Chemical Dependence: Diagnosis, Treatment, and Prevention

373 Pages·1990·16.094 MB·English

by  H. Thomas Milhorn Jr. M.D., Ph.D. (auth.)

ChenricruDependence
H. Thomas Milhorn, Jr.
Chemical Dependence
Diagnosis, Treatment, and Prevention
With 11 Illustrations
Springer-Verlag
New York Berlin Heidelberg London
Paris Tokyo Hong Kong Barcelona
H. Thomas Milhorn, Jr., M.D., Ph.D.
Department of Family Medicine
University of Mississippi Medical Center
Jackson, Mississippi 39216-4505
USA
Library of Congress Cataloging-in-Publication Data
Milhorn, Howard T.
Chemical dependence: diagnosis, treatment, and prevention / H.
Thomas Milhorn
p. cm.
Includes bibliographical references.
ISBN-13:978-1-46l2-8004-0 (alk. paper)
1. Substance abuse. 2. Psychotropic drugs. I. Title.
[DNLM: 1. Psychotropic Drugs-pharmacology. 2. Substance
Dependence. WM 270 M644C]
RC564M53 1990
616.86-dc20
DNLMIDLC
for Library of Congress 90-9708
Printed on acid-free paper.
© 1990 Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1st edition 1990
All rights reserved. This work may not be translated or copied in whole or in part without the written
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Typeset by Publishers Service of Montana, Bozeman, Montana.
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ISBN-13:978-1-4612-8004-0 e-ISBN -13: 978-1-4612-3418-0
DOl: 10.1 007/978-1-4612-3418-0
Preface
Chemical dependence is a disease whose time has come. Alcoholism and other
drug dependencies in our society have reached epidemic proportions. Physicians
are in an excellent position to help prevent the disease, to diagnose it, to aid fami
lies in getting addicts into treatment, and to play an important role in long-term
recovery. This text was written for medical students, interns, residents, and prac
ticing physicians who daily come in contact with chemically dependent
individuals and their families. It should also be helpful to physicians who treat
chemical dependence, as well as to other health professionals, including psychol
ogists, marriage and family therapists, social workers, and alcohol and drug
counselors.
The introductory chapter covers basic definitions, concepts, and classification
of psychoactive substances. After that the book is divided into three parts. Part
One covers the basics - diagnosis, treatment, recovery, the family, and preven
tion. Part Two describes the basic principles of pharmacology and drugs of abuse
(central nervous system depressants, opioids, central nervous system stimulants,
cannabinoids, hallucinogens, phencyclidines, and inhalants). Part Three is
devoted to chemical dependence in special groups-women, adolescents, the
elderly, minority groups, the dual diagnosis patient, the patient infected with
immunodeficiency virus, and the impaired physician. This book is my concept of
what a medical school curriculum in chemical dependence should include.
I would especially like to thank Lyndell Gardner who did all the literature
searches and typed the entire manuscript, all with an enthusiastic attitude. I
would also like to thank my wife Kay for her patience and understanding during
the many months of my partial absence while I worked on the manuscript.
H. THOMAS MILHORN, JR.
Jackson, Mississippi
v
Contents
Preface............................................................ v
Chapter 1. Introduction ........................................... .
The Problem ............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
Basic Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Progression to Chemical Dependence . . . . . . . . . . . . . . . . . . . . . . . . 6
Denial......... ......................... ................ 8
Etiology of Chemical Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Classification of Drugs by Their Effects
on the Central Nervous System. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Controlled Substance Act Classification
of Drugs.... .............. .... ....................... . 12
Part I The Basics
Chapter 2. Diagnosis.............................................. 19
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Problems in Diagnosis .................................... 19
Making the Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Presenting the Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Final Comments ......................................... 39
Chapter 3. Treatment.............................................. 42
Getting the Addict into Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Treatment Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Choosing a Treatment Program ............................. 55
Aftercare ............................................... 58
Confidentiality.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
The Role of the Referring Physician ......................... 59
Comment............................................... 60
Chapter 4. Recovery and Relapse. ...... ..... ... .... .... .... ........ 62
Recovery ............................................... 62
Relapse.... ..... ............. ....... ..... .... .... . ...... 68
vii
viii Contents
Methadone Maintenance .................................. 76
The Role of the Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Chapter 5. The Family ........................................... 79
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
The Healthy Family ..................................... 79
The Alcoholic Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Getting the Alcoholic Sober . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Getting the Family Well ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
The Family in Recovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Adult Children of Alcoholics (ACOAs) ...................... 92
The Role of the Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Chapter 6. Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Primary Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Prevention of Prescription Drug Abuse. . . . . . . . . . . . . . . . . . . . .. 102
The Role of the Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 105
Part II Psychoactive Substances
Chapter 7. Basic Principles of Pharmacology ... . . . . . . . . . . . . . . . . . . .. 109
Pharmacokinetics ....................................... 109
Pharmacodynamics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 115
Tolerance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121
Physical Dependence and Abstinence
Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 122
Chapter 8. CNS Depressants: Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 124
History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 124
Pharmacology .......................................... 125
Alcoholism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 132
Diagnosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 143
Methyl Alcohol and Ethylene Glycol Toxicity ................ 146
Chapter 9. CNS Depressants: Barbiturates, Barbiturate-like Drugs,
Meprobamate, Chloral Hydrate, Paraldehyde............. 149
Barbiturates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 149
Barbiturate-like Drugs ................................... 154
Meprobamate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 156
Chloral Hydrate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 157
Paraldehyde. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 157
Chapter 10. CNS Depressants: Benzodiazepines. . . . . . . . . . . . . . . . . . . . .. 160
History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 160
Pharmacology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 160
Contents ix
Health Consequences of Benzodiazepine Abuse . . . . . . . . . . . . . .. 164
Diagnosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 164
Chapter 11. Opioids............................................... 167
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 167
Pharmacology .......................................... 167
Medical Uses and Contraindications . . . . . . . . . . . . . . . . . . . . . . .. 172
Specific Opioid Drugs ................................... 173
Health Consequences of Opioid Abuse ........ . . . . . . . . . . . . .. 180
Diagnosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 181
Chapter 12. CNS Stimulants: Amphetamines, Amphetamine Cogeners,
Caffeine, Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 184
Amphetamines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 184
Amphetamine Cogeners ........ . . . . . . . . . . . . . . . . . . . . . . . . .. 189
Caffeine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 189
Other CNS Stimulants ................................... 190
Chapter 13. CNS Stimulants: Cocaine............................... 193
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 193
Pharmacology .......................................... 194
Health Consequences of Cocaine Abuse ..... . . . . . . . . . . . . . . .. 200
Diagnosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 20 I
Chapter 14. CNS Stimulants: Nicotine. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 204
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 204
History .............................................. " 204
Trends in Cigarette Smoking .............................. 205
Pharmacology .......................................... 206
Health Consequences of Nicotine Abuse. . . . . . . . . . . . . . . . . . . .. 210
Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 213
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 217
Role of the Physician .................................... 218
Other Forms of Tobacco Use .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 221
Chapter 15. Cannabinoids......................................... 224
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 224
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 224
Pharmacology .......................................... 225
Therapeutic Uses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 228
Health Consequences of Marijuana Abuse ................... 228
Diagnosis and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 229
Chapter 16. Hallucinogens......................................... 232
The Hallucinogens ...................................... 232
LSD.................................................. 232
Other Hallucinogenic Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 236
x Contents
Chapter 17. Phencyclidines........................................ 242
History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 242
Pharmacology ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 242
Health Consequences of PCP Abuse ........ . . . . . . . . . . . . . . .. 244
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 244
Management ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 249
Emergence Phenomenon :................................ 253
Chapter 18. Inhalants.............................................. 255
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 255
The Inhalants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 255
Tolerance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 261
Dependence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 261
Abstinence Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 261
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 261
Management ............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 261
Part III Special Groups
Chapter 19. Women............................................... 267
Alcohol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 267
Other Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 268
Fertility ............................................... 268
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 269
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 269
The Pregnant Addict. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 271
The Fetus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 272
The Role of the Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 277
Chapter 20. Adolescents........................................... 279
The Normal Adolescent .................................. 279
The Substance Abuse Problem. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 279
Why Adolescents Use Drugs .............................. 281
The Chemically Dependent Adolescent. . . . . . . . . . . . . . . . . . . . .. 282
Diagnosis of Adolescent Chemical Dependence . . . . . . . . . . . . . .. 284
Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 286
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 286
Aftercare ............... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 288
Role of the Physician .................................... 289
Chapter 21. The Elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 291
Pathophysiology of Aging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 291
The Elderly Addict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 293
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 296
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 297
Aftercare ................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 300
Role of the Physician .................................... 300
Contents xi
Chapter 22. Ethnic Minority Groups.... ......... ................... 302
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 302
Ethnic Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 302
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 305
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 305
Role of the Physician .................................... 305
Chapter 23. The Dual-Diagnosis Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 307
Primary Versus Secondary Psychiatric Disorders . . . . . . . . . . . . .. 307
Primary Psychiatric Disorders ......................... . . .. 307
Secondary Psychiatric Disorders ........................... 315
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 318
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 318
DSM-III-R Classification System. . . . . . . . . . . . . . . . . . . . . . . . . .. 318
Role of the Physician.................... ............. ... 319
Chapter 24. The HIV-Positive Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 322
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 322
Epidemiology .......................................... 322
Why Treatment Centers Should Be Involved. . . . . . . . . . . . . . . . .. 323
Official ASAM Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 324
HIV Infection .......................................... 324
HIV Antibody Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 327
Treating HIV-Positive and At-Risk Patients. . . . . . . . . . . . . . . . . .. 330
Precautions in Treatment Programs . . . . . . . . . . . . . . . . . . . . . . . .. 333
Role of the Physician .................................... 333
Chapter 25. The Impaired Physician ..... . . . . . . . . . . . . . . . . . . . . . . . . . .. 336
The Impaired Physician .................................. 336
State Medical Society Programs. . . . . . . . . . . . . . . . . . . . . . . . . . .. 339
Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 341
Treatment of the Impaired Physician . . . . . . . . . . . . . . . . . . . . . . .. 344
Aftercare ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 344
Recovery .............................................. 345
Appendix A. Terminology.......................................... 347
Appendix B. Street/Slang Names for Drugs .......................... 357
Index.............................................................. 363
CHAffER I
Introduction
The Problem
The use of alcohol and other drugs has reached an epidemic level in the United
States. The cost to the economy of such use is staggering. However, the cost in
broken homes, damaged lives, and human suffering is beyond calculation.
Alcohol
The estimated consumption of alcohol in the United States is 2.65 gallons of pure
ethanol per person each year. This is equivalent per person to approximately 50
gallons of beer, 20 gallons of wine, or more than 4 gallons of distilled spirits. Only
10 percent of the drinking population consumes half the alcohol drunk in the
United States a year.l One-third of Americans report that alcohol has caused
problems in their families.2
Alcohol is associated with a variety of physical and psychological disorders. The
greatest chronic health hazard that results from the use of alcohol is liver disease.
Cirrhosis of the liver is the ninth leading cause of death in the United States; most
cirrhosis results from alcoholism.l Alcohol use is a factor in 10 percent of all deaths
in the United States, accounting for 200,000 deaths a year. Almost 20,000 deaths
a year are directly attributable to medically related alcohol problems, 24,000 are
caused by motor vehicle accidents in which alcohol played a role, and 30,000 result
from alcohol-related mishaps, such as falls, fires, and suicides.3 In addition, almost
300,000 disabilities result each year from alcohol use.4 The incidence of alcohol
abuse and dependence is 1.5 times that of diabetes.2
Nearly half of convicted jail inmates were under the influence of alcohol at the
time they committed their crimes. More than half of people convicted of violent
crimes had been drinking at the time of their offenses.!
Of high school seniors, 91 percent have tried alcohol at least once, 66 percent
use it in anyone month, and 5 percent use it daily. Daily drinking is reported to
be the same (5 percent) among college students; however, heavy drinking is much
higher-at 45 percent. This number increases to 57 percent for men. Abuse of
alcohol or other drugs is involved in 50 percent of young suicides, and drinking