Pocket ObGyn – Substance Abuse
See Abbreviations
Definitions
- Use: Sporadic consump, no adverse effects
- Abuse: Maladaptive pattern or inappropriate use of a substance, adverse effects from use
- Dependence: Individual persists in substance use despite problems
Physical: Characterized by withdrawal sx if abrupt cessation of substance or antag administered
Psychological: Need for substance either for positive effects of use or to avoid negative effects of abstinence
- Addiction: Behaviors that include impaired control, compulsive use, use despite harm, & craving
Epidemiology
- Affects 10% of the general 48% of 12th graders have reported using an illicit substance at some point. 140 million people worldwide are EtOH dependent.
- 30% of suicides relate to EtOH Accounts for up to 40% of hospital admissions.
Clinical Manifestations
- Repetitive use ® drug tolerance ® withdrawal sx when drug is stopped, including depression, anxiety, malnutrition, wt loss, suicidality, agitation, & sleep
- EtOH: P/w tolerance, blackouts or memory lapses, sleep disturbances, Intoxication = slurred speech, incoordination, unsteady gait, nystagmus, memory impairment, stupor, or coma.
- Delirium tremens: Withdrawal syn of sev EtOH abuse, hallucinations, disorientation, tachycardia, HTN, fever, agitation,
- Cocaine: Acute intoxication = increased energy/alertness/sociability, euphoria, decreased fatigue/need for sleep/appetite, pupillary Chronic use = cognitive impairment, risk–reward decision making, suicidality.Withdrawal = depression, anxiety, fatigue, difficulty concentrating, anhedonia, increased appetite, increased sleep.
- Opioids: Acute intoxication = sedation, euphoria, respiratory depression, pupillary constriction, constipation, slurred Withdrawal = anxiety, irritability, drug cravings, tachypnea, rhinitis, muscle aches, nausea/vomiting, diarrhea, sweating, tremors.
- On physical exam note papillary size (dilation/constriction), behavior, tachycardia, speech patterns, skin inspection for injection marks, hepatomegaly, signs of HIV/ AIDS, nasal mucosal atrophy/nasal septum perforation, signs of
Diagnostic Workup/Studies
- Screening tools:
CAGE-AID: Adapted for EtOH & drug abuse (Wis Med J 1995;94:135): “Have you ever tried to cut down on your alcohol or drug use?”
“Do you get annoyed when people comment on your alcohol or drug use?” “Do you feel guilty about things that you have done while drinking or using drugs?” “Do you need an eye-opener to get started in the morning?”
T-ACE: Specifically for EtOH abuse in Preg:
“How many drinks does it take you to feel high?” (T = tolerance) “Do you feel annoyed by people complaining about your drinking?” “Have you ever felt the need to cut down on your drinking?”
“Have you ever had a drink first thing in the morning?” (E = eye-opener)
Single-item screening test: 100% sens, 73% spec
“How many times in the past year have you used an illegal drug or used a pre- scription med for nonmedical reasons?”
- Labs: Urine or serum toxicology screening
Treatment and Medications
- Stages of change (Am Psychol 1992;47:1102):
Precontemplation: Lack of awareness of problem, no intention to change behavior.
Contemplation: Aware of problem, weighing pros & cons to solve problem, no commitment to change action but considering changing behavior in next 6 mo. Preparation: Intend to take action in the next month, some reductions in prob-
lem behavior.
Action: Modification of behavior/experiences/environment to overcome problem.
Maintenance: Extends from 6 mo onward, working to prevent relapse & consoli- date gains achieved in the action phase.
- FRAMES: Physician motivational interviewing to help trigger pt change. Giving feedback based upon a thorough Helping the pt take responsibility for changing. Giving clear advice on what behavior must change. Offering a menu of options for making the change. Expressing empathy for the ambivalence & difficulty in making changes. Evoking self-efficacy to foster commitment & confidence.
- Nonpharmacologic: Cognitive behavior therapy, family therapy, exposure
• Pharmacologic:
Methadone: Synthetic opioid, long half-life, used to treat opioid dependence.
Buprenorphine: Semisynthetic opioid, used to treat opioid dependence.
Naltrexone: Opioid receptor antag, used to treat opioid & EtOH dependence.
Disulfiram: Causes acute sens to EtOH leading to adverse affects if EtOH used (ie, nausea & vomiting), used to treat EtOH dependence.
Bupropion: Antidepressant & smoking cessation aid.
Varenicline: Aid in smoking cessation, more effective w/ physician support.
- Prog: Remission in 35–60% of pts varies based on duration, social support, comorbid conditions, level of functioning at initiation of rx, premorbid