Case Files Pediatrics, (LANGE Case Files) 4th Ed.

CASE 2

A healthy 16-year-old adolescent arrives at your office with his parents, who are concerned about his several months’ history of erratic behavior. At times he has a great deal more energy, seems to be in a terrific mood, and has unusually high self-esteem; during these episodes he has difficulty concentrating, remembering things, and often has headaches. At other times he seems to be his “normal” self. He had previously been a good student, but his grades have fallen this year. Last evening he appeared flushed and agitated, he had dilated pupils and a rapid heart rate, and he complained “people were out to get him.” The family reluctantly reports that he was arrested for burglary 2 weeks previously. You know him to be in otherwise good health. Today he appears normal.

Image What is the most likely diagnosis?

Image What is the next step in the evaluation?

Image What is the long-term evaluation and therapy?

ANSWERS TO CASE 2: Adolescent Substance Abuse

Summary: A 16-year-old previously healthy adolescent with recent behavior changes and declining school performance.

• Most likely diagnosis: Drug abuse (probably MDMA [ecstasy] or possibly cocaine or amphetamines).

• Next steps in evaluation: History, examination, urine drug screen, and screening for other commonly associated drug abuse consequences (sexually transmitted infections [STIs], hepatitis).

• Long-term evaluation and therapy: Threefold approach: (1) detoxification program, (2) follow-up with developmentally appropriate psychosocial support systems, and (3) possible long-term assistance with a professional trained in substance abuse management.

ANALYSIS

Objectives

1. Learn the pattern of behavior found among drug-abusing adolescents.

2. Know the signs and symptoms of the drugs most commonly abused by adolescents.

3. Understand the general approach to therapy for an adolescent abusing drugs.

Considerations

Rarely, a brain tumor could explain an adolescent with new onset of behavior changes. In general, however, an adolescent’s new-onset truant behavior, depression or euphoria, or declining grades is more commonly associated with substance abuse. A previously undiagnosed psychiatric history (mania or bipolar disease), too, must be considered. A history, family history, physical examination (especially the neurologic and psychological portions), and screening laboratory will help provide clarity. Information can come from the patient, his family, or other interested parties (teachers, coaches, and friends). Direct questioning of the adolescent alone about substance abuse is appropriate during routine health visits or when signs and symptoms are suggestive of abuse.

APPROACH TO:

The Substance-Abusing Adolescent

DEFINITIONS

SUBSTANCE ABUSE: Alcohol or other drug use leading to impairment or distress, causing failure of school or work obligations, physical harm, substance-related legal problems, or continued use despite social or interpersonal consequences resulting from the drug’s effects.

SUBSTANCE DEPENDENCE: Alcohol and other drug use, causing loss of control with continued use (tolerance requiring higher doses or withdrawal when terminated), compulsion to obtain and use the drug, and continued use despite persistent or recurrent negative consequences.

CLINICAL APPROACH

Experimentation with alcohol and other drugs is common among adolescents; some consider this experimentation “normal.” Others argue it is to be avoided because substance abuse is often a cause of adolescent morbidity and mortality (homicide, suicide, and unintentional injuries). In all cases, a health-care provider is responsible for discussing facts about alcohol and drugs in an attempt to reduce the adolescent’s risk of harm and for identifying those requiring intervention.

Children at risk for drug use include those with significant behavior problems, learning difficulties, and impaired family functioning. Cigarettes and alcohol are the most commonly used drugs; marijuana is the most commonly used illicit drug. Some adolescents abuse common household products (inhalation of glue or aerosols); others abuse a sibling’s medications (methylphenidate, which is often snorted with cocaine).

The American Academy of Pediatrics (AAP) recommends pediatricians ask about alcohol or drug use during the adolescent’s annual health examination or when an adolescent presents with evidence of substance abuse. Direct questions can identify drug or alcohol use and their effect on school performance, family relations, and peer interactions. Should problems be identified, an interview to determine the degree of drug use (experimentation, abuse, or dependency) is warranted.

Historical clues to drug abuse include significant behavioral changes at home, a decline in school or work performance, or involvement with the law. An increased incidence of intentional or accidental injuries may be alcohol or drug related. Risk-taking activities (trading sex for drugs, driving while impaired) can be particularly serious and may suggest serious drug problems. Alcohol or other drug users usually have a normal examination, especially if the use was not recent. Needle marks and nasal mucosal injuries are rarely found.

An adolescent with recent alcohol or drug use can present with a variety of findings (Table 2-1). A urine drug screen (UDS) can be helpful to evaluate the adolescent who: (1) presents with psychiatric symptoms, (2) has signs and symptoms commonly attributed to drugs or alcohol, (3) is in a serious accident, or (4) is part of a recovery monitoring program. An attempt to obtain the adolescent’s permission and maintain confidentiality is paramount.

image

image

Table 2-1 • CLINICAL FEATURES OF SUBSTANCE ABUSE

Treatment of life-threatening acute problems related to alcohol or drug use follows the ABCs of emergency care: manage the Airway, control Breathing, and assess the Circulation. Treatment then is directed at the offending agent (if known). After stabilization, a treatment plan is devised. For some, inpatient programs that disrupt drug use allow for continued outpatient therapy. For others, an intensive outpatient therapy program can be initiated to help develop a drug-free lifestyle. The expertise necessary to assist an adolescent through these changes is often beyond a general pediatrician’s expertise. Assistance with this chronic problem by qualified health professionals in a developmentally appropriate setting can maximize outcome. Primary care providers can, however, assist families to find suitable community resources.

COMPREHENSION QUESTIONS

2.1 A 14-year-old boy has ataxia. He is brought to the local emergency department, where he appears euphoric, emotionally labile, and a bit disoriented. He has nystagmus and hypersalivation. Many notice his abusive language. Which of the following agents is most likely responsible for his condition?

A. Alcohol

B. Amphetamines

C. Barbiturates

D. Cocaine

E. Phencyclidine (PCP)

2.2 Parents bring their 16-year-old daughter for a “well-child” checkup. She looks normal on examination. As part of your routine care you plan a urinalysis. The father pulls you aside and asks you to secretly run a urine drug screen (UDS) on his daughter. Which of the following is the most appropriate course of action?

A. Explore the reasons for the request with the parents and the adolescent, and perform a UDS with the adolescent’s permission if the history warrants.

B. Perform the UDS as requested, but have the family and the girl return for the results.

C. Perform the UDS in the manner requested.

D. Refer the adolescent to a psychiatrist for further evaluation.

E. Tell the family to bring the adolescent back for a UDS when she is exhibiting signs or symptoms such as euphoria or ataxia.

2.3 A previously healthy adolescent male has a 3-month history of increasing headaches, blurred vision, and personality changes. Previously he admitted to marijuana experimentation more than a year ago. On examination he is a healthy, athletic-appearing 17-year-old with decreased extraocular range of motion and left eye visual acuity. Which of the following is the best next step in his management?

A. Acetaminophen (APAP) and ophthalmology referral

B. Glucose measurement

C. Neuroimaging

D. Trial of methysergide (Sansert) for migraine

E. Urine drug screen

2.4 An 11-year-old girl has dizziness, pupillary dilatation, nausea, fever, tachycardia, and facial flushing. She says she can “see” sound and “hear” colors. Which of the following agents is responsible for this?

A. Alcohol

B. Amphetamines

C. Ecstasy

D. Lysergic acid diethylamide (LSD)

E. PCP

ANSWERS

2.1 E. PCP is associated with hyperactivity, hallucinations, abusive language, and nystagmus.

2.2 A. The adolescent’s permission should be obtained before drug testing. Testing “secretly” in this situation destroys the doctor-patient relationship.

2.3 C. Despite previous drug experimentation, his current neurologic symptoms and physical findings make drug use a less likely etiology. Evaluation for possible brain tumor is warranted.

2.4 D. LSD is associated with symptoms that begin 30 to 60 minutes after ingestion, peak 2 to 4 hours later, and resolve by 10 to 12 hours, including delusional ideation, body distortion, and paranoia. “Bad trips” result in the user becoming terrified or panicked; treatment usually is reassurance of the user in a controlled, safe environment.


CLINICAL PEARLS

Image Cigarettes and alcohol are the most commonly used drugs in adolescence.

Image Marijuana is the most common illicit drug used in adolescence.

Image Substance abuse behaviors include drug dealing, prostitution, burglary, unprotected sex, automobile accidents, and physical violence.

Image Children at risk for drug use include those with significant behavior problems, learning difficulties, and impaired family functioning.


REFERENCES

Crewe SN, Marcell AV. Substance use and abuse. In: Rudolph CD, Rudolph AM, Lister G, First LR, Gershon AA, eds. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011:278-282.

Heyman RB. Adolescent substance abuse and other high-risk behaviors. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:579-584.

Kaul P. Adolescent substance abuse. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011:145-158.

Kulig JW. The Role of the pediatrician in prevention, identification, and management of substance abuse. Pediatrics. 2005:115; 816-821.

Stager MM. Substance abuse. In: Kleigman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:671-685.