When conducting a comprehensive substance use assessment, clinicians will ask patients about their use of many drugs including caffeine, nicotine, alcohol, cannabis, stimulants such as cocaine and crystal meth, opiates, hallucinogens, and party drugs like ecstasy or ketamine. Often times one will even ask about misuse of prescription or over the counter medications like Gravol or benzodiazepines or ADHD medications. However, chances are you haven't been asking about misuse of common household spices ... but new case studies and research suggests we should!
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While spices may not be commonly abused substances, they are legal, readily available, and are ideal recreational substances for those including youth, those in the prison system or even those who are under drug monitoring and are looking for a "legal high" as these spices cannot be identified with toxicology testing. 

"Clinicians often are unaware of a patient’s misuse or abuse of easily accessible substances such as spices, herbs, and natural supplements. This can lead to misdiagnosed severe psychiatric disorders and, more alarmingly, unnecessary use of long-term psychotropics and psychiatric services...

Acute nutmeg intoxication [for example] produces anxiety, fear, and hallucinations, and generally is self-limited, with most symptoms resolving within 24 hours. Chronic effects of nutmeg abuse resemble those of marijuana abuse."

To learn more about abuse of spices and their psychoactive effects, check out these two articles:

• "Out of the cupboard and into the clinic: Nutmeg-induced mood disorder" by Parthasarathi U, Hategan A and Bourgeois JA (Current Psychiatry).
• "Taking the spice route: Psychoactive properties of culinary spices" by Bourgeois JA, Parthasarathi U, and Hategan A (Current Psychiatry).  

If you've heard of the medication gabapentin before, you'll recall that it is most often used in the treatment of seizures as well as neuropathic pain.

However, addiction medicine specialists have been beginning to use the medication in the management of patients with alcohol use disorder, due to growing evidence that gabapentin, when used at moderate-high doses and compared to placebo, increases abstinence rate and days free of heavy drinking. In addition, studies also demonstrate that gabapentin can reduce withdrawal symptoms and aid in long-term recovery by reducing anxiety, insomnia, and cravings. 

The most common side effect of the medication is sedation and drowsiness. Doses tend to commonly range from 900-1800mg per day in TID divided dosing, but can be as high as 3600mg a day.
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To find out more, check out one of the RCTs that examined the utility of gabapentin for alcohol use disorder:
http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/1764009

Alcohol withdrawal is not an uncommon presentation in our healthcare system. From patients making ER visits to get help for withdrawal symptoms to patients with a history of heavy or chronic alcohol use being admitted to medical and surgical units where they experience abrupt cessation of their alcohol consumption, it is important that physicians of all specialties be able to determine an individual's drinking history and risk of alcohol withdrawal, as well as be able to manage the withdrawal syndrome accordingly.

While the CIWA protocol is the tool we are most familiar with in terms of assessing a patient's withdrawal symptoms and guiding treatment with medications, in the last few years a new assessment tool has been developed as a way to help providers distinguish between those who are at risk of developing more "complicated" forms of withdrawal that require more intensive monitoring and management, and which are more highly associated with morbidity, mortality, and healthcare resources.

The tool is known as PAWSS "Prediction of Alcohol Withdrawal Severity Scale", and provides physicians with guidelines of both clinical investigations to order and questions to ask patients, to determine one's risk of experiencing severe withdrawal including seizures and delirium tremens. Based on current literature, it is thought that the scale is both highly sensitive and specific, when a score threshold of 4 is used.
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To read more about the PAWSS tool, click here: 
http://alcalc.oxfordjournals.org/content/50/5/509.long

Catch up on all the news related to mental health and psychiatry from the last few weeks!

Put your knowledge and skills to the test with the case of Mr. R, a 19 year old, who presented to the ER with mutism, reduced oral intake, and ‪catatonia‬. His family tell you that these symptoms gradually developed over the last month after Mr. R began using a synthetic cannabinoid called "Spice".

Mr. R has no past psychiatric history, although there have been new psychosocial stressors in his life recently. Mr. R has used marijuana in the past and experienced paranoia while using this substance.

What investigations would you order? How would you treat this patient?

"Unresponsive and mute after he smokes 'Spice'" by David R Williams, Brian J Miles, Aniket Tatugade, Ranjan Avasthi, and Peter F Buckley (Current Psychiatry).

Put your knowledge and skills to the test with the case of Mrs. M, a 37 year old woman, who two weeks after an admission to hospital following an overdose where she received treatment for rhabdomyolysis and multi-organ system failure, returns to hospital and is diagnosed with ‪‎catatonia‬. During her admission, she develops fever, tachycardia, and increased rigidity and is presumed to have malignant catatonia. She undergoes multiple courses of ‪ECT‬ and clinically improves, but is noted to have persistent word-finding difficulties.

Her medical and psychiatric history includes type 2 diabetes, ‪#bipolar‬ disorder, and opioid, ‪‎cocaine‬, and ‪‎alcohol‬ use disorders. Her medications include gabapentin and paroxetine.

What is your differential diagnosis? What work-up would you order for this patient?

"Malignant catatonia and aphasia follow multiple drug overdose" by Neeta Shenai, Crystal White, Pierre Azzam, Priya Gopalan, and LalithKumar K. Solai (Current Psychiatry).

Put your knowledge and skills to the test with the case of Mr. D, a 23 year old male, who presents with new-onset ‪psychosis‬ with auditory and visual ‪hallucinations‬ and ‪catatonia‬ 10 days after taking 2C-B, a new designer drug. Specifically, Mr. D reported that he and his friends obtained 2C-B off the internet, and while his friends recovered well after using the drug, Mr. D instead has been decompensating. He reported abruptly quitting his job and thinking he is in alien in a spaceship over the last few days.

While his family and friends report that Mr. D has been acting strange, sleeping only 2-3 hours a night and talking rapidly since the use of the drug, they deny any other recent stressors in his life. They report that Mr. D is an Ivy-League educated man and has no significant medical or psychiatric history, and no family history of psychiatric disorders. About 1 month ago however, Mr. D began to smoke marijuana daily.

What is your differential for this patient? What work-up would you order? How would you treat his psychosis and catatonia?

"Psychosis and catatonia after dancing with a dangerous partner" by Surbhi Khanna, Jordan Rosen, Derek Blevins, and Pamila Herrington (Current Psychiatry)

Put your knowledge and skills to the test with the case of Mr. N, a 48 year old gentleman, who has a longstanding psychiatric history involving multiple admissions to hospital for bipolar disorder, and ‪‎schizophrenia‬. He has been tried on numerous medications, however he is often non-compliant with treatment, which results in delusions and disorganized thoughts. He has been ‪‎homeless‬ for much of his life, has cellulitis of both legs and chronic venous stasis, and has obsessive-compulsive and paranoid personality traits.

Most recently, Mr. N was arrested for possession of ‪#cocaine‬, and was placed in jail where his mental status deteriorated further. He was declared incompetent to stand trial and was transferred to a psychiatric facility. He denies any suicidal or homicidal ideation, and fails to show signs of perceptual disturbances, however he does have poor insight and judgment.

What work-up do you think Mr. N requires to investigate his deteriorating mental status? What's on your differential and how would you manage this case?

"Malnourished and psychotic, and found incompetent to stand trial" by Patel R.R, Hornstra R, Munro S, and Dellenbaugh T (Current Psychiatry).

In "Waking Up Naked", a second heartfelt and moving poem from Michael Lee, we learn more about Lee's personal history of alcoholism‬, ranging from the humorous and seemingly harmless memories to those that are darker and more dangerous. Lee's poem also touches on the impact his drinking had on his family, and what it feels like to be sober now. As Lee has shared with his followers in the past "I need to continue to write about addiction and insanity not because those things are hugely present in my life any longer, but specifically because they are not. I seek to understand my past in as many ways as can, so I never have to return to it, or so it does not return to me".

Most especially, Lee's poem is a powerful reminder to be mindful of those who are overcoming addiction‬, and more conscientious before we label those who are fighting to maintain sobriety as "weak" or "lame".

"Don't you dare call me weak
I have swallowed more pints of regret than you pump blood through your body.

Tell my father it was boring
to look his only son in the eyes
and tell him if he drank one more time
you would not be welcomed in this house.

Tell my mother I am weak
She failed to hold back tears, driving me home from the psych ward
She would see her son handcuffed to an emergency room bed
She spent four years praying for my sobriety nightly
You will not take this from her."