Toxidrome of an Easily Obtainable Nootropic: A Case Report of Phenibut Intoxication and Withdrawal Delirium.

PURPOSE/BACKGROUND: Phenibut (4-amino-3-phenyl-butyric acid) is a structural analog of GABA with central nervous system depressant and anxiolytic properties, developed in the former Soviet Union for anxiety, insomnia, and alcohol withdrawal. Its primary mechanism of action is believed to be a GABA-B receptor agonist-with high affinity at the α 2 δ subunit-containing voltage-dependent calcium channels and therefore gabapentinoid activity-as well as, to a lesser extent, GABA-A agonist activity. While not approved or regulated by the FDA, phenibut is easily obtainable online, where it is marketed as a nootropic, or cognitive enhancer. However, phenibut can lead to problems related to intoxication, dependency, and withdrawal, similar to other sedatives. METHODS/PROCEDURES: We present a case of phenibut intoxication and withdrawal delirium that provided diagnostic and management challenges because of a patient that was initially not forthcoming about his phenibut use which resulted in five presentations to the hospital including two admissions. FINDINGS/RESULTS: Initial differential including adrenergic, serotonergic or anticholinergic toxidrome based on clinical picture and history reported at that time, however phenibut use of 50 g daily was eventually revealed, an amount exceeding the highest reported cases in our review of the English literature. IMPLICATIONS/CONCLUSIONS: High-dose phenibut intoxication and withdrawal can appear as dramatic and dangerous as high-dose sedative withdrawal, however given its specified receptor affinity and binding profile we found that a pharmacotherapeutic approach targeting GABA-B, GABA-A, and gabapentenoid receptors were effective in stabilizing this patient, eventually leading to the patient's full and sustained recovery.

Kratom use disorder: case reports on successful treatment with home induction of buprenorphine-naloxone.

BACKGROUND: Kratom has been used for different reasons such as pain, opioid withdrawal, and relaxation. Kratom can cause dependence and overdose, and it's classified under 'drugs of concern' by the US Drug Enforcement Administration. Despite these concerns, kratom is legal in most of the United States and many countries around the world with easy accessibility. Literature searches reveal recommendations to use buprenorphine (or buprenorphine-naloxone), which are medications to treat opioid use disorder, in order to treat patients with kratom use disorder; however, there are no formal guidelines available. Buprenorphine (or buprenorphine-naloxone) induction is recommended to be conducted under observation (i.e. in the clinic) in the United States, but COVID-19 has resulted in shifts toward telehealth. OBJECTIVES: Describe case series of successful management of kratom use disorder using telehealth followed by unobserved buprenorphine-naloxone home induction and highlight implications for future management, including maintenance dosage and induction method. METHODS: We present 2 very similar kratom use disorder patients who reported taking 35 g of kratom per day who underwent unobserved buprenorphine-naloxone home induction. RESULTS: Both were seen via telehealth initially. They reported no adverse effects before, during, or after the unobserved home induction on buprenorphine-naloxone but stabilized on significantly different dosages. CONCLUSION: Telehealth followed by unobserved buprenorphine-naloxone induction at home may be an alternative to traditional buprenorphine-naloxone induction where treatment accessibility is limited. In addition to daily doses of kratom use, other factors, such as duration of kratom use and individual psychological factors may determine the most comfortable dose of buprenorphine-naloxone.

Urine drug screening on labor and delivery.

BACKGROUND: Substance use including opioids, methamphetamines, benzodiazepines, and barbiturates during pregnancy is harmful for the pregnant person and the fetus. Routine screening using validated questionnaires is recommended, but often biologic sampling is done instead. There is often bias in urine drug screening on labor and delivery units. OBJECTIVE: This study aimed to compare characteristics of people who did and did not receive urine drug screening during labor and delivery and to examine the relationship of maternal results to neonatal results. STUDY DESIGN: This was a retrospective chart review examining all people in 2017 who delivered in the labor and delivery unit at our institution. We collected urine drug screening result information, maternal demographic data, follow-up after positive maternal tests, and neonatal test results. Individual characteristics and obstetrical outcomes were analyzed. RESULTS: Of 6265 deliveries, 297 urine drug screening tests were ordered. People who were tested identified most commonly as Native Hawaiian or Pacific Islander (P<.0001). The most common indications for ordering tests were a history of substance use and insufficient prenatal care (P<.0001). People who tested positive were more likely to self-identify as White (P=.03) and have history of substance use (P<.0001). Among the positive test results, 24 (24%) were caused by a provider-ordered medication. Self-identification as Native Hawaiian or Pacific Islander was not predictive of a positive result. Of the tested people, 36% (108/297) had a positive result on preliminary testing, and 33% (98/295) on confirmatory testing. CONCLUSION: Native Hawaiians and Pacific Islanders were more likely to undergo testing, whereas White people were more likely to have a positive result. Maternal results were not reliable for predicting neonatal drug test results and vice versa. With rising rates of substance use disorders in the pregnant and reproductive-age population, standardized unbiased race-neutral guidelines for urine drug screening should be implemented using laboratory test results that include preliminary and reflex confirmatory results.

A case of buprenorphine-precipitated withdrawal managed with high-dose buprenorphine.

BACKGROUND: Buprenorphine-naloxone has a very high affinity for the mu-receptor and can cause precipitated opioid withdrawal, typically more severe than withdrawal that occurs naturally, when administered while a full mu-opioid receptor agonist remains in a person's system. To avoid precipitated withdrawal, one needs to be in mild to moderate opioid withdrawal at the time of buprenorphine-naloxone induction. Recently, there have been reported cases of precipitated withdrawal occurring in patients taking fentanyl knowingly or unknowingly, despite them being in adequate opioid withdrawal at the time of induction. When this occurs, the current recommendation is to provide 2 mg of buprenorphine-naloxone every 1-2 hours. OBJECTIVES: Describe a case of successful management of buprenorphine-precipitated withdrawal with escalation of the dose of buprenorphine and highlight implications for future management. METHODS: We present a case of a patient with a history of opioid use disorder who was in moderate opioid withdrawal at the time of buprenorphine-naloxone induction and experienced precipitated withdrawal after buprenorphine-naloxone administration. RESULTS: High-dose buprenorphine-naloxone was given to the patient and precipitated withdrawal subsided after receiving a total of 20 mg. On the next day, the patient had no symptoms of opioid withdrawal and is currently maintained on 16 mg/day. CONCLUSION: With the rising prevalence of fentanyl-laced drugs, increased instances of precipitated withdrawal are likely to be encountered. In cases of precipitated withdrawal, giving a high dose of buprenorphine-naloxone rapidly is safe and will allow rapid reversal of withdrawal symptoms.

Implications for a System of Care in Hawai'i: Primary Care Integration of Substance Use Disorder Treatment.

Primary care physicians (PCPs) in Hawai'i face many challenges in treating patients with substance use disorders (SUD) who tend to have higher medical complexity and thus require more resources. PCPs play a vital role in identifying early misuse, integrating and coordinating care for patients with SUD including office-based interventions like medication-assisted treatment, and connecting patients to community treatment programs. In addition to enormous burdens to care for and increasingly complex patient panels, the challenges include lack of education on addiction medicine, insufficient resources and SUD treatment programs in the office and community, low reimbursement for the complexity of care provided, and an overall physician shortage which drives higher patient volume and less time for any given physician. This article suggests responses to address these challenges such as providing more training and continuing education in SUD for PCPs and trainees, enhancing team-based care to better support PCPs, and funding more SUD treatment programs. More funding should widen accessibility to treatment and reduce the overall burden on the health care system by preventing or treating the disease early, which is a core principle of primary care. Additionally, incentives to practice in Hawai'i in primary care, and especially to treat patients with SUD, need to be improved. Such steps must be taken to address the overall physician shortage that limits patients' access to SUD treatment. A collaborative care model between PCPs, care managers, and addiction specialists is an example of an integrated care system that may address many of these challenges in the short term. To truly improve care for all in Hawai'i, however, system wide interventions are essential to increase the incentive for PCPs to remain and practice in Hawai'i to take care of its unique population, including those dealing with SUD.

Hydromorphone-Induced Tactile Hallucinations: Rare Opioid Side Effect.

Opioids are strong analgesics widely employed to treat various types of pain. In 2018, an estimated 168 million opioid prescriptions were dispensed in the United States. Opioids carry a number of side effects and up to 80% of patients treated with opioids experience a minimum of one adverse event. Although uncommon, hallucinosis is an effect experienced with opioids, which may be under-reported and attributed to underlying psychiatric disease rather than to the side effects of the opioid itself. Most of the opioid-induced hallucinoses reported are auditory and visual, and rarely tactile. Although opioid medication prescribing is decreasing in the United States, considering the continued opioid epidemic and deaths related to overdose, it is important for physicians to be aware of this potential adverse effect of opioids in isolation. We present a case of oral hydromorphone causing visual and tactile hallucinations. Discontinuing hydromorphone led to immediate cessation of the patient's psychotic signs and symptoms. To our knowledge, this is the first description of the use of hydromorphone resulting in tactile hallucinations.

A Case Report of Wound Botulism - Rare Disease on the Rise with the Opioid Crisis.

Wound botulism is a rare, underrecognized life-threatening illness caused by a toxin produced by Clostridium botulinum, a spore-forming anaerobic bacterium. Approximately 20 cases are reported in the United States each year, mostly from California. Most wound botulism cases occur in drug injectors, particularly among those using black tar heroin. The initial presentation of botulism may overlap with other diagnoses, including opioid intoxication and pre-existing neurological disease, making accurate diagnosis difficult. A healthy 40-year-old patient with a history of injecting black tar heroin presented to an emergency department complaining of generalized weakness and throat discomfort. He was given antibiotics and was sent home. The next day, the patient presented to another emergency department with additional complaints of slurred speech and blurring of vision. He was admitted for a possible cerebrovascular injury. In the absence of positive findings from laboratory or imaging studies, botulism was considered. The patient decompensated and was intubated. Botulism antitoxin was given, and the patient eventually recovered. Prompt decision-making based on clinical suspicion and an informed presumptive diagnosis, administration of botulism antitoxin, and aggressive provision of supportive care can arrest the progression of paralysis and be life-saving. With the rise of opioid use in the United States, leading to a reversion to heroin as a cheaper form of opioids, cases of wound botulism may be on the rise. Clinician attentiveness to obtaining substance history and being aware of botulism presentation may lead to life-saving treatments for these patients.

Acute myocardial infarction and Friedreich's ataxia.

While cardiac disease is noted in 90% of patients with Friedreich's ataxia (FRDA), the finding of coronary artery disease is unusual. To the best of our knowledge only two cases of acute myocardial infarction (AMI) has been reported in patients with FRDA. Large vessel CAD has not been reported previously in patients with FRDA. We report a young patient with AMI and obstruction of large epicardial arteries.