Drug Misuse - Unusual Presentations

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Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Recreational Drugs article more useful, or one of our other health articles.

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Managing people with drug misuse problems in primary care involves not only treating patients who admit to their dependency but also recognising the signals in those who are reluctant to share this information. Not infrequently, you will also be approached by temporary patients attempting to obtain drugs by deception. GPs need to be alert to the possible significance of the following:

  • Temporary residents just passing through the area.
  • Patients with an overly familiar knowledge of medications, demanding analgesia for renal colic, sickle-cell crises, etc.
  • Patients giving evasive answers.
  • Signs of heavy smoking, strange smoke smells (cannabis, cocaine, heroin).
  • Acetone or glue smell on breath (solvent abuse).
  • Small pupils (opiates).
  • Needle tracks on arms, groin, legs, between toes; intravenous access difficult.
  • Abscesses and lymphadenopathy in nodes draining injection sites.
  • Signs of drug-associated illnesses (eg, endocarditis, AIDS, chronic viral hepatitis).

Patients may present with a variety of medical conditions but the doctor may not be aware of the history of drug dependency. The following is a list of scenarios:

  • Patient found unconscious - consider narcotics, barbiturates, solvents and benzodiazepine  as well as alcohol (see also Opiate Poisoning and Coma).
  • Psychosis - consider methylenedioxymethamfetamine (MDMA, or 'ecstasy'), lysergic acid diethylamide (LSD), amfetamine, anabolic steroids[1, 2].
  • Agitation - common with benzodiazepines.
  • Asthma/dyspnoea - consider opiate-induced pulmonary oedema, asthma (may follow the smoking of heroin).
  • Reduced lung density, lung cysts and chronic obstructive pulmonary disease (COPD) - may be related to cannabis use[3].
  • Lung abscess - may be a complication of right-sided staphylococcal endocarditis (common in intravenous drug users)[4].
  • Airway burns, pneumothorax, pneumomediastinum, 'crack lung' - these can all be complications of crack cocaine, due to its method of delivery[5].
  • Fever/pyrexia of unknown origin (PUO)/shivering - may be the only sign of endocarditis. 
  • Shivering and headache - due to chemical/organism contamination of intravenous drug. If suspicious, outline risks and offer immediate referral to secondary care - may need blood cultures, and antibiotics - eg, gentamicin.
  • Hyperpyrexia - consider 'ecstasy'[6]; be wary of associated myoglobinuria, disseminated intravascular coagulation, renal failure.
  • Abscesses - if over an injection site, then often of mixed organisms.
  • Deep vein thrombosis - may result from injecting suspension of tablets into a groin; consider acute compartment syndrome; organise a creatinine kinase test.
  • Pneumonia - pneumococcus, haemophilus, tuberculosis, pneumocystis.
  • Tachyarrhythmia - in young patients consider cocaine, amfetamines, endocarditis.
  • Jaundice - hepatitis B, C, or D, anabolic steroids (cholestasis).
  • Symptoms suggestive of glandular fever - may actually be HIV seroconversion illness.
  • Pain in a limb or back pain with fever - consider osteomyelitis.
  • Severe constipation - unusual in a young patient, and may be sign of opiate abuse.
  • Cystitis - ketamine abuse can cause inflammation of the bladder lining, leading to frequency, urgency and nocturia (ketamine bladder syndrome)[7].
  • Severe sight impairment - may be secondary to fungal or bacterial endophthalmitis with or without endocarditis, or talc or other particulate emboli.
  • Rhinitis - consider opiate withdrawal; other features may be colic/diarrhoea, lacrimation, dilated pupils, insomnia, piloerection, myalgia, low mood; (rhinitis may also be a sign of cocaine use).
  • Signs of sensory or motor neuropathy - consider solvent abuse.
  • Myocardial infarction - may be associated with:
    • Cocaine[8]
    • Cannabis use[9]
    • MDMA[10]
  • Stroke or transient ischaemic attack (TIA), spinal infarction - consider:
    • Cocaine use[11]
    • MDMA[12]
  • Myocarditis, hypertrophic cardiomyopathy, dilated cardiomyopathy, aortic dissection - all noted in cocaine users[8].
  • Mental health conditions (principally anxiety and depression) and physical effects, such as hypertension and arthritis, are more common in older patients who misused drugs in the 1970s compared with individuals with no history of dependence.

The Department of Health produced 2017 UK guidelines on clinical management of drug misuse and dependence[13]. They were prepared by an Independent Expert Working Group. The following chapters are covered within the guidance:

  • Essential elements of treatment provision.
  • Psychosocial components of treatment.
  • Pharmacological interventions.
  • Criminal justice system.
  • Health considerations.
  • Specific treatment situations and populations.
  • Advice on writing prescriptions.
  • Interactions.
  • Travelling abroad with controlled drugs.
  • Drugs and driving.

Further reading and references

  • Murray-Thomas T, Jones ME, Patel D, et al; Risk of mortality (including sudden cardiac death) and major cardiovascular events in atypical and typical antipsychotic users: a study with the general practice research database. Cardiovasc Psychiatry Neurol. 20132013:247486. doi: 10.1155/2013/247486. Epub 2013 Dec 26.

  • Drugs and Alcohol; Public Health England

  1. Glasner-Edwards S, Mooney LJ; Methamphetamine psychosis: epidemiology and management. CNS Drugs. 2014 Dec28(12):1115-26. doi: 10.1007/s40263-014-0209-8.

  2. Piacentino D, Kotzalidis GD, Del Casale A, et al; Anabolic-androgenic steroid use and psychopathology in athletes. A systematic review. Curr Neuropharmacol. 2015 Jan13(1):101-21. doi: 10.2174/1570159X13666141210222725.

  3. Chatkin JM, Zabert G, Zabert I, et al; Lung Disease Associated With Marijuana Use. Arch Bronconeumol. 2017 Sep53(9):510-515. doi: 10.1016/j.arbres.2017.03.019. Epub 2017 May 5.

  4. Gupta S, Banach DB, Chirch LM; Pulmonary artery intravascular abscess: A rare complication of incomplete infective endocarditis treatment in the setting of injection drug use. IDCases. 2018 Mar 3012:88-91. doi: 10.1016/j.idcr.2018.03.019. eCollection 2018.

  5. Greenberg A, Stammers K, Moonsie I, et al; Image of the month: All puffed out - a case of crack lung. Clin Med (Lond). 2017 Apr17(2):186-187. doi: 10.7861/clinmedicine.17-2-186.

  6. Onal O, Hasdiraz L, Oguzkaya F; A Rare Cause of Spontaneous Pneumomediastinum: Ecstasy Ingestion. Turk Thorac J. 2015 Oct16(4):198-200. doi: 10.5152/ttd.2015.4466. Epub 2015 Apr 9.

  7. Hong YL, Yee CH, Tam YH, et al; Management of complications of ketamine abuse: 10 years' experience in Hong Kong. Hong Kong Med J. 2018 Apr24(2):175-181. doi: 10.12809/hkmj177086. Epub 2018 Apr 6.

  8. Havakuk O, Rezkalla SH, Kloner RA; The Cardiovascular Effects of Cocaine. J Am Coll Cardiol. 2017 Jul 470(1):101-113. doi: 10.1016/j.jacc.2017.05.014.

  9. Lee J, Sharma N, Kazi F, et al; Cannabis and Myocardial Infarction: Risk Factors and Pathogenetic Insights. Scifed J Cardiol. 20171(1). Epub 2017 Jul 22.

  10. Saricopur A, Dursunoglu D, Sanlialp M, et al; Subacute myocardial infarction due to long-term paint thinner and ecstasy abuse. Anatol J Cardiol. 2015 Feb15(2):167-8. doi: 10.5152/akd.2015.5975. Epub 2015 Jan 21.

  11. Cheng YC, Ryan KA, Qadwai SA, et al; Cocaine Use and Risk of Ischemic Stroke in Young Adults. Stroke. 2016 Apr47(4):918-22. doi: 10.1161/STROKEAHA.115.011417. Epub 2016 Mar 10.

  12. Muntan CD, Tuckler V; Cerebrovascular accident following MDMA ingestion. J Med Toxicol. 2006 Mar2(1):16-8.

  13. Drug misuse and dependence - UK guidelines on clinical management; GOV.UK, 2017