Substance- Related Disorders

Professor
Dr Sirwan K Ali
Department of Psychiatry
CCP

Psychoactive substance dependence

Opiod dependence
 Problem
A 54-year-old man with a long-standing
history of substance abuse presents to the
emergency department with abdominal pain,
sweats, diarrhea, and body aches.
On initial evaluation, the patient is noted to
have a watery nose and eyes, a slightly
elevated temperature of 100°F (37.8°C), and
dilated pupils. His mood is dysphoric, and his
affect is irritable.
 Problem
His abdominal examination is benign. Laboratory
examinations including electrolytes, complete blood
count, liver function tests, amylase, and lipase are all
normal. A plain abdominal x-ray showed no clear
cause for his abdominal pain.

 What is the most likely diagnosis for this patient?

 What medications can be used to alleviate the

patient’s symptoms?
 Discussion
Summary of the case: A 54-year-old man
presents with abdominal pain, sweats, diarrhea,
and body aches. A physical examination shows
pupillary dilation, lacrimation, rhinorrhea, and a
mild fever of 100°F (37.8°C). His mood is
dysphoric, and he is irritable.
• Most likely diagnosis: Opioid withdrawal.
• Medication to help alleviate symptoms:
Methadone or clonidine
 Analysis
 Objectives
1. Recognize opioid withdrawal in a patient.

2. Understand the use of methadone,

clonidine, and buprenorphine in
ameliorating
opioid withdrawal symptoms.
 Differential diagnosis 1

The differential diagnosis for opioid

withdrawal is generally straight forward
because patients undergoing withdrawal are
conscious, usually able to give their history,
and know when the last dose of their drug of
choice was taken. Other withdrawal
syndromes are not manifested in the same
way.
 Differential diagnosis 2

For example, patients undergoing alcohol

and/or benzodiazepine withdrawal present
with anxiety, restlessness, irritability, and
insomnia, as well as hyper reflexia and tremor.
As withdrawal progresses, tachycardia,
hypertension, hyperthermia, and muscle
fasciculation are seen. In severe
cases, seizures, delirium, and death can occur..
 Differential diagnosis 3

Withdrawal from cocaine includes a

“crash,” including hypersomnia, hyperphagia,
and depressed mood. Withdrawal from
nicotine produces anxiety, depression,
irritability, headaches, poor concentration,
sleep disturbance, and increased blood
pressure and heart rate.
 Differential diagnosis 4

Opioid withdrawal generally does not cause

tremors, confusion, delirium, or seizures.
Patients are seldom lethargic or tired. If any of
these symptoms are present, the concurrent or
separate use of other drugs of abuse should be
considered.