Answer to Question 1:
Is the Patient Physically Dependent on Opioids?
Physical dependence on a substance is typically demonstrated by the presence
of a withdrawal syndrome when a person abruptly stops or markedly decreases his
or her use of a substance. The opioid withdrawal syndrome is characterized by
lacrimation (runny eyes), rhinorrhea (runny nose), sweating, diarrhea, vomiting,
gooseflesh, mydriasis (pupillary dilation), and yawning. Other features can be
muscle and joint aches, irritation, sleep difficulties, craving for opioids, and
nausea. A person does not necessarily have all these features when in opioid
withdrawal, but the presence of several suggests the opioid-using person is
physically dependent.
This patient initially reports sporadic use of heroin (limited to the
weekends), which suggests she is not physically dependent. However, her
subsequent admission that she also uses during the week on occasion is
worrisome, and she is now reporting on a Monday morning (after last using the
previous 2 days) that she is craving opioids. These features of her presentation
provide suggestive evidence that she may have become physically dependent on
opioids. It would be useful to evaluate the results from her physical
examination and consider whether there is further evidence that she is in early
opioid withdrawal.
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