3rd Friday Addiction Toxicology Case Conference

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.