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Clinical Summary

Substance use disorders (SUDs) are highly prevalent in the United States, with a 2017 national survey estimating that 7.2% of individuals over the age of 12 had a diagnosable SUD in the previous year.

Clinical presentation of SUD varies by substance. Skin manifestations of injectable illicit drug use include needle track marks and excoriations on the extremities, neck, and genitals. In patients with chronic injectable illicit drug use, lesions in various stages of healing overlying a background of chronic skin changes with hypo- and hyperpigmented scarring may be present. Patients presenting with long-term methamphetamine use may exhibit dental erosions associated with dry mouth and long periods of poor oral hygiene. Epistaxis in the setting of acute or chronic cocaine may represent nasal septal perforation.

FIGURE 27.12

Needle Track Marks. Track mark ecchymoses is seen in the patient’s nondominant hand along the length of the visible dorsal veins. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 27.13

Needle Track Marks. Needle track mark ecchymoses from intravenous heroin use on the patient’s right thigh along the visible veins. (Photo contributor: R. Jason Thurman, MD.)

FIGURE 27.14

Skin Abscess from Intravenous Drug Use. Warmth, tenderness, swelling, and redness over the antecubital fossa at the site of intravenous drug use likely due to unclean needles, unclean technique, or drug extravasation. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 27.15

Skin Abscesses from Skin Popping. Acute complications of skin popping include abscess, cellulitis, folliculitis, and chronic erosions and are seen here. (Image appears with permission from VisualDx [].)

When a SUD is suspected, immediate medical complications of the presenting SUD must be excluded. The patient’s comorbid psychiatric and medical conditions, their perception of their condition, and identification of barriers reducing their substance abuse is paramount. Specific clinical manifestations vary by substance but may include cardiovascular (endocarditis), pulmonary (septic pulmonary emboli, e-cigarette– or vaping-associated lung injury), infectious (necrotizing fasciitis), dermatologic, neurologic (stroke), psychiatric (mood disorders), hematologic, and pregnancy-related (neonatal abstinence syndrome) complications.

Management and Disposition

Specific interventions should address the presenting toxidrome and immediate complications in acutely ill patients: benzodiazepines for those presenting with agitation and aggression, naloxone for those presenting with respiratory depression, and further interventions to specifically address the bodily system affected by the substance abused. For stable patients deemed to be a danger to self or others or those seeking detoxification and rehabilitation for ongoing substance use and abuse, a medical screening examination is warranted prior to psychiatric evaluation.

FIGURE 27.16

Skin Abscess and Scarring from Skin Popping. Skin abscess and chronic scarring are seen ...

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