The prevalence of alcohol disorders is 16-28%, and the prevalence of drug disorders is 7-9%. Alcoholism is character- ized by impaired control over drinking, preoccupation with alcohol, use of alcohol despite adverse consequences, and distortions in thinking (denial). Substance abuse is a pattern of misuse during which the patient maintains control. Addiction or substance dependence is a pattern of misuse during which the patient has lost control.
I.Clinical assessment of alcohol use and abuse A.The amount and frequency of alcohol use and other drug use in the past month, week, and day should be deter- mined. Whether the patient ever consumes five or more drinks at a time (binge drinking) and previous abuse of alcohol or other drugs should be assessed.
B.Effects of the alcohol or drug use on the patient's life may include problems with health, family, job or financial status or with the legal system. History of blackouts, motor vehicle crashes, and the effect of alcohol use on family members or friends should be evaluated.
Clinical Clues to Alcohol and Drug Disorders
Social history
Arrest for driving under the influence
Loss of job or sent home from work for alcohol- or drug-related reasons Domestic violence Child abuse/neglect
Family instability (divorce, separation)
Frequent, unplanned ab- sences
Personal isolation Problems at work/school Mood swings
Medical history
History of addiction to any drug Withdrawal syndrome Depression Anxiety disorder Recurrent pancreatitis Recurrent hepatitis Hepatomegaly Peripheral neuropathy Myocardial infarction at less than age 30 (cocaine) Blood alcohol level greater than 300 mg per dL or greater than 100 mg per dL
Alcohol smell on breath or intoxicated during office visit Tremor
Mild hypertension Estrogen-mediated signs (telangiectasias, spider angiomas, palmar erythema, muscle atrophy) Gastrointestinal complaints Sleep disturbances Eating disorders Sexual dysfunction
DSM-IV Diagnostic Criteria for Substance Depend- ence
A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by 3 or more of the following occurring at any time during the same 12- month period.
Tolerance, as defined by one of the following:
• A need for markedly increased amounts of the sub- stance to achieve intoxication of the desired effect. • Markedly diminished effect with continued use of the
same amount of the substance.
Withdrawal, as manifested by one of the following:
• The characteristic withdrawal syndrome for the sub- stance.
• The same, or a closely related, substance is taken to relieve or avoid withdrawal symptoms.
• The substance is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use. • Substance use is continued despite knowledge of hav-
ing a persistent or recurrent physical or psychologic problem that is likely caused or exacerbated by the substance.
II.Laboratory screening
A.Mean corpuscular volume. An elevated mean corpus- cular volume (MCV) level may result from folic acid deficiency, advanced alcoholic liver disease, or the toxic effect of alcohol on red blood cells. MCV has poor sensitivity for predicting addiction.
B.Gamma-glutamyltransferase. The sensitivity of GGT for predicting alcohol addiction is higher than that of MCV, but its specificity is low.
C.Other liver function test results may be elevated because of heavy alcohol consumption, including aspartate aminotransferase (AST) and alanine aminotransferase (ALT). These markers have low sensitivity and specificity. An AST/ALT ratio greater than 2:1 is highly suggestive of alcohol-related liver disease.
D.Carbohydrate-deficient transferrin (CDT). Consump- tion of 4 to 7 drinks daily for at least 1 week results in a decrease in the carbohydrate content of transferrin.The sensitivity and specificity of CDT are high.
III.Alcohol intoxication. Support is the main treatment for alcohol intoxication. Respiratory depression is frequently the most serious outcome. Unconscious patients should receive thiamine intravenously before receiving glucose. IV.Alcohol withdrawal. Treatment consists of four doses of chlordiazepoxide (Librium), 50 mg every 6 hours, followed by 3 doses of 50 mg every 8 hours, followed by 2 doses of 50 mg every 12 hours, and finally 1 dose of 50 mg at bedtime.
Signs and Symptoms of Alcohol Withdrawal Withdrawal is characterized by the development of a combi- nation of any of the following signs and symptoms several hours after stopping a prolonged period of heavy drinking:
1. Autonomic hyperactivity: diaphoresis, tachycardia, elevated blood pressure
2. Tremor 3. Insomnia 4. Nausea or vomiting
5. Transient visual, tactile, or auditory hallucinations or illu- sions
6. Psychomotor agitation 7. Anxiety
8. Generalized seizure activity
Management of Alcohol Withdrawal
Clinical Disorder Mild/Moderate AWS, able to take oral Mild/Moder ate AWS, unable to take oral Severe AWS Adrenergic Hyperactiv- ity Lorazepam (Ativan) 2 mg po q2h or Chlordiazepox- ide (Librium) 25-100 mg po q6h Lorazepam 1-2 mg IM/IV q1-2h as needed Lorazepam 1-2 mg IV q 5-10 min
Dehydration Water or juice po NS 1 liter bolus, then D5NS 150- 200 mL/h Aggressive hydration with NS /D5NS Nutritional Deficiency Thiamine 100 mg po Multivitamins Folate 1 mg po Thiamine 100 mg IV Multivita- mins 1 amp in first liter of IV fluids Folate 1 mg IV in first liter of IV fluids Thiamine 100 mg IV Multivitamins 1 amp in first liter of IV fluids Folate 1 mg IV in first liter of IV fluids Hypoglycem ia High fructose solution po 25 mL D50 IV (repeat as neces- sary) 25 mL D50 IV (repeat as necessary) Hyperthermi a Cooling blan- kets Seizures Lorazepam (Ativan) 2 mg IV Lorazepam 2 mg IV Lorazepam 2 mg IV
V.Sedative-hypnotic withdrawal. Establishment of physical dependence usually requires daily use of therapeutic doses of these drugs for 6 months or higher doses for 3 months. Treatment of withdrawal from sedative-hypnotics is similar to that of withdrawal from alcohol; chlordiazepoxide (Librium) and lorazepam (Ativan) are the drugs of choice.
VI.Maintenance treatment
A.Twelve-step programs make a significant contribution to recovery. Alcoholics Anonymous (AA) is the root of 12- step programs.
B.Drugs for treatment of alcohol addiction 1.Disulfiram inhibits aldehyde dehydrogenase. On ingesting alcohol, patients taking disulfiram experience flushing of the skin, palpitations, decreased blood pressure, nausea, vomiting, shortness of breath, blurred vision, and confusion. Death has been reported. Side effects include drowsiness, lethargy, peripheral neuropathy, hepatotoxicity, and hypertension. The usual dose is 250 to 500 mg daily.
2.Naltrexone, an opioid antagonist, reduces drinking. It has diminished effectiveness over time and does not reduce relapse rates.
3.Serotonergic drugs reduce drinking in heavy- drinking, nondepressed alcoholic patients, but only 15% to 20% from pretreatment levels.
4.Acamprosate (calcium acetylhomotaurinate) reduces the craving for alcohol. Acamprosate appears to result in more frequent and longer-lasting periods of abstinence than does naltrexone.
VII.Opiates
Signs and Symptoms of Opiate Withdrawal 1. Mild elevation of pulse and respiratory rates, blood pres- sure, and temperature
2. Piloerection (gooseflesh) 3. Dysphoric mood and drug craving 4. Lacrimation and/or rhinorrhea 5. Mydriasis, yawning, and diaphoresis
6. Anorexia, abdominal cramps, vomiting, and diarrhea 7. Insomnia
8. Weakness
Agents Used to Treat Opiate Withdrawal
Methadone (Dolophine) is a pure opioid agonist restricted to
inpatient treatment or specialized outpatient drug treatment programs. Treatment is a 15- to 20-mg daily dose for 2 to 3 days, followed by a 10 to 15 percent reduction in daily dose.
Clonidine (Catapres) is an alpha-adrenergic blocker. One
0.2-mg dose every 4 hours to relieve symptoms of withdrawal may be effective. It may be continued for 10 to 14 days, followed by tapering.
Buprenorphine (Buprenex) is a partial mu-receptor agonist
which can be administered sublingually in doses of 2, 4, or 8 mg every 4 hours for the management of opiate withdrawal symptoms.
Naltrexone (ReVia, Trexan)/clonidine involves pretreatment
with 0.2 to 0.3 mg of clonidine, followed by 12.5 mg of naltrexone (a pure opioid antagonist). Naltrexone is increased to 25 mg on day 2, 50 mg on day 3, and 100 mg on day 4, with clonidine doses of 0.1 to 0.3 mg 3 times daily.
VIII.Stimulant Drugs
Signs and Symptoms of Cocaine or Stimulant Withdrawal
1. Dysphoric mood 2. Fatigue, malaise 3. Vivid, unpleasant dreams 4. Sleep disturbance 5. Increased appetite
6. Psychomotor retardation or agitation
A.Stimulant withdrawal is treated with bromocriptine (Parlodel). This drug reduces stimulant craving and withdrawal symptoms. Bromocriptine dosage is 0.625 to 2.5 mg taken orally three times daily.
B.An alternative protocol uses desipramine to reduce the stimulant craving and postwithdrawal symptoms. Desipramine may be used alone or with bromocriptine. The initial dosage of desipramine is 50 mg per day taken orally. This dosage is increased until a dosage of 150 to 200 mg is achieved. Paranoia or combativeness is treated with lorazepam, 2-mg IM.
References