Encyclopedia of drugs, alcohol, & addictive behavior Vol 2 (D-L)

380 Pages·2009·8.46 MB·English

by  Kranzler

VOLUME
2
Encyclopedia of
Drugs, Alcohol & Addictive Behavior
Third Edition
HENRY R. KRANZLER & PAMELA KORSMEYER
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/14/20089:23AMPage3
ENCYCLOPEDIA OF
DRUGS, ALCOHOL
& ADDICTIVE
BEHAVIOR
THIRD EDITION
Volume 2
D–L
Pamela Korsmeyer and Henry R. Kranzler
EDITORSINCHIEF
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/13/200819:22PMPage1
D
percent of community dwelling and 64 percent of
DAST. SeeDrugAbuseScreeningTest(DAST). nursing home residents are delirious. Delirium is
associated with increased morbidity and mortality.
For example, 25 percent of elderly patients with
delirium during hospitalization die within six
n
monthsafterdischarge(AmericanPsychiatricAsso-
DELIRIUM. The primary clinical feature of
ciation, 2000).
delirium is the disturbance of consciousness and/
or attention. Associated symptoms are disorienta- Risk factors associated with delirium are as fol-
tion, memory deficits, and language or perceptual lows: age over sixty-five, physical frailty, severe ill-
disturbances.Anycognitivefunctionmaybeaffected. ness, multiple diseases, dementia, visual or hearing
Fleeting false beliefs, including paranoid ideas, are impairment, polypharmacy, sustained heavy drink-
commonbutusuallyshort-lived.Additionalclinical ing, renal impairment, and malnutrition. Precipi-
symptoms include sleep/wake cycle disturbances tants are acute infections, electrolyte disturbances,
(insomnia, daytime drowsiness, sleep/wake cycle drugs (especially anticholinergics), alcohol with-
reversal,nocturnalworseningofsymptoms),increased drawal, pain, constipation, neurological disorder,
or decreased psychomotor activity, increased or hypoxia, sleep deprivation, surgery, and environ-
decreasedflowofspeech,increasedstartlereaction, mental factors (Young & Inouye, 2007).
andemotionaldisturbances(irritability,depression,
Delirium is an acute dysfunction of arousal
euphoria,anxiety,apathy).Deliriumdevelopswithin
and/or attentional brain networks. Since arousal
hours to days, and its symptoms fluctuate over
and attention are the bases for higher cognitive
time. Although many cases of delirium resolve
functions, most cognitive functions are affected.
promptly with the treatment of the underlying
Neurochemically, delirium is characterized by dis-
cause,symptomsmaypersistformonthsaftertreat-
turbances in acetylcholine, dopamine, norepi-
ment, especially in the elderly. Sometimes an epi-
sode of delirium establishes a new, lower cognitive nephrine, glutamate, gamma aminobutyric acid,
baseline. and serotonin systems. Cytokines and blood-brain
barrier abnormalities may also play a role (Alagia-
Regardingepidemiology,thecommunityprev-
krishnan & Wiens, 2004; Van Der Mast, 1998).
alence of delirium is age-dependent: 0.4 percent in
those over 18, 1.1 percent in those over 55 and Treatments for delirium target the underlying
13.6 percent in those over 85 (Folstein, Bassett, cause(s), as well as the associated behavioral prob-
Romanowsk, et al., 1993). Delirium is common in lems and neuropsychiatric symptoms. Modifiable
the hospital setting: 11 to 42 percent. Among the risk factors or precipitants should be addressed
elderly presenting for hospital admission, 24 (e.g.,bytreatingtheunderlyingmedicalcondition,
1
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/13/200819:22PMPage2
DELIRIUM TREMENS (DTS)
withdrawing of possible offending medications, considerably longer. Early treatment of withdrawal
correcting sensory deficits by using hearing aids symptoms is thought to prevent the risk of devel-
and eyeglasses). Behaviors that put an individual opingDTsanditsrelatedmortality.Riskfactorsfor
at risk should be managed by changing the envi- DTs include infection, a history of epileptic sei-
ronment (e.g., providing access to familiar people zures, tachycardia (rapid heart rate)upon admission
and objects, protecting the individual on a locked to hospital, withdrawal symptoms with a blood
treatment unit when there is a risk of wandering) alcohol concentration 1 g/L, and a prior history
of DTs. Concurrent medical conditions such as
andthroughbehavioralinterventions(e.g.,reorien-
infection, trauma, and liver failure may increase
tation,de-escalationtechniques),possiblyincombi-
the mortality of DTs.
nationwithmedications.Neuropsychiatricsymptoms
(e.g., perceptual disturbances, agitation, aggression) Symptoms of DTs include those typically seen
are managed with antipsychotics, mood stabilizers, in delirium, including disorientation, confusion,
or antiepileptics. Benzodiazepines may be useful in fluctuating levels of consciousness and attention,
treatingwithdrawalfromalcohol. vivid hallucinations, delusions, agitation, and also
include those found in alcohol withdrawal; fever,
SeealsoComplications. elevated blood pressure, rapid pulse, sweating, and
tremor. Delirium is the hallmark and defining fea-
BIBLIOGRAPHY ture of DTs and differentiates the syndrome from
Alagiakrishnan,K.,&Wiens,C.A.(2004).Anapproachto uncomplicated alcohol withdrawal. The delirium
drug induced delirium in the elderly. Postgraduate may at times be preceded by a withdrawal seizure,
MedicalJournal,80,388–393. although a seizure neither defines nor is its pres-
encerequiredtodiagnoseDTs,andnotallpatients
American Psychiatric Association. (2000). Diagnostic and
that experience withdrawal seizures develop DTs.
Statistical Manual of Mental Disorders (4th rev. ed.).
Washington,DC:Author. The treatment of DTs necessitates close monitor-
ing in the hospital setting.
Folstein, M. F., Bassett, S. S., Romanowsk, A. J., et al.
(1993).Theepidemiologyofdeliriuminthecommun- For patients in alcohol withdrawal but without
ity: The Eastern Baltimore Mental Health Survey. DTs,astheseverityofwithdrawalincreases,patients
InternationalPsychogeriatrics,3,169–179.
may experience transient mild hallucinations that
VanDerMast,R.C.(1998).Pathophysiologyofdelirium. are auditory, visual, or tactile in nature. Loss of
Journal of Geriatric Psychiatry and Neurology, 11(3),
insightintohallucinationsor developmentofmore
138–45.
severe and persistent hallucinations may suggest
Young, J., & Inouye, S. (2007). Delirium in older people. that the syndrome has progressed or is progressing
BritishMedicalJournal,334,842–846.
toDTs.Deliriumtremensisdifferentiatedfromthe
KALOYANTANEV syndromesofalcoholichallucinosisandchronicalco-
holic hallucinosis, which are terms used inconsis-
tently in the literature to refer to the transient
n hallucinosis experienced during alcohol withdrawal
DELIRIUM TREMENS (DTS). Delir- and/or the subsequent development of a state of
ium tremens (DTs) refers to the most severe form psychosis accompanied by hallucinations and/or
of the alcohol withdrawal syndrome, occurring delusions (particularly persecutory) that persists
with the abrupt cessation of, or reduction in, alco- beyond the period of detoxification. There is con-
hol consumption in an individual who has been a troversy as to whether chronic alcoholic hallucino-
heavydrinkerformanyyears.Itisassociatedwitha sis syndrome exists.
significant mortality rate of an estimated 1 to 5
SeealsoDelirium;Withdrawal.
percent, which is likely higher (perhaps up to 15
percent) if untreated.
BIBLIOGRAPHY
DTs usually begin at seventy-two to ninety-six
Debellis, R., Smith, B. S., Choi, S., & Malloy, M. (2005).
hours after the cessation of drinking and usually
Managementofdeliriumtremens.JournalofIntensive
last two to three days but can occasionally last CareMedicine,20(3),164–173.
2 ENCYCLOPEDIA OF DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR, 3RD EDITION
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/13/200819:22PMPage3
DEPRESSION
DeMillas,W.,&Haasen,C.(2007).Treatmentofalcohol suicidal attempt); and functional impairment or
hallucinosis with risperidone. American Journal of clinically significant distress.
Addictions,16(3),249–250.
If the symptoms of depression are the direct
Graham,A.W.,Schultz,T.K.,Mayo-Smith,M.,&Ries,R.
physiological effects of heavy consumption of alco-
K. (Eds.). (2003). Principles of addiction medicine,
third edition. Chevy Chase, MD: American Society of hol or another psychoactive substance and are
AddictionMedicine. greater than the expected effects of intoxication
or withdrawal, the depression is considered to be
MYROSLAVAROMACH
substance-induced. In DSM-IV, normal bereave-
KARENPARKER
REVISEDBYALBERTJ.ARIAS(2009) ment isnot presentifinappropriate guilt,thoughts
of death unrelated to the deceased person, a pre-
occupation with worthlessness, marked psychomo-
tor retardation, and hallucinations that are not a
phenomenon shared by others in one’s cultural
DENMARK. SeeNordicCountries(Denmark, grouparepresent,signalingthepresenceofamajor
Finland,Iceland,Norway,andSweden).
depressive episode. Major depressive disorder is
also distinguished from low mood resulting from
amedicalconditionandmoodchangesthataredue
n to exposure to a toxin or chemical substance.
DEPRESSION. The term depression refers to
Major Depression is one of the most common
both a mood and a group of psychiatric disorders.
psychiatric disorders experienced by adults. One
IntheDiagnosticandStatisticalManualofMental
study of datadrawn fromthe 2001–2002 National
Disorders (DSM-IV-TR, 2000) depressed mood
Epidemiologic Survey on Alcohol and Related
occurs as part of major depressive disorder (MDD),
Conditions indicated that approximately 13 percent
dysthymic disorder (chronic, less severe depres-
of the U.S. population has experienced a major
sion), and schizoaffective disorder (psychosis co-
depressive episode (Hasin et al., 2005). Women
occurring with depressed or manic mood), and
have higher rates of lifetime depression than men
canalsooccurinbipolardisorder(periodsofmania
(17.10percentvs.9.01percent),NativeAmericans
that can alternate with periods of depression) and
are at greater risk for depression than other ethnic
during intoxication or withdrawal from certain
groups, and individuals who are middle-aged or
substances.
widowed, separated, or divorced, and those with
Many people experience brief periods of
lower income levels are at increased risk. Depres-
depressed mood that are often responses to stress-
sion is associated with substantial impairment
ful life events or negative experiences. However,
(Weissmanetal.,1991;Kessleretal.,1994;Kessler
when depression-related symptoms cluster, persist,
etal.,2003),psychiatriccomorbidity(Weissmanetal.,
and ultimately cause impairment in functioning,
1991;Kessleretal.,1994;Kessleretal.,2003;Hasin
the person is considered to be experiencing a
etal.,2005),poorhealth(Dentinoetal.,1999),and
depressive syndrome. The DSM-IV classifies this
mortality(Insel&Charney,2003).
syndromeasamajordepressiveepisodeandrequires
the following criteria: a period of low mood (or Thecauseofdepressionismulti-systemic.Imag-
lossofinterestorpleasureinusualactivities)lasting ing studies have shown abnormal neurochemical
at least two weeks; four or more out of eight addi- activity and changes in volume in specific areas of
tional symptoms (significant change in weight or the brain of depressed people. These biological
appetite, poor or increased sleep nearly every day, changes, combined with genetic and psychosocial
psychomotoragitationorretardationthatisnotice- factors(e.g.,lifeevents, learnedbehaviors,andcog-
able to others nearly every day, fatigue or low nitions)allinteracttovaryingdegrees.Depressionis
energy nearly every day, feelings of worthlessness a highly recurrent but treatable illness. Effective
or inappropriate guilt nearly every day, difficulty treatmentoptionsareavailable(e.g.,psychotherapy,
concentrating or making decisions nearly every pharmacotherapy, psychoeducation, and, generally
day, and recurring thoughts of death, suicide, or as a last option, electroconvulsive therapy), and the
ENCYCLOPEDIA OF DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR, 3RD EDITION 3
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/13/200819:22PMPage4
DESIGNER DRUGS
choice of treatment depends on multiple factors the pharmaceutical industry, the design of new
such as the individual’s psychiatric history, the drugs often utilizes principles of basic chemistry,
severity of the current episode, family and social so that the structure of a drug molecule is slightly
support, general medical health, the patient’s level altered in order to change its pharmacological
of motivation, and the compatibility of the treat- activity. This strategy has a long and successful
ment with the patient’s current circumstances. history in medical pharmaceutics, and many useful
new drugs or modifications of older drugs have
SeealsoComplications:MentalDisorders;RiskFactors
forSubstanceUse,Abuse,andDependence:An clearly resulted in improved health care for many
Overview. people throughout the world. The principles of
structure-activity relationships have been applied
to many medically approved drugs, especially in
BIBLIOGRAPHY
the search for a nonaddicting opioid analgesic for
American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (4th rev. ed.). the treatment of pain. However, the clandestine
Washington,DC:Author. production of ‘‘designer’’ street drugs is intended
Dentino, A. N., Pieper, C. F., Rao, M. K., Currie, M. S., to avoid federal regulation and control. This prac-
Harris, T., Blazer,D. G.,etal. (1999). Association of tice can often result in the appearance of new and
interleukin-6andotherbiologicvariableswithdepres- unknown substances with wide-ranging variations
sion in older people living in the community. Journal
in purity. The quality of personnel involved in
oftheAmericanGeriatricSociety,47,6–11.
clandestine designer-drugsynthesis can range from
Hasin, D., Goodwin, R., Stinson, F. S., & Grant, B. F.
‘‘cookbook’’ amateurs to highly skilled chemists,
(2005). Epidemiology of major depressive disorder:
which means that these substances have the poten-
Results from the national epidemiologic survey on
alcoholism and related conditions. Archives of General tial to cause dangerous toxicity with serious health
Psychiatry,62,1097–1106. consequences for the unwitting drug user.
Insel, T. R., & Charney, D. S. (2003). Research on major
Aresurgenceinthepopularityofarelativelyold
depression: Strategies and priorities. Journal of Amer-
drug, methamphetamine, was observed during the
icanMedicalAssociation,289,3167–3168.
first decade of the twenty-first century. Although
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz,
methamphetamine is manufactured in foreign or
D.,Merikangas,K.R.,etal.(2003).NationalComor-
bidity Survey Replication: The epidemiology of major domestic ‘‘superlabs,’’ the drug is also easily made
depressivedisorder:ResultsfromtheNationalComor- insmall clandestinelaboratorieswithrelativelyinex-
bidity Survey Replication (NCS-R). Journal of Ameri- pensive over-the-counter ingredients. This practice
canMedicalAssociation,289,3095–3105.
can lead to wide variations in the purity of the
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C., methamphetamine available for illicit distribution.
Hughes,M.,Eshleman,S.,etal.(1994).Lifetimeand Methamphetamine is a highly addictive central ner-
12-month prevalence of DSM-III-R psychiatric disor-
voussystemstimulantthatwasdevelopedearlyinthe
ders in the United States: Results from the National
twentieth century and initially used in nasal decon-
ComorbiditySurvey.ArchivesofGeneralPsychiatry,51,
8–19. gestantsandbronchialinhalers.Likeamphetamine,
methamphetamine produces increased activity and
Weissman,M.M.,Bruce,L.M.,Leaf,P.J.,Florio,L.P.,&
Holzer, C., III. (1991). Affective disorders. In L. N. talkativeness, anorexia, and a general sense of well-
Robins & D. A. Regier (Eds.), Psychiatric disorders in being. However, methamphetamine differs from
America: The Epidemiologic Catchment Area Study amphetamine in that much higher levels of meth-
(pp.53–80).NewYork:FreePress.
amphetamine get into the brain when comparable
SHARONSAMET doses are administered, making it a more potent
stimulant drug. And while methamphetamine
blocks the reuptake of dopamine at low doses, in
n a manner similar to cocaine, it also increases the
DESIGNER DRUGS. ‘‘Designer drugs’’ release of dopamine, leading to much higher con-
aresyntheticchemicalanalogsofabusedsubstances centrations of this neurotransmitter. Although the
that are designed to produce pharmacological pleasurableeffectsofmethamphetaminemostlikely
effects similar to the substances they mimic. In result from the release of dopamine, the elevated
4 ENCYCLOPEDIA OF DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR, 3RD EDITION
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/13/200819:22PMPage5
DESIGNER DRUGS
release of this neurotransmitter also contributes to degenerationofserotonergicnerveterminalsinrats,
the drug’s deleterious effects on nerve terminals. implying that it might induce chronic neurological
Specifically, brain-imaging studies have demon- damageinhumansaswell.
strated alterations in the activity of the dopamine
Newerdesignerdrugsofabusethathaverecently
system that are due to methamphetamine use.
emergedontheblackmarketincludeamphetamine-
Recent studies of chronic methamphetamine users
derived drugs such as para-methoxyamphetamine
have revealed structural and functional changes in
(PMA), para-methoxymethamphetamine (PMMA)
areas of the brain associated with emotion and
and 4-methylthioamphetamine (4-MTA). In addi-
memory, which may accountfor many ofthe emo-
tion, newer designer drugs of the benzyl or phenyl
tional and cognitive problems experienced by
piperazinetype,andofthepyrrolidinophenonetype,
chronic users.
have gained popularity and notoriety as party or
‘‘rave’’ drugs. These include N-benzylpiperazine
Addicts typically exhibit anxiety, confusion,
(BZP); 1-(3, 4-methylenedioxybenzyl)piperazine
insomnia, mood disturbances, and violent behav-
(MDBP); 1-(3-chlorophenyl)piperazine (mCPP);
ior,andtheycanalsodisplayanumberofpsychotic
1-(3-trifluoromethylphenyl)piperazine (TFMPP);
features, including paranoia, visual and auditory
1-(4-methoxyphenyl)piperazine (MeOPP); alpha-
hallucinations, and delusions. These psychotic
pyrrolidinopropiophenone (PPP); 4’-methoxy-
symptoms can last for months or years after meth-
alpha-pyrrolidinopropiophenone (MOPPP); 3’,
amphetamine use has ceased, and stress has been
4’-methylenedioxy-alpha-pyrrolidinopropiophe-
showntoprecipitatethespontaneousrecurrenceof
none (MDPPP); 4’-methyl-alpha-pyrrolidinopro-
methamphetamine psychoses. Methamphetamine
piophenone (MPPP); and 4’-methyl-alpha-pyrroli-
can also produce a variety of cardiovascular effects,
dinoexanophenone(MPHP).Thesedrugsproduce
including rapid heart rate, irregular heartbeat, and
feelings of euphoria and energy and a desire to
increased blood pressure. Hyperthermia (elevated
socialize. While ‘‘word on the street’’ suggests that
bodytemperature)andconvulsionsmayoccurdur-
these designer drugs are safe, studies in rats and
ing a methamphetamine overdose, and, if not
primates have suggested that they present risks to
treated immediately, this can result in death. Tol-
humans. In fact, a variety of adverse effects have
erance to methamphetamine’s pleasurable effects
beenassociatedwiththeuseofthisclassofdrugsin
develops with chronic use, and abusers may take
humans,includingalife-threateningserotoninsyn-
higher doses of the drug, take it more frequently,
drome (due to an excess of this neurotransmitter),
or change their method of drug intake in an effort
andtoxiceffectsontheliverandbrainthatresultin
to intensify the desired effects. Methamphetamine
behavioral changes.
has also become associated with a culture of risky
sexual behavior, both among men who have sex An opioid that has resulted in serious health
with men and heterosexual populations, because hazards on the street is fentanyl (Sublimaze), a
methamphetamineandrelatedpsychomotorstimu- potent and extremely fast-acting narcotic analgesic
lants can increase libido. Paradoxically, however, withahighabuseliability.Thisdrughasalsoserved
long-term methamphetamine abuse may be associ- as a template for many look-alike drugs in the
ated with decreased sexual functioning. clandestine chemical laboratory. Very slight mod-
ifications in the chemical structure of fentanyl can
Other hallucinogenic designer drugs that are
resultinanalogssuchaspara-fluoro-,3-methyl-,or
amphetamine analogs—such as methylenedioxyam-
alpha-methyl-fentanyl, with relative potencies that
phetamine(MDA),methylenedioxymethamphetamine
are 100, 900, and 1,100 times that of morphine,
(MDMA or ‘‘Ecstasy’’) and methylenedioxyetham-
respectively. Unfortunately, a steady increase in
phetamine (MDEA or ‘‘Eve’’)—can also produce
deaths from drug overdoses associated with fen-
acuteandchronictoxicity.Acutetoxicityfromthese
tanyl-like designer drugs has been reported.
drugsisusuallymanifestedasrestlessness,agitation,
sweating, high blood pressure, tachycardia, and Designer drugs already on the street, such as
othercardiovasculareffects,allofwhicharesugges- methamphetamine and related stimulants,can pro-
tiveofexcessivecentralnervoussystemstimulation. duce significant brain damage following long-term
Followingchronicadministration,MDAproducesa use,andanalogsoftheopioidfentanylcanproduce
ENCYCLOPEDIA OF DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR, 3RD EDITION 5
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/13/200819:22PMPage6
DEXTROAMPHETAMINE
fatal overdoses. Taken to the extreme, the wide- Ziporyn, T. (1986). A growing industry and menace:
spreadillicitmanufactureanduseofdesignerdrugs Makeshift laboratory’s designer drugs. Journal of the
AmericanMedicalAssociation,256(22),3061–3063.
with unknown toxicity could result in millions of
people ingesting the drug before the toxic effects NICHOLASE.GOEDERS
are known, potentially producing an epidemic of
neurodegenerative disorders and fatalities.
n
SeealsoControlledSubstancesActof1970;MDMA;
DEXTROAMPHETAMINE. This is the
MPTP.
d-isomer of amphetamine. It is classified as a psy-
chomotorstimulantdrugandisthreetofourtimes
BIBLIOGRAPHY
aspotentasthel-isomerinelicitingcentralnervous
Barnett, G., & Rapaka, R. S. (1989). Designer drugs: An
system (CNS) excitatory effects. It is also more
overview.InK.K.Redda,C.A.Walker,&G.Barnett
potent than the l-isomer in its anorectic (appetite
(Eds.),Cocaine,marijuana,designerdrugs:Chemistry,
suppressant) activity, but slightly less potent in its
pharmacology, and behavior (pp. 163–174). Boca
cardiovascular actions. It is prescribed in the treat-
Raton,FL:CRCPress.
mentofnarcolepsyandobesity,althoughcaremust
Beebe, D. K., & Walley, E. (1991). Substance abuse: The
be taken in such prescribing because of the sub-
designer drugs. American Family Physician, 43(5),
stantial abuse liability.
1689–1698.
Christophersen, A. S. (2000). Amphetamine designer High-dose chronic use of dextroamphetamine
drugs: An overview and epidemiology. Toxicology Let- can lead to the development of a toxic psychosis as
ters,112–113,127–131.
well as to other physiological and behavioral prob-
de Boer, D., Bosman, I. J., Hidve´gi, E., Manzoni, C., lems.ThistoxicitybecameaproblemintheUnited
Benko¨, A. A., dos Reys, L. J., et al. (2001). Pipera- States in the 1960s, when substantial amounts of
zine-likecompounds:Anewgroupofdesignerdrugs-
the drug were being taken for nonmedical reasons.
of-abuse on the European market. Forensic Science
Although still abused by some, dextroamphet-
International,121(1–2),47–56.
amineisnolongerthestimulantofchoiceformost
Klein, M., & Kramer, F. (2004). Rave drugs: Pharmaco-
psychomotor stimulant abusers.
logicalconsiderations.AANAJournal,72(1),61–67.
SeealsoAmphetamineEpidemics,International;Coca/
Maurer,H.H.,Kraemer,T.,Springer,D.,&Staack,R.F.
Cocaine,International.
(2004). Chemistry, pharmacology, toxicology, and
hepatic metabolism of designer drugs of the amphet-
amine (ecstasy), piperazine, and pyrrolidinophenone
BIBLIOGRAPHY
types: A synopsis. Therapeutic Drug Monitoring,
deWit,H.,etal(2002).Acuteadministrationofd-amphet-
26(2),127–131.
aminedecreasesimpulsivityinhealthyvolunteers.Neu-
Nichols,D.E.(1989).Substitutedamphetaminecontrolled ropsychopharmacology,27,813–825.
substance analogues. In K. K. Redda, C. A. Walker &
Schmetzer,A.D.(2004).Thepsychostimulants.Annalsof
G.Barnett(Eds.),Cocaine,marijuana,designerdrugs:
theAmericanPsychotherapyAssociation,7,31–32.
Chemistry, pharmacology, andbehavior (pp.175–185).
BocaRaton,FL:CRCPress. MARIANW.FISCHMAN
Soine,W.H.(1986).Clandestinedrugsynthesis.Medicinal
ResearchReviews,6(1),41–47.
Staack, R. F., & Maurer, H. H. (2005). Metabolism of n
designerdrugsofabuse.CurrentsinDrugMetabolism, DIAGNOSIS OF SUBSTANCE USE
6(3),259–274.
DISORDERS: DIAGNOSTIC CRI-
Trevor, A., Castagnoli, N., Jr., & Singer, T. P. (1989). TERIA. Diagnosis is the process of identifying
Pharmacologyandtoxicology ofMPTP:Aneurotoxic and labeling specific disease conditions. The signs
by-product of illicit designer drug chemistry. In K. K.
and symptoms used to classify a sick person as
Redda, C. A. Walker & G. Barnett (Eds.), Cocaine,
havingadiseasearecalleddiagnosticcriteria.Diag-
marijuana, designer drugs: Chemistry, pharmacology,
nostic criteria and classification systems are useful
and behavior (pp. 187–200). Boca Raton, FL: CRC
Press. for making clinical decisions, estimating disease
6 ENCYCLOPEDIA OF DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR, 3RD EDITION
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/13/200819:22PMPage7
DIAGNOSIS OF SUBSTANCE USE DISORDERS: DIAGNOSTIC CRITERIA
prevalence, understanding the causes of disease, CLASSIFICATION SYSTEMS
and facilitating scientific communication. Alcoholismanddrugaddictionhavebeenvariously
definedasmedicaldiseases,mentaldisorders,social
Diagnostic classification provides the treating
problems, and behavioral conditions. In some
clinicianwithabasisforretrievinginformationabout
cases, they are considered the symptom of an
apatient’sprobablesymptoms,thelikelycourseofan
underlying mental disorder (Babor, 1992). Some
illness, and the biological or psychological processes
ofthesedefinitionspermittheclassificationofalco-
thatunderliethedisorder.Forexample,theDiagnostic
holism and drug dependence within standard
and Statistical Manual (DSM) of the American Psy-
nomenclatures such as the DSM and ICD. The
chiatric Association is a classification of mental disor-
most recent revisions of both of these diagnostic
ders that provides the clinician with a systematic
systems—DSM-IV (1994) and ICD-10 (1992)—
description of each disorder in terms of essential fea-
have resulted in a high degree of compatibility
tures,ageofonset,probablecourse,predisposingfac-
between the classification criteria used in the
tors, associated features, and differential diagnosis.
United States and those used internationally. Both
Mental health professionals can use this system to
systemsnowdiagnosedependenceaccordingtothe
diagnose substance use disorders in terms of the fol-
elements first proposed by Edwards and Gross
lowingcategories:acuteintoxication,abuse,depend-
(1976). They also include a residual category
ence, withdrawal, delirium, and other disorders. In
(harmful alcohol use [ICD-10]; alcohol abuse
contrast to screening, diagnosis typically involves a
[DSM-IV]) that allows classification of psycholog-
broaderevaluationofsigns,symptoms,andlaboratory
ical, social, and medical consequences directly
dataastheserelatetothepatient’sillness.Thepurpose
related to substance use.
of diagnosis is to provide the clinician with a logical
basisforplanningtreatmentandestimatingprognosis.
HISTORY TAKING
Another purpose of classification is the collec- Obtaining accurate information from patients with
tion of statistical information on a national and alcohol and drug problems is often difficult
international scale. The primary purpose of the because of the stigma associated with substance
World Health Organization’s International Classi- abuse and the fear of legal consequences. At times,
fication of Diseases (ICD), for example, is the enu- theseindividualswanthelp forthemedicalcompli-
merationofmorbidityandmortalitydataforpublic cationsofsubstanceuse(suchasinjuriesordepres-
health planning. In addition, a good classification sion)butareambivalentaboutgivingupalcoholor
will facilitate communication among scientists and drug use entirely. It is often the case that these
providethebasicconceptsneededfortheorydevel- patients are evasive and attempt to conceal or min-
opment. Both the DSM and ICD have also been imize the extent of their alcohol or drug use.
used extensively to classify persons for scientific Acquiringaccurateinformationaboutthepresence,
research. Classification thus provides a common severity, duration, and effects of alcohol and drug
frame of reference in communicating scientific use therefore requires a considerable amount of
findings. clinical skill.
Diagnosis may also serve a variety of adminis- The medical model for history taking is the
trative purposes. When a patient is suspected of most widely used approach to diagnostic evalua-
having a substance use disorder, diagnostic proce- tion. This model consists of identifying the chief
dures are needed to exclude ‘‘false positives’’ (i.e., complaint, evaluating the present illness, reviewing
people who appear to have the disorder but who past history, conducting a review of biological sys-
reallydonot)andborderlinecases.Insurancereim- tems (e.g., gastrointestinal, cardiovascular), asking
bursement for medical treatment increasingly about family history of similar disorders, and dis-
demands that a formal diagnosis be confirmed cussing the patient’s psychological and social func-
according to standard procedures or criteria. The tioning. Ahistoryofthepresentillnessbeginswith
need for uniform reporting of statistical data, as questions on the use of alcohol, drugs, and
well as the generation of prevalence estimates for tobacco. The questions should cover prescription
epidemiological research, often requires a diagnos- drugs as well as illicit drugs, with additional elabo-
tic classification of the patient. ration of the kinds of drugs, the amount used, and
ENCYCLOPEDIA OF DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR, 3RD EDITION 7
EncyclopediaofDrugs,Alcohol&AddictiveBehavior,3rdEdition,Vol2-Finals/10/13/200819:22PMPage8
DIAGNOSIS OF SUBSTANCE USE DISORDERS: DIAGNOSTIC CRITERIA
the mode of administration (e.g., smoking, injec- substanceusedisorders,butalsoaboutphysicalcon-
tion). Questions about alcohol use should refer ditions and psychiatric disorders that are commonly
specifically to the amount and frequency of using associatedwithsubstanceabuse.Becauseofitsstand-
the major beverage types (wine, spirits, and beer). ardized questioning procedures, the CIDI has been
A thorough physical examination is important usedbythe World Health Organizationtoestimate
because each substance has specific pathological the prevalence of mental disorders, including sub-
effects on certain organs and body systems. For stance use disorders, in the general populations of
example, alcohol commonly affects the liver, stom- countriesthroughouttheworld(Haroetal.,2006).
ach, cardiovascular system, and nervous system, In the United States, the Alcohol Use Disorder
while drugs often produce abnormalities in ‘‘vital and Associated Disabilities Interview Schedule-IV
signs’’ such as temperature, pulse, and blood (AUDADIS-IV) has been used extensively in popu-
pressure. lationsurveys,includingtheNationalEpidemiologic
SurveyonAlcoholandRelatedConditions(Grantet
A mental status examination frequently gives
al., 2003). It covers alcohol consumption, tobacco
evidence of substance use disorders, which can be
use,familyhistoryofdepression,andselectedDSM-
signaled by poor personal hygiene, inappropriate
IVAxisIandIIpsychiatricdisorders.
affect (e.g., sad, euphoric, irritable, anxious), illog-
ical or delusional thought processes, and memory Asecondtypeofdiagnosticinterviewisexempli-
problems.Thephysicalexamination canbesupple- fiedbytheStructuredClinicalInterviewforDSM-IV
mentedbylaboratorytests,whichsometimesaidin (SCID), which is designed for use by mental health
early diagnosis beforesevereor irreversible damage professionals(Spitzeretal.,1992;Firstetal.,2002).
has taken place. Laboratory tests are useful in two The SCID assesses the most commonly occurring
ways: (1) alcohol and drugs can be measured psychiatricdisordersdescribedinDSM-IV,including
directly in blood, urine, or exhaled air; (2) bio- mood disorders, schizophrenia, and substance use
chemical and psychological functions known to be disorders. A similar clinical interview designed for
affected by substance use can be assessed. Many internationaluseistheSchedulesforClinicalAssess-
drugs can be detected in the urine for 12 to 48 ment in Neuropsychiatry (SCAN; see Wing et al.,
hours after their consumption. An estimate of 1990). The SCID and SCAN interviews allow the
blood alcohol concentration (BAC) can be made experienced clinician to tailor questions to fit the
directly by blood test or indirectly by means of a patient’s understanding, to ask additional questions
breath or saliva test. Elevations of the liver enzyme thatclarifyambiguities,tochallengeinconsistencies,
gamma-glutamyl transpeptidase (GGTP) or the andtomakeclinicaljudgmentsabouttheseriousness
protein carbohydrate-deficient transferrin (CDT) of symptoms. Both are modeled on the standard
are sensitive indicators of chronic and heavy alco- medical history practiced by many mental health
hol intake. However, while these tests can detect professionals. Questions about the chief complaint,
recent use of a wide variety of psychoactive sub- past episodes of psychiatric disturbance, treatment
stances (e.g., opioids, cannabis, stimulants, barbi- history, and current functioning all contribute to a
turates), they are not able to detect alcohol or thorough and orderly psychiatric history that is
drug dependence. extremelyusefulfordiagnosingsubstanceusedisor-
Inadditiontothephysicalexaminationandlabo- ders. The Psychiatric Research Interview for Sub-
ratory tests, a variety of diagnostic interview proce- stance and Mental Disorders (PRISM; Hasin et al.,
dures have been developed to provide objective, 2006) is another semistructured diagnostic inter-
empiricallybased,reliablediagnosesofsubstanceuse view. It is designed to deal with the problems of
disorders in various clinical populations. One type, psychiatricdiagnosiswhensubjectsorpatientsdrink
exemplified by the Diagnostic Interview Schedule heavilyorusedrugs.ThePRISMisusedformakinga
(DIS; see Robins et al., 1981) and the Composite number of DSM-IV Axis I and Axis II diagnoses,
InternationalDiagnosticInterview(CIDI;seeRobins including alcohol and drug use disorders, in a way
et al., 1988), is highly structured and requires a that allows differentiation of psychiatric disorders
minimum of clinical judgment by the interviewer. from substance-induced disorders and from the
Theseinterviewsprovideinformationnotonlyabout expectedeffectsofintoxicationandwithdrawal.
8 ENCYCLOPEDIA OF DRUGS, ALCOHOL & ADDICTIVE BEHAVIOR, 3RD EDITION