Joshua Grossman, MD

(The following are case studies discussing the impact of proper evaluation of comorbid psychiatric illness and medical disorders. To read more case studies and find out how to effectively recognize and treat patients with these disorders, please see the January 2002 issue of 

 A 52-year-old Asian American gentleman was admitted to the inpatient psychiatry service to "dry out" following a drinking binge. At morning report, the addiction treatment team reported that the patient claimed, "belly discomfort during the night with no relief from antacids." 

. Exquisite right upper quadrant stomach tenderness was noted at bedside exam. 

. Stomach X-rays (films) were performed prior to the hospitalization on the inpatient psychiatry service. The radiologist stated that the calcification visible in the right upper quadrant belly film was "a pill."

. The chief of surgery was consulted for a second opinion, and he diagnosed a gallstone rather than a pill. Upon bedside examination, he diagnosed acute cholecystitis and ordered immediate intravenous antibiotics, intravenous fluids and cholecystectomy. The patient said he appreciated the timely and definitive diagnostics, treatment and care. He added, "Doctor, I was told I had a sick gallbladder with a gallstone years ago. I was advised then to have my gallstone and my gallbladder taken out surgically, but I did not get it done." When asked why his previously recommended gallbladder surgery had not been performed, the patient answered, "Different reasons, Doctor. First my doctor died; then my car died; then my dog died; then I lost my insurance; then I just lost my nerve, and I was afraid to have the surgery. Doctor, I guess the major reason was that I just could not stop drinking long enough, and I could not ever dry out long enough to have my gallbladder taken out." Twelve-step work with sponsorship was recommended, and the recommendation documented, for him to develop and use his Tools of Recovery. 

. When a step-by-step review was initiated to ascertain how our patient with an acutely inflamed gallbladder came to be hospitalized on our detoxification unit, we learned that the findings of the patient's medical physical examination were initially unimpressive; that is, his stomach was soft, with no guarding, tenderness or rebound tenderness. However, as his blood alcohol level dropped and he became more alert, the findings from his medical physical examination changed. The core issue would appear to be that the willingness to provide repeated medical physical examinations at the bedside leads to the correct diagnosis, and thus reasonably timely treatment and care of the underlying and previously ignored medical issues.

. An 85-year-old white gentleman was admitted to the inpatient psychiatry service to "dry out" following a drinking binge. At morning report, the addiction treatment team said that the patient was "sleeping it off." 

. At the bedside, I observed the patient to have a pulse of 120 beats per minute, a respiratory rate of 40 breaths per minute, and to be in a semi-coma, from which he could not be awakened. 

. The medical intensive care team was called. With correction of his fluid and electrolyte imbalance and stabilization of his pulmonary status, the patient woke from his semi-coma and was returned to our inpatient psychiatry unit, where he remained comfortable and stable until our social work service could provide comfortable alcohol-free housing for him. He verbalized his appreciation of our timely diagnostics, treatment and care and also for our human services liaison. Twelve-step work with sponsorship was recommended and documented for him to develop and use his Tools of Recovery. 

. In a review of how this patient came to be hospitalized on our detoxification unit, it became apparent that his first medical physical examination was performed on the morning after he arrived on our detoxification unit. Records documented previous detoxification unit hospitalizations; at this repeat hospitalization the patient appeared in a reasonable disposition. The only glitch was that in the middle of the night the patient was minimally examined, if at all; and, in the absence of a complete medical physical examination, was simply labeled as a patient who was "sleeping it off." Once the pulse rate, respiration rate and level of consciousness were determined on the detoxification unit, then an accurate diagnosis of semi-coma became much more clear. It is probably a good and reasonable diagnostic rule-of-thumb that the majority of hospital inpatients, whether chemically dependent or not, need a thorough medical, physical examination by their health care providers on morning rounds.

These two case studies are representative of the many reasons why health care providers need to put aside typical stereotypes and tunnel vision and provide our chemically-dependent patients with the same care as our non-chemically dependent patients.

Articles

The following are case studies discussing the impact of proper evaluation of comorbid psychiatric illness and medical disorders. To read more case studies and find out how to effectively recognize and treat patients with these disorders, please see the January 2002 issue of Psychiatric Times.

Detox Diagnosis--Keeping Medicine in Psychiatry

It has long been known and generally appreciated that psychiatric diagnoses can be established in medical and surgical special care units and in the general medical and general surgical patient populations, both in hospital units and in ambulatory care settings. The impact of comorbid psychiatric illness on medical disorders is reasonably well-appreciated (Glassman and Shapiro, 1998; Musselman et al., 1998). Is the reverse also true? Need mental health care professionals remain vigilant to identify and address general medical and surgical issues in psychiatry units?

The following vignettes briefly review patients admitted to the inpatient psychiatry unit with either alleged acute psychiatric conditions or to "dry out" but who were in urgent need of timely medical and surgical interventions. (

To read more case studies, please refer to the 

Since we know cholelithiasis with cholecystitis, respiratory failure and malignancy to be common disorders in our general patient population, and we know that our chemically dependent patients are representative of our general patient population, then we can reasonably expect to see these potentially serious and potentially life-threatening (yet readily treatable) disorders in our chemically dependent patient population as well. When we, as health care providers, are willing to give up, rescind and/or withhold the label of "alcoholic" and/or "addict" and focus our bedside history and physical examinations on our chemically dependent patients, just as we have always done on our medical and surgical patients, then we can be empowered to provide comprehensive, high quality care. While we recognize the increased percentage of chronic hepatitis B, chronic hepatitis C and (chronic and acute) AIDS in our chemically dependent patients and the need for specific testing and appropriate treatment and care, I present the following cases to raise the index of suspicion on the rapid and timely, beginning-at-the-bedside diagnosis, treatment and care of acute respiratory failure and curable cancer in chemically dependent patients.

 A 23-year-old Hispanic college sophomore was admitted to the inpatient psychiatry unit with "acute anxiety." He specifically denied penicillin allergy, substance abuse and any family history of psychiatric disorder. His spleen had been removed three years previously, following a motorcycle wreck.

 The admitting vital signs revealed an oral temperature of 104F. During the admitting physical examination he began to cough rusty sputum.

 A chest X-ray revealed a pulmonary consolidation.

 Sputum gram stain revealed gram-positive diplococci. Sputum culture revealed the pneumococcus sensitive to penicillin. His pneumococcal rusty pneumonia and his alleged acute anxiety resolved with the administration of penicillin and intravenous fluids. He was also provided and documented with the pneumococcal polysaccharide vaccine. He appreciated the timely diagnostics, treatment and care. Acute anxiety can have an underlying medical cause.

 When our 23-year-old college sophomore was asked: "How did you come to be hospitalized on our acute inpatient psychiatric unit?" he said, "When I telephoned my student health service and I said that I was suddenly very nervous and I could not sit still, they telephoned the hospital and they put me here. The first time I was examined was after I was put in bed here." The medical physical examination of our patient led to his sputum gram stain and chest X-ray, which led directly to his diagnosis of pneumonia. 

 A 42-year-old African American male was seen in ambulatory aftercare a month following a drinking binge stating, "Doctor, this will only take a moment. I only want my Antabuse [disulfiram] re-started, one-half a pill every Friday morning. I know that is all I need, because I only drink on weekends. Oh, and Doctor, I would like my dentures adjusted." The patient took no other medications regularly. There was no evidence of liver, cardiovascular, pulmonary, renal or diabetes disorders. The patient presented with his significant other who pledged to now watch and thank him for taking his weekly medication, and the patient pledged to thank his significant other for watching him take it. Further, the patient and his significant other pledged to begin, for the first time, 12-step work with sponsorship.

 This robust, muscular man was seen to have a soft tissue lesion on his lower lip.

 When I recommended surgical excision of his lower lip lesion, he said he was not worried about it because it did not hurt or bleed. "I just want my dentures adjusted," he repeated, "and I want to re-start my weekly Antabuse. Now can we get that done, Doctor?" I just sat quietly; not speaking, not moving, not writing, not typing, just maintaining eye contact with him and letting him and his significant other feel my concern for him as a person, as well as a patient. After a moment the patient said, "OK, Doctor, I will have it cut off of my lip, but also make sure that my dentures are adjusted and my weekly Antabuse is re-started!"

 The patient was provided with timely and definitive dental oral surgical treatment and care. Disulfiram was provided; 125 mg taken by mouth once a week every Friday morning, per the specific request of the patient and his significant other. The histopathologic report of his soft tissue lip lesion was squamous cell carcinoma, completely excised. The patient said he appreciated the adjustment of his dentures and the excision of the cancer on his lower lip. He thanked me for providing his "weekly Antabuse as one of his Tools of Recovery" (Grossman, 2001). Twelve-step work with sponsorship was recommended (and documented) for him and for his significant other to develop and use their Tools of Recovery.

 Our chemically dependent patients' needs may differ from their wants. The painless feature of his lip tumor led me directly to the diagnosis!

 A 49-year-old Native American woman was admitted to the inpatient psychiatry service to sleep off a drinking binge. On her second hospital day she complained of "belly discomfort."

 Her urinalysis was well within the reference ranges of our laboratory. Specifically, there were no red blood cells in the microscopic examination of her urinary sediment.

 Her belly ultrasound revealed a right kidney mass with no gallstones visualized.

Surgical operation and (tumor board) pathology.

 Her right kidney mass was surgically removed. Histopathologic examination revealed a carcinoma of her kidney, but there was no cancer invasion of her renal vein or renal capsule. The chief of surgery commented, "The kidney cancers that we cure are the ones which we find incidentally." The patient expressed her thanks for our timely diagnostics, treatment and care. Twelve-step work with sponsorship was recommended (and documented) to help her to develop and use her Tools of Recovery. Curable cancer may be found in our chemically dependent patients.

 The diagnosis of kidney cancer in this woman was an incidental finding. The kidney is normally difficult to assess on a medical physical examination. The absence of fever and of red blood cells in the patient's urine made the diagnosis of kidney malignancy more challenging. From this woman we relearn our limitations.

This review would appear to document that attention by addiction treatment team members to the baseline and periodic vital signs, including but not limited to computerized documentation of the pulse rate, blood pressure and temperature respiratory rate as well as attention to the baseline and periodic bedside physical diagnosis (Modai and Rabinowitz, 1993), including but not limited to the level of consciousness and the general appearance of the patient, ensures a high probability of definitive and timely identification and treatment of the medical and/or surgical issues found on an inpatient psychiatry service.

While it is generally appreciated that our chemically dependent patients may well be afflicted with chronic disorders, my focus in this paper is to address the issue of the diagnosis and treatment of the acute and potentially life-threatening disorders of these patients. Coordination of care may be best achieved by recognizing that:

Chemically dependent patients may well be medically as well as psychiatrically ill.

As with any patient admitted and hospitalized on a medical and/or surgical unit, chemically dependent patients require a reasonably complete history and physical examination.

Chemically dependent patients must be viewed as whole patients rather than simply labeled with tunnel vision as "just an addict" or "just a drunk." 

Last, and perhaps most important, counterphobia, when and if it occurs in health care providers, needs to be confronted and addressed.

Decades ago, "alcoholics" and "addicts" were provided with just halfway houses. Then, for a period of several decades, we provided residential inpatient chemical dependency units. Now, with the closing of our residential inpatient units and our return to just halfway houses (or in some instances, three-quarter travel-under-escort housing), we may have come full circle. This is just the time to approach our chemically dependent patients with renewed enthusiasm and intensity of purpose, to focus our history and physical examinations in order to identify both acute conditions and chronic conditions.

Our addiction treatment team meetings provide us with an opportunity to share our provider learning experiences with each other. Lessons we have learned include:

The value of our search for underlying medical issues.

The value of consultation with our fellow surgical providers.

The value of consultation with our fellow critical care providers.

The value of our ongoing search for curable malignancy.

The value of our endeavors to refocus our efforts on the medical needs of our patients.

The two core principles in the diagnosis, treatment and care of our chemically dependent patients would appear to be logic and humility. Decades ago, as an undergraduate at Johns Hopkins University, I learned to avoid the fallacy of "Post hoc, ergo propter hoc." Logic empowers me to search for any and all underlying, treatable, curable causes. Appropriate humility leads me to the realization that curable malignancy may well be discovered incidentally and that it may not be the initial primary focus of the patient, and my humility mandates my sitting down personally with every patient from whom and for whom we need to obtain written, witnessed operative procedure consent. After any surgical procedures my patients are encouraged to follow-up with me. This includes calling and writing to inform me of how they are doing. My patients know that I am concerned about them as people as well as patients. My patients and I also know that the best laboratory test is the second office visit. I recall the words of a dean spoken to the graduating class of a respected medical school in the South, "All you need to know after medical school is to remember to say, 'I don't know how to do thisPlease help me!'"

With the realization that our chemically dependent patients deserve the very best of our knowledge and experience, we can make all due reasonable efforts and attempts to "keep the medicine in psychiatry."

 Glassman AH, Shapiro PA (1998), Depression and the course of coronary artery disease. Am J Psychiatry 155(1):4-11.
 

 Grossman J (2001), Disulfiram-one tool of recovery. Psychiatric Times 18(8):1, 6-12.
 

 Modai I, Rabinowitz J (1993), Why and how to establish a computerized system for psychiatric case records. Hosp Community Psychiatry 44(11):1091-1095 [see comment].
 

 Musselman DL, Evans DL, Nemeroff CB (1998), The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Arch Gen Psychiatry 55(7):580-592.

What happens when a chemically dependent patient is in urgent need of timely medical and/or surgical interventions? According to one psychiatrist, logic and humility are two core principles essential to providing these patients with the care they deserve.

Detox Diagnostics -- Keeping Medicine in Psychiatry

At "Parents' Weekend" at a major university, I was informed, "Every year, universities are graduating more alcoholics than M.D.s and Ph.D.s combined!" Might our medical judgment render disulfiram (Antabuse) a reasonable medical consideration as one tool of recovery in the recovery program of an otherwise healthy alcohol-dependent university graduate?

The ideal candidate for disulfiram might well be physiologically young and vigorous; be on no other medications; have no evidence of cardiovascular, cardiopulmonary, hepatobiliary, renal or neurologic disorders or comorbid psychosis; have fully accepted the neuropsychiatric diagnosis of alcohol dependency with ongoing 12-step sponsorship and step work; have a caring significant other working a 12-step program of recovery to witness and affirm the disulfiram oral pharmacotherapy; and not be looking for a quick fix.

At the outset, it is fair and reasonable to endorse and accept that, at a nickel per tablet, there really is no money in disulfiram. I have personally spoken to the pharmaceutical company that manufactures disulfiram, and I have been informed that historically there has been little interest in promoting disulfiram since, from the pharmaceutical company's point of view, there is no money in the drug. From personal communications with my colleagues in the pharmaceutical industry, I am persuaded that over $300 million is spent to bring each new pharmaceutical from the research and development level to clinical use. Disulfiram is a quasi-historic, inexpensive pharmaceutical that may be better known and respected in our judicial system than in our health care delivery system.

I inform my alcohol-dependent patients that disulfiram has been in use prior to World War II. I inform my alcohol-dependent patients that disulfiram, at a nickel per pill, may be viewed as inexpensive. I inform my alcohol-dependent patients that drinking while on disulfiram may be fatal.

First and foremost, let me state that I personally adjust the dose of disulfiram for each patient. In general, given a patient who is chronologically and physiologically young with adequate nutrition, a reasonable dose may be one 250 mg tablet by mouth daily. For more senior patients with less than optimal nutrition, a reasonable dose may be 125 mg by mouth daily.

I provide a tablet splitter, along with patient education on the use of the tablet splitter, to my patients willing to take disulfiram. I recognize and inform my alcohol-dependent patients that liver failure has been described, albeit rarely, following the administration of disulfiram.

To reduce the severity of the expected side effects and the percent probability of a fatality from drinking while on disulfiram, I do not provide the "pre-World War II" 500 mg daily disulfiram dose and loading doses. Should my patients choose to drink alcohol after taking disulfiram, I do not want them to suffer nausea, vomiting, diarrhea, hypotension, chest pain, flushing and shock, which may occur and which may be fatal pursuant to drinking on disulfiram. Instead, I would hope that, at most, they experience only mild to moderate retching. I inform my alcohol-dependent patients and their families and/or significant others of this, and they accept and appreciate my empowering and considerate treatment and care.

According to the 1999 Physicians' Desk Reference and other sources (Barker et al., 1995; Carey et al., 1998), certain pharmaceuticals cannot and should not be taken with disulfiram:

Metronidazole (Metrolotion), which may produce an adverse reaction similar to alcohol and disulfiram;

Phenytoin (Dilantin), which may elevate the blood level of phenytoin toxicity; and

Warfarin (Coumadin), which may elevate the International Normalized Ratio/Prothrombin Time and produce bleeding.

I hesitate to provide disulfiram to my senior alcohol-dependent patients since 1) renal function decreases with age; 2) cardiovascular disorders increase with chronologic age; and 3) the risk of a fatal drinking-on-disulfiram reaction may be reasonably anticipated to increase with chronologic age (Dambro, 2000; Rowland, 1984).

I am cautious with disulfiram. If a 55-year-old patient states, "I have been on 250 mg disulfiram per day for a decade," I just might consider advising a reduction in dosage to 125 mg/day. I would rather not provide disulfiram to alcohol-dependent patients with comorbid psychosis, since mania has been described pursuant to the administration of disulfiram (Nasrallah, 2000).

I do not require my alcohol-dependent patients to take disulfiram; however, I have provided care for alcohol-dependent patients who said, "Doctor, I wish your program would just make me take it!"

I discourage -- strongly discourage -- family members of alcohol-dependent patients who want to sneak disulfiram into the soup or stew of the alcohol-dependent member of their family, even though I have been privileged to provide health care to recovering alcohol-dependent patients who were in strong favor of doing just that. Of course, ethically, I forbid such shenanigans, and instead, I encourage Alcoholics Anonymous (AA) for the actively drinking alcoholic and Al-Anon and Alateen for the family members and significant others. Their daily meetings, sponsorship and step work help them to develop and use the tools of recovery (AA World Service Office, 1986).

Compliance, with the notable exception of court-ordered disulfiram, may be suboptimal (Martin et al., 2000).

No family member or significant other of an alcohol-dependent patient should ever have to beg the patient to take disulfiram. If, and only if, the alcohol-dependent patient is ready, willing and eager to take the medically prescribed and provided disulfiram, then it may be reasonable for the parent, spouse, adult child or significant other to witness, affirm and validate the compliance by saying, "Thank you for taking your daily medication." In turn, the alcohol-dependent patient can choose to say, "Thank you for watching me take my daily medication." I was informed by one of my patients, "My wife places my disulfiram on the kitchen counter, and then she watches me take my disulfiram with my morning orange juice. Then I thank her for watching me take my medication." Another told me, "My wife stuffs my disulfiram all the way down my throat every night, and then she pours a big glass of water down my throat every night. I thank her."

Through personal communications with respected, reasonable addiction medicine provider teams, I have been informed that disulfiram may be a reasonable adjunct to an alcohol-dependent patient's recovery. These dedicated health care providers acknowledge that when it is used alone -- without 12-step work, addiction therapy group work or spiritual support -- disulfiram may be of no value toward a sustained recovery program. An analogy to antibiotics may be useful here. Given a college football player with fever, chills, rusty sputum, and imaging evidence on chest X-ray of pneumonia proven by gram stain to be pneumococcal and by culture to be sensitive to antibiotics, then the prescribed antibiotics would need to be accompanied by increased fluid intake and rest in order to be reasonably effective toward resolving the bacterial pneumonia and returning the student to pre-pneumonia level of college studies and football activities. Unlike antibiotics, there is currently no parenteral disulfiram yet!

Hard evidence for the efficacy of disulfiram is lacking. Nevertheless, in selected, motivated, alcohol-dependent patients who are working a program of recovery in AA and whose family and/or significant others are also working a program of recovery in Al-Anon or Alateen, disulfiram may be a reasonable tool of recovery. Respected addiction medicine providers liken disulfiram to both a cast on a fracture and a crutch to reduce weight-bearing on a fracture. A crutch and/or a cast, like disulfiram, provides one, and only one, tool of recovery; the alcohol-dependent patient and their family and/or significant others have to develop and use all of their tools of recovery.

There can and will be no broad recommendation of any new pharmacotherapy or new application of previous pharmacotherapy without more in the way of hard evidence than we currently appear to have when focusing on disulfiram. Nevertheless, the increased awareness of the impact of alcohol dependency on the lives of our patients, which may include some of our alcohol-dependent colleagues; the varying health care expectations of ethnic groups; the documentation of the effects of alcohol on the incidence of disorders, including cancer; the increased awareness of self-help groups; and the growing awareness of the role of spirituality in the lives of our alcohol-dependent patients may support a reasonable judgment in favor of a focused health care provision of disulfiram in selected recovering alcohol-dependent patients. Just as the digitalis preparations are used in selected patients with cardiovascular disorders and chemotherapeutic agents are used in selected patients with malignant disorders, disulfiram may have a place in the recovery of selected alcohol-dependent patients.

The risk of providing the digitalis preparations and chemotherapeutic agents needs to be balanced against the risk of not providing them. Likewise, the risk of providing disulfiram needs to be balanced against the risk of not providing it. A vast number of studies have shown, in carefully selected alcohol-dependent patients, providing disulfiram would appear to reasonably outweigh the risks involved (Granfield and Cloud, 1996; Sobell et al., 1996).

Alcoholics Anonymous World Service Office (1986), Alcoholics Anonymous. Center City, Minn.: Hazelden Publishing and Educational Services. 
 

Barker LR, Burton JR, Zieve PD, eds. (1995), Principles of Ambulatory Medicine, 4th ed. Baltimore: Williams & Wilkins.
 

Carey CF, Lee HH, Woeltje KF et al., eds. (1998), The Washington Manual of Medical Therapeutics, 29th ed. St. Louis: Lippincott-Raven.
 

Dambro MR (2000), Griffith's 5-Minute Consult. Baltimore: Williams and Wilkins.
 

Granfield R, Cloud W (1996), The elephant that no one sees: natural recovery among middle-class addicts. Journal of Drug Issues. 26(1):45-61.
 

Martin BK, Clapp L, Bridgeford DC et al. (2000), Compliance with court-ordered versus voluntary disulfiram therapy. NR583. Presented at the 153rd Annual Meeting of the American Psychiatric Association. Chicago; May 17.
 

Nasrallah HA (2000), Psychosis genotypes and phenotypes, diagnosis and treatment. No.29A. Presented at the 153rd Annual Meeting of the American Psychiatric Association. Chicago; May 16.
 

Rowland LP (1984), Merritt's Textbook of Neurology, 7th ed. Philadelphia: Lea & Febiger.
 

Sobell LC, Cunningham JA, Sobell MB (1996), Recovery from alcohol problems with and without treatment: prevalence in two population surveys. Am J Public Health 86(7):966-972.

When treating alcohol-dependent patients, clinicians may be well advised to integrate disulfiram into the treatment plan. Who are good candidates, and who are not? How can you enlist the aid of family members and friends to ensure compliance?

Joshua Grossman, MD

Articles

Detox Diagnosis--Keeping Medicine in Psychiatry

Detox Diagnostics -- Keeping Medicine in Psychiatry

Disulfiram -- One Tool of Recovery