A 37-year-old man with a history of depression, alcohol, and polysubstance use comes to the emergency department saying, "I feel awful; I need help." The patient says he was feeling fine until last night, when he developed abdominal cramps that were initially mild but gradually worsened in intensity. Since this morning, he has had 4 loose stools with no blood or mucus. The patient has also had persistent nausea but no vomiting. He has had no fever. His medications include paroxetine, clonazepam, and diphenhydramine. Temperature is 36.6 C (97.8 F), blood pressure is 144/98 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination shows a diaphoretic, thin man in considerable distress. His pupils are dilated. This patient's clinical presentation is most consistent with withdrawal from which of the following drugs?

Question

A 37-year-old man with a history of depression, alcohol, and polysubstance use comes to the emergency department saying, "I feel awful; I need help."  The patient says he was feeling fine until last night, when he developed abdominal cramps that were initially mild but gradually worsened in intensity.  Since this morning, he has had 4 loose stools with no blood or mucus.  The patient has also had persistent nausea but no vomiting.  He has had no fever.  His medications include paroxetine, clonazepam, and diphenhydramine.  Temperature is 36.6 C (97.8 F), blood pressure is 144/98 mm Hg, pulse is 88/min, and respirations are 16/min.  Physical examination shows a diaphoretic, thin man in considerable distress.  His pupils are dilated.  This patient's clinical presentation is most consistent with withdrawal from which of the following drugs?

Quizplus · Accepted Answer

11ec25c8_d76a_cc6c_bc81_eb3c0f9e3128_MD0003_00 This patient is demonstrating signs and symptoms often seen following abrupt withdrawal from prolonged opioid (eg, heroin) use. In opioid withdrawal, symptoms present within 6-12 hours, can peak within 36-72 hours, and may continue for several days. Common withdrawal symptoms include myalgias, arthralgias, nausea and vomiting, diarrhea, abdominal cramps, rhinorrhea, lacrimation, and sweating. On examination, patients may be restless and irritable with elevated heart rate and blood pressure (although usually not as elevated as in alcohol withdrawal). Pupillary dilation (mydriasis), piloerection, and yawning may be evident. The symptoms can be very distressing but are not life-threatening. (Choice A) Alcohol withdrawal develops 6-24 hours after the last drink, and is characterized by tremulousness, significant elevations in pulse and blood pressure, diaphoresis, and possible seizures. If left untreated, severe cases can progress to potentially life-threatening delirium tremens 2-4 days after the last drink. This patient's abdominal cramps, diarrhea, and dilated pupils are more suggestive of opioid withdrawal. (Choices B and D) Amphetamine and cocaine withdrawal present similarly. Patients may feel irritable, drowsy, fatigued, and hungry (as opposed to hyperactive and anorexic while intoxicated). Depressive symptoms may also occur. (Choice C) Benzodiazepine withdrawal presents with symptoms similar to alcohol withdrawal, but with less predictability in time of onset and duration of symptoms. Long-acting benzodiazepines (eg, clonazepam) are likely to have later onset and a longer course of withdrawal symptoms. (Choice E) Diphenhydramine is an antihistamine with anticholinergic effects. Withdrawal symptoms from stopping prescribed doses of diphenhydramine are rare. However, if present, withdrawal would be characterized by cholinergic rebound symptoms such as bradycardia and pupillary constriction (miosis). (Choice G) Abrupt discontinuation of short-acting serotonergic antidepressants (eg, paroxetine, venlafaxine, duloxetine) may lead to a discontinuation syndrome that can include physical symptoms such as dizziness, fatigue, headaches, and myalgias. Neurological symptoms such as perceptual changes, paresthesias, and "electric shock" sensations may also occur. This patient's abdominal cramping, diarrhea, and mydriasis are more likely due to opioid withdrawal. Educational objective: Heroin withdrawal should be suspected in patients with muscle and joint aches, nausea, diarrhea, abdominal cramping, rhinorrhea, and pupillary dilation. These subjective symptoms are often severe but generally not life-threatening. References: Opioid use disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27338968) Update on pharmacotherapy for treatment of opioid use disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27734745)

A 37-Year-Old Man with a History of Depression, Alcohol, and Polysubstance