Primary Diagnosis: Substance Abuse

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Psychoactive substance-related disorder ICD 10 Code F19.0

This disorder is characterized by a repeated pattern of indiscriminate drug usage that is illegal or beyond the intended prescribed limit. It results in compulsive behavior aimed to seek drugs and has detrimental effects on the brain. The disorder affects both social life and physical well-being: it induces a significant burden for patients by hindering the performance of their daily roles and activities while raising the occurrence of infections, suicidal and neuropsychological conditions (National Institute on Drug Abuse [NIDA], 2016). The factors defining the occurrence of drug use disorders include genetic predisposition and increased sensitivity of reward receptors in the brain, as well as the widespread availability of drugs, i.e., frequent prescription of opioid analgesics and a more open public attitude towards recreational narcotics (Miller, Oberbarnscheidt, & Gold, 2017).

S & S: Exhibition of the indiscriminate and irregular taking of psychoactive substances with contributions of diverse types of drugs should be labeled as F.19 as disorders caused by multiple drug usage. Diagnostic classifications include acute intoxication (uncontrollable behavior), harmful use (evidence of physical or mental damages), dependence syndrome (the compulsion to obtain and use the substance), withdrawal state, and psychiatric disorder (American Psychiatric Association [APA], 2013). The use of cocaine presents symptoms of increased alertness, changes to behavior (including confusion or irritability), nausea (with potential weight loss), and damage to the nasal mucous membrane (Mayo Clinic, 2017).

Pertinent positive data: The patient exhibits signs of a psychological dependence on drug use as a pain management tool and increased substance tolerance. Behavior changes include agitation and restlessness. Persistent nosebleeds confirm the deterioration of the nasal mucous membrane due to cocaine sniffing.

Secondary Diagnosis

Chronic pain syndrome ICD 10 Code G89.4

The condition is associated with consistent pain lasting for longer than 3-6 months after an expected healing time. It can affect any part of the body and lead to the development of various complications, stressors, and psychological factors adversely impacting a patient’s health. Chronic pain syndrome can be a behavioral condition that starts with a noxious stimulus provoking the reinforcement of pain behavior (Singh, 2017). It is common in elderly adults suffering from musculoskeletal disorders (Singh, 2017).

S & S: enduring chronic pain (acute or persistent), discomfort, soreness interfering with daily activities, fatigue, and sleeplessness (Singh, 2017).

Pertinent positive data: The patient shows issues with pain management over the years. The pain is chronic and is suspected to affect the nervous system.

Differential Diagnosis

Major depressive disorder, single episode, unspecified ICD 10 Code F32.9: The condition is associated with the emotion regulation deficit, which is considered the major predisposing factor for its development. Depression is characterized by an inability to influence the intensity and duration of the unfavorable emotional states. The given quality of the disorder leads to an inability to meet essential physiological and social needs, respond to situations adequately, and achieve personal goals (Ehret, Kowalsky, Rief, Hiller, & Berking, 2014).

S & S: A depressed mood for a longer part of the day/week, weight loss, energy loss, reduced cognitive capabilities and concentration, insomnia/hypersomnia, suicidal thoughts (APA, 2013).

Pertinent positive data: a subjective report of feeling sad and hopeless, disturbed sleep.

Diagnostic Tests

  • Diagnostic and Statistical Manual of Mental Disorders (DSM-V) confirms a severe form of substance use disorder as the patient shows autonomic system responses, activation of the reward system, cross-addiction (cocaine and alcohol), behavioral effects of brain changes (e.g., impaired control and social impairment), etc. (APA, 2013).
  • Drug Use Disorder (DUD) Questionnaire provides a subjective, self-reported data revealing a high level of substance abuse and dependence in the patient (Scherer, Furr-Holden, & Voas, 2013).
  • Blood and urine toxicology – a high level of the substance in the blood indicating an increased degree of the patient’s tolerance.

Other tests to consider

  • Computed tomography (CT) − physiological origins of the pain;
  • Urinalysis − orthotoluidine reaction is positive for heme;
  • CBC − Positive.

P: Plan

Medication

Rx: Buprenorphine (Suboxone) (NIDA, 2018)

Sig: Take one tablet under the tongue twice daily

Dispense 28 tabs only

Refill: None Date: Prescriber Name:

Rx: Azelastine (Astelin) nasal spray

Sig: Two times a day in each nostril

Dispense one container

Refill: None Date: Prescriber Name:

Rx: Disulfiram (NIDA, 2018)

Sig: 250 mg daily

Dispense: 14 tabs

Refill: None Date: Prescriber Name:

Education

Patient education covers the following topics:

  • Condition and nature of chronic pain,
  • Pain management options,
  • medication and potential side effects (especially Buprenorphine and disulfiram),
  • effects of withdrawal and detoxification,
  • techniques to manage acute pain or episodes of withdrawal,

Additionally, the practitioner aims to

  • Encourage the need for therapy even if the patient does feel control of drug intake,
  • Emphasize the importance and benefits of intervention adherence (Center for Substance Abuse Treatment, 2012; Substance Abuse and Mental Health Services Administration [SAMHSA], 2016).

Conservative Measures

  • Behavioral therapy,
  • Referral to a rehabilitation center,
  • Lifestyle changes,
  • Support groups for substance addiction, particularly for those living with chronic pain (SAMHSA, 2016).

Referral/Consults

The patient should be evaluated and work with a psychiatrist over addiction to resolve the issue of turning to drugs as pain management (SAMHSA, 2016).

Followup

Early followup

Weekly follow-up of non-intensive outpatient care aimed to evaluate immediate epistaxis symptoms and medication dosage (SAMHSA, 2016).

Late followup

post 30-day return to the clinic to evaluate the effectiveness of treatment, pain management, and therapy progress.

CPT: 99409

Pathophysiology of Substance-Related Disorder

The major pathophysiological mechanism defining substance dependence is dopamine neurotransmission. “Tonic release of dopamine in the Nucleus Accumbens (Nac) has been associated with cravings due to sensitization, while increasing phasic release in response to consumption is thought to underlie sustained or increased reinforcement and addictive behavior” (Alba-Ferrara, Fernandez, & de Erausquin, 2014, p. 2). The given process taking place in the prefrontal cortex triggers the rewarding process. When the dorsal striatum receives dopamine signals, a person with substance abuse engages in behaviors aimed to receive a reward in the form of drug intake (Alba-Ferrara et al., 2014).

Pharmacology

According to NIDA (2018), there is still no approved drug that could be used to treat cocaine abuse. However, disulfiram (which is also used to intervene in alcoholism) is a promising medication as it prevents stress-reduced relapse to cocaine abuse through inhibiting the conversion of dopamine to norepinephrine (affecting dorsal striatum and decision-making). It can also be recommended for patients to take methadone and buprenorphine as they help block the effects of drugs at receptors in the brain until the detoxification period is complete (NIDA, 2018).

Treatment Guidelines

Multiple national guidelines, standards, and evidence-based principles of care developed by organizations specialized in the prevention and management of substance abuse were used for the diagnosis and intervention. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, by APA is the major standardized tool to identify the severity of the patient’s condition. The severe condition was determined by the presence of 6 symptoms. The “Specialized Substance Abuse Treatment Programs” and other materials by SAMHSA, NIDA, and the Center for Substance Abuse Treatment were used as the information base for the selection of appropriate pharmacological and behavioral treatments, as well as the followup plan.

Quality

While the suggested plan was developed considering the primary high-quality standards of diagnostics and care for the targeted disorder, to improve patient experience and outcomes, it is possible to consider a wider range of related factors determining addiction (e.g., environmental) and comorbidities. Referral to social and psychological counseling sessions could be prescribed along with psychological interventions.

References

Alba-Ferrara, L. M., Fernandez, F., & de Erausquin, G. A. (2014).Addictive Disorders & Their Treatment, 13(1), 1–7. Web.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Web.

Center for Substance Abuse Treatment. (2012). Managing chronic pain in adults with or in recovery from substance use disorders. Rockville, Maryland: Substance Abuse and Mental Health Services Administration.

Ehret, A. M., Kowalsky, J., Rief, W., Hiller, W., & Berking, M. (2014). BMC Psychiatry, 14, 20. Web.

Mayo Clinic. (2017). Web.

Miller, N. S., Oberbarnscheidt, T., & Gold, M. S. (2017). Marijuana addictive disorders and DSM-5 substance-related disorders. Journal of Addiction Research & Therapy, S11. Web.

National Institute on Drug Abuse. (2016). Web.

National Institute on Drug Abuse. (2018). Treatment approaches for drug addiction. Web.

Scherer, M., Furr-Holden, C. D., & Voas, R. B. (2013). Evaluation Review, 37(1), 35-58. Web.

Singh, M. (2017). Epistaxis. Web.

Substance Abuse and Mental Health Services Administration. (2016). Treatment for substance use disorders. Web.

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