The Internet may represent a new mechanism by which adolescents initiate the use of illicit substances. The existence of multiple partisan websites providing misinformation regarding the safety of these substances may lead to an increase in unsafe behavior among this age group. Adverse outcomes related to Internet-based drug information are rarely identified. We report a case of an adolescent whose use of the Internet to obtain drug information led to severe poisoning from the combination of a monoamine oxidase inhibitor, harmaline, and a hallucinogenic tryptamine, 5-methoxydimethyltryptamine (5-MeO-DMT).
While opioids remain a valid and effective analgesic strategy for patients suffering from a wide variety of painful conditions, they are not a panacea. Increasingly, physicians must balance patient expectations of adequate pain control with known limitations of opioid pharmaceuticals including adverse effects, tolerance, addiction, withdrawal, and drug diversion. Further complicating the issue over the last decade is a growing body of evidence suggesting chronic opioid use may unexpectedly worsen the perception of pain in some individuals. This syndrome, termed opioid-induced hyperalgesia (OIH), fundamentally changes our understanding of opioid pharmacodynamics and may influence our approach to management of chronic pain. This manuscript describes the concept OIH and provides an overview of basic science and clinical research to date attempting to characterize this syndrome, as well as ascertain its clinical relevance. The potential existence of OIH in humans is framed within the context of our current understanding of opioids and our prescribing patterns so that physicians may begin to incorporate these ideas into their philosophy of pain management as further information develops. Animal studies reliably validate OIH in controlled models. Rigorous research protocols in humans are lacking, and we cannot yet confidently conclude that OIH manifests in clinically significant ways. However, clinicians should consider the possibility of OIH when evaluating outcomes of patients on chronic opioid therapy.Keywords Opioids . Hyperalgesia . Opioid-induced hyperalgesia . Chronic pain
Current Opioid ParadigmPhysicians regularly prescribe opioids for control of moderate to severe pain in the acute care setting. This includes administration in emergency, outpatient, and inpatient environments for patients suffering from a variety of acute and chronic painful conditions. Our current paradigm for opioid utilization suggests they provide effective analgesia for short-term use in most patients. Unfortunately, the risk of adverse effects or addiction is not rare and may be difficult to accurately quantify [1]. Regular prescription of opioids also occurs in the long-term care setting for patients with cancer-related pain offering effective pain relief and limited concern for addiction. However, long-term use of opioids for treatment of certain chronic conditions such as back pain, fibromyalgia, or neuropathic pain syndromes sparks more debate regarding therapeutic efficacy, adverse effects, and potential for misuse, abuse, and diversion of prescription opioids. Concerns regarding opioid use for patients with chronic non-cancer pain may relate to a subset of these patients who require significant dose escalation over time, visit multiple providers seeking opioid prescriptions, and report insufficient pain relief despite high dose therapy. These scenarios generate several concerns including the possibility that chronic opioid administration may be an ineffective strategy for long-term analgesia. Emerging evidence suggests t...
We report two cases of olanzapine-induced mental status changes treated with physostigmine. The utility of physostigmine as a safe or necessary antidote in the setting of olanzapine overdose remains to be determined.
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