Methadone Withdrawal-Induced Psychosis: A Case Report.

Methadone is a synthetic full µ-opioid receptor agonist and N-methyl-D-aspartate antagonist given to patients who have recently stopped using illicit opioids or are tapering off chronic opioid pain medication. Maintenance treatment with methadone is today the most widespread and effective way to treat opiate addiction, which achieves abstinence, decreases morbidity and mortality, improves quality of life, and reduces crime genesis, among other benefits. It is also approved by the Food and Drug Administration for treating moderate-to-severe pain that remains unresponsive to nonopioid medications. Patients sometimes abruptly discontinue the medication for several reasons and sometimes suffer distressing but non-life-threatening withdrawal symptoms. More common withdrawal symptoms include anxiety, agitation, rhinorrhea, nausea, and vomiting, like other opioid agonist medications. Psychosis has been reported in some rare cases of methadone withdrawal. However, more research is required because, although psychotic symptoms have been described in different case reports after the reduction or withdrawal of methadone, they have not been sufficient. This case report contributes to the literature on rare manifestations of psychosis in patients who abruptly discontinue the use of methadone.

Sociodemographic Attributes and Prevalence of Arrest With Possession of Substances in Incarcerated Population in the United States.

Background and objectives In recent years, there has been an increase in the US imprisonment rate. A substantial percentage of those incarcerations are for drug-related offenses. The authors investigated the relationship between the pattern of substance use and drug-related offenses across a broad spectrum of various sociodemographic attributes of the incarcerated population in the United States. Methods Cross-sectional data from the 2016 Survey of Prison Inmates conducted by the Bureau of Judicial Statistics were extracted with inmates who reported possession of a drug at the time of arrest as a primary outcome of interest. Using SAS 9.4 statistical software (SAS Institute Inc., Cary, USA), the authors used multivariate analyses to determine the odds ratios between various sociodemographic attributes of the inmates and possession of substance at the time of the arrest. Logistic regression analysis for age groups in relation to substance possession at the time of arrest is presented in the form of an adjusted odds ratio and their respective confidence interval at p ≤0.5. Results Out of the total 23,798 inmates who reported possession of a drug at the time of arrest, 34.07% were Non-Hispanic Whites, and 31.5% were within the age group of 25-34 years. Only 59.47% of inmates were employed 30 days before the arrest, and 58.02% had less than a high school education. Different patterns of drug use were linked with different types of drugs found in their possession at the time of the arrest. Possession of cannabis at the time of arrest was highest in the age group 18-24 years compared to other age groups (odds ratio: 1.362; 95% CI: 1.159 - 1.602). Inmates with a history of stimulant or hypnotic use were more likely to have another psychoactive substance during a time of the arrest. Only 8.46% of inmates had psychiatric and psychological treatment as part of their sentence. Conclusions A large proportion of incarcerations in the US is because of drug-related offenses, with most of the burden on the younger age group. Inmates should receive psychiatric and psychological treatments for substance use as part of their sentencing while in prison and after release as a form of targeted intervention for this vulnerable group.

Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient with Opioid Use Disorder.

Posterior Reversible Encephalopathy Syndrome (PRES) is a characteristic clinical radiographic syndrome with diffuse structural alteration of cerebral white matter secondary to myelin damage with diverse and multifactorial etiologies. It can present with acutely altered mentation, somnolence or occasionally stupor, vision impairment, seizures, and sudden or chronic headaches that are not focal. The pathophysiology remains unclear, but mechanisms involving endothelial injury and dysregulation of cerebral autoregulation have been purported. We report the case of a 36-year-old male with a history of heroin use disorder, who was admitted to our hospital for opioid withdrawal. CT head without contrast and MRI with and without gadolinium showed significant white matter disease in both cerebral hemispheres and cerebellum. He was diagnosed with Posterior Reversible Encephalopathy Syndrome secondary to heroin use and managed on the medical floor in collaboration with the neurology team. His clinical symptoms improved and he was discharged after six weeks. To our knowledge, this case did not present with the risk factors for PRES reported in the literature. For patients with heroin use disorder who present with an altered mental status, PRES should be highly suspected. The diagnosis and management require collaboration between psychiatry and neurology.

Persistent Tachycardia in a Patient on Clozapine.

Tachycardia emergent from clozapine treatment is usually transient, often missed, unreported, and therefore frequently goes untreated resulting in possible premature discontinuation of an otherwise effective treatment. Clozapine-induced tachycardia results from direct effects on the sympathetic nervous system including the blockade of cardiac muscarinic M2 receptors, presynaptic α 2 adrenoceptors, and indirect activation of the ß adrenoceptors. Unfortunately, there are no clear guidelines for monitoring or treating tachycardia induced by clozapine. We present a case of a 55-year-old man with treatment-resistant schizophrenia initiated on clozapine who developed persistent tachycardia and right bundle branch block in the course of treatment. Tachycardia persisted despite treatment with metoprolol and necessitated a transfer to the intensive care unit. A reduction in clozapine dose with the addition of adjunctive antipsychotic(lurasidone) stabilized the patient's heart rate. This case highlights the need for consistent physical examination and a multidisciplinary-based treatment approach for patients on clozapine. The case also suggests that clozapine dose reduction and combination antipsychotic treatments may preclude the need to discontinue clozapine in patients with persistent tachycardia.

Two Cases of Persistent Complex Bereavement Disorder Diagnosed in the Acute Inpatient Unit.

Pathological grief has been noted to have considerable adverse effects on affected individuals. In the DSM-5, the diagnosis of complicated grief is included under conditions for further study as Persistent Complex Bereavement Disorder (PCBD). PCBD can be easily missed because it is a relatively new and developing diagnosis. It can also be overlooked when it is comorbid with more common psychiatric disorders. We present 2 patients with PCBD diagnosed in the inpatient unit, while the patients were admitted for comorbid disorders. PCBD contributed immensely to both patients' suffering and decline in functioning. This report highlights the presentation, diagnoses, and management of these patients. We theorize that paying attention to separation distress, reactive distress to loss, and identity disruption in individuals who have been bereaved for over 12 months will enhance treatment specificity and lead to better patient outcomes.

Comparing the Validity of Self-Report and Urinalysis for Substance Use among Former Inmates in the Northeastern United States.

BACKGROUND: Problems with self-reported drug use include difficulties with recall and recognition as well as the desire to respond to questions in a socially desirable manner. Various methods have been developed to improve and/or validate estimates based on direct questioning of individuals regarding their substance use. For this study, we were interested in validating self-reported use of: 1) tobacco, 2) marijuana, and 3) other substances (i.e., heroin, cocaine, opiates, oxycodone, benzodiazepines, methamphetamine, phencyclidine, and barbiturates) employing urinalysis among inmates who participated in a randomized controlled trial of a smoking abstinence intervention in a tobacco-free prison located in the northeastern United States. METHODS: Two-hundred and seven men and women with a mean age of 34.9 (standard deviation = 9.0) completed questions regarding their substance use on a 7-day Timeline Follow-Back and provided urine specimens three weeks following prison release. RESULTS: Self-reported tobacco and marijuana use were highly consistent with urine drug testing in terms of overall agreement and Kappa (93.7% and.804 for tobacco, respectively; and 90.3% and.804 for marijuana, respectively); however, consistency was much lower for other drug use grouped together (62.7% and.270). DISCUSSION: Although some former inmates may not accurately report substance use, our findings indicate that they are in the minority, suggesting that self-report is valid for tobacco and marijuana use but much less so for other drugs grouped together. Future research should be conducted with a larger and more diverse sample of former inmates to establish the generalizability of our findings from this study.