The role genetics plays in the disease.
The gene that is essential for the emergence of opiate addiction is the receptor MOP-r gene (OPM1), which is the main target of opioids (Genereaux, 2019). Opioid addiction is more common in those with an OPM1 variant. Opiate drugs have stronger effects because of their higher substrate affinity. Nonetheless, the genetics of opiate addiction is influenced by both heredity and nurture. While certain natural mutations increase a person’s susceptibility to opiates, the environment can also encourage genes that especially contribute to the overuse of opiates (Genereaux, 2019).
Why the patient is presenting with the specific symptoms described.
This patient is exhibiting signs of soft tissue necrosis and hyperkalemia; it is probable that he is suffering from rhabdomyolysis as a result of a drug overdose with an unidentified downtime. Rhabdomyolysis is the result of muscles breaking down quickly and releasing intracellular materials (Kumar et al., 1999). In this instance, the patient’s full weight being directly compressed into a hard surface and the resulting decreased blood circulation led to the breakdown of skeletal muscle fibers and tissue necrosis over the left greater trochanter and forearm (Bigham, 2017).
The physiologic response to the stimulus presented in the scenario and why you think this response occurred.
In rhabdomyolysis, the breakdown of the muscle cell’s plasma membrane, or sarcolemma, results in a change in the sodium-potassium gradients that permits an excess of potassium to enter the bloodstream. Due to the hyperexcitability of the heart muscle, hyperkalemia alters the EKG; sustained depolarization inactivates sodium channels, lengthening the PR interval. Furthermore, hyperkalemia causes peaked T waves because it raises action potential and reduces repolarization because of the ventricular sensitivity to potassium (McCance & Huether, 2019). This patient’s gangrenous necrosis is another symptom of rhabdomyolysis. Cell death, or necrosis, can happen when damage to a cell becomes irreversible (Bigham, 2017). Gangrenous necrosis is a severe hypoxic damage that usually results from a blood flow obstruction, like the patient’s weight resting against his forearm and hip.
The cells that are involved in this process.
Although distinct genetic materials can influence the characteristics and functions of cells, there does not appear to be a genetic component to this patient’s particular physiological reaction to rhabdomyolysis. Gene deficiencies resulting in the lack of certain enzymes, such as myophosphorylase, carnitine, lactate dehydrogenase, or myoadenylate deaminase, can cause rabdomyolysis (McCance & Huether, 2019).
How another characteristic (e.g., gender, genetics) would change your response.
If the patient had been a woman instead of a man, the evaluation of the case would still not have changed. Although men are more likely than women to experience rhabdomyolysis (Cabral et al., 2020), a female’s gender would not influence the cellular changes that occur in pathophysiology.
References
Bigham, B. (2017). Are you considering crush injury in narcotic overdoses? Emergency and Mobile Medicine Learning Network. Retrieved from https://www.hmpgloballearningnetwork.com/site/emsworld/article/12317524/are-you- considering-crush-injury-in-narcotic-overdoses.
Cabral, B. M., Edding, S., Portocarrero, J., & Lerma, E. (2020). Rhabdsomyolysis. Disease-a- Month, 66(8). https://doi.org/10.1016/j.disamonth.2020.101015
Genereaux, N. M. (2019). The Opioid Crisis: Biological, Psychological and Sociological Factors in the Etiology and Future Mitigation of Opioid Addiction.
Kumar, R., West, D. M., Jingree, M., & Laurence, A. S. (1999). Unusual consequences of heroin overdose: rhabdomyolysis, acute renal failure, paraplegia and hypercalcaemia. The British Journal of Anaesthesia, 83(3), 496–498.
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.
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Guadalupe Angie Ruelas
Nov 28, 2023 7:58pm
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Last reply Dec 2, 2023 10:51am
Reply from Guadalupe Angie Ruelas
Week 1 discussion :
Case study
A 27-year-old patient with a history of substance abuse is found unresponsive by emergency medical services (EMS) after being called by the patient’s roommate. The roommate states that he does not know how long the patient had been lying there. The patient received naloxone in the field and has become responsive. He complains of burning pain over his left hip and forearm. Evaluation in the ED revealed a large amount of necrotic tissue over the greater trochanter as well as the forearm. EKG demonstrated prolonged PR interval and peaked T waves. Serum potassium level 6.9 mEq/L.
Response
To my understanding the patient is most likely experiencing rhabdomyolysis which can be defined as muscle tissue breakdown which leads to the release of muscle cells into the bloodstream. Matsusue et al (2011) states that “there is a possibility that rhabdomyolysis can be triggered by fragility of muscular cells or a reduction in the metabolism of a causative agent, such as methamphetamine”. Since the patient reacted to naloxone, we can say he was under some sort of substance. then cells being affected. with this disease are the muscle cells.
McCance & Huether (2019) states that rhabdomyolysis may cause a number of serious side effects, such as hyperkalemia (from the release of intracellular potassium into the blood), metabolic acidosis (from the release of intracellular phosphorus and sulfate), acute renal failure (myoglobin precipitates in the tubules, obstructing flow through the nephron and causing injury), and even disseminated intravascular coagulation (DIC) (brought on by activation of the clotting cascade by sarcolemma damage and release of intracellular components from the injured muscles). The patient is experiencing the prolonged PR interval and peaked T waves from the hyperkalemia. The burning pain over his left hip and forearm and necrotic tissue is due to muscle cell contents being released into the bloodstream, irritating surrounding tissues and causing severe muscle damage. The patients present with the following symp0toms due to several factors including possible trauma since he was found on the floor and substance abuse.
If the patient would have had a genetic family history of muscle related diseases in his family, we could possibly attribute the muscle damage to the genetics itself. Matsusue et al (2011) mention that “ion channel mutations may cause further muscle phenotypes, including progressive myopathies, altering muscle structure, thereby highlighting a significant role of ion channels in muscle cell division, proliferation, differentiation, and survival”.
References
Matsusue, A., Hara, K., Kashiwagi, M., Kageura, M., Sugimura, T., & Kubo, S. (2011). Genetic analysis of the rhabdomyolysis-associated genes in forensic autopsy cases of methamphetamine abusers.
Legal Medicine
,
13
(1), 7–11. https://doi.org/10.1016/j.legalmed.2010.08.007
McCance, K. L. & Huether, S. E. (2019).
Pathophysiology: The biologic basis for disease in adults and children
(8th ed.). St. Louis, MO: Mosby/Elsevier.
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Joseph Costa
Nov 28, 2023 7:21pm
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Last reply Dec 1, 2023 6:29pm
Reply from Joseph Costa
CASE STUDY:
A 27-year-old patient with a history of substance abuse is found unresponsive by emergency medical services (EMS) after being called by the patient’s roommate. The roommate states that he does not know how long the patient had been lying there. The patient received naloxone in the field and has become responsive. He complains of burning pain over his left hip and forearm. Evaluation in the ED revealed a large amount of necrotic tissue over the greater trochanter as well as the forearm. EKG demonstrated prolonged PR interval and peaked T waves. Serum potassium level 6.9 mEq/L.
All conditions affect the body on a cellular level. High potassium interferes with the cell’s ability to move sodium and potassium across the membrane causing depolarization. The cell membrane cannot function when outside of the optimal range causing the cell to become less effective, if effective at all. Ischemia causes lack of nutrients, oxygen, and ability to remove waste from cells. The substances being used by this individual can be causing an inflammatory response causing the body to attack healthy cells through the immune response. It all comes down to the cells ability to produce ATP, synthesize proteins, and regenerate. Disruptions to this process cause abnormalities resulting in cellular death.
Genetics plays a broad role in most disease processes. Genetics refers to the susceptibility or resistance of any given environmental factor. Whether a disease progresses or not, can be determined by individual genetic makeup. Differences in response to medications can be influenced by genetics. It’s possible for individuals to carry and pass on genetic traits without showing symptoms themselves. Genetic testing can be done to predict the likelihood of developing certain diseases.
Genetics can influence the body’s response to substances and its ability to process and eliminate them. Certain genetic predispositions may affect the metabolism of drugs, leading to toxic build up and complications like hyperkalemia. In this case, if there’s a genetic disposition affecting the kidney’s ability to regulate potassium, it could exacerbate the condition.
The symptoms could be a result of substance abuse leading to prolonged immobility, causing pressure sores and tissue damage. It could also be the substance being used, it could be having a necrotic effect on the tissue itself. The cardiac symptoms are indicative of hyperkalemia , affecting cardiac muscle contractility.
The high potassium level affects the electrical activity of the heart, leading to abnormal EKG findings. The prolonged PR interval and peaked T waves are classic findings in hyperkalemia, reflecting the high potassium on cardiac cells.
Muscle cells are directly affected by high potassium levels, altering their electrical and functional properties. Skin and subcutaneous tissue cells are involved in necrosis due to prolonged pressure and possible ischemia.
Gender and genetics can influence the presentation and severity of these symptoms. For example, genetic differences in potassium channels or drug metabolism enzymes could alter the severity of hyperkalemia and cardiac effects. Additionally gender differences in body composition and cardiovascular responses could influence the presentation and progression of symptoms.
These conditions affect the body on a cellular level. High potassium interferes with the cell’s ability to move sodium and potassium across the membrane causing depolarization. The cell membrane cannot function when outside of the optimal range causing the cell to become less effective, if effective at all. Ischemia causes lack of nutrients, oxygen, and ability to remove waste from cells. The substances being used by this individual can be causing an inflammatory response causing the body to attack healthy cells through the immune response. It all comes down to the cells ability to produce ATP, synthesize proteins, and regenerate. Disruptions to this process cause abnormalities resulting in cellular death.
References:
Lin SH, Yang SS, Chau T. A practical approach to genetic hypokalemia. Electrolyte Blood Press. 2010 Jun;8(1):38-50. doi: 10.5049/EBP.2010.8.1.38. Epub 2010 Jun 30. PMID: 21468196; PMCID: PMC3041498
NIDA. 2023, March 22. New NIH study reveals shared genetic markers underlying substance use disorders. Retrieved from https://nida.nih.gov/news-events/news-releases/2023/03/new-nih-study-reveals-shared-genetic-markers-underlying-substance-use-disorders on 2023, November 27
McCance, K. L. & Huether, S. E. (2019).
Pathophysiology: The biologic basis for disease in adults and children
(8th ed.). St. Louis, MO: Mosby/Elsevier.
Chapter 2: Altered Cellular and Tissue Biology: Environmental Agents (pp. 46-61; begin again with Manifestations of Cellular Injury pp. 83-97); Summary Review
Potential complications of IV drug use
. Potential Complications Of IV Drug Use | Semel Institute for Neuroscience and Human Behavior. (n.d.). https://www.semel.ucla.edu/dual-diagnosis-program/News_and_Resources/Potential_Complications_Of_IV_Drug_Use
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Brooke Hurst
Nov 28, 2023 5:15pm
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Last reply Dec 2, 2023 6:22pm
Reply from Brooke Hurst
Main Posting Response:
The Role Genetics Play
Scientists have discovered through data taken from over 1,000,00 people that genes are commonly inherited across addiction disorders, regardless of the substance being used. Substance use disorders are inheritable by complex genes and multiple environmental factors. (NIDA 2023) Through a lot of research, it has been found that genomic patterns can predict whether a person will have a genetic predisposition to substance use disorders. However, I do not believe that genetics lead to the necrosis that the patient had suffered or hyperkalemia.
Symptom Presentation, Physiologic Response, and Cells
Narcan is an opioid antagonist, meaning that it attaches to the opioid receptors in the brain and blocks the effects of the opioids being used. (NIDA 2022) This could explain why the patient began to complain of the pain that was associated with the necrosis on the left hip and forearm. When it comes to the necrosis in the hip, we can assume that the tissue had became infected and died via autolysis. After research into causes of these symptoms, we can also assume that the patient is in a state of rhabdomyolysis. Rhabdomyolosis can be drug induced and can lead to the interference of ATP production, leading to the death of the tissue. (Cabral et, al. 2020) One of the symptoms of rhabdomyolysis includes hyperkalemia. With the destruction, ATP depletion causes intracellular calcium to increase. The plasma membrane of the cells is supposed to exchange calcium for potassium. The increased number of calcium, leads to the inability to exchange the appropriate amount of potassium, leading to hyperkalemia. (Cabral et, al. 2020) According to many studies, hyperkalemia can lead to noticeable EKG changings. With the change in the potassium level, there is change in the electrical gradient across the membranes of the cell. This can lead to increased usage of the cardiac muscles and rapid repolarization of the ventricles, leading to peaked T-Waves on the EKG. (Parham et. all, 2006)
Other Characteristics
It would be interesting to know how long the patient has been unconscious prior to EMS arriving and administering the narcan. Something else that may change the outcome of my thought process would be to know how long the necrotic tissue had been there prior to the patient overdosing. Could it had been caused by a used needle, which lead to infection? How long had the patient been in active use prior to this event? I am unsure that the sex of the individual would change my response to the scenario.
Cabral, B. M., Edding, S. N., Portocarrero, J. P., & Lerma, E. V. (2020). Rhabdomyolysis.
Disease-a-Month
,
66
(8), 1–21. https://doi.org/10.1016/j.disamonth.2020.101015
NIDA (2022).
Naloxone Drug Facts
. https://nida.nih.gov/publications/drugfacts/naloxone
NIDA (2023).
New NIH Study Reveals Shared Genetic Markers Underlying Substance Use Disorders
. https://nida.nih.gov/news-events/news-releases/2023/03/new-nih-study-reveals-shared-genetic-markers-underlying-substance-use-disorders
Parham, W. A., Mehdirad, A. A., Biermann, K. M., & Fredman, C. S. (2006). Hyperkalemia revisited.
Texas Heart Institute journal
,
33
(1), 40–47.v
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Andrea M Ward
Nov 28, 2023 2:59pm
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Last reply Dec 2, 2023 6:07pm
Reply from Andrea M Ward
Initial Post: Andrea Ward
Scenerio :A 27-year-old patient with a history of substance abuse is found unresponsive by emergency medical services (EMS) after being called by the patient’s roommate. The roommate states that he does not know how long the patient had been lying there. The patient received naloxone in the field and has become responsive. He complains of burning pain over his left hip and forearm. Evaluation in the ED revealed a large amount of necrotic tissue over the greater trochanter as well as the forearm. EKG demonstrated prolonged PR interval and peaked T waves. Serum potassium level 6.9 mEq/L.
The role genetics plays in disease.
Substance abuse has a complex etiology which is influenced by many things. Genetic factors can play a large role in an individual’s susceptibility to substance abuse in several ways. Certain genetic variations may increase the risk of developing substance use disorders. These genetic factors can influence the brain’s reward pathways, making some individuals more susceptible to the reinforcing effects of drugs. For example, “Genes that code for cytochrome enzymes in the liver (CYP variants) can influence how quickly an individual metabolizes a drug, which influences how they respond to medications and other substances” (Mosel,2023). Variations in drug metabolism enzymes can influence the intensity and duration of the drug’s effects. Therefore, a person with a genetic predisposition for slower metabolism of a particular substance may experience more prolonged and intense effects, potentially increasing the risk of substance abuse.
Why the patient is presenting with the specific symptoms described.
The patient was found to be unresponsive with an unknown amount of downtime lying on the floor. The patient is unresponsive due to the toxic levels of the drugs in the body which surpasses the body’s ability to metabolize and eliminate it. The substance which was taken by the patient caused respiratory depression and lack of oxygen to the brain as well as other organs. After the Naloxone was given the patient complained of burning over his left hip and forearm. The ED evaluation revealed that the patient had a large among of necrotic tissue over his hip and The burning pain and necrotic tissue are a result of vasoconstriction and tissue hypoxia caused by increased intracellular calcium. The EKG shows prolonged PR interval and peaked T- waves. The peaked T- waves are an indicator of high potassium. Which is correlated with the serum potassium of 6.9 meq/ml.
The physiologic response to the stimulus presented in the scenario and why you think this response occurred.
Opioids suppress the respiratory system. Leading to slow and shallow breathing, or respiratory arrest. The patient may become hypoxic due to his inability to ventilate himself properly. Which leads to his decreased level of consciousness. Due to his inability to ventilate and oxygenate himself properly the body naturally delivers the oxygen first to the main organs. When muscle and tissues do not get enough oxygen the membrane structure deteriorates and causes cell death. His body is going through rhabdomyolysis. According to the Cleveland Clinic (n.d), during rhabdomyolysis the muscles breakdown and deteriorate into your blood. This includes large amounts of Potassium, Phosphate, Myoglobin, Creatinine Kinase, and urate. Since the Kidneys are responsible for removal of these components from your blood, thru urine. The inability of the kidneys to function properly causes kidney damage, electrolyte abnormalities, and metabolic acidosis. Necrosis happens when there is a “rapid loss of plasma membrane structure, organelle swelling mitochondrial dysfunction and lack of typical features of apoptosis” (McCance, K. L. & Huether, S. E. (2019). So, the lack of oxygenation to the cells caused the cells to breakdown and auto digest. Due to the membrane integrity being lost, the necrotic cell contents leaked out into the tissue.
The inability to excrete Potassium led to the 6.9 meq/ml of potassium in the blood and the peaked T-waves. T waves represent repolarization of the ventricles. During repolarization there is movement of the potassium ions into the cell. Therefore, the peaked T-waves are due to delayed repolarization from excess amount entering the cell.
The cells that are involved in this process.
In an opioid overdose, the primary cells involved in the physiological response are neurons in the brain and spinal cord. Opioids bind to specific opioid receptors which inhibit the release of certain neurotransmitters. According to Rameriez et. al, Opioid receptors are plentiful in the brainstem, specifically in the medulla oblongata. The medulla oblongata is critical for controlling autonomic functions such as respiration and cardiovascular activity. By administering the naloxone, it reversed the effects of the opioid by binding to those receptors. Waking the patient up.
Skeletal muscle cells are the main cells involved in rhabdomyolysis. These cells make up the skeletal muscles, which are under voluntary control and are responsible for body movement. When these cells become damaged or injured, the contents of the muscle cells, including myoglobin’s, get released into the bloodstream. Myoglobin, which is found in muscle cells, is responsible for storing and transporting oxygen. When the muscle cells are damaged, myoglobin is released into the bloodstream. High levels can lead to kidney damage, as the kidneys can struggle to filter and excrete a large amount of this protein.
How another characteristic (e.g., gender, genetics) would change your response.
If the patient were female, the scenario might differ. This is because men generally exhibit a greater muscle mass. Consequently, rhabdomyolysis could potentially result in more severe cases in men compared to women, given their elevated muscle mass. “The incidence of rhabdomyolysis is higher in males than in females, especially in the subgroups of patients with trauma and inherited enzyme deficiencies” (Morales De Guzman, 2021). Understanding the individual’s medical history, including any gender-specific risk factors, can guide the diagnostic and management approach of rhabdomyolysis.
References
Cleveland Clinic. (n.d.).
How do I know if I have rhabdomyolysis?
. Rhabdomyolysis. https://my.clevelandclinic.org/health/diseases/21184-rhabdomyolysis
McCance, K. L. & Huether, S. E. (2019).
Pathophysiology: The biologic basis for disease in adults and children
(8th ed.). St. Louis, MO: Mosby/Elsevier.
Morales De Guzman, M. (2021, October 16).
Rhabdomyolysis
. Practice Essentials, Background, Pathophysiology. https://emedicine.medscape.com/article/1007814-overview?form=fpf#a5
Mosel, S. (2023, August 29).
Is drug addiction genetic?
. American Addiction Centers.
https://americanaddictioncenters.org/rehab-guide/addiction-genetic
Links to an external site.
Ramirez, J. M., Burgraff, N. J., Wei, A. D., Baertsch, N. A., Varga, A. G., Baghdoyan, H. A., Lydic, R., Morris, K. F., Bolser, D. C., & Levitt, E. S. (2021). Neuronal mechanisms underlying opioid-induced respiratory depression: our current understanding.
Journal of neurophysiology
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(5), 1899–1919. https://doi.org/10.1152/jn.00017.2021
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Oluwatosin Adeyemo
Nov 28, 2023 1:46pm
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Last reply Dec 3, 2023 7:03pm
Reply from Oluwatosin Adeyemo
The role genetics plays in the disease.
The role that genetics can play in the case study is that, given the patient’s family history, there could be an element of substance abuse linked to the patient’s family lineage. Due to the predisposition to substance abuse, the individual in the case study was more likely to have chronic drug use.
Why the patient is presenting with the specific symptoms described.
The rationale behind some of the symptoms that the patient is undergoing can be attributed to various reasons. One of the issues is the patient’s potassium levels in the blood. Potassium is an essential electrolyte in cardiac contraction and performance(McCance & Huether, 2019). However, the excess buildup in the blood can cause electrical dysrhythmias in the heart. This would explain why the patient has prolonged PR intervals and PTS due to the distribution of appropriate electrical Conduction of the SA, AV, and bundle of his and Purkinje fibers(McCance & Huether, 2019). In addition, the patient could have developed elevated potassium due to the possible extended downtime. We are unsure how long they were on the floor until they received medical attention. Rhabdomyolysis can occur when an individual is on the ground for a prolonged period, which causes musculoskeletal breakdown (Meng et al., 2023). When this occurs, muscle proteins from the breakdown travel through the blood, and once they reach the kidneys, acute kidney damage can occur, causing ineffective filtration and elimination and buildup of electrolytes such as potassium (Meng et al., 2023).
The physiologic response to the stimulus presented in the scenario and why you think this response occurred.
The physiological response that occurs in this scenario happened to this individual for several reasons. Because they used the naloxone on the individual, there is a possibility that what they may have overdosed on is an opiate. In addition to that, the burning necrotic tissue found in the left forearm and left hip area, coupled with the fact that the individual is a substance user, leads me to believe that these necrotic sites are from IV drug insertion. Necrotic and infected tissue can be linked to substance use, especially if the insertion equipment is not clean, reused, and administered in an unsterile manner(Peyrière et al., 2013).
The cells that are involved in this process.
The cells involved in this scenario are the cardiac muscles as well as the electrical pathways of the heart. Due to the necrosis, skin cells are also damaged depending on how deep the closest is. It could affect the dermis epidermis hypodermis, if not more profound, such as musculoskeletal tissue.
Lastly, the cells in the kidneys are also affected if the individual is undergoing Rhabdomyelitis (McCance & Huether, 2019).
References
McCance, K. L. & Huether, S. E. (2019).
Pathophysiology: The biologic basis for disease in adults and children
(8th ed.). St. Louis, MO: Mosby/Elsevier.
Meng Y, Zhou M-X, Wu C-B, Wang D-H, Zhao J-R, Shi D-Y. Continuous venovenous hemodiafiltration versus standard medical therapy for the prevention of rhabdomyolysis-induced acute kidney injury: a retrospective cohort study.
BMC
nephrology
. 2023;24
(1):215. doi:10.1186/s12882-023-03242-x
Peyrière H, Léglise Y, Rousseau A, Cartier C, Gibaja V, Galland P. Necrosis of the Intranasal Structures and Soft Palate as a Result of Heroin Snorting: A Case Series.
Substance Abuse
. 2013;34
(4):409-414. doi:10.1080/08897077.2013.781565
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Catrina Michelle Grant
Nov 27, 2023 6:13pm
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Last reply Dec 2, 2023 7:42pm
Reply from Catrina Michelle Grant
Pathophysiology explains the cause for all diseases, conditions, ailments, etc. It is a means of getting to the root cause of a health problem which also shows us how to correct the deficiency. In this case study, I noticed many systems impacted by the patient’s actions. As opioid abuse continues to be a rising epidemic, the correlating rise in these fatalities are very concerning. Drug overdoses seem obvious on the surface, but the pathophysiology of how this unfortunate adverse effect occurs is quite complex. In this discussion post, I will show the correlation between genetics and addiction, explain the reasoning behind the symptoms mentioned in this case study, the body’s physiologic response, the cells and systems involved and variables that could present a different outcome for the patient.
Role genetics plays in the disease
Nature vs nurture shows that sometimes role our genetics plays gravely supersedes our environment, but not always. Genetic and environmental influences both contribute to addiction, in this case genetics carries the responsibility. For instance, the 5-HTTLR gene, MAOA gene, and the CRHR1 genes are all inherited (Jiang et al., 2023). These are genes responsible, in some way, for the serotonin transfer that is contributes to addiction being passed from one generation to the next. It is estimated that nearly thirty-six million people suffer from substance abuse disorders, currently. 11.7% of those age twelve or older admit to some type of illicit drug use at some point in their lives (CDC, 2022). Heritability accounts for up to 75% of substance abuse and dependency (CDC. , 2022). Stressful life events play a significant role in altering an individuals normal mental health status. When the mental health status is negatively affected, the likelihood of substance abuse exponentially increases.
Why is the patient presenting with the specific symptoms.
With the Narcan treatment being effective in the field in helping the patient to regain consciousness and given the other symptoms he experienced, it is safe to assume his emergency was an opioid drug overdose. Overdoses are a type of chemical injury, an injury in which a cell is exposed to a toxin. In this case, the patient’s affected cells were not able to adapt to the injury which resulted in cellular necrosis of his hip and arm (). IV drug users often experience this due to missing the vein or deterioration of the vascular system in the affected extremities due to repetitive needlesticks. It causes an interruption in the plasma membrane which ultimately prevents protein synthesis and ATP generation resulting in cellular death. In this case, the cellular death manifested itself as necrosis. The effects of the opioid receptor agonism on his cardiovascular system are multifactorial (2023). Usage of illicit drugs in an amount large enough to cause an overdose will affect the polarization of the heart’s atrium and ventricles. This increases the depolarization and repolarization of the SA node, also known as the pacemaker of the heart, thus causing the tachycardia present on his initial assessment (Schiller et al., 2023). With the increased pulse the patient is at increased risk for cardiac tamponade, which is only heightened by his elevated potassium level. Opioid receptor activation enhances the smooth muscle contractility of the potassium channel while inhibiting the calcium channel which, in turn, presents as an elevated potassium level (Schiller et al., 2023).
The physiologic response to the stimulus presented in the scenario and why this response occurred.
I determined that the patient was experiencing an overdose of an opioid of some classification. An overdose occurs when a person has excessive unopposed stimulation of the opiate pathway which decreases the respiratory effort and can cause death (Haynes & Mihailoff, 2018). This is because the opioid acts as a potent antagonist against the mu receptor. The result is a euphoric feeling as it releases dopamine in the brain and blocks pain signals. The mu receptor controls multiple bodily functions such as analgesia, euphoria, respiratory depression, and physical dependence. In the process of an overdose, they are responsible for a decreased medullary response from the medulla oblongata (Iodanova & Reddivari, 2018). This impaired response of this vital part of the brain controls many involuntary functions in the body such as breathing. In essence, opioids block the firing of synapses to and from the medulla which results in a decreased stimulus to breathe and causes apnea. This is why the patient was found unresponsive due to a slowing of involuntary bodily functions when the level of CO2 in his blood became too high (Leader, 2023). He likely went into hypercarbic respiratory failure as a result.
The cells that are involved in this process.
Opiates bind to receptors on nerve cells in the body (Schiller et al., 2023). In normal dosing, they block the pain receptors, but slow your breathing, digestion and heartbeat. In the case of an overdose, they can have an opposite effect on the cardiovascular system. The nerve receptors most affected are a group of proteins, G protein-coupled receptors. These cells are activated inside the nerve cells at the surface. They induce nanobody signaling of the golgi apparatus and the golgi outposts (2018).
How another characteristic (e.g., gender, genetics) would change your response.
If the patient has fewer risk factors, either modifiable or nonmodifiable, my answers would vary slightly. Given there was no genetic predisposition to chemical dependency, the statistics are remarkably diminished . If the user were to not be alone, the risk for an overdose related event would likely decrease as well, given the co-user remains lucid enough to alert EMS. If the user were female, the risk for overdose is tripled as compared to the male counterpart (APA, 2023). All other answers would not change as opioid overdose have a consistent manner of absorption and its relating affects despite genetics, gender, etc. Age related changes makes it more likely that the opiate will cross the blood-brain barrier which can intensify the effects more rapidly and cause a poorer prognosis (CDC, 2019).
In summation, opioid drug overdoses affect a diverse population. Regardless of if it is prescribed or illicit, opioid substance abuse can have grave consequences, including death. Prescriptions should only be taken as prescribed and illicit drugs should be avoided by everyone. Help should be sought for anyone experiencing an addiction to or dependency on opiates before it’s too late. The patient in this case study was fortunate in that emergency medical services were alerted prior to complete suppression of his respiratory drive.
Jiang, Z., Chen, Z., & Chen, X. (2023). Candidate gene-environment interactions in substance abuse: A
systematic review. PLoS ONE, 18(10), 1–31.
https://doi.org/10.1371/journal.pone.0287446
Links to an external site.
Overdose. Addiction Center. (2023, October 26).
https://www.addictioncenter.com/drugs/overdose/
Links to an external site.
Schiller EY, Goyal A, Mechanic OJ. Opioid Overdose. [Updated 2023 Jul 21].
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470415/
Links to an external site.
Haines DE, Mihailoff GA. The Medulla Oblongata. Fundamental Neuroscience for Basic and Clinical
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Expand discussion thread from Catrina Michelle Grant
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Rosy Ofili
Nov 27, 2023 4:36pm
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Last reply Dec 2, 2023 11:24pm
Reply from Rosy Ofili
The scenario presented involves a 27-year-old patient with a history of substance abuse who was found unresponsive and subsequently treated with naloxone. The patient complains of burning pain over the left hip and forearm, and upon evaluation, necrotic tissue is identified over the greater trochanter and forearm. Additionally, the patient exhibits an EKG with a prolonged PR interval and peaked T waves, along with a serum potassium level of 6.9 mEq/L.
The role genetics plays in the disease
.
In the context of this scenario, there may be a
genetic predisposition to the patient’s susceptibility to substance abuse
. Genetic factors can influence an individual’s vulnerability to addiction through various mechanisms, including the regulation of neurotransmitter pathways and the response to external stimuli such as drugs. Genetic variability can affect drug metabolism, receptor sensitivity, and the overall neurobiological response to substances of abuse, contributing to the development of substance use disorders (McCance & Huether, 2019).
Why the patient is presenting with the specific symptoms described.
The patient’s presentation with burning pain and necrotic tissue over the left hip and forearm suggests a potential complication known as rhabdomyolysis (Cabral et al., 2020). Substance abuse, particularly opioids, can lead to prolonged immobility and pressure on specific body parts, resulting in ischemia and subsequent tissue necrosis. Rhabdomyolysis involves the breakdown of skeletal muscle tissue, releasing myoglobin and other intracellular contents into the bloodstream, leading to tissue damage and potential renal impairment (Cabral et al., 2020). The burning pain is likely a manifestation of the ischemic insult to the affected areas.
The physiologic response to the stimulus presented in the scenario and why you think this response occurred.
The prolonged PR interval and peaked T waves on the EKG, along with the elevated serum potassium level (6.9 mEq/L), are indicative of hyperkalemia (Palmer et al., 2021). Opioid toxicity, as seen in this case, can lead to the inhibition of the sympathetic nervous system, causing a release of acetylcholine. This excess acetylcholine can lead to hyperkalemia by promoting the shift of potassium out of cells. The resultant elevation in serum potassium levels can lead to cardiac conduction abnormalities, manifesting as the observed EKG changes.
The cells that are involved in this process.
Rhabdomyolysis involves the breakdown of skeletal muscle cells (Cabral et al., 2020). The release of intracellular contents, such as myoglobin, can overwhelm the kidneys, potentially leading to acute kidney injury. Additionally, the cardiac conduction abnormalities observed in the EKG involve cells of the cardiac conduction system, specifically affecting the atrioventricular (AV) node and the myocardium.
How another characteristic (e.g., gender, genetics) would change your response.
Another characteristic that could influence the response is the specific substance or substances abused. Different substances have varying effects on the body, and the pharmacogenetics of drug metabolism may vary among individuals. Gender may also play a role, as there can be differences in drug metabolism and susceptibility to certain complications. Furthermore, the presence of any underlying genetic cardiac conditions could exacerbate the observed EKG abnormalities (Palmer et al., 2021).
In conclusion, the presented scenario involves a complex interplay of substance abuse, rhabdomyolysis, and opioid toxicity, with genetic factors potentially contributing to the patient’s susceptibility to substance abuse. The resulting pathophysiology includes tissue necrosis, hyperkalemia, and cardiac conduction abnormalities, highlighting the intricate connections between genetic predisposition, substance abuse, and organ system dysfunction (McCance & Huether, 2019).
References:
Cabral, B. M. I., Edding, S. N., Portocarrero, J. P., & Lerma, E. V. (2020). Rhabdomyolysis.
Disease-a-Month
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(8), 101015.
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier
Muzyk, A., Smothers, Z. P., Collins, K., MacEachern, M., & Wu, L. T. (2019). Pharmacists’ attitudes toward dispensing naloxone and medications for opioid use disorder: a scoping review of the literature. Substance abuse, 40(4), 476-483.
Palmer, B. F., Carrero, J. J., Clegg, D. J., Colbert, G. B., Emmett, M., Fishbane, S., & Weir, M. R. (2021). Clinical management of hyperkalemia. In Mayo Clinic Proceedings (Vol. 96, No. 3, pp. 744-762). Elsevier.
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