Alcoholism and Substance Dependence
Karen Drexler, MD
Introduction
Definition of psychoactive substance dependence and abuse
Overview of the disease of addiction: epidemiology, pathophysiology, risk factors, diagnosis and treatment
Introduction to 12-Step self-help groups
Introduction to patient-centered approach to intervention
Definition
Substance Dependence (DSM-IV) is "a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems."
Epidemiology: Substance Use
90% of adult Americans use alcohol
80% use caffeine
25% use nicotine
7% use at least one illicit drug
Epidemiology
According to the ECA data for alcohol dependence,
5-7% six month prevalence
13% lifetime prevalence
Prevalence of illicit drug dependence
1% or more point prevalence
However, 37% of adults have used illicit drugs with a 7% point prevalence for illicit drug use
Criteria for Diagnosis: DSM-IV
DSM-IV classifies the effects of substances in 5 major categories:
Substance dependence
Substance abuse
Substance intoxication
Substance withdrawal
Substance-persisting disorder
Substance-use disorder, NOS
Criteria for Diagnosis: DSM-IV
At least three of the following occurring over a 12-month period of time:
Tolerance; the need for increased amounts of the substance in order to achieve the desired effect; or markedly diminished effect with use of the same amount of substance.
Characteristic withdrawal symptoms; or the use of the substance to avoid or relieve withdrawal.
Criteria for Diagnosis: DSM-IV
Substance often taken in larger amounts than the person intended
Persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time spent getting the substance, taking the substance, or recovering from its effects
Important social, occupational, or recreational activities given up or reduced because of use
Criteria for Diagnosis: DSM-IV
Continued substance use despite knowledge of having a persistent or recurrent psychological or physical problem that is caused by or exacerbated by use of the substance
Criteria for Diagnosis: DSM-IV
DSM-IV defines 11 distinct categories of psychoactive substances
Alcohol
Amphetamines or related stimulants
Caffeine
Cannabis
Cocaine
Criteria for Diagnosis: DSM-IV
Hallucinogens
Inhalants
Opioids
Nicotine
Phencyclidine or related substances
Sedatives, Hypnotics, and Anxiolytics
Evaluating Substance Use
Three primary tasks:
Detect and confirm the diagnosis
Establish a therapeutic alliance
Initiate treatment
The Interview
The single-most important tool for establishing diagnosis
Also sets the tone for treatment
Empathy and concern are necessary to instill trust
Judgmental attitudes and pejorative statements severely limit one’s ability to gather data
The Interview
Collateral history from family members, medical records, and other sources
Focus on whether the patient has experienced negative consequences from the use of psychoactive substances.
Quantity and frequency questions ("How much?" or "How often?") are not effective.
Michigan Alcoholism Screening Test (MAST)
Selzer, 1971
25-item scale which identifies abnormal drinking through the social and behavioral consequences
10-item Brief MAST and Self-administered MAST have similar efficacy
CAGE Questionnaire
Ewing, 1984
Briefest validated screen available
For 1 positive , 85% sensitive, 89% specific
For 2 positive, 75% sensitive and 96% specific
For 3 positive, 51% sensitive and 99.7% specific
For 4 positive, 20% sensitive and 100% specific
CAGE Questionnaire
Have you every felt the need to Cut down?
Have you ever felt Annoyed by criticisms of your drinking?
Have you ever had Guilty feelings about drinking?
Have you ever taken a morning Eye opener?
Interview
If screens are positive obtain an history of present illness for alcoholism
First drink, First drunk, when alcohol first became a problem
Times when drinking patterns have changed
DSM-IV criteria
Complicated withdrawal- seizures or DTs
Time of last drink
The Physical Examination
Vital signs
Appearance (odor of Ethanol, disheveled appearance)
Nystagmus, opthalmoplegia
Rhinophyma, acne rosacea, parotid gland enlargement
Inflamed or perforated nasal septum
The Physical Examination
Telangiectasis, palmar erythema, needle tracks, cutaneous absesses, vasculitis
Rales, S3
Enlarged liver, RUQ tenderness
Ascites, jaundice
Heme-positive stool
The Physical Examination
Cerebellar signs, "liver flap", peripheral neuropathy
Testicular atrophy, gynecomastia
Multiple bruises, broken bones
Cognitive deficits and peripheral neuropathy
Laboratory Testing
CBC
Serum electrolytes (including Mg)
Liver enzymes (including GGT), bilirubin, PT/PTT
Glucose
Protein
Laboratory Testing
B12 and folate
Urine drug screen (Obtained under direct observation)
Blood alcohol level
CXR
EKG
Treatment: General Considerations
Know options for short and long term treatment
Treatment is most effective when patients are matched to the most appropriate level of care
Establish a therapeutic alliance
Engage patient and family in short and long-term treatment
Treatment: Short-term
Relieving symptoms of distress due to intoxication or withdrawal
Preventing and/or treating serious complications (DTs, seizures, GI bleed, MI, Alcohol amnestic disorder)
Preparing for referral to specialist treatment
Engaging the family in the treatment
Treatment: Long-term
Psychological: Relapse prevention, others
Social: AA and other Twelve Step groups, legal, job changes, half-way house
Spiritual: Twelve steps, pastoral counseling, church home
Medical: Disulfiram, naltrexone, etc.
Family: Education, therapy, Al-Anon, etc.
Withdrawal Syndrome
0 - 36 hours after the last drink:
Anxiety, tremor, nystamus
Hypertension, tachycardia, hyperthermia
Withdrawal seizures
0 - 72 hours after the last drink:
Hallucinosis
3 - 10 days after the last drink
Alcohol withdrawal delirium
Alcohol Withdrawal Delirium
Symptoms include:
Delirium: confusion, agitation, disorientation
Hallucinations, paranoia
Autonomic hyperactivity
About 5 % of untreated alcohol withdrawal
Historically, 5 - 15% mortality
Cardiac arrhythmias
Other underlying illnesses
Alcohol Detoxification
Thiamine 100 mg. po or im q day x 5 days
Benzodiazepines:
Chlordiazepoxide 25 - 50 mg. p.o. q 6 hours
Oxazepam 15 to 30 mg. p.o. q 2 - 4 hours
Taper by 20% per day
Diazepam 20 mg. po q 2 hours up to 60 mg
Phenobarbital
30 mg. p.o. q 6 to 8 hours
Long-term Treatment
Abstinence-based
Alcoholics Anonymous, Alanon, Alateen
Evening, Day, Residential, Inpatient Rehabilitation Programs (includes family rx)
Treatment of concurrent illness
Depression, chronic pain, PTSD
Disulfiram 250 - 500 mg. po. qhs
Naltrexone 50 mg. po q day
Wernicke’s Encephalopathy
Acute confusional state, plus the following:
Ataxia
Nystagmus
Opthalmoplegia
May progress to Alcohol Amnestic Syndrome
Memory difficulties ( short-term especially)
Formerly, Korsakoff’s psychosis
Summary
Addiction is a primary chronic biopsychosocial disease
Diagnosis depends on a high index of suspicion and a caring, empathic relationship with the patient.
Knowledge of the pharmacology of addictive substances facilitates short-term treatment.
Summary
Long-term rehabilitation must be comprehensive and include medical, psychological, spiritual, and social interventions.