Alcohol and Drug Abuse as Encountered in Office Practice

337 Pages·1990·45.316 MB·\337

by  Frank L. Iber (Author)

Alcohol and Drug
Abuse as Encountered
in Office Practice
Editor
Frank Lynn Iber
Professor of Medicine
Stritch College of Medicine
Loyola University
Maywood, Illinois
Chief of Gastroenterology
Edward Hines Jr. Hospital
Hines, Illinois
0
CRC Press
c~
Taylor & Francis Group
Boca Raton London New York
CRC Press is an imprint of the
Taylor & Francis Group, an informa business
Library of Congress Cataloging-in-Publication Data
Alcohol and drug abuse as encountered in office practice/editor,
Frank Lynn lber.
p. em.
Includes bibliographical references.
Includes index.
ISBN 0-8493-0166-1
I. Alcoholism-Treatment. 2. Drug abuse-Treatment. 3. Family
medicine. I. Iber, Frank L., 1928-
[DNLM: I. Alcoholis~iagnosis. 2. Alcoholism-rehabilitation.
3. Substance Abuse-diagnosis. 4. Substance Abuse-rehabilitation.
WM 270 A35415)
RC564.73.A43 1990
616.86-dc20
DLC 90-2334
This book represents information obtained from authentic and highly regarded sources. Reprinted material is
quoted with permission, and sources are indicated. A wide variety of references are listed. Every reasonable
effort has been made to give reliable data and information, but the author and the publisher cannot assume
responsibility for the validity of all materials or for the consequences of their use.
All rights reserved. This book, or any parts thereof, may not be reproduced in any form without written
consent from the publisher.
Direct all inquiries to CRC Press, Inc., 2000 Corporate Blvd., N.W., Boca Raton, Florida 33431.
© 1991 by CRC Press, Inc.
International Standard Book Number 0-8493-0166-1
Library of Congress Card Number 90-2334
Printed in the United States
Dedication
In 1956 Tom Burnett and W. Dixon Gibbs of Baltimore convinced me that working
with alcoholics was rewarding and showed me how to become effective; I have been involved
in this labor ever since. This book is dedicated to the volunteers who help people with
substance abuse.
ACKNOWLEDGMENT
This book required the participation of many workers. Our secretary Norma Jackson
produced the manuscript. Gloria Kelly, R.N. assisted with editing. Billie Ladas produced
all of the art work and Gerda Kirschner and Willie Marks made the photographs. John Cline
of Hines, Pat Padgett of the NIH, and the many workers at Pracon Inc. Reston Va. provided
many bibliographies and obtained many library references. A large number of colleagues
critiqued one or more chapters, sharing their expertise and suggesting important information
that might be included. I am grateful to these people for their excellent suggestions. Many
of the best features of this book are because of their intervention, but I accept full respon
sibility for failure to fully carry out their ideas if errors appear. Richard Baum, M.D.; John
Crayton, M.D.; Charles Davidson, M.D.; Carole Dorsch, M.D.; Walter Dorus, M.D.;
Kathryn Eiler, M.D.; Barbara Ganem, M.D.; Richard Iber, B.S.; Robert Iber, J.D.; Gloria
Kelly, R.N.; Harry Klinefelter, M.D.; U. Malkemecker, M.D.; Ron Medej, M.S.W.;
Esteban Mezey, M.D.; Robert Miller, B.A.; Kevin O'Brien, M.D.; David Posner, M.D.;
Jeanne Riley, M.B.A.; Herbert Trace, M.D.; and Janice Willms, M.D. responded to this
need.
The ideas in this book came from a much wider group. I have shared responsibilities
for the care of substance abuse patients at Johns Hopkins Hospital, Baltimore City Hospitals,
Lemuel Shattuck Hospital, Boston Alcoholism Dependence Project, Baltimore Veterans
Administration Hospital, Fort Howard VA Hospital, University Hospitals, and Edward Hines
Jr. Hospital for more than 30 continuous years. These programs and the several hundred
staff persons who worked with them through these years of may involvement were my
teachers. To these who shared the work, the excitement of helping people, and the evolution
of the ideas expressed here I direct my thanks and hope they share pride in what is put forth
in this book.
PREFACE
I became active with substance abusing patients as a resident physician in internal
medicine in the 1950s. At that time many physicians did not treat abuse and more than half
the hospitals were reluctant to admit such patients. Volunteer and self-help groups filled the
gap that hospitals and physicians left and I learned a great deal from them and helped with
their half-way houses and homes for withdrawal. I began research on alcohol injury and
recovery. The clear advantage of a physician cooperating with volunteer groups was apparent
in the resources I could offer to my patients.
A few years later I was working in Boston and had an opportunity to establish large
withdrawal facilities for derelict abusing patients and worked out programs that continue to
this day. During these years I became active in teaching medical students and physicians
about substance abuse. The need for a practical guide for office-based physicians seeing
only the abuse problems in a standard private practice was then clearly apparent. Physicians
were increasingly aware of abusing patients, but were not utilizing self-help groups and
other trained persons in the recovery process. This book was delayed, for many books on
the subject appeared but none quite hit the mark to which I was aiming.
This book is for the office-based physician doing a family or internal medicine practice.
It is a guide to handle about 95% of the problems of abuse that come to attention in practice
and to indicate clearly those which require other facilities. Its primary purpose is to point
out that the skills that each of us physicians has learned can be used to great benefit for
helping abusing patients. As with most chronic diseases, assistance at an early stage produces
a much greater impact on future health and I hope with this guide such an improved outcome
becomes more frequent.
Frank lber, M.D.
Chicago, Illinois 1990
THE AUTHOR
Frank L. Iber, M.D., is Professor of Medicine at Loyola University in Chicago and
Chief of Gastroenterology at Edward Hines Jr. Hospital. He received his A.B. and M.A.
degrees from Miami University in Oxford, Ohio, his M.D. degree from Johns Hopkins
University School of Medicine in Baltimore, and did postgraduate work at Hopkins and at
the Postgraduate Medical School in London, England. He became an Assistant Professor at
Hopkins in 1960, an Associate Professor in 1965, and Professor of Medicine at Tufts
University in Boston in 1968. In 1973 he returned to Baltimore as Director of the Gastroin
testinal Division at University of Maryland and the Baltimore VA Hospital. He is a founding
member of the American Council on Alcoholism, director of programs for alcoholics and
drug abuse at the Baltimore VA Hospital, the Lemuel Shattuck Hospital in Boston, and has
established a model inner city program for derelict abusers in Boston. He has served on the
board and as a backup physician for some 30 organizations providing services for abusing
persons. The training divisions of these programs provided laboratory experience for more
than 200 professionals in ministry, social work, psychology, nurse practioners, physicians,
and physicians assistants, the majority of whom remain in addiction work.
Dr. Iber is a member of the American College of Physicians, the American Society of
Addiction Physicians, Research Society in Alcoholism and some 15 other learned societies
in medicine, liver disease, nutrition, and addictions. He has been the principal investigator
on more than 50 grants from the National Institutes of Health, the Veterans Administration,
and foundations and is an author of more than 200 publications, 25 book chapters, and 2
complete books. His research has been in the treatment of liver disease and its complications,
nutritional problems of the addictions, medical problems associated with addictions, and
evaluations of treatment. His current research interests are in the formation of gallstones in
cirrhosis of the liver, evaluation of treatment, and training.
TABLE OF CONTENTS
Chapter 1
Introduction to Abused Substances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
II. Health-Related Toxicities ......................................................... 2
III. Emergencies ...................................................................... 2
IV. Conditions Frequently Associated with Addictions ................................ 3
V. Problems During Withdrawal ..................................................... 3
VI. Aberrant Response to Medication ................................................. 4
VII. Responsible Requests to Assist in Cessation of the Addiction .................... 4
References ................................................................................ 6
Chapter 2
Terminology, Definitions, Classification of Abused Substances, and
Diagnostic Criteria ...................................................................... 7
I. Introduction ....................................................................... 7
A. Terms Used Interchangeably .............................................. 7
B. Terms Used in a Restrictive Sense ........................................ 8
II. Food and Drug Administration Classification ..................................... 8
III. FDA Classification of Experimental Drugs for Human Use ....................... 9
IV. DSM IIIR Definitions and Classifications ........................................ 10
References ............................................................................... 12
Chapter 3
The Molecular Basis of Action of Abused Substances ................................ 13
I. Introduction ...................................................................... 13
A. Cell Wall Receptors ...................................................... 13
B. Neurotransmitter Substances .............................................. 14
C. Plasma Membrane Properties ............................................. 14
II. Alcohol and Volatile Anesthetics and Inhaled Agents ............................ 14
A. Anesthetics and Inhaled Agents .......................................... 14
B. Alcohol ................................................................... 15
III. Substances of Abuse for Which the Mechanism of Action Seems to be
Understood ....................................................................... 15
A. Cocaine and Amphetamines .............................................. 15
B. Opioids ................................................................... 16
C. Phencyclidine ............................................................. 16
D. Benzodiazapines .......................................................... 16
E. Barbiturates .............................................................. 16
F. Atropine and Other Anticholinergic Drugs ............................... 16
G. Caffeine and Other Theophyllines ........................................ 16
H. Nicotine .................................................................. 17
I. Agents for Which the Molecular Basis of Action is Unknown ........... 17
IV. Animal Models of Addiction ........ ·. ............................................ 17
References ............................................................................... 17
Chapter 4
Etiology of Substance Abuse and Similarities in Alcoholism and Drug Abuse ...... 19
I. Etiology .......................................................................... 19
A. Introduction .............................................................. 19
B. Thoughts on Drug Abuse ................................................. 20
C. Conclusions on the Etiology of Alcoholism by Vaillant .................. 20
II. Similarities Between Alcohol and Drug Abuse ................................... 21
A. Introduction .............................................................. 21
B. Social Aspects ............................................................ 22
C. Psychology of Addiction ................................................. 23
D. Treatment ................................................................ 23
References ............................................................................... 24
Chapter 5
Essential Pharmacology of Abused Drugs ............................................. 25
I. Introduction ...................................................................... 25
II. Absorption of Drugs ............................................................. 26
A. Routes of Absorption ..................................................... 26
B. Importance of pH ........................................................ 26
III. Transport, Metabolism, and Removal of Drugs .................................. 26
A. Transport ................................................................. 26
B. Biotransformation ........................................................ 27
C. Excretion ................................................................. 28
IV. Pharmacokinetics ................................................................ 28
V. Receptors, Tolerance, and Antagonists .......................................... 29
A. Receptors ................................................................. 29
B. Tolerance ................................................................. 29
C. Antagonists ............................................................... 29
Chapter 6
Issues of Law and Custom ............................................................. 31
I. Introduction ...................................................................... 31
A. Prohibition ............................................................... 32
II. The Law ......................................................................... 33
References ............................................................................... 36
Chapter 7
Attitudes Among Medical Staff That Influence Substance Abuse Care .............. 37
I. Introduction ...................................................................... 37
II. The "Typical Substance Abuser" and the Influence of Treatment. .............. 38
III. Economics, Hazards to Staff. .................................................... 38
A. Economics ................................................................ 38
B. Hazards .................................................................. 39
IV. Origins of Poor Attitudes Toward Addicts ....................................... 40
A. The Abuse Personality ................................................... 40
B. Relapse After Prolonged Therapy ........................................ 40
C. Further Solutions ......................................................... 41
References ............................................................................... 41
Chapter 8
Obtaining an Accurate Drug and Alcohol History .................................... 43
I. Introduction ...................................................................... 43
A. Purpose ................................................................... 44
B. Sources of Information ................................................... 44
II. Suggested Approach for Obtaining an Alcohol or Drug Use History ............. 44
III. Determination of the Circumstance of the Consultation .......................... 46
IV. Useful Components of a Drug History ........................................... 46
A. Substances Used .......................................................... 46
B. Tolerance ................................................................. 47
C. Abuse .................................................................... 47
D. Age of First Use of the Abused Substance ............................... 47
E. Experiences with Withdrawal. ............................................ 47
F. Meaning of the Substance Use to the Patient. ............................ 47
G. Previous Experiences with Treatment .................................... 48
V. Specific Things to Av oid in Taking a History of Substance Abuse .............. 48
VI. Special Problems ................................................................. 49
A. Adolescents .............................................................. 49
B. Paroled Convicts ......................................................... 49
C. Professionals ............................................................. 49
D. Mixed Drug Abusers ..................................................... 50
E. Psychotic Patients ........................................................ 50
VII. Use of Self-Administered Tests .................................................. 50
VIII. Michigan Alcoholism Screening Test ............................................ 51
References ............................................................................... 52
Chapter 9
Recognizing the Alcoholic or Substance-Abusing Patient in Your Practice .......... 53
I. Introduction ...................................................................... 53
II. Medical History .................................................................. 54
III. Physical Examination ............................................................ 54
A. Findings Related to the Route of Administration ......................... 54
B. Nonspecific Indications of Substance Abuse .............................. 54
C. Changes in Mental Status ................................................ 55
D. Changes Seen in Examination of the Head ............................... 55
E. Changes Encountered in the Chest and Heart ............................. 55
F. Changes Found in the Abdomen ......................................... 56
G. Findings in the Genitourinary System .................................... 56
H. Musculoskeletal and Neurological Problems .............................. 57
IV. Constellation of Findings ........................................................ 58
V. Diseases Commonly Associated With Abuse .................................... 58
VI. Other Features ................................................................... 59
References ............................................................................... 59
Chapter 10
Emergencies in Drug and Alcohol Use and Their Management ...................... 61
I. Introduction ...................................................................... 61
II. Toxic Reactions .................................................................. 62
III. Psychiatric Emergencies ......................................................... 63
A. Psychosis ................................................................. 63
B. Panic Reactions .......................................................... 65
C. Violence .................................................................. 65
IV. Withdrawal ...................................................................... 66
V. Other Infrequent Reactions Leading to Emergency Visits ........................ 66
A. Blackouts ................................................................. 66
B. Convulsions .............................................................. 66
C. Epilepsy ........................................................... : ...... 67
D. Dry Drunkenness or Flashbacks .......................................... 68