Substance Abuse

SUBSTANCE ABUSE 64A

A 32-year-old unemployed man presents to the emergency department with right lower quadrant (RLQ) abdominal pain of 17 hours’ duration. He has a fever of 38.9°C, rebound tenderness over MacBurney’s point, and a white blood cell (WBC) count of 18,900/mcL (with a left shift). He says he drinks alcohol “socially” (“a glass or two of wine with dinner”). He undergoes emergency appendectomy. On postoperative day 2, he becomes anxious, restless, and diaphoretic, with a heart rate of 125 beats/min and blood pressure of 164/95 mm Hg, and he begins to pick at his intravenous line. When he becomes tremulous and begins to hallucinate about “bugs,” his girlfriend admits that since losing his job 1.5 years ago, he has been depressed and drinking “almost continuously,” up to 3 to 4 bottles of wine daily. Over the next 72 hours, he develops mental confusion, sensory hyperacuity, and both hypokalemia and hypomagnesemia.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Unemployment; heavy alcohol use, then abstinence for 48 to 72 hours; tremulousness; visual hallucinations; abnormal vital signs; diaphoresis; anxiety, confusion; hypokalemia, hypomagnesemia

How to think through: Tachycardia and confusion in a postoperative patient warrants consideration of infection, pain, pulmonary embolism, a medication side effect, and delirium. Substance use disorders are stratified as “at risk,” “abuse,” and “dependence.” This man’s symptoms and signs of withdrawal suggest the diagnosis of alcohol dependence. The interval since the patient’s last alcohol intake can help us to anticipate the risks of its abrupt withdrawal. What are these risk? (Hallucinations [12–48 hr since last intake]; seizures [12–48 hr]; tremor, autonomic instability, delirium tremens [48–96 hr]; falls, danger to staff, need for restraints and, in rare cases, death.) Delirium tremens is characterized by a clouded sensorium and signs of autonomic instability. How should he be managed? (Benzodiazepine; thiamine; hydration; electrolyte repletion.) However, when dysautonomia is controlled by benzodiazepines but hallucinations and agitation are not, haloperidol is often used. Oversedation is a major management challenge because benzodiazepines accumulate, and it can result in endotracheal intubation to avoid aspiration.