A 32-year-old woman comes to the emergency department due to swelling of the left arm over the last 24 hours. Temperature is 37.8 C (100 F), blood pressure is 105/62 mm Hg, pulse is 92/min, and respirations are 16/min. Examination of the extremities shows several needle marks. The left arm is erythematous and swollen, as well as warm and tender to the touch. Intravenous clindamycin is started. The next morning, the swelling and pain are improved, but the patient reports "feeling miserable." She has nasal congestion, nausea, and abdominal cramps, in addition to multiple episodes of vomiting and loose stools. On repeat examination, the patient is restless and reports aching muscles and joints. Blood pressure is 132/88 mm Hg, pulse is 102/min and regular, and respirations are 16/min. Laboratory results from the time of admission and 24 hours later are as follows:
| Complete blood count | Admission | 24 hr later |
| Hemoglobin | 12 g/dL | 11.8 g/dL |
| Platelets | 280,000/mm3 | 270,000/mm3 |
| Leukocytes | 13,800/mm3 | 8,500/mm3 |
| Neutrophils | 80% | 62% |
| Lymphocytes | 15% | 24% |
Which of the following is the most appropriate next step in management of this patient?
Opioid withdrawal | |
Time course |
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Clinical |
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Diagnosis |
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Management |
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This patient with evidence of intravenous drug use (eg, needle marks) initially had upper extremity cellulitis, which appears to have responded appropriately to clindamycin, as noted by improved local pain and swelling and resolution of leukocytosis. However, her new symptoms suggest that she is experiencing acute opioid withdrawal.
Patients with opioid dependence typically develop withdrawal symptoms within 4-12 hours of the last dose of a short-acting opioid, with a peak 24-48 hours after symptom onset. Manifestations frequently include nausea, vomiting, cramps, diarrhea, restlessness, rhinorrhea, lacrimation, myalgia, and arthralgia. Examination can show hypertension, tachycardia, mydriasis, piloerection, and hyperactive bowel sounds. Diagnosis is made based on history and examination findings alone.
Treatment options include buprenorphine (partial agonist) or low-dose methadone (long-acting full agonist). Adjunctive medications may also be given for symptom relief; these may include loperamide (diarrhea), ibuprofen (myalgia), baclofen (muscle cramps), and clonidine (anxiety, restlessness, hypertension).
(Choice A) Clindamycin can be associated with diarrhea, nausea, vomiting, and anorexia. However, the patient's restlessness, arthralgia, and evidence of substance use are more suggestive of opioid withdrawal.
(Choice B) Intravenous naloxone is a potent opioid antagonist used for a patient with opioid intoxication. It can induce rapid withdrawal and should not be used in an individual who already has withdrawal symptoms because it may worsen them acutely.
(Choice D) Symptoms caused by natural opioid cessation (ie, not triggered by administration of an antagonist) are generally not life-threatening but can be quite uncomfortable. Providing opioid agonist therapy not only improves patient comfort, but also provides an opportunity to treat the underlying substance use disorder; if it is not provided, patients commonly leave against medical advice.
(Choice E) Clostridioides difficile infection typically occurs in hospitalized patients with antibiotic exposure and can cause abdominal cramps, nausea, and diarrhea. However, it is typically associated with leukocytosis (resolved in this patient), usually develops within 5-10 days of antibiotic use, and is unlikely to cause arthralgia.
Educational objective:
Common symptoms of opioid withdrawal include nausea, cramps, diarrhea, restlessness, rhinorrhea, lacrimation, myalgia, and arthralgia. Examination can show hypertension, tachycardia, mydriasis, piloerection, and hyperactive bowel sounds. Treatment options include buprenorphine or low-dose methadone.