Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment

283 Pages·1984·7.35 MB·English

by  Marc A. Schuckit M.D. (auth.)

Drug and
Alcohol Abuse
A Clinical Guide to Diagnosis and Treatment
Second Edition
CRITICAL ISSUES IN PSYCHIATRY
An Educational Series for Residents and Clinicians
Series Editor: Sherwyn M. Woods, M.D., Ph.D.
University of Southern California School of Medicine
Los Angeles, California
Recent volumes in the series:
LAW IN THE PRACTICE OF PSYCHIATRY
Seymour L. Halleck, M.D.
NEUROPSYCHIATRIC FEATURES OF MEDICAL DISORDERS
James W. Jefferson, M.D., and John R. Marshall, M.D.
ADULT DEVELOPMENT: A New Dimension in Psychodynamic Theory
and Practice
Calvin A. Colarusso, M.D., and Robert A. Nemiroff, M.D.
SCHIZOPHRENIA
John S. Strauss, M.D., and William T. Carpenter, Jr., M.D.
EXTRAORDINARY DISORDERS OF HUMAN BEHAVIOR
Edited by Claude T. H. Friedmann, M.D., and Robert A. Faguet, M.D.
MARITAL THERAPY: A Combined Psychodynamic-Behavioral Approach
R. Taylor Segraves, M.D., Ph.D.
TREATMENT INTERVENTIONS IN HUMAN SEXUALITY
Edited by Carol C. Nadelson, M.D., and David B. Marcotte, M.D.
CLINICAL PERSPECTIVES ON THE SUPERVISION OF
PSYCHOANALYSIS AND PSYCHOTHERAPY
Edited by Leopold Caligor, Ph.D., Philip M. Bromberg, Ph.D.,
and James D. Meltzer, Ph.D.
MOOD DISORDERS: Toward a New Psychobiology
Peter C. Whybrow, M. D., Hagop S. Akiskal, M.D., and
William T. McKinney, Jr., M.D.
EMERGENCY PSYCHIATRY: Concepts, Methods, and Practice
Edited by Ellen Bassuk, M.D., and Ann W. Birk, Ph.D.
DRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis
and Treatment, Second Edition
Marc A. Schuckit, M.D.
A Continuatiol' Order Plan is available for this series. A continuation order will bring
delivery of each new volume immediately upon publication. Volumes are billed only
upon adual shipment. For further information please con tad the publisher.
Drug and
Alcohol Abuse
A Clinical Guide to Diagnosis and Treatment
Second Edition
Marc A. Schuckit, M.D.
University of California, San Diego
School of Medicine
Veterans Administration Hospital
San Diego, California
Plenum Press • New York and London
Library of Congress Cataloging in Publieation Data
Sehukit, Mare A.
Drug and alcohol abuse.
Includes bibliographical referenees and index.
1. Drug abuse. 2. Alcoholism. I. Title.
RC564.533 1983 616.86 83-13815
ISBN 978-1-4684-1178-2 ISBN 978-1-4684-1176-8 (eBook)
001 10.10071978-1-4684-1176-8
First Printing-April 1984
Second Printing-October 1985
©1984 Plenum Press, New York
Softcover reprint of the hardcover I st edition 1984
A Division of Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
All rights reserved
No part of this book may be reprodueed, stored in a retrieval system, or transmitted,
in any form or by any means, electronie, meehanical, photocopying, microfilming,
reeording, or otherwise, without written permission from the Publisher
To Sam who taught me how to laugh,
Lil who showed me how to love those close to me,
and to Judy, Dena, and Jordan who keep me doing both.
Foreword
When this series was conceived, a book on substance abuse, including
alcohol and alcoholism, was to be of the highest priority. This priority was
a reflection of my view that the subject is often inadequately or insufficient
ly taught in many training programs. Few clinicians have had comprehen
sive didactic education in this area, despite the frequency with which these
problems are encountered in practice. All too often these encounters are in
situations in which accurate diagnosis and rapid treatment are of critical im
portance. We wanted a book that would be concise and easily readable but
also comprehensive in its presentation of the basic principles underlying
clinical manifestations, diagnosis, and management. It was of particular im
portance that the book also serve as an easy reference guide in emergency
situations.
Marc Schuckit, a man with impeccable credentials as a scholar and an
experienced clinician in this field, produced just such a book with his
critically acclaimed first edition. That volume rapidly became a resource of
great significance for psychiatrists, psychotherapists, and physicians in
general. It has been adopted as a text in medical schools and residency train
ing, as well as for courses in psychology, emergency medicine, social work,
and nursing.
The entire volume has been revised and updated to reflect changes in
knowledge and clinical practice since the publication of the first edition and
in order to keep the comprehensive references current. There is a new
chapter on phencyclidine and another on caffeine and nicotine. There are
chapters on eNS depressants; alcohol and alcoholism; stimulants; opiates
and other analgesics; cannabinols; hallucinogens; glues, solvents, and
aerosols; and over-the-counter drugs. Multidrug use is dealt with
thoroughly, and there is an extensively revised chapter on rehabilitation.
The rapid guide to emergency problems will continue to be of great
relevance to all practitioners. Whether one's goal is an understanding of
each drug class and its associated clinical problems or the need to diagnose
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viii FOREWORD
rapidly and treat a specific drug emergency, the reader is led step by step
through all the elements underlying the mechanism of action, the clinical
and laboratory findings, and the specifics of treatment.
Since substance abuse is such a complicated and prevasive problem,
and one that has resisted our attempts at primary prevention, Dr. Schuckit's
revised and expanded book will undoubtedly make an even greater con
tribution to clinical practice in medicine, psychiatry, and all the mental
health disciplines.
SHERWYNM. WOODS, M.D., PH.D.
Series Editor
Preface to the Second Edition
In the intervening years between the publication of the first and second edi
tions, this book has been used as a text for teaching in medical schools,
psychology and social work courses, nursing curricula, and so on. As a
result of my own efforts in this area and of correspondence from teachers in
different disciplines, revisions have been carried out in every chapter. The
goal has been primarily to clarify questions raised by students and to ex
pand into areas of need. Regarding the latter, two new chapters have been
added, one dealing with phencyclidine to meet the increasing use of this
drug over the years and the other dealing with the two most prevalent
substances of misuse, caffeine and nicotine. Additional changes include a
thoroughly revised chapter on rehabilitation.
This revision could never have been carried out properly without the
help of Cheyvonne Frontiero, the editorial assistance offered by Plenum
Press, as well as the encouragement of Sherwyn Woods and my colleagues
at the University of California, San Diego. Of course, this book could never
have been written were it not for the love and happiness generated by my
wife, Judy, and children, Dena and Jordan.
MARC A. SCHUCKIT, M.D.
ix
Preface to the First Edition
This book grew out of a series of lectures developed to help the
nonpharmacologist make sense out of a complex literature. The core of my
approach is to learn the characteristics of drug classes, understand the usual
types of difficulties associated with drugs, and then apply these general
rules in clinical settings. It is hoped that the text will be a beginning place for
gathering knowledge about drug types in the classroom and also a first step
in handling emergency problems in clinical setting.
So that the book may properly serve as a resource for survey courses
and as an emergency handbook, I have kept my comments relatively short,
attempting to relate the most essential material. In order to help the reader
understand drugs of abuse in greater depth, each chapter is highly refer
enced in the hopes that he will further expand his knowledge in this area.
I have never read a perfect manuscript or book, and (the views of my
mother aside) this is not one. As with any complex endeavor, a series of
compromises must be made as one decides whether to pursue Road A or
Road B. My aim is to have this text strike a proper balance between the im
mediate needs of the clinician and those of the student looking for an in
troduction to substances of abuse.
I wish to extend my appreciation to Jane Ramsey, Edna Glenn, and my
colleagues at the Alcoholism and Drug Abuse Institute of the University of
Washington, as well as to my wife, Judy, and my colleagues at the Universi
ty of California at San Diego Medical School, Department of Psychiatry,
for their help in preparing this manuscript.
MARC A. SCHUCKIT, M.D.
xi
Contents
Chapter 1: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1. Introduction........................................... 1
1.2. Some Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2.1. Drug of Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2.2. Drug Abuse ........................................ 4
1.2.3. Dependence ................................... . . . . . 4
1.3. General Comments about Drug Mechanisms. . . . . . . . . . . . . . . . 5
1.4. One Approach to Drug Classification. . . . . . . . . . . . . . . . . . . . . . 5
1.4.1. General CNS Depressants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4.2. CNS Sympathomimetics or Stimulants. . . . . . . . . . . . . . . . . . 6
1.4.3. Opiate Analgesics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4.4. The Cannabinols, or Marijuana. . . . . . . . . . . . . . . . . . . . . . . . 7
1.4.5. Psychedelics or Hallucinogens. . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4.6. Solvents, Glues, and Aerosols . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4.7. Over-the-Counter Drugs and Other Prescription
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5. Alternate Classification Schemes. . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.6. A Classification of Drug Problems. . . . . . . . . . . . . . . . . . . . . . . .. 10
1.6.1. Panic Reaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12
1.6.2. Aashback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 13
1.6.3. Toxic Reaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14
1.6.4. Psychosis .......................................... 14
1.6.5. Organic Brain Syndrome .. . . . . . . . . . . . . . . . . . . . . . . . . . .. 15
1.6.6. Withdrawal or Abstinence Syndrome. . . . . . . . . . . . . . . . . .. 17
1.7. A General Introduction to Emergency and
Crisis Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 17
1.7.1. Acute Emergency Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 17
1.7.2. Evaluation ......................................... 18
1.7.3. Subacute Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 18
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