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Azithromycin
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Methadone
Metronidazole
Oseltamivir
Supportive therapy
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This patient, who presents with a flu-like prodrome as well as diarrhea, vomiting, and mydriasis in the setting of opioid use, most likely has opioid withdrawal. The most appropriate long-term management of opioid dependence and withdrawal is methadone. Opioid withdrawal presents with myalgias, arthralgias, rhinorrhea, diarrhea, nausea, vomiting, restlessness, piloerection, lacrimation, and mydriasis. When these symptoms are seen in the setting of chronic opioid use and repeated requests for prescription refills, opioid use disorder should be suspected. The most appropriate therapy for reducing opioid use is methadone. Other options for managing opioid use disorder include buprenorphine, which is a partial mu-receptor agonist, but it can precipitate withdrawal in a patient who is actively using opioids. Patients with opioid use disorder should also be prescribed naloxone in order to reverse potentially fatal overdoses.Ferrari et al. review the evidence regarding the diagnosis and treatment of opioid use disorder. They discuss how methadone is important in the treatment of this disorder. They recommend monitoring the pharmacokinetics in order to avoid withdrawal.Figure/Illustration A is a clinical photograph demonstrating an eye with prominent findings of mydriasis (red circle). These findings are consistent with opioid withdrawal.Incorrect Answers: Answer 1: Azithromycin would be appropriate therapy for pneumonia caused by Mycoplasma. This patient has no pulmonary findings or history suggestive of pneumonia, such as fever or productive cough. Pneumonia would not present with mydriasis.Answer 3: Metronidazole covers for anaerobic organisms and could be appropriate additional coverage for an aspiration pneumonia.Answer 4: Oseltamivir is appropriate therapy for influenza within the first 48 hours, which can present similarly to opioid withdrawal. This patient’s history of opioid use and mydriasis suggests a diagnosis of opioid withdrawal.Answer 5: Supportive therapy would be inappropriate as this patient’s opioid dependence should be managed to avoid further dependence and drug-seeking behavior.Bullet Summary: Opioid use disorder and withdrawal can be managed long-term with monitored methadone treatment.
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