be a simple ED bup induction until..., "What do you mean I can't order Suboxone(R)?  What do we have for doing a buprenorphine induction?"
• "I have to wait at least 2 days to start," doing buprenorphine inductions in the setting of heavy 'illicit fentanyl' use.
• 36-week pregnant patient has been off of buprenorphine x 7-10 days and using heroin/cocaine, wants to get back on medication, but there are a few challenges...

Cases discussed:

• An opioid dependent 21 year-old F on Suboxone(R) presents to the ED with tremor and report of seizure 2 days after abruptly stopping “3 street Xanax bars a day.”
• A 32 year-old M is electively admitted to an inpatient detox facility and reports using a ‘bundle’ of heroin, 8 mg clonazepam and 3600 (+)mg ‘Gabbies’ daily (Rx’d - didn’t bring bottle) UDS + fentanyl, cocaine, opiates, THC, BZD...
• A health care professional hospitalized after use of ‘Molly’

Cases discussed:

• "I haven't seen that before with buprenorphine but let me look into it," a case of 71 year-old patient with new onset seizures since starting MAT -Neurology suggests d/c Suboxone(R). Discussion involves treatment of opioid use disorder in patients with epilepsy and whether bup/naloxone adverse effect profile includes seizures or increased risk of seizures in patients treated with anticonvulsants.
• "I had to use my breakthrough medicine since you went up on my Suboxone(R)..." Patient with stable seizure disorder maintained on carbamazepine presents to clinic questioning whether an increase in dose from 8/2 mg to 12/3 mg daily may have triggered a first in 12 months break-through seizure. In addition to reviewing issues discussed in case 1, we will discuss the patient's refusal of the MAT provider to contact his Neurologist, "I don't want them knowing I was using heroin..." Patient driving and refuses to notify provider of reported seizure.
• 39 year-old M with stable maintenance on buprenorphine/naloxone 12/3 mg daily has worsening symptoms such as dyspnea on exertion, orthopnea and edema from cardiomyopathy hospitalized for Left Ventricular Assist Device implementation. Discussion of pre/post operative management for patient with LVAD.
• 27 year-old M with IVDU using heroin and cocaine seen at detox unit. During intake the provider notices he's currently prescribed methylphenidate and clonazepam and last picked up an Rx for 30 days of each 10 mg methylphenidate IR 6 tabs daily and 1 mg clonazepam 2 mg PO BID x 60 tabs, neither of which he brings in -"I haven't taken them for months, I've been selling them to buy heroin and cocaine." UDS pos heroin and cocaine, THC and methamphetamine. Refuses consent to contact prescriber of methylphenidate and clonazepam. Discussion of consent, confidentiality and other issues involving communication between providers when a patient in treatment for chemical dependency.
• Ether-huffing of a medical student identified while on a rotation... Discussion of ether intoxication, toxic effects and appropriate care and treatment of an impaired health care professional student. 

Cases discussed:

• Methadone for pain is different than methadone for dependence.   Case discussion involving a patient hospitalized with IVDU related complications who has methadone initiated in the inpatient setting for treatment of craving, withdrawal and pain. 
• "Day 6 she didn't come in for her dose..."  a review of a methadone-related fatality during first week of dose initiation in an Opioid Treatment Program.
• QT prolongation and concern for arrhythmia in a patient with long term stability on methadone -what are the options for ongoing treatment? 
• It's Saturday at 5:00 PM and a patient presents to the ED reporting they missed their methadone clinic dosing for the weekend due to an emergency...  Options for handling ED requests for missed methadone doses.
• Patient previously on 100 mg/day methadone out of state is fleeing domestic violence situation presents to the ED on day 3 after last dose requesting help and treatment of the withdrawal. 

Cases discussed:

• A 27 year-old M self-described, “amateur pharmacologist, learned from hours on Erowid,” is struggling with severe dextromethorphan abuse and has some questions for the toxicology service about potential treatments after recovering from a bout of DXM intoxication in the ED.

• An 82 year-old M with chronic stable dose of oxycodone/Oxycontin®, gabapentin and baclofen becomes somnolent and develops respiratory failure after coming in from gardening for a prolonged period on a very hot summer day.

• A 28 year-old M on methadone maintenance becomes argumentative and then somnolent while at the methadone clinic. After being brought to the ED he reports, “taking a couple of Lyrica® to ‘chill out’.

• A 32 year-old F with IVDU has been treated for an epidural abscess but has complications related to this and requires emergent C-spine surgery. She is taking 8/2 mg Suboxone(R) once daily. Emergent surgery is scheduled for later in the day.

• A 24 year-old M with heroin, cocaine and alprazolam dependence presents to the ED after an overdose. He is given naloxone and admitted for monitoring. The following AM he is complaining of both opioid and alprazolam withdrawal.

• Funny buprenorphine metabolite results in a 52 year-old M with opiate and cocaine dependence who is waiting to get the SC buprenorphine injection.

Title:  Certification and Fellowship Training Programs in Addiction Medicine

Presenters from The Addiction Medicine Foundation:

• Kevin Kunz, M.D., M.P.H., DFASAM -- Executive Vice President
• Tim Brennan, M.D., M.P.H., FASAM -- Vice President for Medical and Academic Affairs
• Andy Danzo -- Director of Fellowship Development     

The Addiction Medicine Committee hosts 3 national experts in physician certification and training in Addiction Medicine. Certification eligibility criteria for Medical Toxicology physicians will be reviewed, as well as the state of fellowship training and the development of new fellowship programs. There will be time for questions and answers and an example of a successful application for the Addiction Medicine Board Exam (from a Medical Toxicologist) will be reviewed.

Cases discussed:

• "I have a weird metabolism, the cocaine stays in my system for at least two weeks!"  Patient with heroin and cocaine dependence hospitalized for the treatment of a perinephric abscess returns from a smoking break altered and a new urine shows cocaine positive > 12 days from admission.

• A 36 year-old M with recurrent tricuspid valve endocarditis has an upcoming tricuspid valve replacement.  Maintained on 2/0.5 mg SL TID (somnolent with higher doses) he will undergo surgery in 2 days (via sternotomy) what is your peri/post-operative pain/dependence management plan?

• Two patients with funny urine --discussion of addressing adulteration and substitution and review specimen validity testing in urine.

• Coffee ground emesis, refractory vomiting and coma in a 20 year-old M who just, "drank a bottle of Everclear along with some Mucinex(R) (DXM)"  --a very, very high alcohol level...

• 27 year-old M with respiratory failure after insufflating 2 bags of heroin after taking several of his prescribed clonazepam.  You are consulted to provide recommendations for his opioid and benzodiazepine withdrawal. 

Cases discussed:

• A 40 year-old with severe pain during complex dressing change and debridement of a wound associated with IVDU -patient maintained on high doses of buprenorphine.

• A 57 year-old grandmother has car accident after taking gabapentin for her opiate withdrawals.  Discussion involves reporting (CPS),  gabapentin abuse, identification and treatment of opiate withdrawal in the hospital setting and linkage to ongoing MAT.

• A 35 year-old F maintained on 90 mg/day of methadone falls asleep laying on her curling iron while taking excessive doses of gabapentin.  Delay in seeking treatment.

• A patient with positive fentanyl immunoassay but negative confirmatory screen and some other puzzling fentanyl immunoassay results and their confirmatory tests.