Alcohol and Drug Abuse as Encountered in Office Practice

Frank L. Iber

• Publisher: CRC Press
• Year: 2020
• ISBN:
  9781000144406
• Edition: 1
• Topic: Kunst
• Subtopic: Kulinarische Künste

This book has been written to serve as a manual for physicians practicing in a private office setting to recognize and recommend appropriate treatment for patients believed to be substance abusers. While it is not written for drug abuse specialists, it provides information regarding the diagnosis and treatments a competent, concerned physician can provide without becoming immersed in addiction treatment. Topics discussed include the degree to which a physician should become involved, when it is appropriate to refer, using other professions and volunteer groups, and useful medications. Guidelines for recognizing substance abuse, testing to confirm the abuse, confronting the patient, and motivating the patient into specific treatment are also presented. Tables and illustrations are used to summarize major points, making this an extremely useful reference tool for internists and other non-specialist private practitioners.

Chapter 1

Introduction to Abused Substances

I. INTRODUCTION

Addictive substances that are important to primary-care physicians in several different ways are presented briefly in this chapter and covered in much more specific detail later. Table 1 indicates ways in which addictions affect a doctor’s patients.

Clearly the physician, by training and disposition, will undertake the management of some of these problems (such as the chronic obstructive lung disease of cigarette smoking), but may not choose to treat some of the psychiatric emergencies (such as panic or hallucinosis) and will appropriately refer such patients. The American Medical Association (AMA) has developed guidelines as to the responsibilities of the physician in such situations, and these guidelines are discussed in a later section of this chapter.

No physician can avoid patients who use addictive substances. Caffeine addiction will not be discussed in this book because it is so ubiquitous and creates very few health problems. Assisting patients with cessation of smoking is a common practice of physicians, and the health problems resulting from smoking and from alcohol abuse exceed by far the problems produced by all other addictions combined. Some 90% of American adults use alcohol at least monthly, and at any time from 5 to 15% are abusers. At least 15% of Americans under age 40 use an illicit drug at least monthly, but only a small fraction of these are addicted. Modest use of tobacco, almost always in the form of cigarette smoking, exceeds abuse, but more than 20% of adults in all states except Utah use tobacco.¹

TABLE 1
Impact of Addiction on Practice Decisions

1. Health-related toxicities of the addiction 2. Emergencies related to the addiction 3. Conditions often associated with addiction 4. Problems encountered during withdrawal 5. Aberrant responses to medication 6. Responsible requests to stop the addiction 7. Addictions in family members producing health problems in your patient

TABLE 2
Classification of Substances of Abuse

Class	Major members	Problems*
Sedatives	Alcohol, sedatives, hypnotics, anxiolytics	I, W, H
Caffeine	Caffeine, a few others, theophylline	I
Marijuana	Hashish	I, D
Amphetamines	Amphetamines, cocaine	I, W, D
Opiates		I, W, H
Nicotine	Tobacco	W
Hallucinogens	LSD, mescaline	I, P
Inhalants	Glue, ether, toluene	I, P
PCP		I, D, P

* I = intoxication, W = withdrawal, H = health problems, D = delirium, P = psychosis.

Throughout this book we will classify abused drugs into the broad groups outlined in Table 2.

II. HEALTH-RELATED TOXICITIES

Every physician is familiar with the coronary, vascular, and pulmonary problems associated with chronic cigarette smoking and with the cirrhosis of the liver associated with alcohol, which facts emphasize that different drugs have different health effects. Nearly all physicians are familiar with the endocarditis and abscesses in strange locations associated with use of nonsterile intravenous drugs and with the human immunovirus (HIV) and hepatitis B infections associated with shared intravenous needles.

The panic reactions associated with use of marijuana, hallucinogens, PCP, and solvents are less familiar. Although alcohol and opiate withdrawal are well publicized, many physicians have no clear plan for management of these difficulties in their own offices and have not thought about specific criteria for recommending hospitalization. Chronic organic brain syndrome is known to most physicians as a consequence of alcohol abuse, but it is also a consequence of every group of drugs except perhaps marijuana.

III. EMERGENCIES

Schuckit delineates a priority system using initial physical examination to guide physicians in addressing the most urgent problem first. In his scheme,² severely compromised vital signs are most important; only when these are stable at acceptable levels can one address signs or symptoms of withdrawal. If the vital signs are in an acceptable range for safety and there is no withdrawal, then confusion can be addressed. If none of these problems are present but there are hallucinations and/or delusions without insight, this represents a psychosis. Schuckit’s scheme thus offers a straightforward method for prioritizing emergencies and deciding where and how to care for them.

TABLE 3
Medical Conditions Associated with Drug Addiction

Common to all	Depressants
Increased trauma	Overdose, psychosis
Increased suicide	Organic brain syndrome
Malnutrition	Withdrawal
Common to all i.v. use	Stimulants
Hepatitis, AIDS	Overdose, psychosis
Endocarditis, abscesses	Hallucinogens
Common to all smoking	Panic reactions
Allergic bronchitis	Opiates
Emphysema	Overdose, withdrawal
Alcohol	Phencyclidine (PCP)
Cirrhosis, pancreatitis	Overdose
Brain injury, withdrawal	Neuritis

Other urgent patients have panic reactions, “dry drunks,” or flashbacks, which are discussed in Chapters 10, 17, 18, and 20.

IV. CONDITIONS FREQUENTLY ASSOCIATED WITH ADDICTIONS

Table 3 lists some of the common medical problems associated with specific substances of abuse; a great deal more detail is presented in the subsequent chapters of this book.

V. PROBLEMS DURING WITHDRAWAL

Alcohol and opiates produce the most marked withdrawal reactions, with reactions to other sedatives being infrequently encountered but of similar severity. Withdrawal reactions occur only after tolerance has developed. There is biochemical adaptation to the chronic presence of the drug, as a part of tolerance development associated with increase in the rate and intensity of use. As the drug is removed, the unopposed addicted person has manifestations in all systems of the body. The autonomic nervous system, muscles, and central nervous system participate in these reactions. Multiple receptor systems are overactive during withdrawal, but particularly prominent features of hyperactivity of the norepinephrine, dopaminergic, and gababenzodiazepine receptors occur.

The setting for withdrawal to occur starts with sufficient regular use of the agent to produce biochemical adaptation or tolerance. In a tolerant person the same amount of drug produces less effect. For some agents this involves increased numbers of receptors, for others altered rates of production of neurotransmitters. To attain identical effects the user must increase the dose, frequency of use, or both, and this constitutes tolerance and is the setting for withdrawal.

For withdrawal to occur in such a susceptible...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication
• Acknowledgment
• Preface
• The Author
• Table of Contents
• Chapter 1 Introduction to Abused Substances
• Chapter 2 Terminology, Definitions, Classification of Abused Substances, and Diagnostic Criteria
• Chapter 3 The Molecular Basis of Action of Abused Substances
• Chapter 4 Etiology of Substance Abuse and Similarities in Alcoholism and Drug Abuse
• Chapter 5 Essential Pharmacology of Abused Drugs
• Chapter 6 Issues of Law and Custom
• Chapter 7 Attitudes Among Medical Staff That Influence Substance Abuse Care
• Chapter 8 Obtaining an Accurate Drug and Alcohol History
• Chapter 9 Recognizing the Alcoholic or Substance-Abusing Patient in Your Practice
• Chapter 10 Emergencies in Drug and Alcohol Use and Their Management
• Chapter 11 Laboratory Screening and Verification of Drug Use
• Chapter 12 Cost-Effective Screening of Addicted Persons for Significant Illness
• Chapter 13 Classes of Drugs Needed for the Successful Management of Addictions
• Chapter 14 Informing the Patient of the Diagnosis of Abuse and Motivating Him or Her to Treatment
• Chapter 15 What Can be Learned from Smoking and Nicotine Addiction
• Chapter 16 Alcohol and Sedatives
• Chapter 17 Medical Problems in Alcoholics
• Chapter 18 Psychiatric Problems in Addicts
• Chapter 19 Opium Derivatives
• Chapter 20 Medical Problems Related to Illicit Drugs
• Chapter 21 Cocaine and Amphetamines
• Chapter 22 Marijuana
• Chapter 23 Hallucinogens and Phencyclidine
• Chapter 24 Miscellaneous Abused Drugs
• Chapter 25 Mixed Drug Abuse
• Chapter 26 Management of Substance Abuse — What is Treatment and What Does it Accomplish?
• Chapter 27 Drug Withdrawal: Recognition and Treatment
• Chapter 28 Entering Treatment
• Chapter 29 Professionals and Others Providing Skilled Services to Substance Abuses
• Chapter 30 The Range of Treatment and Rehabilitation Programs; Factors in the Selection of an Appropriate Program
• Chapter 31 Setting and Meeting Realistic Goals for Rehabilitation
• Chapter 32 Volunteer Groups in the Treatment of Addictions; The Model of Alcoholics Anonymous
• Chapter 33 Crises in Treatment
• Chapter 34 Prevention and Pertinent Public Health Issues
• Chapter 35 Special Problems of Substance Abuse in Adolescence
• Chapter 36 Special Problems in Women Abusers
• Chapter 37 Problems of Addiction During Pregnancy and Problems in the Child
• Chapter 38 Children of Alcoholics and Drug Abusers
• Chapter 39 Problems of Alcohol and Drug Use in the Elderly
• Chapter 40 Ethnic and Special Social Groups
• Chapter 41 Substance Abuse Among Health Professionals
• Glossary
• Index