H. Thomas Milhorn, MD, PhD Substance Use Disordersdownload.e-bookshelf.de/download/0010/4044/96/L-G... · tions of substance dependence, and Chap. 3 covers the pharmacology of addictive

Substance Use Disorders

123

H. Thomas Milhorn, MD, PhD

A Guide for the Primary Care Provider


H. Thomas Milhorn


A Guide for the Primary Care Provider

ISBN 978-3-319-63039-7 ISBN 978-3-319-63040-3 (eBook)DOI 10.1007/978-3-319-63040-3

Library of Congress Control Number: 2017947158

© Springer International Publishing AG 2018This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer NatureThe registered company is Springer International Publishing AGThe registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

H. Thomas Milhorn, MD, PhDDirector, Didactics SectionEast Central HealthNet Family Medicine Residency ProgramMeridian, Mississippi

Formerly Professor of Family Medicine, Professor of Physiology and Biophysics, and Associate Professor of Psychiatry and Human Behavior

University of Mississippi School of MedicineJackson, Mississippi

v

This book was written for primary care physicians, who almost daily come into contact with substance-dependent individuals and their families. However, it also should be helpful to primary care nurse practitioners and physician assistants, as well as medical students, primary care residents, emergency medicine physicians, ASAM- and APA-certified addictionists and those studying for certification in those specialties, psychiatrists, psycholo-gists, and alcohol/drug counselors.

Primary care physicians are in excellent position to diagnose substance use disorders and to help the families of these patients get them into treat-ment. In addition, primary care physicians can detoxify patients as needed. On return from treatment, they can participate in the patients’ recovery pro-grams to help prevent relapse.

The book is divided into four parts: (1) The Basics; (2) Psychoactive Substance Dependencies; (3) Diagnosis, Treatment, Recovery, Relapse, and the Family; and (4) Special Groups.

Part 1 (The Basics) consists of an overview, the various definitions of sub-stance dependence, and the pharmacology of addictive substances. Chapter 1 “Overview” is an introductory chapter that covers material common to the entire field of substance dependence, such as classification of psychoactive substances based on their effects on the central nervous system, primitive survival brain concept, criteria for substance dependence, addiction medicine specialists, denial, abstinence syndromes, 12-step programs, prescription drug addiction, and DEA drug schedules. Chapter 2 covers the various defini-tions of substance dependence, and Chap. 3 covers the pharmacology of addictive substances.

Part 2 (Psychoactive Substance Dependencies) covers the various drug dependencies—alcohol dependence, sedative-hypnotic dependence, opioid dependence, stimulant dependence, nicotine dependence, cannabis depen-dence, dissociative dependence, inhalant dependence, hallucinogen depen-dence, and anabolic steroid dependence.

Part 3 covers diagnosis, treatment, recovery, relapse, and the family.Part 4 (Special Groups) covers women, adolescents, the elderly, ethnic

minority groups, co-occurring disorders, LGBT patients, HIV-positive patients, and the impaired physician.

To keep from repeatedly saying “his or her,” I have used the generic “he” to mean all addicts regardless of sex.

Preface

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I would like to thank Toby Milhorn who did some of the typing and put the references into the appropriate format, my wife Kay for her patience and understanding while I worked on the manuscript, and the residents in the EC-HealthNet Family Medicine Residency Program for giving me the inspi-ration to write the book.

Meridian, MS, USA H. Thomas Milhorn

Preface

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AA Alcoholics AnonymousACOA Adult Children of AlcoholicsADH Alcohol dehydrogenaseADM Addiction medicineAIDS Acquired immune deficiency syndromeALDH Aldehyde dehydrogenaseALS Amyotrophic lateral sclerosisALT Alanine aminotransferaseAMA American Medical AssociationASAM American Society of Addiction MedicineAST Aspartate aminotransferaseAUDIT Alcohol Use Disorders Identification TestBAC Blood alcohol concentrationBAL Blood alcohol levelBBB Blood-brain barrierCo Zero concentrationcAMP Cyclic adenosine monophosphateCBD CannabidiolCDT Carbohydrate-deficient transferrinCIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol—Revised

VersionCMRO Certified medical review officerCNS Central nervous systemCT Computed tomographyDo Initial doseDAST Drug Abuse Screening TestDEA Drug Enforcement AdministrationDHHS Department of Health and Human ServicesDSM Diagnostic and Statistical Manual of Mental DisordersDUI Driving under the influenceED Emergency departmentEEG ElectroencephalogramEMIT Enzyme multiplied immunoassay techniqueEtG Ethyl glucuronideFAE Fetal alcohol effectsFAS Fetal alcohol syndromeFDA US Food and Drug Administration

Abbreviations

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GABA Gamma-aminobutyric acidGBL Gamma-butyrolactoneGC/MS Gas chromatography/mass spectrometryGGT Gamma-glutamyl transpeptidaseGHB Gamma-hydroxybutyrateHALT Hungry, angry, lonely, or tiredHIV Human immunodeficiency virusHPPD Hallucinogen persisting perception disorderKCl Potassium chlorideLAAM Levo-alpha-acetylmethadolLSD Lysergic acid diethylamideMAO Monoamine oxidaseMAST Michigan Alcoholism Screening TestMCV Mean cell volumeMDMA 3,4-MethylenedioxymethamphetamineMEOS Microsomal ethanol oxidizing systemMME Morphine milligram equivalentsMRI Magnetic resonance imagingNAD Nicotinamide adenine dinucleotideNADPH Nicotinamide adenine dinucleotide phosphateNIAAA National Institute on Alcohol Abuse and AlcoholismNIDA National Institute on Drug AbuseNMDA N-Methyl-D-aspartateNSAID Nonsteroidal anti-inflammatory drugOBOT Office-based opioid therapyOTC Over the counterPAWS Post-acute withdrawal syndromePCP PhencyclidinePDMP Prescription drug monitoring programPT Prothrombin timeREM Rapid eye movementSAMHSA Substance Abuse and Mental Health Services AdministrationSIDS Sudden infant death syndromeSMAST Short Michigan Alcoholism Screening TestTo Time zeroTHC TetrahydrocannabinolVd Volume of distributionVTA Ventral tegmental area

Abbreviations

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Part I The Basics

1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3The Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

The Financial Cost of Substance Dependence . . . . . . . . . . . . . . . 4Substance Use Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Emergency Department Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Treatment Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Substance Use Disorders and the Primary Care Physician . . . . . . 5

How Psychoactive Substances Differ from Other Drugs . . . . . . . . . 5Classification of Psychoactive Substances Based on Their Effects on the Central Nervous System . . . . . . . . . . . . . . . 5

Club Drugs and Date Rape Drugs . . . . . . . . . . . . . . . . . . . . . . . . . 5The Primitive Survival Brain Concept of Substance Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Normal Response to Substance Use . . . . . . . . . . . . . . . . . . . . . . . 7Development of Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Tools of Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Addicted Versus Addict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Abstinence Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Severity of Abstinence Syndromes . . . . . . . . . . . . . . . . . . . . . . . . 9The Beginning of All 12-Step Programs . . . . . . . . . . . . . . . . . . . . . . 10The Prescription Drug-Dependent Patient . . . . . . . . . . . . . . . . . . . . 10

Patient Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Characteristics of Overprescribing Physicians . . . . . . . . . . . . . . . 11

Addiction Medicine Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12American Society of Addiction Medicine . . . . . . . . . . . . . . . . . . . 12American Psychiatric Association . . . . . . . . . . . . . . . . . . . . . . . . 12

DSM-5 Criteria for Substance Dependence . . . . . . . . . . . . . . . . . . . 12DEA Drug Schedules and Prescribing Regulations . . . . . . . . . . . . . 13

DEA Drug Schedules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Prescribing Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Contents

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2 Definitions of Substance Dependence . . . . . . . . . . . . . . . . . . . . . . 17The Biopsychosocial Definition of Substance Dependence . . . . . . . 17

Biological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Psychological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Sociological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Disease Concept Definition of Substance Dependence . . . . . . . . . . 20Genetic Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Conclusions About Genetic Studies . . . . . . . . . . . . . . . . . . . . . . . 20Natural Course of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . 21The Disease Concept and the Primary Care Physician . . . . . . . . . 22

AMA’S Definition of Substance Dependence . . . . . . . . . . . . . . . . . . 22ASAM’S Definition of Substance Dependence . . . . . . . . . . . . . . . . 22Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

3 Pharmacology of Psychoactive Substances . . . . . . . . . . . . . . . . . . 25Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Synapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Reward Center of the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Neurotransmitters Affected by Psychoactive Substances . . . . . . . 29Upregulation and Downregulation . . . . . . . . . . . . . . . . . . . . . . . . 29Dose-Response Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Kindling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Route of Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Enzymatic Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Steady-State Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Cross-Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Physical Dependence and Abstinence Syndrome . . . . . . . . . . . . . . . 36Set and Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Part II Psychoactive Substance Dependencies

4 Alcohol Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Forms of Alcoholic Beverages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Prevalence of Alcohol Use and Dependence . . . . . . . . . . . . . . . . . . 42

Prevalence of Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Prevalence of Binge Drinking and Heavy Drinking . . . . . . . . . . . 42Prevalence of Alcohol Use Disorder . . . . . . . . . . . . . . . . . . . . . . . 42Treatment Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Alcohol-Related Liver Problems . . . . . . . . . . . . . . . . . . . . . . . . . 42Alcohol-Related Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42The Financial Cost of Alcohol Dependence . . . . . . . . . . . . . . . . . 43

Contents

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Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Interaction of Alcohol with Other Drugs . . . . . . . . . . . . . . . . . . . 45

Street Names for Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45What Is Excessive Drinking? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Subtypes of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Observational Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Genetic Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Short-Term Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Long-Term Health Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Health Benefits of Drinking Alcohol . . . . . . . . . . . . . . . . . . . . . . . . 48Evaluation of the Alcoholic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Stages of the Alcohol Abstinence Syndrome . . . . . . . . . . . . . . . . 49Differential Diagnosis of Alcohol Withdrawal . . . . . . . . . . . . . . . 50Treatment of Alcohol Abstinence Syndrome . . . . . . . . . . . . . . . . 50

Ethanol Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Other Alcohols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Isopropyl Alcohol Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Methyl Alcohol Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Ethylene Glycol Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55


5 Sedative-Hypnotic Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Barbiturates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59The Barbiturates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Current Uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64The Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Street Names for Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . 64Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Contents

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Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Flunitrazepam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Z Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Gamma-Hydroxybutyric Acid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Tolerance, Dependence, and Abstinence Syndrome . . . . . . . . . . . 72Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Sedative-Hypnotics of Historical Interest . . . . . . . . . . . . . . . . . . . . . 73Barbiturate-Like Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Meprobamate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Carisoprodol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Chloral Hydrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

6 Opioid Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77The Opioid Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Clinical Uses of Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Opioid Conversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Interactions with Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Opioid Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Natural Opiates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Semisynthetic Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Krokodil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Synthetic Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Antidiarrheal Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Opioid Agonist-Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86Pentazocine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86Nalbuphine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Butorphanol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Buprenorphine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

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Opioid Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Naltrexone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Naloxone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Designer Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Principles for Prescribing to Prevent Opioid Dependence . . . . . . 90Determining When to Initiate or Continue Opioids for Chronic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Opioid Selection, Dosage, Duration, Follow-up, and Discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Assessing Risk and Addressing Harms of Opioid Use . . . . . . . . . 91

Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Rapid Detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Opioid Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94


7 Stimulant Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97The Amphetamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98The Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Interactions with Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Methamphetamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Amphetamine Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Cocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102The Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104Interaction with Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

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Methylphenidate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Tolerance, Dependence, and Abstinence Syndrome . . . . . . . . . . . 108

Phentermine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Tolerance, Dependence, and Abstinence Syndrome . . . . . . . . . . . 109

Modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Bath Salts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Tolerance, Dependence, and Abstinence Syndrome . . . . . . . . . . . 109

Flakka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Intoxication and Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Caffeine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Caffeine Powder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Caffeine Intoxication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Caffeine Tolerance and Dependence . . . . . . . . . . . . . . . . . . . . . . . 111Caffeine Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Caffeine Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111


8 Nicotine Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Trends in Cigarette Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116Percentage of Smokers by Group . . . . . . . . . . . . . . . . . . . . . . . . . 116Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Interactions with Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Factors That Influence Who Will Smoke Cigarettes . . . . . . . . . . . . . 118Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118Benefits of Quitting Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118Electronic Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120Poisoning from Liquid Nicotine . . . . . . . . . . . . . . . . . . . . . . . . . . 121Illegal Use of Electronic Cigarette Cartridges . . . . . . . . . . . . . . . 121

Cigars and Pipes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121Smokeless Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Chewing Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121Snuff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122Quitting Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

Reasons for Quitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122Five Stages of Quitting Smoking . . . . . . . . . . . . . . . . . . . . . . . . . 122Techniques to Help Patients Quit . . . . . . . . . . . . . . . . . . . . . . . . . 123The Five-Step Smoking Intervention . . . . . . . . . . . . . . . . . . . . . . 123

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Triggers for Tobacco Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124Steps to Take After the Quit Date . . . . . . . . . . . . . . . . . . . . . . . . . 124

Nicotine Dependence Medications . . . . . . . . . . . . . . . . . . . . . . . . . . 125Nicotine Replacement Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Long-Term NRT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126Non-nicotine Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126Long-Term Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126Second-Line Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126Combination Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Weight Gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

9 Cannabis Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

Marijuana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132Interactions with Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Medical Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Cannabis indica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Synthetic Cannabinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Spice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Hashish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Hash Oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139


10 Dissociative Drug Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Phencyclidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Intoxication and Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

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Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Polydrug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Emergence Phenomena . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Ketamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Health Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Tolerance, Dependence, and Abstinence Syndrome . . . . . . . . . . . 150Intoxication and Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Dextromethorphan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Tolerance, Dependence, and Abstinence Syndrome . . . . . . . . . . . 151Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152


11 Inhalant Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155The Inhalant Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Solvents and Aerosols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156Symptoms of Solvent and Aerosol Intoxication . . . . . . . . . . . . . . 157Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157Tolerance and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Gases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160Nitrous Oxide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Tolerance, Dependence, and Absence Syndrome . . . . . . . . . . . . . 162Other Gases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Alkyl Nitrites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163Tolerance, Dependence, and Abstinence Syndrome . . . . . . . . . . . 163Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163


12 Hallucinogen Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167The Hallucinogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168Lysergamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168LSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

Contents

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Lysergic Acid Hydroxyethylamide . . . . . . . . . . . . . . . . . . . . . . . . 169Phenylethylamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Mescaline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169Salvia divinorum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Indolealkylamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170Psilocybin and Psilocin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170Mappine and 5-MeO-DMT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Amphetamine-Related Hallucinogens . . . . . . . . . . . . . . . . . . . . . . . 171MDMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172MDEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Other Hallucinogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Muscimol and Ibotenic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Atropine and Scopolamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Myristicin and Elemicin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173N-Bomb and Smiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175Hallucinogen Persisting Perception Disorder . . . . . . . . . . . . . . . . . . 175Tolerance, Dependence, and Abstinence Syndrome . . . . . . . . . . . . . 175Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175Laboratory Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176


13 Anabolic Steroid Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179The Anabolic Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Legal Uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180Patterns of Illegal Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181Doses of Illegal Anabolic Steroids . . . . . . . . . . . . . . . . . . . . . . . . 181Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Street Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183Abstinence Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183Drugs Used to Mask Anabolic Steroid Use . . . . . . . . . . . . . . . . . . . 183Alternatives to Anabolic Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Clenbuterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184Creatine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184Erythropoietin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

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Gamma Hydroxybutyrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184Human Chorionic Gonadotropin . . . . . . . . . . . . . . . . . . . . . . . . . . 184Human Growth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184Insulin-Like Growth Factor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184Vitamins and Amino Acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184


Part III Diagnosis, Treatment, Recovery, Relapse, and the Family

14 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189Problems in Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Undereducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190False Beliefs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190Feelings of Inadequacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Making the Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191Screening Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191Other Drug Dependencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192Personal and Family History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192Patient Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195Laboratory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198Other Drug Dependencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201Drug Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201Confirmatory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203Cutoff Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203Length of Time Drugs Can Be Detected in the Urine . . . . . . . . . . 203False-Positive Immunoassay Tests . . . . . . . . . . . . . . . . . . . . . . . . 204

Mixed Drug Dependencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204Criteria for Substance Dependence . . . . . . . . . . . . . . . . . . . . . . . . 205

Presenting the Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

15 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209History of Substance Dependence Treatment . . . . . . . . . . . . . . . . . . 209

Early Institutional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209Early Drug Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210Modern Alcoholism Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 210Civil Commitments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211Drug Courts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Getting the Addict into Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 211Legal Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211Family Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211Medical Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

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Work Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212Court-Ordered Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212Tough Love and Intervention by Confrontation . . . . . . . . . . . . . . 212

Support Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212Non-12-Step Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212Twelve-Step Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213What Treatment Involves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

Treatment Program Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214ASAM Patient Placement Criteria for the Treatment of Substance- Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 215Inpatient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217Outpatient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219Therapeutic Communities and Halfway Houses . . . . . . . . . . . . . . 220Support Groups as Primary Treatment . . . . . . . . . . . . . . . . . . . . . 221

Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221The Primary Care Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

16 Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225Recovery Dimensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225Tasks of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226The Recovery Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226

Three Stages of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226Six Developmental Periods of Recovery . . . . . . . . . . . . . . . . . . . 228

The Five Rules of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229Partial Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230Controlled Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230Drugs That May Be Hazardous to Recovery . . . . . . . . . . . . . . . . . . 230Rational Use of Medications in Recovery . . . . . . . . . . . . . . . . . . . . 231Support Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

History of AA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232Philosophy of AA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232The Twelve Suggested Steps of AA . . . . . . . . . . . . . . . . . . . . . . . 232AA Slogans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233The Twelve Traditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234The Sponsor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234The AA Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Web-Based Recovery Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235Pharmacological Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Alcohol Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236Acamprosate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237Naltrexone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

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Opioid Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237Naltrexone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238Buprenorphine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238Levo-Alpha-Acetylmethadol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239


17 Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243The Relapse Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243Major Kinds and Stages of Relapse . . . . . . . . . . . . . . . . . . . . . . . . . 244

Three Kinds of Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244Factors Contributing to Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

Preventing Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249What to Do When Relapse Occurs . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Does Relapse Mean Treatment Has Failed? . . . . . . . . . . . . . . . . . 250Primary Care Physician’s Role in Preventing Relapse . . . . . . . . . . . 250Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

18 The Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253The Healthy Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254The Addicted Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

A Family Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256Family Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256The Grief Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257Rules in the Alcoholic Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258Family Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258The Spouse of an Alcoholic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259The Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

Getting the Addict Sober . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261Tough Love . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262Intervention by Confrontation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

Getting the Family Well . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263Importance of Family Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 264Family Treatment Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264Codependent Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264Support Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

The Family in Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266Stages of Family Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

Adult Children of Alcoholics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267Consequences of Growing Up in an Alcoholic Home . . . . . . . . . 267Dysfunctional Characteristics of ACOAs . . . . . . . . . . . . . . . . . . . 267The Other Laundry List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268Support Groups for ACOAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269


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Part IV Special Groups

19 Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275Gender Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276The Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279Screening Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280The Pregnant Addict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

Medical Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283Obstetrical Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283Health Risks Associated with Drug Use . . . . . . . . . . . . . . . . . . . . 283Maternal Detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

The Fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284Congenital Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284Stillbirth Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284Specific Drug Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284Neonatal Abstinence Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . 286Estimated Times of Onset of Withdrawal Symptoms . . . . . . . . . . 287Neonatal Detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287Nonpharmacologic Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

20 Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291The Normal Adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291The Substance-Dependent Adolescent . . . . . . . . . . . . . . . . . . . . . . . 292

Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293Why Adolescents Use Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293Differences from Adult Substance Dependence . . . . . . . . . . . . . . 294

Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294The Adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294The Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295Behavioral Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . 295Drug-Use History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296Screening Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296Psychosocial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297Family History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Contents

xxii

Laboratory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297Getting the Adolescent into Treatment . . . . . . . . . . . . . . . . . . . . . . . 298

Tough Love and Intervention by Confrontation . . . . . . . . . . . . . . 298Court Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298Inpatient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299Treatment Plan Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300Outpatient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303Residential Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

21 The Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308Pathophysiology of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308The Elderly Addict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Recommended Drinking Limits . . . . . . . . . . . . . . . . . . . . . . . . . . 309Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Health Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310Surviving Street Addicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311Prescription Addicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311Screening Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313Detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

22 Other Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317The Ethnic Minority Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

American Indians/Alaska Natives . . . . . . . . . . . . . . . . . . . . . . . . . 318Asian/Pacific Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318African Americans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319Hispanic Americans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Co-occurring Disorder Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321Secondary Versus Primary Psychiatric Disorders . . . . . . . . . . . . . 321Primary Psychiatric Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Contents

xxiii

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

LGBT Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323LGBT Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

HIV-Positive Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325Substance Dependence Treatment . . . . . . . . . . . . . . . . . . . . . . . . 326Developing Treatment Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326Psychosocial Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327Risk Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327Community Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327


23 The Impaired Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331Prevalence of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332Characteristics of the Impaired Physician . . . . . . . . . . . . . . . . . . . . . 332

Community Involvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332Family Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332Employment Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333Physical Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333Office Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333Hospital Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

The Impaired Woman Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334Physician Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Early Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335The Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335Federation of State Physician Health Programs . . . . . . . . . . . . . . 336

Intervention by Confrontation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336The Intervention Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336Preparing for the Confrontation . . . . . . . . . . . . . . . . . . . . . . . . . . 336The Confrontation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

Contents

Part I

The Basics

3© Springer International Publishing AG 2018H.T. Milhorn, Substance Use Disorders, DOI 10.1007/978-3-319-63040-3_1

Overview 1

Key Chapter Points

• Substance abuse can be costly, both finan-cially and health wise.

• Primary care physicians are not well prepared to deal with substance dependence.

• Psychoactive substances differ from other drugs in a number of ways.

• Drugs are usually divided into seven catego-ries according to how they most prominently affect the central nervous system.

• With dependence, the primitive survival brain seizes control from the cerebral cortex.

• Denial is a major component of substance dependence.

• An abstinence syndrome may occur after ces-sation or cutting down the dose of a psychoac-tive substance.

• Primary care physicians need to be aware of the prescription-dependent addict.

• Addiction medicine specialists are certified by the American Society of Addiction Medicine and the American Psychiatric Association.

• The American Psychiatric Association spells out the criteria for substance dependence in DSM-5.

• The Drug Enforcement Administration sets the regulations for prescribing controlled substances.

A primary care physician is a specialist in fam-ily medicine, internal medicine, or pediatrics who provides care to patients at the point of first contact and provides continuing and com-prehensive care of that patient. Care provided by primary care physicians may include chronic, preventive, and acute care in both inpatient and outpatient settings. As a result, primary care physicians are in an excellent position to identify and treat substance use dis-orders and thereby reduce the associated adverse health, family, and societal effects. However, minimal attention in medical schools and residencies has been given to educating pri-mary care physicians to respond to the needs of individuals and their families affected by sub-stance use problems [1, 2]. The information provided in this book is intended, in part, to improve that situation.

When talking about individuals who are addicted to alcohol or other drugs we need a name. The first thing we should agree on is that alcohol is a drug. Therefore, a drug addict is defined as one who is dependent on alcohol or another drug. A psychoactive substance is any drug that acts on the brain to alter its function, resulting in temporary changes in perception, mood, consciousness, or behavior. Alcoholism is a lay term for alcohol dependence.

4

The Problem

The Financial Cost of Substance Dependence

The cost to the United States due to crime, lost work productivity, and health care from tobacco, alcohol, and illicit drug use is staggering, exact-ing more than $700 billion annually in costs.

Tobacco The health-care cost related to tobacco is about $130 billion annually, with the overall tobacco-related cost being about $295 billion.

Alcohol For alcohol, the annual health-care cost is approximately $25 billion, with the overall alcohol-related cost about $224 billion.

Illicit drugs The annual health-care cost related to illicit drugs is on the order of $11 billion, with the overall illicit drug-related cost being $193 billion.

The $700 billion annual cost does not include family expenses for counseling, rehabilitation, theft, car crashes, or the incalculable cost of fam-ily despair at the loss of a loved one to drug overdoses, drug-related medical problems, drug-related accidents, or drug-related suicides. Drug overdoses now cause more deaths than traffic accidents [3].

Substance Use Prevalence

Substance use is common in the general popula-tion and among persons presenting to primary care physicians. In 2014, 16.3 million Americans over the age of 12 reported heavy alcohol use in the prior month. Six and a half million Americans over the age of 12 reported current, nonmedical use of prescription drugs, such as painkillers, tranquilizers, stimulants, and sedatives. Twenty seven million Americans over the age of 12 reported using illicit drugs. Of these, 1.5 million reported using cocaine [4].

Prevalence of illicit drug use for age 12–17, age 18–25, and age 26 and older is given in Table 1.1.

Emergency Department Visits

In 2014, 2.1 million emergency department (ED) visits were related to the use of illicit substances. Of these, more than 27% were caused by the non-medical use of prescription drugs, over-the- counter medications, and supplements, and 21.2% involved illicit drugs. Over 14% involved alcohol in combination with other drugs.

Each day, almost 7000 people are treated in emergency departments for using prescription drugs in a manner other than as directed [4].

Deaths

Every day, 44 people in the United States die from overdose of prescription painkillers; more people die from abusing prescription pain relievers than cocaine and heroin combined. The number of overdose deaths caused by prescription painkillers quadrupled between 1999 and 2010 [4].

Treatment Demographics

Of the 2.5 million who received substance abuse treatment in 2014, 41% of admissions were for alcohol dependence, 20% were for opiate/opioid dependence, and 17% were for of marijuana dependence [4].

Consequences

The consequences of illicit substance use include loss of productivity, increased health-care costs, and increased morbidity and mortality. There is increasing recognition of the similarities between substance use disorders and other common

Table 1.1 Prevalence of illicit drug use for ages 12–17, ages 18–25, and ages 26 and older for 2015 (%) (From [4])

Ages 12–17

Ages 18–25

Age 26 and older

Lifetime 25.30 57.50 50.10

Past year 17.50 37.50 14.60

Past month 8.80 22.30 8.20

1 Overview

5

chronic illnesses, such as hypertension and dia-betes mellitus. Like those illnesses, substance use disorders also can be identified early when there are fewer sequelae and when less intensive treat-ments can be successful [5].

Substance Use Disorders and the Primary Care Physician

Less than 20% of primary care physicians described themselves as very prepared to identify alcoholism or illegal drug use. More than 50% of patients with substance use disorders said their primary care physician did nothing to address their substance use [5]. Primary care physicians clearly are in need of improved education in regard to substance use disorders.

How Psychoactive Substances Differ from Other Drugs

Psychoactive substances differ from other drugs (aspirin, acetaminophen, lisinopril, metformin, and so forth) in a number of ways [6]:

• They produce an altered mood state, such as sedation, relaxation, or euphoria.

• These effects reinforce the drug use; that is, the feelings aroused by the drug make the user want to use it again.

• Compulsive use occurs when the user feels as though he must have the drug. Without the drug, the user may feel anxious, nervous, or dysphoric. Use continues despite the known, harmful effects. The alcoholic continues to drink despite severe liver disease. The cocaine addict continues to use cocaine despite numer-ous arrests for possession and a period of prison time from selling the drug.

• Regular and temporal patterns of use occur. The alcoholic may drink every day and at the same time every day. I had one cocaine addict in treatment who every evening at 6:00 o’clock came to the nurses’ station demanding medica-tion for her withdrawal symptoms. There were two problems with the situation: (1) The symp-

toms she described weren’t those of cocaine withdrawal but anxiety, and (2) she was past the time to be having any legitimate with-drawal symptoms. Turned out, her regular pat-tern of cocaine use had been to come home from work every day and about 6:00 o’clock start smoking crack cocaine. The problem was not cocaine withdrawal but cocaine craving.

• Deprivation increases the desire to use the drug. The cigarette smokers have to go outside for a smoke during intermission of a play.

• Paired stimuli increases use. The sight of a crack pipe on a TV movie may set off an intense desire in a recovering cocaine addict to use crack again.

• Tolerance develops. Over time, more and more of the drug is required to get the same high.

• Physical dependence may develop; that is, regular, prolonged use of a drug may produce withdrawal symptoms on cessation of use.

• The relapse rate is high. Many drug users quit several times before finally achieving perma-nent sobriety. For example, cigarette smokers who successfully quit do so, on average, after six attempts.

Classification of Psychoactive Substances Based on Their Effects on the Central Nervous System

Drugs are usually divided into seven categories according to how they most prominently affect the central nervous system (Table 1.2 [7]).

In addition to the seven categories of psycho-active substances just discussed, I will cover ana-bolic steroids in Chap. 13.

Club Drugs and Date Rape Drugs

Club DrugsClub drugs are chemical substances commonly used at nightclubs, music festivals, raves, and dance parties to enhance social intimacy and sensory stimulation. They include 3,4- methylenedioxymethamphetamine (MDMA), also known as

Classification of Psychoactive Substances Based on Their Effects on the Central Nervous System

6

ecstasy; the naturally occurring neurotransmitter/psychoactive drug gamma-hydroxybutyrate (GHB); the benzodiazepine flunitrazepam (Rohypnol); and the dissociative drug ketamine (Ketalar). These drugs are popular because of their low cost and their pleasant effects. Club drugs usu-ally are taken orally and may be taken with alcohol or with other drugs. Drug screening generally is not available for club drugs [8]. Each club drug will be discussed in its appropriate chapter.

Date Rape DrugsA date rape drug is a chemical substance slipped into a drink to incapacitate someone for a sexual assault. The drugs often have no color, smell, or taste. Because of the amnesia-producing properties of these drugs, the victim is not able to remember what happened. This reduces the chance of a suc-cessful prosecution. Date rape drugs include fluni-trazepam (Rohypnol), gamma- hydroxybutyrate (GHB), and ketamine (Ketalar) [9].

The Primitive Survival Brain Concept of Substance Dependence

When we first crawled out of the sea and began to walk on the land, the primitive survival brain was

in complete control. It was concerned with sur-vival of the individual and the species, that is, finding food and water, fleeing or fighting when circumstances dictated, and having sex for sur-vival of the species. Over time, the thinking, rea-soning cerebral cortex evolved around it (Fig. 1.1).

Within the primitive survival brain is located the reward center of the brain. The reward center is part of the limbic system, which is responsible for feelings. It is the feeling produced by a drug that the user seeks. The cocaine addict, for example, would be just as happy getting a high from stimulation of an electrode placed in the reward center of the brain as from doses of cocaine.

The process of moving from substance use to substance dependence is often described as “crossing the wall,” which is illustrated in Fig. 1.2. On the substance use side of the wall using cocaine, for example, is a choice. The thinking, reasoning cerebral cortex is in con-trol. Once the person becomes addicted due to altered brain chemistry (moves across the wall), the primitive survival brain takes charge. Using cocaine is no longer a choice. To the addict it feels like a matter of life and death [10].

Table 1.2 Classification of psychoactive substances by their effects on the central nervous system (CNS) (From Milhorn [7]. Approved with permission, Springer)

Drug group Examples Effects on the CNS

CNS depressants Alcohol, barbiturates, benzodiazepines, Z drugs Decrease inhibitions, relieve anxiety, intoxicate, sedate

Opioids Heroin, morphine, hydromorphone, hydrocodone, oxycodone

Reduce pain, cause euphoria, sedate

CNS stimulants Amphetamines, cocaine, methylphenidate Cause excitement, produce euphoria, depress appetite, decrease need for sleep

Cannabinoids Marijuana, hashish, hash oil Produce sense of detachment, euphoria, altered time perception

Dissociatives PCP, ketamine, dextromethorphan Produce intoxication and reduced pain; disconnection between thoughts, identity, consciousness, and memory

Inhalants Paint thinners or removers, degreasers, lighter fluid, correction fluid (Liquid Paper), felt-tip marker fluid, electronic contact cleaners, model glue, spray paint

Produce euphoria, sedate

Hallucinogens LSD, psilocybin, mescaline, peyote, 5-MeO-DMT, MDMA

Produce hallucinations (usually visual but may be auditory or olfactory)

1 Overview

7

Denial

Over a period of time, drug users develop behav-iors (manipulation, lying, self-pity, irresponsibil-ity) that allow them to keep using the drug, a phenomenon known as denial.

Normal Response to Substance Use

Drug use acts on the reward center of the brain to cause drug craving, which acts on the cerebral cortex to cause the addictive behaviors (Fig. 1.3). The addictive behaviors in turn cause guilt, which by negative feedback reduces or cuts down the drug use as indicated by the dashed line [11].

Development of Denial

Once drug users develop dependence, the logic center of the brain (cerebral cortex) is unable to control the intense craving for the drug and the drug use. To protect the mind from the psycho-logical pain of the internal conflict between the drug use and the guilt, an elaborate denial system evolves to separate awareness of the addictive behaviors from the drug use, and thereby relieve the guilt (Fig. 1.4). Addictive behaviors no longer cause guilt. The denial system serves to perpetu-ate the drug use.

Denial can take a number of forms:

• My problems are not due to drug use. “I drink too much because my wife nags me all time; she’s the problem.”

• Drugs cause adverse consequences in others, but not me. “I know smoking causes lung can-cer, but in other people, not me.”

• Some ways of using drugs are okay; others are not. “Taking drugs by mouth is okay; doing them I.V. is not.”

• Some forms of drugs are okay, others are not. “I can’t be an alcoholic; I only drink beer (a case a day).”

Denial is not unique to drug addicts. It occurs in other circumstances. For example, it is the first stage in the grief process: Denial leads to anger which leads to bargaining which leads to depres-sion which leads to acceptance [12].

Fig. 1.1 The primitive survival brain (responsible for sur-vival of the individual and the species) and the cerebral cortex (responsible for thinking and reasoning)

Fig. 1.2 Crossing the wall concept of dependence (Based on Milhorn [10])

Denial

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Tools of Denial

Van Cleave (1987) identified eight tools that addicts use to achieve denial [13]:

1. Rationalization: Using socially acceptable but untrue explanations for inappropriate behav-ior. “I have to take more pain pills than my doctor prescribed because my back hurts so bad.”

2. Projection: Blaming others for one’s own fail-ings and inadequacies. “I wouldn’t have to drink so much if my wife would just quit nag-ging me.”

3. Minimization: Underestimating the magni-tude of their drug use. Alcoholics are notori-ous for answering the question of how many drinks did you have with “I only had a couple of beers.”

4. Repression: Unconsciously excluding from one’s conscious mind unbearable thoughts, feelings, or experiences.

5. Suppression: Consciously excluding from one’s conscious mind unbearable thoughts, feelings, or experiences

6. Isolation: Avoiding relationships that might interfere with their drug use. For instance, if the addict has a relative who gives him a hard

time about drug use he simply avoids that person.

7. Regression: Reverting to a level of emotional maturity appropriate for an earlier stage in life. When an alcoholic is told he has to par-ticipate in an activity in which there will be no alcohol, he may throw a temper tantrum.

8. Conversion: Expressing emotional conflicts through physical symptoms. Conversion allows addicts to focus on minor physical problems to avoid dealing with their drug addiction.

All of the mechanisms to achieve denial are subconscious except for suppression, which occurs at the conscious level.

Addicted Versus Addict

Is it possible to be dependent on a drug without being an addict? Most people would say no. Consider the example of people being treated chronically with morphine for pain associated with terminal cancer. They will become addicted. If the drug is stopped, they will suffer withdrawal symptoms, but they are not compulsive users of the morphine and therefore are not addicts.

Fig. 1.3 Guilt due to addictive behaviors causes the addict to cut back or stop the drug use (Based on Milhorn [11])

Fig. 1.4 Denial blocks the internal relationship between addictive behaviors and guilt, allowing the addict to continue using drugs (From Milhorn [7]. Approved with permission, Springer)

1 Overview

Documents

H. Thomas Milhorn, MD, PhD Substance Use Disordersdownload.e-bookshelf.de/download/0010/4044/96/L-G... · tions of substance dependence, and Chap. 3 covers the pharmacology of addictive