Amphetamine (cocaine, crack, adderall, ritalin). Recs for academic articles?

[member2721]

Seeking academic articles relating to cocaine-induced psychosis and treatment/management strategies for the inpatient and community setting.

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[Shikima]

Let me help you out - www.pubmed.org

Can we have this closed now?

 

[OldPsychDoc]

They should probably ponder this first.

 

[member2721]

I am a PGY2 who saw a patient in the emergency room yesterday at a general hospital.

27yoF with reported SCAD and opiate dependence, cocaine dependence, self-presenting with family member to seek pain treatment. Her medication list includes 82 prescriptions from 18 prescribers over the last 12 months. Medically, she has bilateral chronic arm wounds. Substance-wise, her urine toxicologies dating back the last 3 years consistently show cocaine metabolites, benzodiazepenes, and opiates. Her discharge diagnoses from psychiatric hospitalizations within our system include schizoaffective disorder, polysubstance dependence, chronic bilateral arm wounds s/p skin grafts, somatization disorders. I suspect she has cocaine-induced delusional psychosis and delusional parasitosis. Her medications include medium dose paliperidone, effexor, stimulants, multiple opiate medications. Her allergies include haldol, motrin and tylenol. I suspect additional components of malingering and personality disorder. Her mental status is noteable for oddly related, dysphoria. Her family member became verbally agitated towards staff upon discussion of her urine toxicologies. She has been declined admission at multiple psychiatric hospitals and general hospitals due to complexity. How would you go about formulating this patient?

 

[st2205]

I am a PGY2 who saw a patient in the emergency room yesterday at a general hospital.

27yoF with reported SCAD and opiate dependence, cocaine dependence, self-presenting with family member to seek pain treatment. Her medication list includes 82 prescriptions from 18 prescribers over the last 12 months. Medically, she has bilateral chronic arm wounds. Substance-wise, her urine toxicologies dating back the last 3 years consistently show cocaine metabolites, benzodiazepenes, and opiates. Her discharge diagnoses from psychiatric hospitalizations within our system include schizoaffective disorder, polysubstance dependence, chronic bilateral arm wounds s/p skin grafts, somatization disorders. I suspect she has cocaine-induced delusional psychosis and delusional parasitosis. Her medications include medium dose paliperidone, effexor, stimulants, multiple opiate medications. Her allergies include haldol, motrin and tylenol. I suspect additional components of malingering and personality disorder. Her mental status is noteable for oddly related, dysphoria. Her family member became verbally agitated towards staff upon discussion of her urine toxicologies. She has been declined admission at multiple psychiatric hospitals and general hospitals due to complexity. How would you go about formulating this patient?

Personality and substance, with most else being mental masturbation. Simplify and minimize treatment.

 

[hamstergang]

How would you go about formulating this patient?

I'm still not completely clear what you're trying to get from us. I'd recommend being more specific in what you're asking as well as providing your own thoughts to help guide the discussion.

 

[F0nzie]

I see this every day. Schizoaffective + Substance use disorder. The active presentation may be more consistent with intoxication/withdrawal state and drug seeking behaviors if she is already being managed on Invega.

Risk management is the name of the game with this one. Pharmacy lock, PCP lock, minimize opioids, taper benzos, dc stimulants, refer to addiction treatment. As long as this pt continues to abuse drugs the psychiatric and medical disorders will always be on fire.

 

[splik]

well formulating this as cocaine induced psychosis is like pissing on a bonfire and not really addressing what the patient wants which is relief from her pain. I would be inclined to offer her admission (ideally medical with close psychiatric consultation but I am sure medicine would balk at the suggestion!) for further diagnostic workup and simplifying her drug regimen but would tell her we will take her off opiates and stimulants. Did this patient end up on 82 drugs because she elicits some sort of countertransference that leads her physicians to try prescribe for her through helplessness and a misguided attempt to help her? Or is this the result of doctor shopping and never staying with one provider long enough to have her drug regimen rationalized? is she on oral paliperidone? (which would also be diagnostic, who prescribes that?)

If you think she has delusional parasitosis then we can think of a few thinks going on here. Her opiates may be leading to histamine release and itchiness that then leads to belief she is infested as a result of reasoning biases. Her psychostimulants may lead to skin-picking or some sort of impulse control disorder, that then leads to the formation of delusions of infestation. Her cocaine use may have led to formication which is driving delusions of infestation. She may have vascular dementia with white matter disease of the somatosensory cortex/postcentral gyrus from her cocaine use which has led to misperception of sensations and the cognitive impairment led to jumping to conclusions and delusion formation. She may not be delusional at and just have a disorder of motivated behavior. If considering vascular disease do cognitive testing and a neurological examination looking for rigidity, cogwheeling, hyperreflexia, clonus, presence of primitive reflexes. If abnormalities noted do a DWI MRI brain.

If she does has vascular disease then prognosis is very poor. delusional parasitosis often has a poor prognosis and does not really respond to antipsychotics (except in those case reports you find on pubmed). it is best formulated as an OC-spectrum disorder and treated with high dose SSRIs/clomipramine and exposure/response prevention. Obviously she needs to get off the prescribed and non-prescribed drugs too which will be challenging.

But as I said, this seems to be the least of her troubles, my guess is you see this as the lowest hanging fruit. It seems unlikely she has schizoaffective disorder (given that it is rare and vastly overdiagnosed without recourse to diagnostic criteria). It usually is code for cluster B personality disorder +/- substance abuse

 

[notdeadyet]

Nice summary on the delusional parasitosis, splik. Though I'd mention that the poor prognosis is more for primary delusional parasitizes. Secondary has a better response rate when you remove the stressor and manage the symptoms.

And very much agree with viewing Schizoaffective Disorder with suspicion. I had a mentor that pretty much assumed every patient he met with this diagnosis was mis-diagnosed. I'm not quite that extreme, but when I hold patients with SAD under the microscope, I'd guess about 95% are just a combination of psychosis + mood + axis II + substance. And often just the latter two.

 

[member2721]

Thank you for the feedback. Pain team and addictions consult are now involved and she will get back on methadone or suboxone.

 

[F0nzie]

Thank you for the feedback. Pain team and addictions consult are now involved and she will get back on methadone or suboxone.

Sounds like a good start. Hopefully the pain and addictions team will communicate and integrate an aftercare plan for this complex patient. A very likely outcome is the pt follows up with pain, ignores the addictions treatment, provides a dirty urine specimen to the pain clinic, get discharged from the pain clinic, and the cycle repeats itself. A pharmacy and a PCP lock can help reign in the doctor shopping and cross prescribing but that does not stop people from more ER visits or obtaining opioids from the streets.

 

[F0nzie]

I wish my SMI clinic had addictions services. Referring out to addiction clinics has not been successful at all. We have a PCP on site now which has been a huge leap forward.