Drugs of abuse: 


  • heroin

  • prescription opioids 


Who is most affected: 


  • males ≥ 18 years old


Incidence/Prevalence: 


  • in USA

    • in 2006, approximately 5.2 million people reported nonmedical prescription analgesic use

    • opioid dependence in about 4.5% in patients treated with opioids for pain


History: 


  • Chief concern (CC): 

  • patient may be seeking drugs, seeking or in treatment for abuse/dependence, or because mandated

  • may have symptoms of withdrawal

  • History of present illness (HPI): 

    • ask about

      • opioids use

      • any current use of pain medication

      • any use of other psychoactive substances (including alcohol)

      • patterns of substance use, including amount and frequency

      • drug-induced health and social problems

      • previous responses to treatment

      • comorbid medical conditions

      • psychosocial stressors contributing to opioid use

      • patient’s view of substance use and disposition regarding treatment 

      • suicidal ideation

  • Medication history: 

    • any current use of pain medication 

    • any instances of misuse, overdose, or dependence (especially for psychiatric or pain medications)

    • potential for drug interactions 

  • Past medical history (PMH): 

    • history of infections

      • hepatitis B and hepatitis C

      • HIV infection/AIDS

      • tuberculosis

      • endocarditis

      • cellulitis

      • abscess

      • thrombophlebitis

    • psychiatric history

      • depression

      • PTSD

  • Social history (SH): 

    • ask about changes in

      • occupational or relationship status

      • participation in recreational and leisure activities 

    • ask about

      • past treatment experiences

      • living conditions

      • legal issues

      • social and cultural factors

    • for known opioid misusers, ask about source 
of drugs

    • assess 

      • supply of needles and syringes

      • sharing habits

      • knowledge of infectious disease precautions


    Physical: 


    • General physical: 

      • signs of acute intoxication include

        • respiratory depression

        • slurred speech

        • euphoria 

        • disturbances in level of consciousness, cognition, and perception

        • miosis

        • itching

      • signs of opioid withdrawal include

        • elevated respiratory rate, blood pressure, and pulse

        • anxiety

        • agitation

        • dilated pupils

        • myoclonic jerks

        • sweating

    • Skin: 

      • findings suggestive of IV drug abuse

        • track marks 

        • calluses along vein

        • skin abscess

        • injection site lesions

      • piloerection (may suggest opioid withdrawal)

      • jaundice (may suggest hepatitis)

    • HEENT: 

      • nasal septum perforation 

      • gum disease (if poor nutrition)

    • Cardiac: 

      • heart murmur (if endocarditis)

    • Abdomen: 

      • hepatomegaly or ascites (if hepatitis or cirrhosis)


    From the September 01, 2015 Issue of Clinical Advisor

    Topics:

    Addiction Substance Use