Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Substance Abuse
Substance Abuse - Key Features
1. In all patients, and especially in high-risk groups (e.g., mental illness, chronic disability), opportunistically screen for substance use and abuse (tobacco, alcohol, illicit drugs).
2. In intravenous drug users:
a) Screen for blood-borne illnesses (e.g., human immunodeficiency virus infection, hepatitis).
b) Offer relevant vaccinations.
3. In patients with signs and symptoms of withdrawal or acute intoxication, diagnose and manage it appropriately.
4. Discuss substance use or abuse with adolescents and their caregivers when warning signs are present (e.g., school failure, behaviour change).
5. Consider and look for substance use or abuse as a possible factor in problems not responding to appropriate intervention (e.g., alcohol abuse in patients with hypertriglyceridemia, inhalational drug abuse in asthmatic patients).
6. Offer support to patients and family members affected by substance abuse. (The abuser may not be your patient.)
7. In patients abusing substances, determine whether or not they are willing to agree with the diagnosis.
8. In substance users or abusers, routinely determine willingness to stop or decrease use.
9. In patients who abuse substances, take advantage of opportunities to screen for co-morbidities (e.g., poverty, crime, sexually transmitted infections, mental illness) and long-term complications (e.g., cirrhosis).
Presentation and clinical features:
- - Substance use disorders are Axis I diagnoses and include two mutually exclusive sub-categories - substance abuse and substance dependence
Substance Abuse
When any 1 of A and both B and C are "yes," a definite diagnosis of abuse is made:
A. Has the client experienced the following?
- 1. Recurrent failure to meet important responsibilities due to use?
- 2. Recurrent use in situations when this is likely to be physically dangerous?
- 3. Recurrent legal problems arising from use
- 4. Continued to use despite recurrent problems aggravated by the substance use
B. These symptoms have occurred within a 12 month period
C. Client had never met the criteria for dependence
Substance Dependence
When any 3 of A, and B are "yes," a definite diagnosis of dependence is made:
A. Has the client experienced the following?
- 1. Tolerance (needing more to become intoxicated or discovering less effect with same amount)
- 2. Withdrawal* (characteristic withdrawal associated with type of drug)
- 3. Using more or for longer periods than intended?
- 4. Desire to or unsuccessful efforts to cut down?
- 5. Considerable time spent in obtaining, using, or recovering from the effects of the substance?
- 6. Important social, work, or recreational activities given up because of use?
- 7. Continued use despite knowledge of problems caused by or aggravated by use.
B. Have these symptoms been present during the same 12 month period?
* A clearcut withdrawal syndrome is not present with some classes of drugs: caffeine, phencyclidine, or hallucinogens.
- Acknowledge warning signs (e.g., school failure, behaviour change) and discuss substance use and abuse with adolescents and their caregivers
Differential diagnoses:
- Screen for substance use and abuse (tobacco, alcohol, illicit drugs) in all patients, and especially in high-risk groups (e.g., mental illness, chronic disability)
- Consider substance use or abuse when problems don’t respond to appropriate interventions (e.g., alcohol abuse in patients with hypertriglyceridemia, inhalational drug abuse in asthmatic patients, chronic disease)
- Grief
History-taking:
- Conduct multiple assessments over time (e.g. after 2 to 3 weeks of decrease in consumption) and use multiple assessment methods
- Be sensitive to consumers' concerns;
- Conduct the assessment when he/she is sober, drug-free and reasonably stable emotionally;
- Provide assurance of confidentiality;
- Establish a good rapport before asking for a lot of details;
- Use simple direct questions with clearly defined time frames;
- Do not aim for levels of specificity that exceed assessment goals;
- Frame questions to normalize different substance use patterns (e.g., many people have experimented with drugs? Have you ever had any experiences with.....?); and
- Verify the information as much as possible with other sources to converge on a consistent set of conclusions.
- Screen for co-morbidities (e.g., poverty, crime, sexually transmitted infections, mental illness, depression, anxiety, eating disorders) and long-term complications (e.g., cirrhosis)
- Assess family history of disorders
- Assess childhood variables (e.g., trauma, neglect, abuse)
- Assess natural history (i.e., onset, course, fluctuations, remissions)
- Assess patterns and severity of alcohol consumption (e.g., episodic vs. daily)
- Assess the effect of improvements
A detailed substance use history includes:
- the frequency and pattern of use;
- the level of dependence;
- the consequences that result.
- Get the full substance abuse history: (how old were they when they started ____? How did use of ______ change with time? How much ______ are they using now? Have they tried quitting ______ in the past? What were the results? Have they experienced withdrawal? How did that go?
- The best predictor of a substance use problem by the consumer was their perception that others were concerned about their substance use (70% sensitivity: 88% specificity; 76% positive predictive value; and 84% negative predictive value). It is cautiously recommended that the three following questions be used as potential Level I screening questions for substance use disorders. A positive response to any one question should indicate the need for further investigation:
- 1. Have you ever had any problems related to your use of alcohol or other drugs?
- 2. Has a relative, friend, doctor or other health worker been concerned about your drinking or other drug use or suggested cutting down?
- 3. Have you ever said to another person "No, I don't have [an alcohol or drug] problem, when around the same time, you questioned yourself and FELT, "Maybe I do have a problem?"
- Determine whether or not they are willing to agree with the diagnosis (assess stage of change) and routinely determine willingness to stop or decrease use
The "Stages of Change" identifies five stages in the change/recovery process:
• pre-contemplation is the stage at which there is no intention to change behavior in the foreseeable future;
• contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made the commitment to take action;
• preparation combines the intention to take action within the next month with lack of success in taking action during the past year;
• action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems;
• in maintenance, people work to prevent relapse and consolidate the gains attained during the action phase.
Motivational strategies for Behavioral Change:
| Stage | AIM | PLAN |
|---|---|---|
| Pre-Contemplation | • Encourage patient to consider change • Increase Pt’s awareness |
• Raise issue in sensitive manner • Offer neutral exchange of Info |
| Contemplation | • Understand Pt’s Ambivalence | • Offer opportunity to discuss pros and cons |
| Preparation | • Explore options and choose course most appropriate for pt • ID strategies for relapse |
• Offer realistic options for change • Discuss inevitable difficulties |
| Action | • Help pt design way to reward themselves • Develop strategies to prevent relapse |
• Offer positive reinforcement and explore ways to cope with obstacles |
| Maintenance | • Help Maintain motivation • ID high risk situations |
• Discuss progress and cues for impending relapse |
| Relapse | • View it as a learning experience • Provide support |
• Offer non-judgemental discussion about circumstances • How to avoid relapses in the future |
Physical Exam:
Diagnose signs and symptoms of acute intoxication vs withdrawal:
ABC checklist for a mental health status exam includes:
Appearance: General appearance, hygiene, and dress.
Alertness: What is the level of consciousness?
Affect: Elation or depression: gestures, facial expression, and speech.
Anxiety: Is the individual nervous, phobic, or panicky?
Behavior:
Movements: Rate (hyperactive, hypoactive, abrupt, or constant?).
Organization: Coherent and goal-oriented?
Purpose: Bizarre, stereotypical, dangerous, or impulsive?
Speech: Rate, organization, coherence, and content.
Cognition:
Orientation: Person, place, time, and condition.
Calculation: Memory and simple tasks.
Reasoning: Insight, judgment, problem solving.
Coherence: Incoherent ideas, delusions, and hallucinations?
Investigations and diagnostic work:
- Screen for blood-borne illnesses (e.g., HIV infection, hepatitis) in IV drug users
Management
- Treat the context of substance misuse
- Engage client in identifying and managing cues to misuse, practical problem-solving with emphasis on action and reliance on social supports, and resolving ambivalence about change
- Ensure client choice and tailor to the person's stage and motivation for change
- Offer relevant vaccinations in IV drug users
- Offer support to patients and family members affected by substance abuse
- Consider a harm reduction approach (e.g. flexible goals)
- Consider non-pharmacologic: Alcoholics Anonymous or equivalent, detox, treatment centre, rehab, psychotherapy
- Manage symptoms of withdrawal or acute intoxication (pharmacological symptom management which is highly disorder-specific – see below for proposed algorithms)
Proposed algorithm for the diagnosis of drug intoxication and withdrawal:
Drug-Transmitter Actions That Cause Symptom Complexes:
| Neurotransmitters: | ||||||
|---|---|---|---|---|---|---|
| Drug class: | GABA | 5-HTP | Norepinephrine | AcCH | β-Endorphin | Dopamine |
| Opiates | X | X | ||||
| Dissociatives | X | X | X | X | X | |
| Psychedelics | X | |||||
| Stimulants | X | X | ||||
| Alcohol, sedatives, tranquilizers | X | X | X | X | ||
Drugs of Abuse: Six Groups That Are Likely to Require Primary Care Medical:
| Drug class and members | Action on affected neurotransmitter | Neuroreceptors |
|---|---|---|
| Anticholinergics: Asthmador, Benztropine (Cogentin), Dimenhydrinate (Dramamine), Diphenhydramine (Benadryl), Hydroxyzine (Atarax), Locoweed |
Acetylcholine antagonists | Nicotinic and muscarinic |
| Dissociatives: Ketamine (Ketalar), Phencyclidine (PCP), Phenylcyclohexylpyrolidine (PHP) |
Affect actions of all neurotransmitters | All receptors |
| Opiates: Butorphanol (Stadol), Pentazocine (Talwin), Heroin, Hydromorphone (Dilaudid-Hp), Mesipramine, Methadone, Morphine |
β-Endorphin agonists | Κ μ |
| Psychedelics: Borneol, Lysergic acid diethylamide (LSD), Mescaline, Methylenedioxymeth-amphetamine (MDA), Psilocybin, Sufrole |
Serotonin agonists | 5-HT-2 |
| Sedative-hypnotics: Barbiturates, Ethchlorvinyl (Placidyl), Glutethimide (Doriden), Methaqualone, Zolpidem (Ambien), Benzodiazepines Ethyl alcohol |
GABA agonists Ethyl alcohol: GABA and opioid agonist |
GABA-A Benzodiazepines: GABA-A-α |
| Stimulants: Amphetamine, Cocaine Methamphetamine (Desoxyn), Methylphenidate (Ritalin) |
Dopamine, norepinephrine and serotonin agonists | DA-2, 5-HT-2, α and β |
Specific Treatment Based on Affected Neurotransmitter:
| Neurotransmitter: | Treatment: |
|---|---|
| Intoxication and overdose: | |
| Acetylcholine (anticholinergic) | Physostigmine (Antilirium) |
| β-Endorphin | Naloxone (Narcan) |
| Dopamine | Benzodiazepine Butyrophenone |
| GABA | Mechanical support |
| Norepinephrine | Beta blocker Benzodiazepine |
| Serotonin | Benzodiazepine |
| Withdrawal: | |
| β-Endorphin | Methadone Clonidine (Catapres) |
| Dopamine | Bromocriptine (Parlodel) |
| GABA | Barbiturate or benzodiazepine replacement |
| Norepinephrine | Desipramine (Norpramin) |
| Serotonin | Fluoxetine (Prozac) |
Study Guide
Resources
http://cfpc.ca/Low_Risk_Alcohol_Drinking_Guidelines/
http://www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/bp_disorder-mp_concomitants/screening-depistage-eng.php
http://fnih.investinkids.ca/?q=node/443
http://www.bcmhas.ca/Library/ClinicalStaffResources/MedicalLinks/LibBest.htm
http://www.aafp.org/afp/2000/0501/p2763.html#afp20000501p2763-f1
www.ProjectCork.org