Co-occurring Medical Disorders

Abstract

Substance use can lead to significant medical consequences. Development of these associated diagnoses can be common or rare, and they can vary depending on substance used, frequency, duration, and individual vulnerability. This chapter is organized by substance class and affected organ systems that can vary by substance. These complications may be transient and resolve with substance cessation but can also be irreversible. Prognosis may not be dose-dependent. Some risks are associated with route of administration, independent of substance. Additionally, maternal-fetal risks are possible with complications ranging from low birth weight to fetal demise. By systematically reviewing physical effects of substance use, this structured framework will assist busy clinicians with patient care considerations.

Review Questions

• 1. Karl is a 50-year-old male with history of alcohol use disorder. He is reviewing his recent laboratory results with his primary care physician, and the physician discusses labs that may indicate some effects on his body from his alcohol use. The most likely lab values they are discussing are:

  • A. Increased platelet count

  • B. Hyperalbuminemia

  • C. Leukopenia

  • D. Gamma glutamyltransferase (GGT)

  • E. Decreased mean corpuscular volume

  Correct answer: D

  Explanation: Markers of synthetic liver function include albumin level, platelet count, and bilirubin. Patients with severe alcohol use disorder often have thrombocytopenia, hypoalbuminemia, and increased total bilirubin. Decreased white count is not a common finding in alcohol use disorder. Liver enzymes that can be elevated with alcohol use include Alanine transaminase (ALT) Aspartate transaminase (AST), as well as GGT. Elevations in GGT may be more specific to alcohol use. Mean corpuscular volume is often increased with chronic alcohol use due to megaloblastic anemia.

• 2. Candi is a 65-year-old female with a 40 pack/year smoking history. She is a current smoker. What does the United States Preventive Services Task Force (USPSTF) recommend regarding her tobacco use?

  • A. Annual respiratory cultures

  • B. Annual screening non-contrast CT Chest

  • C. Biannual abdominal aorta ultrasound

  • D. Measurement of liver transaminases

  • E. None of the above

  Correct answer: B

  Explanation: USPFTF recommends annual screening non-contrast Chest CT for men and women above the age of 60 with >30 pack/year smoking history. Annual respiratory cultures are not indicated. USPFTF recommends men above the age of 65 who currently smoke with greater than 30 pack/year history to undergo abdominal aorta ultrasound. This recommendation does not apply to women.

• 3. Hector is a 78-year-old male with generalized anxiety disorder. He has been prescribed clonazepam 1 mg TID for the past 10 years by his primary care physician, but was referred to you, a psychiatrist, after his prescriber retired. During your discussion of the risks of benzodiazepine use, you mention which of the following?

  • A. Thrombocytopenia

  • B. Cognitive impairment, including dementia

  • C. Elevated risk of skin cancer

  • D. Cushing’s syndrome

  • E. Intractable vomiting

  Correct answer: B

  Explanation: Long-term use of benzodiazepines has significant health consequences. Notably, the increased fall risk has led to hip fractures in geriatric populations. Benzodiazepine use has also led to a near doubling of dementia risk. There is no association with skin cancer. There is no association with thrombocytopenia, Cushing’s syndrome, or vomiting. Despite these consequences, prescribers should avoid rapid discontinuation, as this can lead to seizures, withdrawal-associated psychosis.

• 4. Barry is a 67-year-old guitar player in a band who began using heroin in the 1960s by inhalation, and quickly progressed to IV use for about 15 years. In the 1980s, he began treatment with methadone, and he remained abstinent from heroin for over two decades. Intravenous infectious complications of heroin use include which of the following?

  • A. HIV

  • B. Hepatitis A

  • C. Increased fall risk

  • D. Constipation

  • E. Somnolence

  Correct answer: A

  Explanation: Intravenous heroin use is associated with blood-borne transmission of infections such as HIV and Hepatitis C. Sharing needles can also result in bacteremia, which requires parenteral antibiotics. While constipation is an effect of opioid use, it is not an infectious complication. Somnolence and concomitant increased fall risk is seen with opioid intoxication.

• 5. After ingesting an unidentified substance, Elmer quickly develops a stabbing feeling radiating to his back. Which emergency condition is most important to consider in your differential diagnosis, and what was the most likely substance involved?

  • A. GERD; alcohol

  • B. Pneumonia; cannabis

  • C. Aortic dissection; cocaine

  • D. Appendicitis; nicotine

  • E. Deep venous thrombosis; cannabis

  Correct answer: C

  Explanation: Cocaine intoxication can cause coronary vasospasm, myocardial infarction, and aortic dissection. Prompt diagnosis and treatment is crucial. None of the other answers are relevant. GERD and pneumonia are not conditions that require emergent treatment. Appendicitis is not a complication of nicotine use.