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Intoxication


Substance abuse evaluation is an important component of a thorough psychiatric interview. Our understanding of the neurobiologic mechanisms of addiction has progressed rapidly. Although we now have a more complex understanding of the intricacies of substance use and substance-induced disorders, evaluating and treating an intoxicated patient remain the most challenging situations to the psychiatrist on call. Often intoxicated patients are behaviorally difficult and may present with potentially life-threatening conditions; hence they require immediate attention. Although these patients may appear to have a primary psychiatric disorder, intoxication must clear before other diagnoses can be considered.

This chapter should serve as a guide to recognizing and managing intoxication syndromes. Obtaining a thorough history is key to providing care quickly and effectively.

Phone call

Questions

  • 1.

    What is the level of consciousness?

  • 2.

    What are the vital signs?

  • 3.

    What were the substances used?

  • 4.

    How much was used?

  • 5.

    How long ago was the last use?

  • 6.

    What is the behavior?

Orders

Measure blood alcohol level and obtain urine toxicology results immediately.

Inform RN

“Will arrive in … minutes.”

Elevator thoughts

What substances has the person been using?

First, consider the category of drug ingested. These most commonly include alcohol, hallucinogens, inhalants, marijuana, opiates, psychostimulants, and sedative-hypnotics. More recently, synthetics such as bath salts, synthetic cannabinoid receptor agonists (SCRAs), and “club drugs” such as methylenedioxymethamphetamine (MDMA), ketamine, and gamma-hydroxybutyrate (GHB) have increased in popularity. Often more than one substance will be involved. Street drugs have the added complication of not being pure, often containing additives and mixtures of drugs. Be aware of a mixed withdrawal and intoxication state. In general, intoxicated patients can be divided into two categories: lethargic or obtunded patients and agitated or restless patients.

If the patient appears lethargic or is in a coma, suspect intoxication from the following:

  • 1.

    Opiates: meperidine (Demerol), morphine, heroin, opium, methadone, narcotic analgesics (OxyContin, Vicodin, fentanyl)

  • 2.

    Sedative-hypnotics: benzodiazepines, barbiturates, zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Lunesta), GHB, meprobamate (Equanil, Miltown)

  • 3.

    Alcohol

If the patient is described as restless or agitated, suspect intoxication from the following:

  • 1.

    Alcohol

  • 2.

    Psychostimulants: cocaine, amphetamines, “bath salts,” or other mephedrone derivatives

  • 3.

    Hallucinogens: phencyclidine hydrochloride (PCP), lysergic acid diethylamide (LSD), ketamine, psilocybin (“mushrooms”), ayahuasca

  • 4.

    Methylenedioxymethamphetamine (MDMA, “ecstasy”)

  • 5.

    Marijuana, synthetic cannabinoid receptor agonists (“K2/Spice”)

Bedside

Quick Look Test

  • What is the patient’s appearance and level of activity?

  • What is the patient’s level of consciousness?

  • What is the patient’s history (enlist friends and relatives if necessary)?

Vital Signs

  • What are the patient’s vital signs?

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