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Toronto Notes 2019 Substance-Related and Addictive Disorders
Psychiatry PS23
■ Cravingorastrongdesiretousesubstance
■ Withdrawal
■ continued use despite Interpersonal problems
■ Tolerance,needingtousemoresubstancetogetsameeffect ■ use in physically Hazardous situations
■ Moresubstanceusedorforlongerperiodthanintended
■ unsuccessful attempts to Cut down
■ Activitiesgivenupduetosubstance
■ excessive Time spent on using or finding substance
Classification of Substances
Depressants Stimulants
Hallucinogens
Drugs
Alcohol, opioids, barbiturates, benzodiazepines, GHB
Amphetamines, methylphenidate, MDMA, cocaine
LSD, mescaline, psilocybin, PCP, ketamine, ibogaine, salvia
Intoxication
Euphoria, slurred speech, disinhibition, confusion, poor coordination, coma (severe)
Euphoria, mania, psychomotor agitation, anxiety, psychosis (especially paranoia), insomnia, cardiovascular complications (stroke, MI, arrhythmias), seizure
Distortion of sensory stimuli and enhancement of feelings, psychosis (++ visual hallucinations), delirium, anxiety (panic), poor coordination
Withdrawal
Anxiety, anhedonia, tremor, seizures, insomnia, psychosis, delirium, death
‘Crash’, craving, dysphoria, suicidality
Usually absent
General Approach to Assessment
• askaboutmoresociallyacceptedsubstances(e.g.nicotine,alcohol)beforeaskingaboutuseof marijuana, misuse of prescription medicines, and about illicit drugs
• obtaininghistoryfromfamilymembersmaybehelpful
General Approach to Treatment
• approachmustbeappropriatetothepatient’scurrentstateofchange(seePublicHealthandPreventive Medicine, Health Promotion Strategies, PH7)
• patientswillonlychangewhenthepainofchangeappearslessthanthepainofstayingthesame
• provider can help by providing psychoeducation (emphasize neurobiologic model of addiction),
motivation, and hope
• principlesofmotivationalinterviewing(seePsychotherapy,PS40)
■ non-judgmental stance
■ space for patient to talk and reflect
■ offer accurate empathic reflections back to patient to help frame issue
• encourageandofferreferraltoevidencebasedservices
■ social: 12-step programs (alcoholics anonymous, narcotics anonymous), family education and
support
■ psychological therapy: addiction counselling, motivational enhancement therapy (MET), CBT,
contingency management, group therapy, family therapy, marital counselling
■ medical management (differs depending on substance): acute detoxification, pharmacologic agents
to aid maintenance
• harmreductionwheneverpossible:safe-sexpractices,avoiddrivingwhileintoxicated,avoidsubstances
with child care, safe needle practices/exchange, pill-testing kits, reducing tobacco use
• comorbidpsychiatricconditions:manywillresolvewithsuccessfultreatmentofthesubstanceuse
disorder but patients who meet full criteria for another disorder should be treated for that disorder with psychological and pharmacologic therapies
Nicotine
• seeFamilyMedicine,FM11
Alcohol
• seeFamilyMedicine,FM12andEmergencyMedicine,ER54
History
• CAGE:validatedscreeningquestionnaire
C ever felt the need to Cut down on drinking?
A ever felt Annoyed at criticism of your drinking?
G ever feel Guilty about your drinking?
E ever need a drink first thing in morning (Eye opener)?
■ for men, a score of ≥2 is a positive screen; for women, a score of ≥1 is a positive screen
■ if positive CAGE, then assess further to distinguish between problem drinking and alcohol use
disorder
Questions to Characterize Substance Use and Risk Assessment
• When was the last time you used?
• How long can you go without using?
• By what route (oral ingestion, insufflation, smoking, IV) do you usually use?
• Are there any triggers that you know will cause you to use?
• How has your substance use affected your work, school, relationships?
• Substances can be very expensive, how do you support your drug use?
• Have you experienced medical or legal consequences of your use?
• Any previous attempts to cut down or quit, and did you experience any withdrawal symptoms?
Confabulations: the fabrication of imaginary experiences to compensate for memory loss
Make sure to ask about other alcohols: mouthwash, rubbing alcohol, methanol, ethylene glycol, aftershave (may be used as a cheaper alternative)