Archive for category Substance-Related Disorders'

Substance-Related Disorders

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 Read more […]

Alcohol-Related Disorders

Workers in the addiction field have attempted to more clearly define alcohol use problems, and accuracy is especially important for making a diagnosis in a medical setting. Several hospitalizations for alcohol-related illness can occur before a direct connection is made between a patient’s alcohol use and medical problems. Alcoholic patients tend to experience many alcohol-related problems before seeking professional help or attending AA meetings. Stigma associated with the term alcoholism frequently inhibits physicians and patients from exploring the connections between abuse and biopsychosocial consequences. Psychiatrists participating in a hospital survey positively identified alcohol abuse two-thirds of the time, whereas physicians treating gynecology patients diagnosed the disorder only 10% of the time. In primary care settings similar underdiagnosis is common; however, in studies that rely on chart review or screening instruments, investigators may underestimate what physicians really suspect to be the case. The official psychiatric nomenclature for alcohol abuse and dependence evolved from the view of alcoholism as a personality disorder (American Psychiatric Association 1952), through recognition of episodic, Read more […]

Sedative-, Hypnotic-, and Anxiolytic-Related Disorders

Abuse and Dependence Sedative-hypnotic and alcohol intoxications are similar in symptoms and complications. Because sedative-hypnotic use is so frequent in hospitalized patients, the detection of sedative abuse can be difficult. Abuse rarely starts as a result of treatment of acute anxiety or insomnia in a hospitalized patient. The risk of sedative abuse in chronically medically ill outpatients is far greater. There are three major classes of benzodiazepine abusers: polysubstance abusers, pure sedative abusers, and therapeutic users who have lost control. Individuals prone to polysubstance abuse tend to use sedatives for their calming effects (i.e., to come down after use of a stimulant such as cocaine) and for their ability to decrease dysphoric affects, including anxiety, or to potentiate euphoric effects of other drug classes (e.g., benzodiazepines in combination with methadone to boost euphoria). Pure sedative abusers usually have significant underlying psychopathological conditions, and relapse is common. In a long-term follow-up study involving subjects with primary sedative-hypnotic dependence, 46% of the subjects continued to abuse drugs after in-hospital rehabilitation treatment. Anyone can develop physiological Read more […]

Opioid-Related Disorders

Opioid abuse manifests in various ways in patients in medical settings. Psychiatrists are frequently consulted regarding opioid therapy for patients who are prescribed methadone, are thought or known to be dependent on prescription or illicit narcotics, engage in drug-seeking behavior, exhibit personality problems that interfere with medical care, or have overdosed. Suspicion is heightened by exaggerated pain complaints, by visits to multiple providers for multiple pain complaints requiring a narcotic prescription (e.g., migraine, back pain, dental pain, fibromyalgia, and endometriosis), and by claims to be “allergic” to every analgesic except for particular opioids (e.g., hydro-codone or oxycodone). Opioid-dependent patients often provoke angry reactions from staff, which can result in discharging a patient prematurely or underprescribing pain medications. Chronic pain patients who develop tolerance to opioids and experience opiate withdrawal on cessation of use are often misla-beled addicts (see “Pain”). Tolerance and withdrawal alone are not sufficient for the diagnosis of either substance abuse or dependence. For example, cancer patients with painful bone metastatic lesions may need high doses of narcotics and Read more […]

Cocaine-Related Disorders

DSM-IV-TR describes both cocaine use disorders (cocaine dependence and cocaine abuse) and cocaine-induced disorders (cocaine intoxication, cocaine withdrawal, cocaine intoxication delirium, cocaine-induced sexual dysfunction, cocaine-induced psychotic, mood, anxiety, and sleep disorders). Epidemiological Characteristics An estimated 193,034 U.S. emergency department visits solely for cocaine use were documented in the 2001 Drug Abuse Warning Network (Office of Applied Studies 2003), and cocaine is the most frequently reported drug in emergency department visits. Frequent reasons for psychiatric consultation in the medical setting are cocaine overdose, positive results of a urine toxicological screen, cocaine-induced depression, cocaine-induced cardiac problems, and cocaine-induced psychosis. According to the 1998 National Household Survey on Drug Abuse, 1.8 million individuals in the United States had used cocaine during a 1-month period. Use of crack cocaine is especially high in poor urban areas, but its use is widespread among other populations, such as rural migrant workers. Many cocaine users are polysubstance abusers. Pharmacological Characteristics Cocaine hydrochloride is a white crystalline powder derived Read more […]

Amphetamine-Related Disorders

Amphetamines (speed) have stimulant and reinforcing properties similar to those of cocaine. Amphetamines cause catecholamine release, especially of dopamine. The signs and symptoms of amphetamine intoxication include tachycardia, increased blood pressure, pupillary dilatation, agitation, elation, loquacity, and hypervigilance. In contrast to cocaine, amphetamines rarely cause myocardial infarction. Amphetamine psychosis can resemble acute paranoid schizophrenia. Visual hallucinations are common. Binge episodes (“runs”), which are similar to those experienced with cocaine use, often alternate with symptoms of a severe crash. Polysubstance use is common. CNS stimulants, such as dextroamphetamine and methylphenidate, are prescribed for the treatment of narcolepsy, attention-deficit/hyperactivity disorder, and fatigue in multiple sclerosis, but the doses used infrequently cause adverse effects such as insomnia, irritability, confusion, and hostility. Amphetamine abuse can start in an attempt to lose weight or to enhance energy. Epidemiological Characteristics and Complications Abuse of methamphetamine (“ice”) is a particular problem in the midwestern, western, and southwestern United States but has been spreading into Read more […]

Club Drugs and Hallucinogens

The term club drugs comes from the association of several drugs with use in dance clubs or all night dance parties (“raves”). Popular club drugs are methamphetamine (see earlier section, “Amphetamine-Related Disorders”), lysergic acid diethylamide (LSD; “acid”), 3,4-methylene-dioxymethamphetamine (MDMA; “Ecstasy” or “X”), gamma-hydroxybutyrate (GHB; “liquid X”), ketamine (“special K”), Rohypnol (“roofies”), and dextromethorphan (“DMX”) (). Emergency department visits due to MDMA and GHB use increased dramatically starting in the late 1990s. In the United States in 2002, emergency department visits for MDMA-related disorders numbered 4,026 and for GHB-related disorders numbered 3,330. Hallucinogenic drugs include LSD, mescaline, psilocybin, and synthetic derivatives such as 3,4-methylenedioxyamphetamine (MDA). The popularity of hallucinogens began to wane in the mid-1970s, but a modest resurgence in use occurred in the early 1990s, particularly among youth. MDMA (“Ecstasy”) MDMA, called “Ecstasy,” was promoted in the 1960s and 1970s as a “mood drug” without the distracting perceptual changes of other hallucinogens. MDMA is usually taken orally but can be taken in-tranasally (snorted). The purity of the drug in tablets Read more […]

Cannabis-Related Disorders

The main psychoactive constituent in marijuana is delta-9-tetrahydrocannabinol (Δ9-THC), one of 60 cannab-inoids. Marijuana sold on the street contains 5%-17% Δ9-THC (Drug Enforcement Administration 2001). Hashish is a resin from the cannabis plant that contains a higher percentage of Δ9-THC than does marijuana. Δ9-THC binds to cannabinoid receptors, located primarily in hippocampal and striatal regions. An endogenous ligand for these receptors, anandamide, has been identified. Results of several studies suggested that there is a genetic vulnerability to cannabis use and dependence. Medical use of marijuana is still a hotly debated scientific and political issue. Laboratory Findings Cannabinoids can be detected in the urine of chronic abusers 21 days or more after cessation of chronic, heavy use, because of slow release from fat stores. In most occasional users, urine drug screen results remain positive for 1-5 days. Intoxication Peak intoxication after smoking cannabis generally occurs in 10-30 minutes. Intoxication usually lasts 2-4 hours, depending on the dose; however, behavioral and psychomo-tor impairment may continue several hours longer. Δ9-THC and its metabolites, which are highly liquid soluble, tend Read more […]

Nicotine-Related Disorders

Nicotine-Related Disorders Tobacco addiction is the most preventable health problem in the United States. In 1993, approximately 60 million Americans smoked tobacco, and 400,000 deaths and $50 billion in direct medical-care expenditures were attributable to tobacco (Medical-Care Expenditures Attributable to Cigarette Smoking 1994). In the United States, approximately 30% of men and 26% of women smoke cigarettes. The percentage of young adults smoking cigarettes significantly increased between 1994 (35%) and 1998 (42%) (Office of Applied Studies 1999). Since 1965, the prevalence of cigarette smoking among adults in the United States has declined almost half. Cigarette smoking prevalence declined in the late 1970s, leveled off in the 1980s, and increased in the 1990s. Similar trends have occurred in other Western countries, but the prevalence of smoking has been increasing in Asia. Nicotine is a psychoactive substance with euphoric and positive reinforcement properties, similar to those of cocaine and opiates. The individual develops tolerance to nicotine and experiences significant withdrawal symptoms, including craving for tobacco, irritability, anxiety, difficulty concentrating, restlessness, decreased heart rate, Read more […]