Addiction Consult

Reason for referral: The patient, John Doe, was referred by Dr. Smith for evaluation and management of substance use disorder. ID: John Doe is a 35-year-old male with a history of hypertension and diabetes, presenting for substance use evaluation. History of presenting illness: John has been experiencing increased cravings and difficulty managing his substance use, particularly with opioids and alcohol. Substance Use History: 1.) Nicotine: Started smoking at age 16, smokes first cigarette within 10 minutes of waking, has tried nicotine patches, smokes up to 20 cigarettes a day. 2.) Alcohol: Last used alcohol 3 days ago, no history of seizures or delirium tremens, drinks to blackout occasionally, has been arrested for DUI, attended AA meetings. 3.) Opioids: Last used opioids 1 week ago, started at age 25, uses heroin, spends approximately $50 daily, injects, has experienced overdose, uses naloxone, longest abstinence was 3 months. 4.) Stimulants: Last used cocaine 2 weeks ago, started at age 28, snorts cocaine, uses weekly, experiences cravings, longest abstinence was 1 month. 5.) Cannabis: Last used cannabis 1 month ago, started at age 18, smokes weed, uses daily, experiences cravings, longest abstinence was 2 weeks. 6.) Benzodiazepines: Started using non-prescribed benzodiazepines 2 years ago, seeks them out occasionally, longest abstinence was 1 month. 7.) LSD, PCP, solvents, MDMA, GHB, Ketamine: Has used MDMA occasionally in the past. Social History: John lives alone, works as a freelance graphic designer, accesses harm reduction supplies, has been incarcerated for 6 months, does not engage in sex work, family doctor is Dr. Lee. Addiction Treatment History: John has been to detox twice and attended an in-patient drug and alcohol treatment center once. Pharmanet Summary: Uses ABC Pharmacy, receives weekly dispensing of methadone, prescribed by two doctors, missed doses occasionally. CIWA: CIWA score of 8, primarily from tremors and anxiety, responds well to benzodiazepines for alcohol withdrawal. Medications in Hospital: Currently receiving methadone and Suboxone, has received 30 mg of methadone in hospital. Physical Exam: Vital signs: BP 130/85, HR 78, RR 16, Temp 98.6°F. Mental status: alert and oriented. Signs of withdrawal: mild diaphoresis, dilated pupils, mild tremor. Investigations: Lab values: CBC normal, LFTs elevated. ECG: normal, QTc 420 ms. Assessment: John is being consulted for opioid and alcohol use disorder, both active. He also has hypertension and diabetes. Concerns for withdrawal and acute pain management. Plan: 1. Continue methadone maintenance therapy. 2. Initiate naltrexone for alcohol use disorder. 3. Monitor blood pressure and glucose levels. 4. Provide counseling and support for substance use. Thank you for involving me in this patient's care, I will follow along while they are in hospital.