Recognizing and Treating Substance Use in the Inpatient Setting
Presenters: Erin McKnight, MD, MPH, Nationwide Children’s Hospital, Columbus, Ohio, Hilary Lin, MD, Children’s Health Orange County, Orange County, Calif., Stephanie Kwon, DO, Medical University of South Carolina, Shawn Jenkins
Children’s Hospital, Charleston, S.C.
Dr. Giordano
Session objectives included identifying substance use disorder (SUD) among adolescents in the inpatient setting, recognizing signs and symptoms of intoxication and withdrawal, formulating an inpatient management framework, and using various treatment strategies for adolescents with SUD.
One in three high school students reports alcohol use, one in five reports marijuana use, and one in seven reports lifetime prescription opioid misuse. Black and Hispanic adolescents have higher rates of misuse and are significantly less likely to receive SUD treatment than white adolescents. Practitioners were reminded always to ask about the history (confidential, with the exceptions of abuse/exploitation and suicidal/homicidal ideations), and never to perform drug testing without the adolescent’s consent. Different types of drug testing were reviewed. Symptoms of intoxication and withdrawal for nicotine, marijuana, alcohol, opioids, benzodiazepines, and amphetamines were discussed in detail, along with management approaches for each.
Drs. Lin and Kwon have presented three cases that portrayed the importance of the topic in clinical encounters. The three cases illustrated: an irritable and restless 16-year-old female with acute asthma exacerbation, whose history confirmed JUUL vaping usage; a 17-year-old male presenting with forearm cellulitis/abscess, admitting to heroin use; and an 18-year-old female presenting with vomiting and abdominal pain, found to have cannabinoid hyperemesis syndrome. The recommended prescriptions included: a nicotine patch and nicotine chewing gum for acute nicotine withdrawal for the 16-year-old; buprenorphine/naloxone (based on the Clinical Opioid Withdrawal Scale) for acute opioid withdrawal for the 17-year-old; and capsaicin cream and haloperidol for the 18-year-old.
Key Takeaways
- Once hospitalized, adolescents with SUD should be clearly identified and the symptoms of intoxication/withdrawal addressed, even when their primary reason for admission is a different medical issue.
- Confidential history remains the best way to identify SUD.
- Failure to quickly identify SUD may cause more medical problems, increased distress and length of stay, and worsening discord between the team and the patient and family.
Dr. Giordano, an associate professor of pediatrics at Columbia University Medical Center in New York, is a pediatric hospitalist with expertise in pediatric surgical co-management in the intermediate care unit.