The provider prescribed it, so what is the issue? Pharmaceutical companies say that it is safe. The government approved it. Opioid use disorder is a chronic use that leads to impairment in the daily functioning of an individual,

-Etiology: There are many factors at play with substance abuse, and it is said to be genetic, environmental, and psychosocial aspects of this behavior

-Epidemiology: 2.1 million people in the United States misused prescription opioid medication, occurring in males over the age of 26 being white, non-Hispanic race and ethnicity. It is reported that mood disorders are usually present with this behavior.

-Pathophysiology: There are pain receptors in the peripheral and central nervous system that are key binding sites for opioids which include mu, delta and kappa receptors which are G-protein coupled receptors in the brain and other parts of the body

-History and physical: Patients presenting with an opioid use disorder may appear intoxicated or exhibit no symptoms at all.

Assessment questions include consumption patterns, route of administration, tolerance and last use along with treatment history. Look for track marks and assess the nasal septum while looking for watery eyes.

Screening tools include rapid opioid dependence screen and OWLS or overuse, worrying, loss of interest and feeling slowed down screen

-Differential Diagnosis: chronic Pain: that lasts for an extended time greater than 12 weeks. It is more common in women with environmental and psychological factors that increase pain and hinder management.

Depression
: Depression and opioid use are linked as those with the capacity to misuse opioids are depressed: Alcohol Intoxication: Alcohol with sedating drugs can be similar in presentation to opioid misuse or overdose.

-Treatment: Treatment is a multilevel approach that includes not only medication based but also behavioral changes to rehabilitate and treat opioid use disorder. Referral should be made to alcoholics anonymous and narcotics anonymous.

Prevention: Prevention is a strategy that involves the family, community and government. The levels of prevention are primary, secondary and tertiary to decrease opioid use disorder.

-Education and follow up: Patient education is about safety and side effects of treatment to decrease mortality and morbidity.

-Conclusion: Opioid use disorder is the chronic use of opioids that causes clinically significant distress or impairment. Receptors in the brain are sensitized during opioid use. Assessments include behavior for consumption, and treatment history along with physical perusal for track marks is useful in diagnosis. Referral to trained specialist in pain management and addiction treatment may better benefit patients other than a primary care provider.

PowerPoint # 2 to reply. Reply to Nozomi

INSECTS BITES

· Overview: > 800,000 species of arthropods

· < 0.5% of are harmful

Arthropods- “bugs”

·
Insects: mosquitoes, chiggers, ticks, fleas, bedbugs, bees, fire ants

·
Arachnids: widow spiders and recluse spiders

· Millipedes, centipedes, crustaceans

Risk Factors: Exposure to heavy insect infestations

· Warm weather (April to October)

· Outdoor exposure: bare feet, bright clothes

· Perfumes/colognes

· Previous episodes of sensitization

· Children > Adults

· Women > Men

Anatomy:

Type of injuries.
Examples

Blisters/vesicles.——-Blister beetle

Envenomation———Bees, ants,spiders

Invasion—————–Human fleas

Contact urticaria——caterpillars, moths, butterflies

Necrosis—————-Brown recluse spider

Disease vector——–mosquitoes, ticks

· Pathophysiology: Immune (IgE-mediated) reaction to saliva or venom

· Inflammatory: within minutes

· Local erythema, pruritus, edema

· Saliva: anticoagulants (factors Xa inhibitors), digestive enzymes (amylase, esterases)

· Delayed: swelling, itching, redness

Disease transmission

·
Ticks

· Lyme disease –
Borrelia burgdorferi

– Doxycycline x 3 weeks; ceftriaxone

·
Rocky Mountain spotted fever –
Rickettsia rickettssii

·
Mosquitoes

·
West Nile virus

·
St. Loius enchephalitis

· Zika virus

Insect bites complications:

·
Rare– Immuno-compromised (AIDS, Epstein-Barr)

· Vesicles; bullae; tissue necrosis

· Lymphadenopathy, fever

·
Systemic allergic reaction (anaphylaxis): widespread activation of mast cells flushing, hypotension, angioedema, generalized urticaria, wheezing, hypotension

Insect bites treatment:

·
Flea: Clean, topical antiseptic, calamine lotion with phenol; hydroxyzine (Atarax)

·
Chigger: hot bath/shower, lather with soap; topical corticosteroid; antihistamine; topical antibiotic

·
Mosquito: ice pack; topical corticosteroid

·
Ticks: Remove with EtOH, machine oil, mineral oil, salad oil withdraw from skin

S
pider Bites: Anatomy:

·
Brown recluse

·
1 cm long, brown, darker violin shade on ventral side

· Dermo-necrotic and hemolytic toxin: sphingomyelinase D

·
Black widow

· 2 cm long, black, red hourglass

· Neurotoxic: alpha-latrotoxin

Brown Recluse: Pathophysiology

·
Clinical Presentation:

·
No pain x 2-3 hours, then pain, necrosis

· Necrotic lesion: red blister surrounded by pale, irregular ischemic halo (bull’s eye lesion)

· Pustule grows crater over 3-4 days

· Severe hemolysis

· Lymphadenopathy, low-grade fever

Brown recluse treatment:

· Rest, Elevate, Cold compress x 4 days

· Self-limiting

· Oral antibiotic: cephalexin, erythromycin, dicloxacillin x 10 days

· Tetanus prophylaxis

· Unknown; < 3 doses of tetanus-toxoid containing vaccine vaccinate

· >3 doses, but > 5 years (major wound), >10 years (minor wound) booster

· Major wounds: Unknown/ <3 doses Human tetanus immune globulin

Severe wound: Dapsone 50 mg PO BID x 10 days (controversial; only G6PD deficiency negative

Black widow: pathophysiology:

· Alpha-latrotoxin acetylcholine muscle spasm; diaphoresis

·
Clinical Presentations

· Local swelling, tiny red dots

· Acute pain, then muscle spasm in abdomen and trunk

· Diffuse parasthesias, ptosis, hyperactive DTRs

· Hypertension, headache, agitation, psychosis

· Peak 2-3 hours, lasts for 24 hours

BLack widow treatment

· Cold compress

· Pain management: opioids or non-opioids

· Valium: painful muscle spasm

· Monitor for hypertension

· Anti-venom: Controversial

· 5%: allergic/anaphylactic reaction

· Only if unresponsive to supportive care

Bee stings

· Venom-containing barbed stinger

· Remove stinger with dull knife- not forceps

· Rest, elevation, ice

· Antihistamines

· Anaphylaxis

· Epinephrine SQ

· IV diphendydramine

· O2, IV fluids, bronchodilators, vasopressors

Diagnostics

· History (OLDCART, insect description, activity)

· Systemic: Blood type and cross match, coagulation, CBC, CMP, UA

· Skin biopsy = non-specific perivascular dermatitis with eosinophils

· RMSF: indirect immunofluorescence antibody (IFA) assay

· Lyme disease: antibody titers

Insect bites general interventions

· Anaphylaxis: Refer to ED; hospitalize

· Local reactions:

· Wash with soap and water

· Remove foreign body

· Ice pack: reduce edema

· Elevate affected extremities

General treatment

·
Antihistamines: Diphenhydramine

· Children (2-6): 6.25 mg Q 4-6 hours

· Children (6-12): 12.5 to 25 mg Q 4-6 hours

· Adults: 50 mg Q 6 hour

·
Persistent pruritus:
Hydroxyzine (Atarax)

· Children: 0.01 mg/kg; repeat in 4 hours

· Adults: 10-25 mg PO Q 4-6 hours

· Severe swelling/induration: PO glucocorticoids

· Topical creams, gels: calamine, pramoxine

Patient and family education:

· Use insect repellant:
N,N-diethyl-3-methylbenzamide

· Do not walk in yard barefooted.

· Capture offending spider for identification.

· Long sleeve, keep shirts and trousers tucked for tick-infested areas

· Treat pets for ticks and fleas

· Avoid concurrent use of PO antihistamines and topical antihistamine over large surface area

· Medical alert bracelet

· Epi-pen education

Follow-up

· Follow-up visit in 24-48 hours

· Possible referral to ED

· Refer to allergy specialist

· Wound care: 1-2 weeks

Differential Diagnosis

· Folliculitis (L73.9)

· Herpes zoster (B02)

· Lymphomatoid papulosis (C86.6)

· Erythema multiforme (L51.9)

· Stevens-Johnson syndrome (L51.1

Conclusion

· Most are self-limiting

· Costly ED visits: insects, arachnids

· Venoms, anaphylactic, infectious disease

· Treatment depends on organism- detailed Hx and examination

·