Special K, Super C, spice. It was 7 a.m. on a Thursday at Internal Medicine 2013 in April, but speaker Osama A. Abulseoud, MD, wasn't listing breakfast options for attendees.
These terms, along with others such as cat valium and ivory wave, may be used by patients to describe illegal drugs they've taken. During his session “Drugs of Abuse,” Dr. Abulseoud, assistant professor of psychiatry and psychology at Mayo Clinic in Rochester, Minn., offered advice on the common presentations of drug problems.
“The history is important” for identifying abuse of some of these drugs, because they are not caught by standard urine tests, Dr. Abulseoud said. For example, ketamine (also known as Special K, Super C and cat valium) won't show up on a drug test but can cause serious medical problems for users.
Typical consequences of repeated use include psychosis and memory impairment, but ketamine users may also present with cystitis, a less obvious clue to drug abuse. In some cases, the problem can be so severe as to require bladder reconstruction, Dr. Abulseoud said.
The pain associated with ketamine-induced cystitis can also create a vicious cycle. “Patients sometimes self-medicate with more ketamine. In this case, you have to treat the pain aggressively. Otherwise the patient will not be able to stop,” he said. Certain antidepressants can be used to reduce cystitis pain, which could help patients get off ketamine, he added.
Serotonin is also an issue with bath salts, another drug that's been gaining popularity in the U.S. People who have used this drug (which is sold under this misleading name and labeled as “not for human consumption” in order to evade drug regulations) may present with serotonin syndrome, because the drug causes a massive release of neurotransmitters.
“Imagine that you use cocaine and methamphetamine together,” said Dr. Abulseoud. “You can imagine the rush the patients will get when they use bath salts.”
But when patients come down from that high, they may suffer terrible panic attacks, psychosis (sometimes violent and aggressive) and, for unknown reasons, green tongues. “We don't have an antidote. But we can use benzodiazepines and antipsychotics that will calm the patient,” said Dr. Abulseoud.
Antipsychotics may also be necessary for some patients who've taken synthetic marijuana (also known as spice). It poses a much higher risk than traditional marijuana of causing psychosis, which can be very long-lasting, requiring as much as 10 days of inpatient care. “Use an antipsychotic and then you would sit next to the patient and pray that this case resolves quickly,” he said.
Synthetic marijuana is a relatively new drug and got its start in the pharmaceutical companies' efforts to replicate the pain relief and antiemetic properties of natural marijuana. Their efforts were unsuccessful but opened the door for other chemists to create synthetic marijuana. “It became public knowledge how to make agonists,” Dr. Abulseoud said. “The use of spice increased significantly in 2009, 2010, 2011.” Synthetic marijuana is another drug that's sold widely with the claim that it's not for human consumption.
Access is also no obstacle to abusing Salvia divinorum, a common garden plant. “In traditional Mexican culture, it was used for religious purposes,” he said. Salvia causes brief, intense hallucinations and can exacerbate preexisting mental health problems. “The patient who is depressed and started using salvia starts thinking about suicide,” he said. Unfortunately, there's no treatment except support, but the good news is that most episodes resolve spontaneously.
Internists should take a much more active role in dealing with the next drug abuse problem on Dr. Abulseoud's list—opioid addiction. The United States has less than 5% of the world's population but consumes 80% of the opioid supply, he reported. Prescription rates have been steadily increasing since 1999. “The more we prescribe, the more people die,” Dr. Abulseoud said. “The number of deaths due to opioid overdose is actually greater than the number of suicides and traffic accidents.”
To combat this problem, physicians should restrict the conditions they treat with opioids. “We are giving opioids right and left, and the patients are asking for opioids right and left,” he said. “There is not enough solid evidence for treating chronic, noncancer pain with opioids.” Another potential solution would be to create a national database of opioid prescriptions to prevent patients visiting multiple physicians and pharmacies, Dr. Abulseoud suggested.
Internists, particularly hospitalists, can also help patients recover from their addiction to opioids by properly treating methadone withdrawal. An audience response quiz during the session showed that many internists' current practices do not conform to Dr. Abulseoud's recommendations. When asked how to treat an emergency department patient who had been receiving methadone in another city and was now going through withdrawal, about 40% of attendees answered (using the audience response system) that they'd send him on his way with a clonidine prescription.
Dr. Abulseoud would prefer admission and methadone treatment. “We get a little worried about using clonidine alone,” he said. One problem with clonidine is that it has less effect on the subjective symptoms of withdrawal, which could make patients more likely to relapse. If you do want to use it, it's better to admit the patient to allow titration of the dose and treatment of his or her troublesome symptoms, he advised. Providing reassurance is also key.
“When they hear you aren't giving them any methadone, they freak out,” he said. “The most important thing to tell the patient is, ‘Don't worry, we're here to assure your comfort.’”