Lausanne orendain m d january 30 2009 adolescent medicine
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Lausanne Orendain, M.D. January 30, 2009 Adolescent Medicine. 15 y.o . male with “behavioral problems”. HPI. Patient’s CC – “I don’t know” Mom’s CC: Behavioral problems

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15 y.o . male with “behavioral problems”

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Lausanne orendain m d january 30 2009 adolescent medicine

Lausanne Orendain, M.D.

January 30, 2009

Adolescent Medicine

15 y.o. male with “behavioral problems”

15 y o male with behavioral problems


  • Patient’s CC – “I don’t know”

  • Mom’s CC: Behavioral problems

  • HPI: 15 year old Filipino male brought in by mom for behavioral problems that began with drug use on Halloween (3 mos PTP)

  • Problems consist of drug use, failing grades, running away, skipping school.



  • Pt admits to having a hard time with transitioning to 9th grade at new school: Bishop Gorman

    • Friends

    • Peers

    • Drug tested twice: negative

    • Grades started to decrease



  • Halloween: Patient drank unknown quantity and type of alcohol, ate pizza and then felt “weird.”

  • Denies knowingly taking drugs by ingesting, drinking, or smoking

  • At home, experienced visual and auditory hallucinations

  • He called his mom

Timeline continued

Timeline… continued

  • Stayed home for next 2 days

  • Brought to U.C. on day 3 post-ingestion

    • UDS positive for marijuana

    • Was discharged from U.C.

  • November: Patient insisted on switching to public school

    • Lost relationships with friends and family

    • Began failing all classes

    • Ran away for 3 days

      • Stayed at friend’s house.



  • December: Patient was switched to public high school

    • Began skipping school

  • 1st week of January: Was found at home high on marijuana with friend

  • 2nd week of January: Continued to miss school for 13 days

    • Sent home after finals because teacher believed he was intoxicated with alcohol



  • Mom grounded patient over Christmas break

  • Mom brought him to 4 sessions with a counselor

  • No meds were taken/given

Past medical history

Past Medical History

  • BHx: FT, NSVD, + PNC

    • Mom denies drugs, alcohol, tobacco while pregnant

    • No complications

  • Broken left wrist, right forearm, right elbow from skateboarding & snowboarding

  • No surgeries

Past medical history1

Past Medical History

  • Diagnosed with ADHD in 7th grade treated with Adderall

    • Stopped by mom because it made him feel “slow”

  • Meds: None

  • ALL: NKDA, no food allergies

  • Development: Doing well (grades As-Bs) until Fall 2008

  • FHx:

    • Mom has arthritis, migraine headaches

    • No substance abuse, depression, or other psychiatric diagnoses

Social history

Social History

  • Home: Lives with mom. “Latch-key kid” since 11 years old.

  • Education: Currently failing 9th grade. Goal is to finish high school and become stunt double in movies.

  • Activity: Inolved in Lacrosse teams and has been showboarding x 4 years

Social history1

Social History

  • Drugs:

    • First substance use on Halloween

    • Admitted to alcohol but denies knowing how he had marijuana in his system

    • Smoked marijuana knowingly for first time 1st week of January

    • Denies any other drug use

Social history2

Social History

  • Suicide: Denies ever having suicide ideation/plans. Admits to feeling a little sad

  • Sex: First intercourse last summer. Has had 2 female partners total, vaginal sex only, condom use 100% of the time.

  • Safety: Feels safe at home and at school.



  • C – Has not ridden in car with someone who was under the influence

  • R – Does not use to relax

  • A – Does not use when alone

  • F – Did forget events at Halloween

  • F – Family has told him to stop using

  • T – Has gotten into trouble while using

    * Has > than 2 positive responses

Physical exam

Physical exam

  • Vitals: T-98 P-65 RR-16 BP-104/66

  • Wt 64kg (75%) Ht 174.5cm (50-75%)

  • Gen: WN, WD, Alert, NAD

  • Rest of exam normal and non-contributory including HEENT and skin exam

15 y o male with behavioral problems


  • Mom wanted “resources” for her son and drug testing.

  • Patient refused any further counseling.

  • Patient plans to attend school and get better grades this semester

    • Wants to get his driving license this summer.

  • Patient agreed to return to clinic in one month and submit to urine drug testing

Substance abuse criteria

Substance Abuse Criteria

  • Substance abuse: maladaptive pattern of substance use leading to clinically significant impairment or distress as manisfested by 1 or more episodes in a 12 month period

  • Symptoms do not meet dependence criteria

Substance abuse criteria1

Substance Abuse Criteria

  • Recurrent substance use resulting in failure to fulfill obligations at work, school, home

  • Recurrent use in situations where it is physically hazardous

  • Substance-related legal problems

  • Continued use despite social/personal problems

Substance dependence criteria

Substance Dependence Criteria

Three or more occurring at any time in same 12 months:

  • Tolerance – need for increased amounts

  • Withdrawal symptoms

  • Taking substance over longer time period or increased amounts

  • Cut Down – persistent desire & efforts

  • Time spent in obtaining substance

  • Social, work, recreational activities are given up

  • Continues substance use despite knowing problems are likely caused by substance



  • Derived from Latin term “Alucinari” which means “to wander in mind”

  • Hallucinogen causes distortion of perceived reality vs. a true hallucination when a person has experiences that do not happen

  • “Synethesias” = mixing of senses

    • Hearing colors or seeing smells

15 y o male with behavioral problems

Percentage of High School Students Who Reported Lifetime Hallucinogenic Drug Use,* by Sex** and Race/Ethnicity,*** 2007

* Used hallucinogenic drugs (e.g., LSD, acid, PCP, angel dust, mescaline, or mushrooms) one or more times during their life.

** M > F

*** W, H > B

National Youth Risk Behavior Survey, 2007

Percentage of high school students who reported lifetime hallucinogenic drug use 2001 2007

Percentage of High School Students Who Reported Lifetime Hallucinogenic Drug Use,* 2001 – 2007

* Used hallucinogenic drugs (e.g., LSD, acid, PCP, angel dust, mescaline, or mushrooms) one or more times during their life.

1 Decreased 2001-2007, p < .05

National Youth Risk Behavior Surveys, 2001 – 2007

15 y o male with behavioral problems


  • d-lysergic acid diethylamide

  • Originally derived from ergot fungus that grew on rye & wheat

  • Street Names: acid, dragon, white lightning, sorcerer’s apprentice, dots, microdot, battery acid, lucy in the sky with diamonds

  • Mechanism : serotonin and dopamine receptors like a serotonin agonist – increased glutamate

15 y o male with behavioral problems


  • Forms: snorted, smoked, liquid, eye drops, blotter sheets

  • Onset: few minutes

    • Flush, mydriasis, pilorection, chills, tachycardia

  • Peak: 30-90 minutes

    • Visual and auditory illusions, synesthesia, see themselves or others aging, feel competent

    • Paranoia, confusion, depression, panic, anxiety

  • Duration: 8-12 hours

15 y o male with behavioral problems


  • Acute toxicity: Coma, respiratory arrest, hypertension, tachycardia, hyperthermia, seizures

  • Chronic reactions:

    • personality changes

    • psychosis

    • ~50-60% will present with spontaneous flashbacks

      • may occur weeks to 1 year after last use, triggered by stress, illness, exercise

15 y o male with behavioral problems


  • Hallucinogen Persisting Perception Disorder (HPPD) – DSM IV diagnosis

  • After few months to 5 years after stopping LSD use, continue to have:

    • geometric hallucinations

    • false perceptions of movement in the peripheral visual fields,

    • flashes of colors, intensified colors

    • trails of images of moving objects, afterimages, halos around objects

15 y o male with behavioral problems


  • Urine tox screen: Not included

    • Have to specifically screen for it

  • Tolerance: Yes

  • Produces tolerance of psilocybin and mescaline, but not PCP and marijuana

  • Dependence: possibly psychological

Morning glory

Morning Glory

  • Lysergic acid amide

  • Forms: Eaten whole or ground to flour and mixed in drinks



  • Psilocybin Cubensis

  • Mushrooms grown in northwest and southeast of US

  • Found in South America, Mexico



  • Street Names: “shrooms,” magic mushrooms, liberty cap

  • Mechanism : Serotonin agonist

  • Forms: eat raw, dried, stewed

    • Average “dose” = 2-6 mushrooms

    • 1/3 of mushrooms sold contain psilocybin, many are laced with LSD or PCP

  • Onset: 20-30 minutes

    • Mydriasis, Facial flushing, dysphoric, hyperreflexia, paresthesia, ataxic, nausea



  • Peak: 1.5 hours

    • visual hallucinations, inappropriate laughter, altered perception of time

    • Cannot tell fantasy from reality

    • Panic reactions and psychosis with larger doses

  • Duration: 6 hours

  • Acute toxicity: chills, myalgia, rarely hyperthermia or seizures or coma



  • Urine tox screen: No

    • Need to specifically screen

  • Tolerance: Yes

  • Dependence: None



  • Peyote cactus found in Southwest US, North/Central Mexico

  • Disc shaped buttons at crown of cactus that are dried

  • Street names: Mescal buttons, Mexc, cactus

  • Mechanism: Serotonin agonist



  • Forms: Ingested by chewing or soaking in water to produce tea

    • Average “dose” = 6-12 peyote buttons

    • Ground into a powder and smoked.

  • Onset: 30 minutes

    • Nausea, vomiting, diaphoresis, dizzyness, ataxia

  • Peak: 4 hours

    • Mydriasis, visual and auditory hallucinations, euphoria, paranoia, sense of increased physical power

  • Duration: 8-12 hours



  • Acute toxicity: nausea, vomiting, muscle weakness

  • Urine tox screen: No

  • Tolerance: Yes

  • Dependence: None

15 y o male with behavioral problems


  • Phencyclidine

  • Originally developed as an anesthetic

  • Street Names: angel dust, loveboat, peace weed, super grass, elephant tranquilizer, rocket fuel, hog

  • Mechanism : Inhibits norepinephrine and dopamine reuptake

    • Some cholinergic and anticholinergic effects

15 y o male with behavioral problems


  • Forms: powder - smoked, mixed with liquid, IV

  • Onset: 2-5 minutes

    • Unpredictable symptoms: calm or wild, violent or disoriented.

  • Peak: 15 minutes

    • Bizarre and psychotic behaviors

    • Dissociative drug – feel minimal pain

    • Tachycardia, hypertension, miosis with a blank stare, nystagmus (rotary)

15 y o male with behavioral problems


  • Duration: 16 hours  48 hours

    • Acute toxicity: Delusions, paranoia, anxiety, Muscle rigidity, myoclonus

  • Complications: severe agitation and muscle rigidity rhabdomyolysis and myoglobinuric renal failure. Violent behavior & decreased sense of pain  law problems

15 y o male with behavioral problems


  • Long term: memory loss, difficulties with speech, thinking, depression can persist up to 1 year after stopping

  • Utox screen: Yes, 3-8 days after

  • Tolerance: Yes

  • Dependence: Yes, psychological. Repeated abuse leads to addiction and craving.

Jimson weed

Jimson Weed

  • Originally derived from poisonous plant native to North America

  • Street Names: Jamestown weed, Angel’s trumpet, Loco weed

  • Mechanism : anticholinergic, has atropine

  • Forms: kidney shaped seed which can be ingested, smoked

Jimson weed1

Jimson Weed

  • "red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare.“

  • Urine tox screen – no

    • Need to specifically screen for it

  • Symptoms: flushing, dry mouth, urinary retention, mydriasis and blurry vision, hyperthermia,

    • tachycardia, decreased GI motility, confused, hallucination, restless, irritable

15 y o male with behavioral problems


  • 3,4-methylenedioxymethamphetamine

  • Synthetically made by accident, initially recommended during marriage counseling

  • Street Names: ecstasy, XTC, Adam, E, X, clarity, Stacy, hug drug

  • Mechanism: massive serotonin release

  • Forms: tablet, powder, liquid

15 y o male with behavioral problems


  • Onset: 30 minutes

    • anxiety, tachycardia, mydriasis

  • Peak: 1-1.5 hours

    • Relaxation, empathy, euphoria, disinhibition, increased sensuality

    • See halos, sense of touch is enhanced, not really hallucinogenic, however may be mixed with other hallucinogenic drugs

  • Duration: 4-8 hours

15 y o male with behavioral problems


  • Acute toxicity: bruxism, hyperthermia, hypertension, v. fib

  • Complications: belief that water is antidote with SIADH-like effect  hyponatremic induced seizures, rhabdomyolysis  myoglobinuric renal failure

  • Long term: permanent mood disorders, degradation of serotonergic neurons

15 y o male with behavioral problems


  • Utox screen: Yes – up to 2 days after

  • Tolerance: Yes

    • “Suicide Tuesday” – lethargy, anorexia, dysphoria about 48 hours after ingestion

  • Dependence: Possibly psychological

Size comparison

Size Comparison

Teen resources

Teen Resources

  • - DEA

  • - National Youth Anti-Drug Media Campaign

  • - National Youth Anti-Drug Media Campaign



  • Barangan, Caroline and Elizabeth Alderman. Management of Substance Abuse. Pediatrics in Review, 2002;23:123-31.

  • Center for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Youth Risk Behavior Surveillance — United States, 2007. June 6, 2008 / Vol. 57 / No. SS-4.

  • Department of Justice.

  • Hahn, IH and D. Yew. Toxicity, MDMA. eMedicine Specialties Toxicology.

  • National Institute on Drug Abuse. High School and Youth Trends 2008.

  • National Institute on Drug Abuse. NIDA InfoFacts: Hallucinogens - LSD, Peyote, Psilocybin, and PCP.

  • National Organization for Drug-Induced Disorders. HPPD DSM-IV Diagnostic Criteria.

  • Richards, M. and Parish, B. Hallucinogens. eMedicine Specialties.

  • Werner, Mark. Hallucinogens. Pediatrics in Review, 1993; 14:466-72.

  • Youth Risk Behavior Survey (YRBS) 2007.

15 y o male with behavioral problems


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