Substance-Related Disorders

2015

The ability to recognize and treat substance use disorders (SUDs) is a core competence in psychosomatic medicine. SUDs are common in both inpatient and outpatient medical settings. Alcohol and tobacco use alone contribute to a host of medical illnesses. Illegal drug use taxes the health care system. Drug and alcohol dependence disorders are best characterized as chronic medical illnesses. Hepatitis C is an example of a potential long-term complication of even brief drug use, injection drug users being at increased risk. Emergency departments have seen a steady increase in overdoses of drugs, including “club drugs” not prevalent until recently. The long-term effects of perinatal drug abuse are becoming known. Devastating complications result from the internal concealment of illicit drugs (e.g., body packing). Core competence in addiction medicine includes the ability to make accurate diagnoses, initiate treatment, and plan and coordinate services. Some hospitals have specialized addiction consultation services, but there is a shortage of board-certified addiction psychiatry specialists. All psychiatrists working in general medical settings are on the front lines of substance abuse and must be sufficiendy knowledgeable.

The span of issues for psychiatrists in medical settings includes drug overdose, withdrawal regimens, diagnosis, engaging patients in the therapeutic process, interface with pain management, assessing transplantation candidates, care of trauma and burn patients (who have a high frequency of drug dependency), substance abuse among pregnant women, drug abuse in geriatric or adolescent patients, and referral to substance abuse specialists. American Psychiatric Association practice guidelines (1995) are valuable resources for the treatment of alcohol, cocaine, and opioid use disorders, and the U.S. Veterans Health Administration has published more recent guidelines. Ideally, the psychiatrist is part of an integrated, multidisciplinary approach to thorough medical evaluation and education, nutritional assessment, housing and family assessment, and complex legal issues.

In this chapter, we provide an update on addiction medicine and highlight issues that arise on general medical units, including intoxication and withdrawal and their complications; psychological and psychiatric factors; treatment resistance; recovery environment; and relapse potential.

DSM-IV-TR Substance-Related Disorders

In DSM-IV-TR (American Psychiatric Association 2000), the broad diagnostic category “substance-related disorders” includes disorders caused by substances taken by individuals to alter mood or behavior, disorders caused by unintentional use of a substance, and medication side effects. Substance-related disorders are divided into substance use disorders, which include abuse and dependence, and substance-induced disorders, which include intoxication,withdrawal, delirium, dementia, sexual dysfunction, and amnestic, psychotic, mood, anxiety, and sleep disorders.

Substance abuse is a diagnosis of exclusion, to be used only when a patient does not meet, and has never met, criteria for substance dependence. This distinction can be confusing, because the term substance abuse is often used in a nondiagnostic sense to refer to a broad spectrum of substance use patterns.

Definitions

Abuse is the harmful use of a substance. Misuse is the use of a prescription drug for other than accepted medical practice. Addiction is characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving. Physical dependence is a state of adaptation that manifests as a specific withdrawal syndrome. Psychological dependence is the feeling of need for a specific substance, either for its positive effects or to avoid negative effects associated with abstinence from it.

Withdrawal is a substance-specific constellation of symptoms that may occur after cessation or a decrease in use of alcohol or drugs by individuals who are physiologically dependent. Withdrawal syndromes are characterized by symptoms opposite to those characteristic of use of the substance. Withdrawal syndromes vary in severity and are not necessarily proportional to the amount of substance use. Some withdrawal syndromes are associated with significant morbidity and, possibly, mortality if not recognized and treated aggressively (e.g., alcohol and benzodiazepines), whereas others are associated with considerable discomfort but are not life-threatening (e.g., opioids). Withdrawal can sometimes precipitate delirium, psychosis, mood disturbances, anxiety, and disordered sleep. It has been postulated that after acute withdrawal from alcohol, opiates, and stimulants, many milder physiological and psychological disruptions can persist for weeks to months (e.g., disordered sleep and mood disturbance). The concept of a protracted substance-specific withdrawal syndrome has been proposed, but its existence and management remain controversial.

Tolerance is the need for increasing amounts of a substance to obtain the desired effect (e.g., intoxication) or lesser effect of a substance with continued use of the same amount over time. For example, a series of alcoholic patients in an emergency department had an average blood alcohol concentration of 467 mg/dL — a level known to cause coma or death in an alcohol-naive individual, yet 88% of these patients were oriented to time, person, and place.

Substance-Related Disorders: General Principles

General principles of management for patients with substance use disorders in medical settings are summarized in table General principles of management for patients with substance use disorders in medical settings. In general hospitals, there are a number of barriers to detection and treatment of SUDs. The psychiatrist may enter a clinical situation in which considerable misunderstanding and animosity have developed between the patient and the medical care team. Nurses and physicians may overestimate or underestimate the impact of a patient’s substance use or may be overly frustrated by rebuffs of attempts to engage an unmotivated patient. Health care professionals may become nihilistic or angry at patients who are repetitively hospitalized with complications of substance use (e.g., alcoholic pancreatitis). Intense negative emotional responses toward patients with substance use disorders can interfere with proper care (e.g., giving lower rather than higher than usual doses of narcotics for postoperative pain to a heroin addict). Patients may acknowledge their substance use but either not realize or deny its relation to their medical and psychosocial problems. The social network of those with SUDs may be either chaotic or unsup-portive or composed mainly of other substance abusers. Patients with SUDs typically do not request psychiatric assistance and often are not told that a psychiatric consultation has been requested. In general, earlier consultations are more desirable, especially if treatment linkage is necessary. While acutely medically ill, patients are often more open to treatment recommendations. Because some patients are reluctant to fully disclose substance abuse or dependence owing to possible legal problems (e.g., issues relating to motor vehicle collisions) or fear of job loss, information gathering can be difficult.

TABLE General principles of management for patients with substance use disorders in medical settings

Have a high index of suspicion for drug abuse

  • Use early urine toxicological screens.

Carefully assess for detoxification

  • Determine the need for inpatient versus outpatient care.
  • Tailor detoxification for medically ill patients (this approach often needed in this patient population).
  • Carry out alcohol and sedative detoxification first in case of polysubstance dependence.
  • Order challenge tests or use conservative estimates if the initial detoxification dose is not clear.

In medical settings, a high index of suspicion for drug and alcohol use disorders is warranted because of their prevalence in the medically ill and their adverse physiological and behavioral effects on disease outcome.

Urine toxicological screening should be performed early in the diagnostic evaluation. Tailored detoxification is often needed by medically ill patients; for example, although alcohol detoxification does not routinely necessitate hospi-talization, it may for a patient with unstable angina. In polysubstance dependence, alcohol and sedative detoxification is the priority because of the higher risk of morbidity and mortality than with other substances. As a rule, challenge tests or conservative estimates should be used if there is doubt about the initial detoxification dose.

Acute Assessment

The elements of a basic substance use history are listed in Table Elements of the substance use history. Important additional aspects of assessment include identifying significant negative countertransfer-ence, triage, and establishing patient eligibility for follow-up care (this function is an administrative one, but a consultant must not make unrealistic recommendations). It is often difficult and sometimes impossible during the initial consultation to differentiate the effects of substance intoxication, withdrawal, or chronic use from other psychiatric disorders. A carefully obtained history provides clues that can aid diagnostic differentiation between substance-induced disorders and major mental disorders with co-morbid substance abuse or dependence, including the historical sequence of substance use and symptoms of a mental disorder. Elements in the history also indicate whether the psychiatric symptoms have occurred during periods of prolonged sobriety. The family history is important given increasing evidence of the heritability of SUDs. Evaluation of the patient’s family is essential as a source of collateral information, for learning the extent of the substance use and its consequences, and because a family system that accommodates the patient’s substance use also may reinforce it. Including the family in treatment increases the chances that the patient will remain abstinent.

TABLE Elements of the substance use history

  • Chief complaint
  • History of present illness
  • Current medical signs and symptoms
  • Substance abuse review of symptoms for all psychoactive substances
  • Dates of first use, regular use, heaviest use, longest period of sobriety, pattern, amount, frequency, time of last use, route of administration, circumstances of use, reactions to use
  • Medical history, medications, HIV status, hepatitis B and C status
  • History of past substance abuse treatment, response to treatment
  • Family history, including substance abuse history
  • Psychiatric history
  • Legal history
  • Object-relations history
  • Personal history

Treatment

Proper implementation of treatment always involves patients and their other medical providers. The steps include 1) educating the patient, 2) motivating the patient to accept the recommended treatment plan, 3) encouraging others to work collaboratively with the patient, 4) suggesting pharmacological treatments, when needed, 5) integrating substance abuse treatment into the overall medical and psychiatric treatment plans, and 6) facilitating transfers to appropriate treatment facilities when appropriate.

Detoxification alone does not constitute treatment of addiction. Some patients with mild substance abuse may resolve drug- or alcohol-related problems without additional treatment or with brief intervention by the consultant or another physician. Brief interventions by primary care physicians have shown promise for heavy drinkers in early addiction patterns. Substance dependence, however, is best viewed as a chronic medical illness, and many substance-dependent patients benefit from referral to specialized treatments that may be required long-term. Failure to refer can reinforce denial of substance-related problems and enable continued addiction. Treatment of SUDs integrated with regular medical care may reduce inpatient hospitalization rates.

It is difficult to arrange proper aftercare during a short hospitalization or when financial resources are limited. Insurance coverage varies considerably. In the United States, Medicare and many state Medicaid programs do not cover treatment of SUDs. Many private insurance plans require preauthorization and use a very limited panel of providers. Patients with little or no coverage usually must wait until public treatment slots are available. While waiting, patients often continue use or have relapses. This problem is especially prevalent among patients who have a poor support system and problems with housing, employment, and income.

Recovery is a process in which patients must develop responsibility for their own addiction. Therefore, the role of the psychiatrist and other health care providers is to empathically confront the patient about substance-related problems and to provide support, information, and access to resources, but not to assume total responsibility for patient follow-up. Education and a motivational approach, rather than continuous confrontation, usually work best. The psychiatric consultant is typically not directly involved in a patient’s aftercare, so a brief intervention model is needed. An early treatment goal is to have patients accept that their substance use is causing them problems and that some form of treatment is needed.

The most common referrals are to a specialized substance abuse treatment program or to a 12-step group such as Alcoholics Anonymous (AA). Most drug and alcohol treatment programs in the United States emphasize a combination of psychoeducation, participation in a 12-step program, and individual, group, and family counseling. Although resource availability is often a determining factor in follow-up treatment recommendations, guidelines such as those developed by the American Society of Addiction Medicine can be used in referring patients to different levels of care. Because most treatment programs require that patients themselves call for services, the role of the consultant is to inform patients and encourage them to contact programs directly.

AA is a worldwide self-help group of recovering alcoholic individuals that was started in 1936 by Bill Wilson and Robert Smith (Dr. Bob). The only requirement for membership is a desire to stop drinking. Meetings provide members with acceptance, understanding, forgiveness, confrontation, and a means for positive identification. AA uses a 12-step program — 12 tenets of recovery that members work through on their way to overcoming addiction. The steps include admitting powerlessness over alcohol, conducting a personal assessment, making amends, and eventually helping others. Members may contact one another outside meetings for sobriety support, and newer members team up with more experienced AA members, sponsors who guide them through the process. Although Alcoholics Anonymous is not affiliated with any religion (25% of Alcoholics Anonymous members identify themselves as atheists), the organization encourages spiritual revaluation. Members frequently remain active in AA for many years, and AA involvement is generally associated with favorable outcome comparable with that of other standard treatment approaches. A prospective study of employed alcoholic patients found that treatment plus Alcoholics Anonymous participation was more effective than AA involvement alone in helping such individuals attain and continue abstinence. In some hospitals, AA members visit inpatients, and many general hospitals host Alcoholics Anonymous meetings.

Other organizations have been modeled on AA. Narcotics Anonymous (NA), founded in 1947, and Cocaine Anonymous (CA), founded in 1982, are two examples. Contacts for Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous (CA), founded in 1982, are two examples. Contacts for Alcoholics Anonymous can usually be found in local telephone directories or on the organizations’ respective Web sites. Patients should be told that some self-help groups address special issues for participants and that it may be necessary for them to attend several different meetings in their area before they find a group that suits them or they make a decision that self-help is not beneficial.

Patients with a substance-related disorder and another psychiatric disorder have better outcomes when both disorders are treated simultaneously and all stakeholders (patients, clinicians, families, and community leaders) are invested. Nevertheless, integrated long-term treatment programs for such patients can be difficult to find. Many psychiatric inpatient units, psychiatric halfway houses, outpatient clinics, and other mental health facilities in the community are unable or unwilling to treat psychiatric patients who also have substance use disorders. In many substance abuse treatment facilities, there is little if any contact with psychiatrists, and treatment is provided by counselors who have minimal psychiatric training. Integrated programs combine rehabilitation, psychiatric evaluation, and the appropriate use of other treatment modalities, such as psychotherapy and pharmacotherapy. AA, NA, and CA officially support the use of psychotropic medications when necessary. Dual-diagnosis or “double-trouble” groups also use a 12-step approach.

Recommendations for patients after a suicide attempt and a recent history of alcohol or drug use or abuse range from discharge with outpatient mental health and substance abuse follow-up to inpatient psychiatric involuntary commitment (i.e., if there is a strong suicidal risk). When ambivalence exists about the correct disposition, a brief inpatient psychiatric stay for further evaluation usually is prudent.

Patients with concomitant chronic medical illnesses that limit participation in formal substance treatment programs pose special problems. Patients, families, and medical staff may focus so much on the medical illness that substance use is neglected as an issue. Patients may encounter difficulties with transportation or difficulty sustaining the concentration necessary to take full advantage of formal rehabilitation programs. For example, a clinical trial of alcoholism treatment after liver transplantation failed in part because of the patients’ infirmity and need for intensive medical management. Medically ill patients often feel estranged from the “world of the well.” Devising aftercare programs tailored to such patients’ needs is often difficult. Patients are sometimes seen individually and attend meetings of AAor professional groups as tolerated.

Additional difficulties occur when patients have spinal cord injuries, blindness, deafness, or other physical disabilities. For example, some caregivers involved in the treatment of paraplegic patients experience excessive sympathy that causes them to ignore significant substance abuse problems. However, it is possible to successfully integrate paraplegic patients into standard treatment programs. Deaf patients often need specialized services, such as sign language interpreters, to utilize standard rehabilitation services. Some communities have Alcoholics Anonymous groups for deaf or blind people. Patients with significant cognitive limitations, including mental retardation, traumatic brain injury, and dementia, pose a difficult problem because they are not able to benefit from standard psychosocial treatment approaches, all of which rely on capacity to communicate and learn.

Patients in recovery from addiction and who are abstinent often face the dilemma of whether to take mood-altering substances (e.g., narcotics for pain or anxiolytics for sedation) in the course of the planned treatment. Recovery teaches people to avoid all mood-altering substances because use of these substances can lead to relapse or a substitute addiction. If the hospitalization is elective, such as for ambulatory surgery, the issue can be discussed with drug treatment staff members or Alcoholics Anonymous sponsors. It may be possible to use pain management techniques that avoid the use of narcotics (“Pain”). When the issue is discussed in advance and adequate support is provided, most patients do not have relapses. The clinician should encourage AA members and sponsors to visit the patient and should halt treatment with mood-altering medication as soon as medically indicated. Continued or increased need for narcotic medications in the face of improving medical response to the treatment or the development of a pattern of continuing complications resulting in ongoing narcotic requests should lead to an evaluation for recurrence of a substance use disorder.

Treatment Outcome

Long-term studies have consistently shown that treatment of substance dependence is beneficial and cost-efficient from a public health or societal perspective. Predicting which individual patients are more apt to benefit from which type of treatment has been a greater problem. Patients who are more compliant with and receive more treatment generally do better, as do patients who receive additional treatment directed at specific ancillary problems, such as housing, employment, and comorbid psychiatric illness. In Project Match, a large randomized trial of alcohol treatment modalities and predictive pretreatment variables, investigators did not find a robust association between specific treatments and specific indicators. In a similar study, the COMBINE study, investigators are evaluating the efficacy of naltrexone and acamprosate alone or together in combination with different intensities of behavioral therapy. Other potential predictors, such as severity of addiction, social status, number of previous treatment attempts, coping style, family history, and patient self-selection of treatment type, have not been shown to have consistent associations with treatment outcome.

Relapse prevention is essential in treating substance dependence. The goals of relapse prevention are to address ambivalence, reduce drug or alcohol availability, minimize high-risk situations, develop coping strategies, recognize conditioned cues to craving and decision patterns that lead to use, establish alternatives to drug or alcohol use, and avoid the attitude that all is lost if drug use occurs in the context of treatment.

Alcohol-Related Disorders

Sedative-, Hypnotic-, and Anxiolytic-Related Disorders

Opioid-Related Disorders

Cocaine-Related Disorders

Amphetamine-Related Disorders

Phencyclidine-Related Disorders

Phencyclidine (PCP) is an anesthetic agent that first appeared as a street drug in the 1960s; PCP abuse peaked between 1978 and 1980. In 2002, 3.2% of the population 12 years or older had used PCP at least once and 1.1% of high school seniors had used PCP within the past year. Current street samples sold as PCP vary greatly in purity. Smoking marijuana cigarettes laced with PCP is the most common form of administration. Phencyclidine is a noncompetitive NMDA/glutamate receptor antagonist and has effects on serotonergic and dopaminergic systems as well.

Medical and Other Complications

The psychoactive effects of PCP generally begin within 5 minutes and plateau 30 minutes after use. Volatile emotionality is the predominant behavioral presentation. Phencyclidine clinical effects are unpredictable, and people who repeatedly seek these experiences may have an underlying psychiatric disorder. Affects range from intense euphoria to anxiety, and behavior can include stereotypical repetitive activities and bizarre aggression. Distorted perceptions, numbness, and confusion are also common. Associated physical signs include hypertension, muscle rigidity, ataxia, and nystagmus (particularly vertical nystagmus). At higher doses, dilated pupils, hypersalivation, hyperthermia, involuntary movements, and coma can occur.

Acute Management of Phencyclidine-Related Disorders

Acute reactions generally require pharmacological intervention. Intravenous diazepam is the drug of first choice; antipsychotics are occasionally necessary. Because supportive treatment may also be needed, management in a medical setting is preferred. After ingestion of PCP, the urine test result may be positive for 7 days; false-negative results can occur. Phencyclidine elimination is initially enhanced by ammonium chloride and subsequently by ascorbic acid or cranberry juice.

Club Drugs and Hallucinogens

Cannabis-Related Disorders

Nicotine-Related Disorders

Inhalant-Related Disorders

Inhalants are a diverse group of chemicals and include gasoline, airplane glue, aerosols (e.g., spray paint), lighter fluid, fingernail polish remover, typewriter correction fluid, a variety of solvents, amyl and butyl nitrites, and nitrous oxide. Inhalant use has been increasing among both male and female adolescents (). A high rate of abuse has also been found among Native Americans. Nitrous oxide abuse occurs among medical and dental personnel. Inhalants are inexpensive and easily obtained. Fumes of glues and paint products are usually inhaled from bags or rags.

Intoxication

Typical signs and symptoms of inhalant intoxication include grandiosity, a sense of invulnerability and immense strength, euphoria, slurred speech, and ataxia. Visual distortions and faulty space perception are also common. Inhalant intoxication is associated with aggressive, disruptive, and antisocial behavior. Among adolescents, inhalant abuse is associated with arrests, poor school performance, increased family disruption, and other drug abuse.

Intoxication can last from a few minutes to as long as 2 hours. Impaired judgment, poor insight, violence, and psychosis are common sequelae. Paint stains around the face are a clear indication of inhalant abuse. Central respiratory depression, cardiac arrhythmia, and accidents can cause death, and long-term damage to bone marrow, kidneys, liver, muscles, and the nervous system has been reported. The lifetime course of an inhalant abuser is not clear. Reports suggest that inhalants are primarily abused by youths. Inhalant abusers are likely to move on to other substances in later life.

Book “The American Psychiatric Publishing textbook of psychosomatic medicine” (2005)