Drug Abuse - Unusual Presentations

Managing drug abusers in primary care involves not only treating patients who admit to their dependency but also recognising the signals in those who are reluctant to share this information. Not infrequently, you will also be approached by temporary patients attempting to obtain drugs by deception. GPs need to be alert to the following clues:

• Temporary residents just passing through the area
• Patients with an overly familiar knowledge of the pharmacopoeia, demanding analgesia for renal colic, sickle-cell crises, etc
• Patient giving evasive answers
• Signs of heavy smoking, strange smoke smells (cannabis, cocaine, heroin)
• Acetone or glue smell on breath (solvent abuse)
• Small pupils (opiates)
• Needle tracks on arms, groin, legs, between toes; intravenous access difficult
• Abscesses and lymphadenopathy in nodes draining injection sites
• Signs of drug-associated illnesses (e.g. endocarditis, AIDS, chronic viral hepatitis)

Patients may present with a variety of medical conditions but the doctor may not be aware of the history of drug dependency. The following is a list of scenarios:

• Patient found unconscious - consider narcotics, barbiturates, solvents and benzodiazepine (see also separate articles Opiate Poisoning and Coma)
• Psychosis - consider MDMA ('ecstasy'), LSD, amfetamine, anabolic steroids¹
• Agitation - common with benzodiazepines
• Asthma/dyspnoea - consider opiate-induced pulmonary oedema, asthma (may follow the smoking of heroin)^2,3
• Reduced lung density, lung cysts and chronic bronchitis - may be related to cannabis use⁴
• Lung abscess - may be a complication of right-sided staphylococcal endocarditis - common in intravenous drug abusers⁵
• Airway burns, pneumothorax, pneumomediastinum - these can all be complications of crack cocaine, due to its method of delivery⁶
• Fever/pyrexia of unknown origin (PUO)/shivering - may be the only sign of endocarditis⁵
• Shivering and headache - due to chemical/organism contamination of intravenous drug; if suspicious, outline risks, and offer immediate referral to secondary care - may need blood cultures, antibiotics, e.g. gentamicin
• Hyperpyrexia - consider 'ecstasy', be wary of associated myoglobinuria, disseminated intravascular coagulation, renal failure
• Abscesses - if over injection site, then often of mixed organisms
• Deep vein thrombosis - may result from injecting suspension of tablets into groin; consider acute compartment syndrome, organise a CK test⁷
• Pneumonia - pneumococcus, haemophilus, tuberculosis, pneumocystis
• Tachyarrhythmia - in young patients consider cocaine, amfetamines, endocarditis⁸
• Jaundice - hepatitis B, C, or D,anabolic steroids (cholestasis)
• 'Glandular fever' - may actually be HIV seroconversion illness
• Pain in a limb or back pain with fever - consider osteomyelitis
• Severe constipation - unusual in a young patient, may be sign of opiate abuse
• Cystitis - ketamine abuse can cause inflammation of the bladder lining leading to frequency, urgency and nocturia (ketamine bladder syndrome)⁹
• Blindness - may be secondary to fungal or bacterial endophthalmitis with or without endocarditis, or talc or other particulate emboli¹⁰
• Rhinitis - consider opiate withdrawal; other features may be colic/diarrhoea, lacrimation, dilated pupils, insomnia, piloerection, myalgia, low mood; (rhinitis may also be a sign of cocaine use)
• Signs of sensory or motor neuropathy - consider solvent abuse
• Myocardial infarction may be associated with cocaine¹¹, cannabis abuse⁴ or MDMA¹²
• Stroke or transient ischaemic attack (TIA), spinal infarction - consider cocaine use^13,14 or MDMA¹²
• Myocarditis, hypertrophic cardiomyopathy, dilated cardiomyopathy, aortic dissection - all noted in cocaine users¹⁵
• Mental conditions (principally anxiety and depression) and physical effects, such as hypertension and arthritis, are more common in older patients who abused drugs in the 1970s compared with individuals with no history of dependence¹⁶

The general management of substance misuse has been extensively revolutionised with the release of consensus guidelines in 2007 (due to be reviewed in 2010).¹⁷ These guidelines take on board National Institute for Clinical Excellence suite of guidance on substance misuse as well as other evidence-based studies.^{18,19,20,21,22} The guidelines cover a wide range of issues and need to be read in detail by health professionals who come into contact with people requiring care for substance misuse. Essential components include:

• The prevalence of drug misuse in the UK
• Drug-related morbidity and mortality
• The impact of drug misuse on families and communities
• Models of drug treatment
• Clinical governance principles
• Non-medical prescribing (i.e. prescribing by health professionals other than doctors or dentists)
• Confidentiality, information sharing and child protection
• Patient and carer involvement
• Assessment, planning care and treatment
• Drug testing
• General health assessment
• Psychosocial components of treatment
• Pharmacological interventions
• Assessing and responding to progress and failure to benefit
• Opioid maintenance prescribing
• Opioid detoxification
• Naltrexone for relapse prevention
• Benzodiazepines
• Stimulants
• Preventing drug-related deaths
• Alcohol misuse
• Specific clinical situations such as prisoners, pregnant patients, mental health issues and older current and ex-drug users
• Pain management
• Hospital admission and discharge

1. Chengappa KN, Levine J, Gershon S, et al; Lifetime prevalence of substance or alcohol abuse and dependence among subjects with bipolar I and II disorders in a voluntary registry. Bipolar Disord. 2000 Sep;2(3 Pt 1):191-5. [abstract]
2. Corkery JM, Schifano F, Ghodse AH, et al; The effects of methadone and its role in fatalities. Hum Psychopharmacol. 2004 Dec;19(8):565-76. [abstract]
3. Tashkin DP; Airway effects of marijuana, cocaine, and other inhaled illicit agents. Curr Opin Pulm Med. 2001 Mar;7(2):43-61. [abstract]
4. Reece AS; Chronic toxicology of cannabis. Clin Toxicol (Phila). 2009 Jul;47(6):517-24. [abstract]
5. Prendergast BD; The changing face of infective endocarditis. Heart. 2006 Jul;92(7):879-85. Epub 2005 Oct 10. [abstract]
6. Devlin RJ, Henry JA; Clinical review: Major consequences of illicit drug consumption. Crit Care. 2008;12(1):202. Epub 2008 Jan 8. [abstract]
7. Tiwari A, Haq AI, Myint F, et al; Acute compartment syndromes. Br J Surg. 2002 Apr;89(4):397-412. [abstract]
8. White SR; Amphetamine toxicity. Semin Respir Crit Care Med. 2002 Feb;23(1):27-36. [abstract]
9. Colebunders B, Van Erps P; Cystitis due to the use of ketamine as a recreational drug: a case report. J Med Case Reports. 2008 Jun 26;2:219. [abstract]
10. Kim RW, Juzych MS, Eliott D; Ocular manifestations of injection drug use. Infect Dis Clin North Am. 2002 Sep;16(3):607-22. [abstract]
11. Jauma S, Olive M, Ferrer X, et al; Neuropathy by n-hexanes: a generalized disorder of the intermediate filaments. Neurologia. 1998 Nov;13(9):417-21. [abstract]
12. Kaye S, Darke S, Duflou J; Methylenedioxymethamphetamine (MDMA)-related fatalities in Australia: Drug Alcohol Depend. 2009 Oct 1;104(3):254-61. Epub 2009 Jul 14. [abstract]
13. Westover AN, McBride S, Haley RW; Stroke in young adults who abuse amphetamines or cocaine: a population-based study of hospitalized patients. Arch Gen Psychiatry. 2007 Apr;64(4):495-502. [abstract]
14. Schreiber AL, Formal CS; Spinal cord infarction secondary to cocaine use. Am J Phys Med Rehabil. 2007 Feb;86(2):158-60. [abstract]
15. Restrepo CS, Rojas CA, Martinez S, et al; Cardiovascular complications of cocaine: imaging findings. Emerg Radiol. 2009 Jan;16(1):11-9. Epub 2008 Sep 5. [abstract]
16. Rosen D, Smith ML, Reynolds CF 3rd; The prevalence of mental and physical health disorders among older methadone Am J Geriatr Psychiatry. 2008 Jun;16(6):488-97. [abstract]
17. Drug misuse and dependence UK guidelines on clinical management; Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive 2007
18. Substance misuse - Interventions to reduce substance misuse among vulnerable young people, NICE Public Health Intervention Guidance (2007)
19. Drug misuse - methadone and buprenorphine, NICE Technology Appraisal Guidance (2007)
20. Drug misuse - naltrexone, NICE Technology Appraisal Guidance (2007); Naltrexone for the management of opioid dependence.
21. Drug misuse: opioid detoxification, NICE Clinical Guideline (2007)
22. Psychosocial interventions for drug misuse; NICE Guidance CG51 2007

• National Treatment Agency for Substance Misuse (NTA)