A 22-year-old man comes to the clinic for routine follow-up of his mild asthma. He has a history of keeping his appointments but has missed the last three. Today he seems distracted and uninterested, answering various questions with very brief replies. At one point, the patient says that he would like to hurry the visit along so he can get home sooner. Following inquiries about his social life, he becomes more animated and describes spending time with new friends who "really know how to party." On further questioning, he says, "I have been snorting cocaine sometimes but it's not a big deal. I haven't used any this past week. I quit school because it was just stupid and I was wasting my money. I'm working as a waiter now and enjoying it. At least I can make my own money and not be dependent on my parents." The patient says that he has been living with his new friends since his parents asked him to move out 2 weeks ago, but he would "rather not talk about that." He denies any symptoms of depression, mania, or psychosis. Temperature is 37.7 C (99.9 F), blood pressure is 120/82 mm Hg, pulse is 86/min, and respirations are 15/min. Physical examination shows perforations of the nasal septum. After discussion, the patient agrees to curtail his cocaine use and says that it will not be a problem. He is receptive to a back-up plan of referrals to 12-step group programs and outpatient substance abuse programs. The physician asks for permission to speak with his parents, and the patient says he will think about it. However, he fails to attend his 1-month follow-up appointment. Six months later, the patient makes an appointment to renew his asthma medications. When the physician notes multiple track marks on his arms, the patient admits he has been injecting cocaine. He has lost his job as a waiter and is currently unemployed. He has not spoken to his parents and is temporarily staying with a friend who also uses drugs. The patient says he tried a few Narcotics Anonymous meetings but did not attend regularly and has been unable to stop using. He admits to feeling depressed and has lost 4.5 kg (10 lb). He has no suicidal ideation. Which of the following is the most appropriate step in managing the patient's substance use problem?

Question

A 22-year-old man comes to the clinic for routine follow-up of his mild asthma.  He has a history of keeping his appointments but has missed the last three.  Today he seems distracted and uninterested, answering various questions with very brief replies.  At one point, the patient says that he would like to hurry the visit along so he can get home sooner.  Following inquiries about his social life, he becomes more animated and describes spending time with new friends who "really know how to party."  On further questioning, he says, "I have been snorting cocaine sometimes but it's not a big deal.  I haven't used any this past week.  I quit school because it was just stupid and I was wasting my money.  I'm working as a waiter now and enjoying it.  At least I can make my own money and not be dependent on my parents."  The patient says that he has been living with his new friends since his parents asked him to move out 2 weeks ago, but he would "rather not talk about that."  He denies any symptoms of depression, mania, or psychosis.  Temperature is 37.7 C (99.9 F), blood pressure is 120/82 mm Hg, pulse is 86/min, and respirations are 15/min.  Physical examination shows perforations of the nasal septum. After discussion, the patient agrees to curtail his cocaine use and says that it will not be a problem.  He is receptive to a back-up plan of referrals to 12-step group programs and outpatient substance abuse programs.  The physician asks for permission to speak with his parents, and the patient says he will think about it.  However, he fails to attend his 1-month follow-up appointment.  Six months later, the patient makes an appointment to renew his asthma medications.  When the physician notes multiple track marks on his arms, the patient admits he has been injecting cocaine.  He has lost his job as a waiter and is currently unemployed.  He has not spoken to his parents and is temporarily staying with a friend who also uses drugs.  The patient says he tried a few Narcotics Anonymous meetings but did not attend regularly and has been unable to stop using.  He admits to feeling depressed and has lost 4.5 kg (10 lb).  He has no suicidal ideation.  Which of the following is the most appropriate step in managing the patient's substance use problem?

Quizplus · Accepted Answer

Explanation: Substance abuse treatment can be provided in various settings and at different levels of intensity. Appropriate referral requires an individualized assessment of the patient, including severity of substance use, whether the patient is currently intoxicated or in withdrawal, evaluation of medical and psychiatric comorbidity or complications, motivation to change, degree of support in the home environment, and level of functional impairment. This patient has progressed from intranasal to intravenous use and is increasingly impaired. He now exhibits depressive symptoms that are most likely substance-induced. He has no social support and is surrounded by people who are using and have ready access to drugs. The best approach is an inpatient rehabilitation program that can provide a safe, drug-free environment; assessment and management of medical and psychiatric complications; and a highly structured, intensive substance abuse treatment. (Choice A) Although cognitive-behavioral therapy is effective in substance use disorders, it is unlikely to be helpful for this patient unless it is incorporated into a comprehensive drug rehabilitation program that restricts his access to drugs. Bupropion may alleviate stimulant withdrawal symptoms by facilitating dopamine neurotransmission, but it is not effective in treating cocaine use disorder. (Choice B) A peer self-help group such as Narcotics Anonymous is a powerful tool for many people in recovery. However, this patient's inability to stop using and lack of support at home suggest that meetings alone would be ineffective. Once abstinence is achieved, attendance in 12-step programs can be critical to maintaining long-term abstinence. Random urine drug tests independent of a comprehensive drug treatment program would not be beneficial. (Choice D) Outpatient rehabilitation programs are appropriate for higher-functioning patients who are self-motivated and have good support systems. This patient is unemployed, is in a temporary living arrangement with a friend who uses drugs, and has increasing symptoms of depression. He has missed a number of follow-up appointments with his physician and is unlikely to adhere to or do well in an outpatient program at this point. (Choice E) Psychiatric hospitalization is indicated for patients experiencing severe intoxication or physical withdrawal symptoms or those who pose a danger to themselves or others. If this patient were actively suicidal, inpatient hospitalization followed by referral to a drug rehabilitation program once he is stabilized would be appropriate. Educational objective: Referral to the appropriate level of treatment for substance use disorders requires individualized assessment of the patient for severity of substance use, intoxication/withdrawal, medical and psychiatric comorbidity, degree of self-motivation, adequacy of social support, and level of functional impairment. References: Residential treatment for individuals with substance use disorders: assessing the evidence. (http://www.ncbi.nlm.nih.gov/pubmed/24445598)

A 22-Year-Old Man Comes to the Clinic for Routine Follow-Up