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Substance Use
Presentation and clinical features:
- Substance use disorders are Axis I diagnoses and include two mutually exclusive subcategories - substance abuse and substance dependence
Substance Abuse
When any 1 of A and both B and C are "yes," a definite diagnosis of abuse is made:
A. Has the client experienced the following?
1. Recurrent failure to meet important responsibilities due to use?
2. Recurrent use in situations when this is likely to be physically dangerous?
3. Recurrent legal problems arising from use
4. Continued to use despite recurrent problems aggravated by the substance use:
B. These symptoms have occurred within a 12 month period
C. Client had never met the criteria for dependence
Substance Dependence
When any 3 of A, and B are "yes," a definite diagnosis of dependence is made:
A. Has the client experienced the following?
1. Tolerance (needing more to become intoxicated or discovering less effect with same
amount)
2. Withdrawal* (characteristic withdrawal associated with type of drug)
3. Using more or for longer periods than intended?
4. Desire to or unsuccessful efforts to cut down?
5. Considerable time spent in obtaining, using, or recovering from the effects of the
substance?
6. Important social, work, or recreational activities given up because of use?
7. Continued use despite knowledge of problems caused by or aggravated by use.
B. Have these symptoms been present during the same 12 month period?
* A clearcut withdrawal syndrome is not present with some classes of drugs: caffeine,
phencyclidine, or hallucinogens.
-
Acknowledge warning signs (e.g., school failure, behaviour change) and discuss
substance use and abuse with adolescents and their caregivers
Differential diagnoses:
- Screen for substance use and abuse (tobacco, alcohol, illicit drugs) in all patients,
and especially in high-risk groups (e.g., mental illness, chronic disability)
- Consider substance use or abuse when problems don’t respond to appropriate
interventions (e.g., alcohol abuse in patients with hypertriglyceridemia,
inhalational drug abuse in asthmatic patients, chronic disease)
- Grief
History-taking:
-
Conduct multiple assessments over time (e.g. after 2 to 3 weeks of decrease in
consumption) and use multiple assessment methods
Be sensitive to consumers' concerns;
Conduct the assessment when he/she is sober, drug-free and reasonably stable
emotionally;
Provide assurance of confidentiality;
Establish a good rapport before asking for a lot of details;
Use simple direct questions with clearly defined time frames;
Do not aim for levels of specificity that exceed assessment goals;
Frame questions to normalize different substance use patterns (e.g., many people
have experimented with drugs? Have you ever had any experiences with.....?); and
Verify the information as much as possible with other sources to converge on a
consistent set of conclusions.
Screen for co-morbidities (e.g., poverty, crime, sexually transmitted infections,
mental illness, depression, anxiety, eating disorders) and long-term complications
(e.g., cirrhosis)
Assess family history of disorders
Assess childhood variables (e.g., trauma, neglect, abuse)
Assess natural history (i.e., onset, course, fluctuations, remissions)
Assess patterns and severity of alcohol consumption (e.g., episodic vs. daily)
Assess the effect of improvements
A detailed substance use history includes:
-
-
the frequency and pattern of use;
the level of dependence;
the consequences that result.
Get the full substance abuse history: (how old were they when they started ____?
How did use of ______ change with time? How much ______ are they using
now? Have they tried quitting ______ in the past? What were the results? Have
they experienced withdrawal? How did that go?
The best predictor of a substance use problem by the consumer was their
perception that others were concerned about their substance use (70% sensitivity:
88% specificity; 76% positive predictive value; and 84% negative predictive
value). It is cautiously recommended that the three following questions be used as
potential Level I screening questions for substance use disorders. A positive
response to any one question should indicate the need for further investigation:
1. Have you ever had any problems related to your use of alcohol or other drugs?
2. Has a relative, friend, doctor or other health worker been concerned about your
drinking or other drug use or suggested cutting down?
3. Have you ever said to another person "No, I don't have [an alcohol or drug]
problem, when around the same time, you questioned yourself and FELT, "Maybe
I do have a problem?"
-
Determine whether or not they are willing to agree with the diagnosis (assess
stage of change) and routinely determine willingness to stop or decrease use
The "Stages of Change" identifies five stages in the change/recovery process:





pre-contemplation is the stage at which there is no intention to change behavior
in the foreseeable future;
contemplation is the stage in which people are aware that a problem exists and
are seriously thinking about overcoming it but have not yet made the commitment
to take action;
preparation combines the intention to take action within the next month with
lack of success in taking action during the past year;
action is the stage in which individuals modify their behavior, experiences, or
environment in order to overcome their problems;
in maintenance, people work to prevent relapse and consolidate the gains
attained during the action phase.
Motivational strategies for Behavioral Change:
Stage
PreContemplation
Contemplation
AIM
 Encourage patient to consider change
 Increase Pt’s awareness
 Understand Pt’s Ambivalence
Preparation
 Explore options and choose course
most appropriate for pt
 ID strategies for relapse
 Strengthen confidence and
PLAN
 Raise issue in sensitive manner
 Offer neutral exchange of Info
 Offer opportunity to discuss
pros and cons
 Offer realistic options for
change
 Discuss inevitable difficulties
commitment
Action
 Help pt design way to reward
themselves
 Develop strategies to prevent relapse
 Support and reinforce convictions
Maintenance
Relapse




Help Maintain motivation
ID high risk situations
View it as a learning experience
Provide support
 Offer positive reinforcement and
explore ways to cope with
obstacles
 Discuss progress and cues for
impending relapse
 Offer non-judgemental
discussion about circumstances
 How to avoid relapses in the
future
 Reassess readiness for change
Physical Exam:
Diagnose signs and symptoms of acute intoxication vs withdrawal:
ABC checklist for a mental health status exam includes:
Appearance: General appearance, hygiene, and dress.
Alertness: What is the level of consciousness?
Affect: Elation or depression: gestures, facial expression, and speech.
Anxiety: Is the individual nervous, phobic, or panicky?
Behavior:
Movements: Rate (hyperactive, hypoactive, abrupt, or constant?).
Organization: Coherent and goal-oriented?
Purpose: Bizarre, stereotypical, dangerous, or impulsive?
Speech: Rate, organization, coherence, and content.
Cognition:
Orientation: Person, place, time, and condition.
Calculation: Memory and simple tasks.
Reasoning: Insight, judgment, problem solving.
Coherence: Incoherent ideas, delusions, and hallucinations?
Investigations and diagnostic work:
- Screen for blood-borne illnesses (e.g., HIV infection, hepatitis) in IV drug users
Management
- Treat the context of substance misuse
- Engage client in identifying and managing cues to misuse, practical problemsolving with emphasis on action and reliance on social supports, and resolving
ambivalence about change
- Ensure client choice and tailor to the person's stage and motivation for change
- Offer relevant vaccinations in IV drug users
- Offer support to patients and family members affected by substance abuse
- Consider a harm reduction approach (e.g. flexible goals)
- Consider non-pharmacologic: Alcoholics Anonymous or equivalent, detox,
treatment centre, rehab, psychotherapy
- Manage symptoms of withdrawal or acute intoxication (pharmacological
symptom management which is highly disorder-specific – see below for proposed
algorithms)
Proposed algorithm for the diagnosis of drug intoxication and withdrawal:
Drug-Transmitter Actions That Cause Symptom Complexes:
Drug class:
Opiates
Dissociatives
Psychedelics
Stimulants
Alcohol, sedatives,
tranquilizers
Neurotransmitters:
GABA 5-HTP Norepinephrine
X
X
X
X
X
X
X
X
AcCH
X
βEndorphin
X
X
Dopamine
X
X
X
Drugs of Abuse: Six Groups That Are Likely to Require Primary Care Medical:
Action on affected
Drug class and members
neurotransmitter
Neuroreceptors
Anticholinergics:
Acetylcholine antagonists
Nicotinic and muscarinic
Asthmador, Benztropine
(Cogentin), Dimenhydrinate
(Dramamine),
Diphenhydramine
(Benadryl), Hydroxyzine
(Atarax), Locoweed
Dissociatives:
Ketamine (Ketalar),
Phencyclidine (PCP),
Phenylcyclohexylpyrolidine
(PHP)
Opiates:
Butorphanol (Stadol),
Pentazocine (Talwin),
Heroin, Hydromorphone
(Dilaudid-Hp),
Mesipramine, Methadone,
Morphine
Psychedelics:
Borneol, Lysergic acid
diethylamide (LSD),
Mescaline,
Methylenedioxymethamphetamine (MDA),
Psilocybin, Sufrole
Sedative-hypnotics:
Barbiturates, Ethchlorvinyl
(Placidyl), Glutethimide
(Doriden), Methaqualone
Zolpidem (Ambien),
Benzodiazepines
Ethyl alcohol
Affect actions of all
neurotransmitters
All receptors
β-Endorphin agonists
Κ
Stimulants:
Amphetamine, Cocaine
Methamphetamine
(Desoxyn),
Methylphenidate (Ritalin)
Dopamine, norepinephrine
and serotonin agonists
μ
Serotonin agonists
5-HT-2
GABA agonists
GABA-A
GABA and opioid agonist
GABA-A-α
GABA-A and μ
DA-2, 5-HT-2, α and β
Specific Treatment Based on Affected Neurotransmitter:
Neurotransmitter:
Treatment:
Intoxication and overdose:
Acetylcholine (anticholinergic)
Physostigmine (Antilirium)
β-Endorphin
Naloxone (Narcan)
Dopamine
Benzodiazepine
Butyrophenone
GABA
Mechanical support
Norepinephrine
Beta blocker
Benzodiazepine
Serotonin
Benzodiazepine
Withdrawal:
β-Endorphin
Methadone
Clonidine (Catapres)
Dopamine
Bromocriptine (Parlodel)
GABA
Barbiturate or benzodiazepine replacement
Norepinephrine
Desipramine (Norpramin)
Serotonin
Fluoxetine (Prozac)
Links:
- http://cfpc.ca/Low_Risk_Alcohol_Drinking_Guidelines/
- http://www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/bp_disordermp_concomitants/screening-depistage-eng.php
- http://fnih.investinkids.ca/?q=node/443
- http://www.bcmhas.ca/Library/ClinicalStaffResources/MedicalLinks/LibBest.htm
- http://www.aafp.org/afp/2000/0501/p2763.html#afp20000501p2763-f1
- www.ProjectCork.org