Drug/Substance Abuse

Substance use and/or substance use disorders (SUDs) are associated with many negative consequences among youth, including accidents, death, health effects, crime, unplanned pregnancy, and lower achievement. Substance use contributes to accidents, death, and a variety of hazardous behaviors. Sexual behaviors are increased during adolescent substance use. Toxic effects of different drugs of abuse include following:

• Opioids: Respiratory and central nervous system (CNS) depression, increased risk of aspiration due to diminished gag reflex, pupillary constriction, seizures, and euphoria
• Barbiturates: Results in marked respiratory depression
• Benzodiazepines: Results in minor respiratory depression
• Amphetamine: Results in euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention, hypertension, tachycardia, anorexia, fever, and paranoia. Severe intoxication can cause cardiac arrest and seizures.
• Cocaine: Impaired judgment, pupillary dilation, hallucinations, paranoid ideation, angina and sudden cardiac death
• Caffeine: In restlessness and muscle twitching
• Nicotine: restlessness
• Phencyclidine: Violence, impulsivity, psychomotor agitation, nystagmus, tachycardia, hypertension, analgesia, psychosis, delirium, and seizures
• LSD: Visual and auditory hallucinations, depersonalization, anxiety, paranoia, psychosis, and flashbacks
• Marijuana: Euphoria, anxiety, paranoid delusions, the perception of slowed time, impaired judgment, amotivational syndrome, dry mouth, increased appetite, conjunctival injection, and hallucinations
• MDMA: Euphoria, disinhibition, hyperactivity, life-threatening hypertension, tachycardia, hyperthermia, hypernatremia, and serotonin syndrome

Alcohol Abuse

Excessive alcohol consumption is the third leading preventable cause of death in the United States. More than 85,000 deaths a year in the United States are directly attributed to alcohol use.

• Toxicity: Emotional lability, slurred speech, ataxia, blackouts[6][7]

Drug/Substance Abuse

History

A detailed history is necessary to establish the diagnosis of drug abuse. Patient’s social history can provide information about risk factors for unhealthy substance use and the impact of substance use on the patient’s role functioning. Look for Partner with a substance use disorder,  poor socio-economic society, violence, and high school alcohol and other drug availability. A family history of substance use disorder (SUD) has been shown to be a risk factor for the development of a Substance abuse disorder. Heritability estimates range from:

• 50% to 70% for alcohol use disorder
• From 34% to 78% for cannabis use disorder
• 42% to 79% percent for cocaine use disorder
• 23% to 54% for opioid use disorder

Dig deep into a history of Disrupted familial and social relationships, Failure to fulfill responsibilities at school or work (e.g., loss of job, poor grades in school. Ask questions about past history of violent behavior, child abuse, financial problems and sexual history (multiple partners, sex habits, etc.)

Physical Exam

During the physical examination, look for:

• Poor personal hygiene
• Significant weight loss or weight gain 
• Signs of injection drug use including scars at injection sites (so-called “track marks”) on the skin
• Signs of drug inhalation including atrophy of the nasal mucosa and perforation of the nasal septum
• Evidence of acute intoxication or withdrawal, for example, slurred speech, unsteady gait, pinpoint pupils, bizarre or atypical behavior, changes in the level of arousal (agitation or sedation), tachycardia, euphoria, conjunctival injection, sweating, watery eyes, runny nose

Mental State Exam

This examination should be performed and look for following symptoms and signs:

• Behavior: Aroused, agitated or sedated.
• Appearance: Personal hygiene, clothes, 
• Speech and Voice: Slurred or pressured
• Mood: Euphoria, elated mood, depressed mood
• Perception: Hallucination
• Thoughts: Paranoia, delusions.
• Insight: Poor insight
• Cognition: Decreased concentration span, disorientation, amnesia
• Judgment: Altered

Alcohol Abuse

History

Ask about current and past alcohol use and treatment, family history of alcohol problems and treatment, and a detailed history regarding the quantity and frequency of alcohol use.

Physical

Physical features accompanying alcohol abuse range from a normal physical exam to features of alcohol withdrawal (tachycardia, tremor, agitation, clouding of the sensorium) to features of the advanced liver disease in case of chronic alcoholism (spider angiomata, palmar erythema, gynecomastia, testicular atrophy, hepatic or splenic enlargement).[1]

DSM-5 Diagnostic Criteria for Substance Use Disorder

Two or more of the following in a 12-month period manifests a problematic pattern of use leading to clinically significant impairment or distress:

1. Often taken in larger amounts or over a longer period than was intended
2. A persistent desire or unsuccessful efforts to cut down or control use
3. A great deal of time is spent in activities necessary to obtain, use, or recover from the substance’s effects
4. Craving or a strong desire or urge to use the substance.
5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home
6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by its effects
7. Important social, occupational, or recreational activities are given up or reduced because of use
8. Recurrent use in situations in which it is physically hazardous.
9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
10. Tolerance
11. Withdrawal

Disorder Severity: DSM-5 specifies mild, moderate, and severe based on the number of diagnostic criteria met by the patient at the time of diagnosis:

• Mild: Two to 3 criteria 
• Moderate: Four4 to 5 criteria       
• Severe: Six or more criteria

DSM-5 Diagnostic Criteria for Alcohol Use Disorder

1. Recurrent drinking resulting in failure to fulfill role obligations
2. Recurrent drinking in hazardous situations 
3. Continued drinking despite alcohol-related social or interpersonal problems
4. Evidence of tolerance
5. Evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal
6. Drinking in larger amounts or over longer periods than intended
7. Persistent desire or unsuccessful attempts to stop or reduce drinking
8. A great deal of time spent obtaining, using, or recovering from alcohol
9. Important activities are given up or reduced because of drinking
10. Continued drinking despite knowledge of physical or psychological problems caused by alcohol
11. Alcohol Craving

Disorder Severity: The severity of alcohol use disorder at the time of diagnosis can be specified as a subtype based on the number of symptoms present: 

• Mild: Two to 3 symptoms    
• Moderate: Four to 5 symptoms
• Severe: Six or more symptoms

Laboratory Tests

Substance Abuse

• Drug of abuse screen
• Urine drug levels
• Blood drug levels
• Hair drug levels
• Saliva drug levels
• Breath drug levels

Alcohol

Diagnosis of alcohol problem can be made in the outpatient department by using CAGE questionnaire which includes the questions: (need to) cut down, annoyance (on drinking), guilt (about drinking), an eye-opener

Screening tools like the 10 question Alcohol Use Disorder Identification Test (AUDIT) and the abbreviated 3-question audit-consumption (Audit-C) are recommended for screening.

Laboratory tests to confirm the diagnosis include:

• Serum alcohol concentration
• Direct alcohol biomarkers: Ethyl glucuronide.
• Liver enzymes: Aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and albumin to test for liver damage. An AST: ALT ratio of 2:1 is indicative of alcohol-induced liver disease
• Hemoglobin, complete blood count (CBC): To determine the presence and severity of anemia, pancytopenia, and macrocytosis. A mean corpuscular volume greater than 100 fL constitutes macrocytosis. Pancytopenia and macrocytosis usually require very heavy and prolonged use and often liver disease
• Gamma-glutamyltransferase (GGT): Is an indicator of excessive alcohol use when elevated (normal reference ranges: 8 to 40 units/L for females and 9 to 50 units/L for males).
• The patient's social network, especially family, should be involved in treatment to the extent possible (and agreed to by the patient, if a legally competent adult), to provide additional history and therapeutic support and to help monitor the patient's progress and adherence to treatment.[1][8]

Psychosocial Interventions   

• Enhance motivation to reduce or end cannabis use  
• Improve social skills  
• Improve social support and interpersonal functioning
• Manage painful feelings
• Education about consequences of drug use

Cognitive-Behavioral Therapy

CBT is used to help patients learn how their thought processes play a role in developing their behavior. Cognitive awareness helps them to develop new ways of behaving, thus leading to change in thinking patterns and emotions.

Mutual Help Groups

Alcoholic Anonymous (AA), is a voluntary program for people with alcoholism/AUD, based on belief in a spiritual basis for recovery. Members attend meeting and experiences are shared and "Twelve steps towards Recovery" are discussed. Avoiding alcohol and benefits of avoiding alcohol are discussed. Abstinence is encouraged on a daily or weekly basis. Alcoholics Anonymous can be reached via their website www.aa.org.

Motivational Interviewing/Motivational Enhancement

Drug or Addiction Counseling 

Pharmacotherapy

• Alcohol: As many as 70% of individuals relapse after psychosocial treatment alone

1. Naltrexone in toxicity and Supportive care.
2. Naltrexone can be started while the patient is still drinking. Disulfiram should be used by abstinent patients to maintain abstinence, while acamprosate should be used once abstinence is achieved.
3. Disulfiram should only be used in patients who are highly motivated to maintain abstinence.
4. Treat Wernicke-Korsakoff with vitamin B-1 (thiamine) intravenously.

• Opioids Intoxication: naloxone
• Opioids Withdrawal: methadone
• Barbiturate intoxication: Artificial ventilatory support.
• Benzodiazepines intoxication: Flumazenil
• Benzodiazepines withdrawal: Benzodiazepines having a long half-life. Gradually cutting dose down
• Amphetamine intoxication: Benzodiazepines for agitation and seizures
• Cocaine intoxication: Alpha-blockers and benzodiazepines
• Caffeine intoxication: Symptomatic support
• Nicotine intoxication: Symptomatic support
• Nicotine withdrawal: Nicotine patch/gum, varenicline, bupropion
• Phencyclidine intoxication: Benzodiazepines and rapid-acting antipsychotics
• Marijuana: N-acetyl cysteine, gabapentin, and dronabinol[1][9][10]

• Psychosis
• Schizophrenia
• Mania
• Bipolar disorder
• Organic brain disorder

Prognosis depends upon follow up and motivational and cognitive behavior therapy. Support like Alcoholics-Anonymous groups play an important role in prognosis.

Substance use leads to a number of problems among youth, including accidents, death, health effects, crime, unplanned pregnancy, and lower achievement.

Psychiatric consultation is necessary.

Cognitive behavioral therapy (CBT), motivational therapy, and psychotherapy are necessary to avoid remission.

The management of alcohol and drug abuse requires an interprofessional team that includes a mental health nurse, psychiastrist, emergency department physician, internist, addiction counselor and pain specialist. Clinicians need to be proactive and identify these patients; the earlier the treatment is undertaken, the better the outcomes. In addition, healthcare workers need to curtail the liberal prescription of analgesics, hypnotics, and sedatives and offer patients alternative means of managing their pain and insomnia.

Unfortunately, the outcomes for patients addicted to alcohol and drugs are poor. Short term recovery does occur, but relapses are common. Drug and alcohol addiction has repercussions beyond health; it can destroy the family, result in job loss and lead to financial loss.