Suspected Substance Withdrawal in Adolescents — History and Physical Exam — Clinical Pathway: Inpatient

Suspected Substance Withdrawal in Adolescents Clinical Pathway — Inpatient

History and Physical Exam

History

  • Adolescents often have good insight into their problem and diagnosis is most often made through history
  • Assess signs and symptoms of withdrawal
  • These can occur 4-72 hrs following last use depending on the substance
  • General Signs and Symptoms of Withdrawal

Review Risk Identified on Screening Tools

ED Behavioral Health Screen: Use Media Tab in EHR found on desktop only to review results if completed

Administer Screening to Brief Intervention (S2BI) and CRAFFT Assessment Tool 2.1+N

S2BI

  • Validated screening tool that helps categorize substance use by adolescent patients into different risk categories
  • Ordering provider completes this during history and physical exam

CRAFFT 2.1 +N

  • Cars, Relax, Alone, Forgetting, Friends, Family, Trouble – Validated screen to identify/predict problematic substance use for ages 12-21 yrs
  • CRAFFT 2.1 includes evidenced based revisions and includes vaping as method of marijuana use
    CRAFFT 2.1+N has additional questions about tobacco and nicotine use
  • Ordering provider completes this during history and physical exam, CRAFFT Assessment Tool
Substance History
  • Substance(s) Ingested
    • Amount
      • e.g., dosage, number of pills, amount of liquid
    • Route(s)
      • e.g., aspiration, ingestion, inhalation
    • Age at first use, longest duration of abstinence
    • Blackout or overdose
  • Risk of Poly-substance Exposure
    • General inventory of prescription and home over-the-counter medications
    • Location, accessibility of additional chemicals, toxins, substances in the home
  • Alcohol Use
    • How much, how often, how many days per week
    • Types of drinks consumed
      • Beer, wine, hard liquor, energy drinks with alcohol
    • Number of drinks during each instance
      • Binge drinking: males ≥ 5, females ≥ 4
  • Benzodiazepine, Opioid Use
    • e.g., Xanax “bars,” “percs,” etc.
    • How many days per week
  • Assess Withdrawal Symptoms
    • History of Symptoms when not using
      • e.g., agitation, tremor, sweats, vomiting, or seizures
    • Identify last drinking, benzodiazepine, or opioid use
Social/Behavioral History
  • Identify Potential Social Concerns
    • Developmental/chronological age with ingestion history, note inconsistencies
    • Current/prior involvement of patient/family with child protection agencies
    • Substance use disorder and/or treatment in adolescent’s care environment
    • Caregiver concerns about patient’s safety
  • Review Behavioral Health Implications
    • Ingestion with intent to self-harm, including suicidal ideation or intent
    • History of substance use disorder
    • History of mental health disorder
Past Medical History
  • Pre-existing Conditions
    • Hepatic or renal failure
    • Metabolic disorder that may impact drug pharmacokinetics
      • e.g., absorption, metabolism, clearance, excretion

Physical Exam

Withdrawal Signs
  • HR, BP, RR, T, O2 saturation
  • Mental status
    • Clouding of sensorium, disorientation, agitation, anxiety
  • Diaphoresis, tachycardia, elevated blood pressures
  • Seizures
Skin
  • Stigmata of injection
    • e.g., needle or tourniquet
  • Evidence of self-harm
    • e.g., cutting, burning, scratching
Full Physical Exam, Including Neurologic Toxidromes and Substance Effects