E.Review use of the following drugs concerning quantity and type (if cigarettes, brand smoked; if alcohol, type of alcohol: Beer, wine, hard liquor), and age at initiation. Query regarding previous attempts to stop use.
F.Start with the past and proceed to the present with use; include first use of the mood-altering substance, amounts, and the last use of the particular substance and amount.
G.Follow the CAGE test. The CAGE (2 out of 4) is highly predictive of addiction:
1.Have you ever tried to cut down on your alcohol/drug use?
2.Do you get annoyed if someone mentions your use is a problem?
3.Do you ever feel guilty about your use?
4.Do you ever have an “eye-opener” first thing in the morning after you’ve been drinking or using the night before?
H.If patient admits drinking or drug use, ascertain specific amounts and last use of each substance.
I.Establish usual weight and recent loss and in what length of time.
J.Determine whether patient experiences suicidal ideation and if there is a history of past attempts (see section Suicide
of this chapter).
Physical Examination
A.Check temperature, pulse, respirations, blood pressure, and weight.
B.Inspect:
1.Observe general appearance, dress, grooming, breath odor, wasted appearance, attitude, sad affect, psychomotor retardation, or tremors.
2.Conduct a dermal examination for spider angiomas, bruises, track marks, color, pallor, rash, jaundice, petechiae, and gynecomastia in men (hallucinogens).
3.Examine the eyes for sclera color and features, pupil size, and reactivity.
4.Inspect the nasal mucosa for erythema, edema, spider telangiectasis, and discharge; look for septal lesions or perforation, deviation, and polyps.
5.Inspect the mouth/pharynx: Oral lesions, poor dental hygiene, erythema, and teeth for uneven surfaces, tooth decay, and gum erosion.
C.Palpate:
1.Palpate the neck and thyroid.
2.Palpate the axilla and groin for lymphadenopathy.
3.Palpate the abdomen; note hepatomegaly/tenderness.
D.Percuss:
1.Percuss the chest; note pulmonary consolidation.
2.Percuss the abdomen for hepatosplenomegaly.
E.Auscultate:
1.Auscultate the heart for murmur, new S4 gallop, single S2, and arrhythmias.
2.Auscultate the lungs for rales, effusion, and consolidation.
F.Perform neurologic examination/mental status.
Diagnostic Tests
A.Blood alcohol level.
B.Cotinine level (nicotine; where available).
C.Urine drug screen.
D.Complete blood count (CBC) with differential.
E.Platelet count.
F.HIV or hepatitis.
Intravenous drug use contributes strongly to the spread of AIDS, hepatitis B and C, and other infectious diseases. Consider evaluation for sexually transmitted infections.
G.Antinuclear antibody, erythrocyte sedimentation rate (ESR), and rheumatoid factor.
H.Electrolytes.
I.Liver panel:
1.Elevated liver enzymes can also be attributed to overuse of acetaminophen (Tylenol), found in combination with opiates.
J.Blood cultures (fever).
K.Bone density studies:
1.Patients who have been drinking for years should have bone density studies done because alcohol increases the risk for osteoporosis.
Differential Diagnoses
A.Substance use disorder.
B.Chronic pain syndrome.
C.Anxiety.
D.Depression.
Plan
A.General interventions:
1.Discuss your concerns about alcohol, nicotine, or drug use and discuss addiction treatment with the patient.
2.At each office visit, provide support to help prevent relapse. If relapse occurs, encourage the patient to try again immediately.
3.Consider signing a contract with the patient to stop smoking, drinking, or using drugs.
4.Assess potential for suicide with every office visit.
5.If possible, obtain confirmation of the patient’s abstinence from a family member.
6.Stress the importance of 12-step meetings such as Alcoholics Anonymous (AA), Cocaine Anonymous (CA), and Narcotics Anonymous (NA).
7.Have the patient sign a written release of information so that you can speak with a rehabilitation counselor. If the patient is willing, refer to an alcohol and drug treatment facility or smoking cessation program, after initial assessment and differential diagnosis is made.
8.Treat physical/laboratory findings as indicated.
9.Identify potential withdrawal symptoms from the cessation of stimulants, such as caffeine intake reduction, alcohol, and drug use.
10.If malnourished, discuss dietary needs and treatment.
B.Patient teaching:
1.Educate the patient about the impact of alcohol, tobacco, and drugs on physical/emotional health. Provide information for the patient to read at home.
2. 
See Section III: Patient Teaching Guide Alcohol and Drug Dependence.
C.Pharmaceutical therapy:
1.Nicotine replacement.
Consider nicotine replacement for those who smoke more than one pack of cigarettes per day or who smoke their first cigarette within 30 minutes of waking. Stress that there is no smoking
while using nicotine replacement.
a.Nicotine patch:
i.21 mg/24 hr for 4 weeks then
ii.14 mg/24 hr for 2 weeks then
iii.7 mg/24 hr for 2 weeks.
b.Nicotine gum:
i.2 to 4 mg of nicotine gum per hour with maximum of 24 pieces/d for up to 12 weeks.
c.Nicotine lozenges:
i.2 to 4 mg every 1 to 2 hours for 6 weeks.
ii.2 mg every 2 to 4 hours for 3 weeks.
iii.2 mg every 4 to 8 hours for 3 weeks.
2.Nonnicotine therapy:
a.Adults: Bupropion (Zyban, Wellbutrin) 150 mg daily for 3 days, then increase to 150 mg twice daily. Treat for 7 to 12 weeks. The patient may continue to smoke during the first 2 weeks of starting medication. This medication should not be given to patients with seizure disorders.
b.Varenicline (Chantix): Start at 0.5 mg/d for the first 3 days, then for the next 4 days, 0.5 mg twice daily. After the first 7 days the dose is 1 mg twice daily:
i.Encourage the patient to choose a stop date for smoking and start the Chantix 1 to 2 weeks prior to this stop date.
ii.Patients should be encouraged to quit even if they have relapses.
iii.Instruct patients that the most common side effects of Chantix are insomnia, vivid or strange dreams, and nausea. Advise that side effects are usually transient.
iv.Give precautions to the patient regarding potential side effects of mood swings, aggression, homicidal thoughts, psychosis, anxiety, and panic disorder, which may occur on rare occasions.
v.See package inserts or Physicians’ Desk Reference for detailed instructions.
3.Detoxification and methadone maintenance: Should be performed by specially licensed and trained professionals.
4.Disulfiram (Antabuse) therapy is not recommended. Patients who consume alcohol after taking Antabuse can become extremely ill.
5.Refer patient to physician or specialist if patient is experiencing withdrawals; consider admission to rehabilitation center for detoxification and treatment.
Follow-Up
A.Make a follow-up appointment weekly. Make contact with the referral source (smoking cessation program, alcohol/drug rehabilitation program) before the next follow-up visit to check on the patient’s progress. At weekly visit, question the patient regarding compliance.
B.Order blood alcohol, urine drug screen, or nicotine level (as appropriate) with every office visit while in outpatient treatment and throughout the year following treatment.
C.Once positive change is seen, the patient can be seen monthly. Discuss changes the patient has made, past relapses, circumstances under which they occurred, and any special concerns.
D.Refer to the medical diagnosis for other applicable followup recommendations.
Consultation/Referral
A.Refer patients with drug and/or alcohol dependence to a community mental health center that has an outpatient alcohol/drug rehabilitation program or to a specialist in the community who deals frequently with substance abuse/dependence.
B.Planning a family meeting to confront the patient is best done with the help of an experienced mental health professional.
C.Have referral numbers at close hand, so that the patient’s moment of motivation is not lost.
D.Refer family members of alcoholics/drug addicts to Al-Anon, Nar-Anon, Co-dependents Anonymous, or Adult Children of Alcoholics (ACOA) meetings.
Individual Considerations
A.Pregnancy:
1.Substance-dependent pregnant women frequently avoid early prenatal care for fear of identification and reprisal.
2.Cocaine use is associated with abruptio placenta and preterm labor. Consider drug screen for emergent admissions for patients in preterm labor and abruption.
3.Notify the hospital nursery personnel/neonatologist before delivery to closely monitor the newborn for withdrawal and seizure precautions.
4.Nicotine/smoking use is associated with intrauterine growth restriction, preterm delivery, and bleeding in pregnancy.
5.Nicotine-dependent pregnant women should be encouraged to stop smoking without pharmacologic treatment. The nicotine patch should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement, and potential concomitant smoking. Similar factors should be considered in lactating women.
6.Pregnant women who use alcohol, tobacco, or drugs should always be classified as substance dependent rather than substance abusive.
B.Adults:
1.With women, tolerance can be established by asking the question, How many drinks does it take to make you high?
More than two drinks indicates some tolerance.
2.In considering a diagnosis of alcohol dependence, consider the following diagnostic findings: hypertension; nonspecific ECG changes; cardiomyopathy; palpitations; increased mean cell volume; decreased red blood cell count; low platelet count; increased alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactic dehydrogenase, g-glutamyltranspeptidase, alkaline phosphatase; type IV hyperlipoproteinemia; gout; and adultonset diabetes mellitus.
C.Geriatrics:
1.Alcohol use disorders are often missed in this population because of reduced social and occupational functioning. Evaluate for signs of poor self-care, hygiene, and malnutrition.
2.At-risk drinking for persons older than 65 is defined as more than three drinks on one occasion or greater than seven drinks per week.
3.Pain medications and benzodiazepines, along with multiple medications for health problems, may contribute to a substance abuse problem.
D.Partners/family members:
1.For fear of retribution, the family may remain silent about the problem, even if accompanying the patient.
2.Some studies by corporate business show that, per capita, business spends more money on the care of family members of substance-dependent patients than on the employee.
3.Refer family members of alcoholics/drug addicts to Al-Anon, Nar-Anon, Co-dependents Anonymous, or ACOA meetings.
Resources
National Institute on Drug Abuse (NIDA): www.drugabuse.gov
Substance Abuse and Mental Health Services Administration: www.samhsa.gov/treatment. Offers free and downloadable publications for patient education, treatment, prevention, and recovery. Also includes professional and research topics and substance abuse treatment facility locator by state
