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CASE 25.1

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A 45-year-old male presents to your clinic to establish care for his chronic back and leg pain. He denies any other medical conditions. He reports being injured at work approximately 5 years ago, at which time he was started on oxycodone. He reports being on a stable dose for the last few years. He appears slightly drowsy during the appointment, has small pupils, and is having moderate difficulty describing his injury and previous treatments. He reports his mood as okay, but becomes irritable when you begin to ask specifics about his injury. He has not been able to keep a job for the last year because "everyone fires me." He states that he needs the oxycodone to function and that he ran out of his medication 1 week ago. He does report occasional alcohol use, although he states the he knows not to mix alcohol with his oxycodone.

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Question 25.1.1 What is the most likely explanation of the patient's current presentation?

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A) Opioid withdrawal.

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B) Opioid intoxication.

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C) Uncontrolled pain.

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D) Alcohol intoxication.

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E) Alcohol withdrawal.

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Answer 25.1.1 The correct answer is "B." The patient presents with pupillary constriction, drowsiness, impairment in attention and memory, psychological changes (dysphoria/irritability), and impairment in functioning (not able to keep a job). All of these findings are included in the diagnostic criteria for opioid intoxication. The DSM-5 criteria for opioid intoxication include: (1) Recent use of an opioid; (2) clinically significant problematic behavioral or psychological changes (euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning) that develop during, or shortly after, opioid use; (3) pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one or more of the following signs: drowsiness or coma, slurred speech, and impairment in attention or memory; (4) and the symptoms are not due to a general medical condition or another mental disorder.

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"A" is incorrect and will be discussed later in this case. "C" is incorrect because a patient would not display the above symptoms with significant pain. "D" could be correct because acute alcohol intoxication is characterized by slurred speech and impairments in memory and judgment; however, the patient does not have other findings consistent with alcohol intoxication such as an unsteady gait or nystagmus. "E" is incorrect as the patient was not hypertensive, febrile, diaphoretic, and did not have tremors or vomiting.

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You are hesitant to prescribe the oxycodone partly because you recall that there were over 16,000 deaths related to prescription opioids in 2013. Although heroin-related deaths have increased much more rapidly than prescription opioids in the last 15 years, they ...

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