1. In all patients, and especially in high-risk groups (e.g., mental illness, chronic disability), opportunistically screen for substance use and abuse (tobacco, alcohol, illicit drugs).
- Use random urine drug screen – new kit distinguishes methadone and oxycodone from opiates.
- Amphetamines, cocaine, etc usually detectable if used within a month
- make sure UDS is appropriate (if negative for Rx – diverging meds? or substitution with other people’s urine)
- Perform a quick pharmnet check to avoid Rx abuse – screen for BZD, opiates Rx
Epidemiology
- 47% substance abusers have mental health problem
- 29% with a mental health disorder have a substance use disorder
- 47% schizophrenia & 25% anxiety disorder have a substance use disorder
Classification of Substances
- Depressants: EtOH, Opioids, Barbiturates, BZD, GHB
- Stimulants: Amphetamines, Methylphenidate, Cocaine
- Hallucinogens: Cannabis, LSD, PCP, ketamine, psilocybin
- Date Rape drugs: GHB, flunitrazepam, ketamine
Types of Substance Use Disorders
- maladaptive pattern of substance use leading to clinically significant impairment or distress
1. Substance abuse: ≥1 within a 12 month period
- Recurrent use resulting in failure to fulfill major role obligation
- Recurrent use in situations in which it is physically hazardous, eg. driving
- Recurrent substance-related legal problems
- continued use despite interference with social or interpersonal function
2. Substance Dependence ≥ 3 in the same 12 month period
- Tolerance
- Withdrawal/use to avoid withdrawal
- Taken in larger amount or over longer period than intended
- Persistent desire or unsuccessful efforts to cut down
- Excessive time to procure, use substance, or recover from its effects
- Important interests/activities given up or reduced
- Continued use despite physical/ psychological problem caused / exacerbated by subatance
2 In intravenous drug users: a) Screen for blood-borne illnesses (e.g., human immunodeficiency virus infection, hepatitis). b) Offer relevant vaccinations.
Summary of recommended screening, counseling, and vaccination services for persons who use drugs illicitly |
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HIV infection* Testing (at least annually) pt at high risk for HIV infection, eg IVDU and their partners Hepatitis A virus (HAV) infection† Hepatitis A vaccination is recommended for illicit drug users – both injection & noninjection routes. Prevaccination testing is not indicated for the vaccination of adolescents who use drugs illicitly but might be warranted depending on the type and duration of illicit drug use. Hepatitis B virus (HBV) infection§
Hepatitis C virus (HCV) infection¶
Tuberculosis (TB)**
Sexually transmitted diseases (STDs)††
Chlamydia & Gonococcal infections
Syphilis***
Herpes simplex virus-2††† Consider HSV serologic in STD evaluation (especially for those persons with multiple sex partners), persons with HIV infection, and MSM at increased risk for HIV acquisition. Human papillomavirus (HPV)§§§
No vaccines are available for the prevention of infection with HIV, HCV, or any STD other than HPV and HBV. |
3 In patients with signs and symptoms of withdrawal or acute intoxication, diagnose and manage it appropriately.
Patient will have 3 of 7 within 12 month period: “WITHDraw IT”:
- Withdrawal symptoms
- Interest or Important activities given up or reduced
- Tolerance
- Harm to physical and psychosocial known but continue to use
- Desire to cut down, control
- Intended time, amount exceeded
- Time spent too much
EtOH Intoxication
- Legal limit for impaired driving is 10.6mmol/L (50mg/dl) reached by 2-3 drinks /h for men & 1-2 drinks/h for women
- Coma can occur with >60mmol/L (non-tolerant drinkers) & 90-120mmol/L (tolerant drinker)
EtOH Withdrawal
- Occurs within 12-48hr after prolonged heavy drinking & can be life-threatening (20% mortality if untreated)
- EtOH withdrawal can be described as having 4 stages:
- Stage 1 (6-12hr after last drink): tremor, sweating, agitation, anorexia, cramps, diarrhea, sleep disturbance
- Stage 2 (1-7 d): Visual, auditory, olfactory, tactile hallucinations
- Stage 3 (12-72hr up to 7 days): Sz – usually tonic-clonic, nonfocal, brief
- Stage 4 (3-5d): delirium tremens: autonomic hyperactivity (diaphoresis, tachycardia, tachypnea), hand tremor, insomnia, psychomotor agitation, anxiety, N/V, tonic-clonic Sz, V/T/AH, persecutory delusions
Management of EtOH Withdrawal – CIWA-A
- Areas of assessment: – scored 0-7 (orientation/sensorium 0-4)
- N/V, tremor, paroxysmal sweats, headache, fullness in head
- Tactile, auditory, vidual disturbances
- Agitation, anxiety, orientation & clouding of sensorium
- Mild <10, moderate 10-20, Severe >20, max score 67
- Basic Protocol:
- Diazepam 20mg po q1-2h until CIWA-A <10, observe 1-2h after last dose & re-assess
- Thiamine 100mg IM then 100mg po daily x 3d
- Supportive Care: hydration, nutrition
- Hx of Withdrawal Sz: Diazepam 20mg po q1h ≥ 3 regardless of CIWA
- >65, Severe liver dz, severe asthma, resp failure: short acting BZD
- + Hallucinations –
- Haloperidol 2-5mg IM/PO Q1-4h – max 5 doses/day or atypical antipsychotics (olanzapine, riseperidone)
- Diazepam 20mg x 3 as Sz prophylaxis (haloperidol lowers Sz threshold)
- Admit if still in withdrawal after 80mg of diazepam, delirium tremens, recurrent arrhythmias, multiple Sz, medically ill or unsafe to d/c
Opioids
Acute Intoxication
- Direct effect on receptors in CNS – decreased pain perception, sedation, decreased sex drive, N/V, decreased GI motility, and respiratory depression
Toxic Reaction
- typical syndrome includes shallow respirations, miosis, bradycardia, hypothermia, decreased LOC
- Tx: ABCs, IV glucose, naloxone (Narcan) 0.4mg up to 2mg IV – Intubation and mechanical ventilation, ± naloxone drip until pt alert w/o naloxone (up to 48h w/ long-acting opioids)
- caution with longer half-life – may need to observe for toxic reaction for >24hr
Withdrawal
- Depression, insomnia, drug-craving, myalgias, nausea, chills, autonomic instability (lacrimation, rhinorrhea, piloerection)
- Onset 6-12 hr, duration 5-10d
- C/I: loss of tolerance (overdose on relapse), miscarriage, premature labour
- Management: long-acting oral opioid (methadone, buprenophine), α-adrenergic agonists (clonidine)
Cocaine
Intoxication
- Elation, euphoria, pressured speech, restlessness, sympathetic stimulation (tachycardia, mydriasis, sweating)
- Prolonged use may result in paranoia & psychosis
Overdose – Medical emergency
- HTN, tachycardia, tonic-clonic Sz, dyspnea, ventricular arrhythmias
- Tx: IV diazepam to control Sz & propanolol / labetalol to manage HTN & arrhythmias
Withdrawal
- Initial crash (1-48hr): increased sleep, increased appetite
- Withdrawal (1-10wks): dysphoric mood plus fatigue, irritability, vivid unpleasant dreams, insomnia or hypersomnia, psychomotor agitation or retardation
- C/I: relapse, suicide (sig increase during withdrawal period)
- Management: supportive management
Amphetamines
- Intoxication: Euphoria, improved concentration, sympathetic & behavioural hyperactivity & at high doses can cause coma
- Chronic use: paranoid psychosis – similar to schizophrenia with agitation, paranoia, delusions & hallucinations
- Withdrawal symptoms: dysphoria, fatigue, restlessness
- Tx of stimulant psychosis: antipsychotics
Cannabis
- Marijuana – most often used illicit drug
- Psychoactive – Δ9-THC
- Cessation does not produce sig withdrawal phenomenon
Intoxication
- tachycardia, conjunctival vascular engorgement, dry mouth, altered sensorium, increased appetite, increased sense of well-bing, euphoria/laughter, muscle relaxation, impaired performance on psychomotor tasks including driving
- High dose – depersonalization, paranoia, anxiety, trigger psychosis & schizophrenia if predisposed
Chronic use – tolerance & an apathetic, amotivational state
Tx of dependence: behavioural & psychological interventions to maintain an abstinent state
Medical Uses
- Anorexia-cachexia (AIDS, Cancer)
- Spasticity, muscle spasms (MS, spinal cord injury)
- Levodopa-induced dyskinesia (Parkinson’s dz)
- Controlling tics & OCD (Tourette’s syndrome)
- Reducing intra-ocular pressure (glaucoma)
Hallucinogens
- types of hallucinogens: LSD, mescaline, psilocybin, PCP, cannabis, ecstasy, salvia
- LSD intoxication – tachycardia, HTN, mydriasis, tremor, hyperpyrexia, perceptual / mood changes
- High dose – depersonalization, paranoia, anxiety
- No specific withdrawal syndrome characterized
- Tx of agitation & psychosis: support, reassurance, diminished stimulation
- BZD / high potency antipsychotics seldom required
4 Discuss substance use or abuse with adolescents and their caregivers when warning signs are present (e.g., school failure, behaviour change).
Common Presentations of Drug Use
- General: Wt loss (cocaine, heroin, injected cannabis), pinpoint pupils (opioids), track marks (IVDU)
- MSK: trauma
- GI: Viral hepatitis (IVDU), unexplained elevations in ALT
- Behavioural: missed appointments, non-compliance, drug seeking (BZD, opioids)
- Psychological: insomnia, fatigue, depression, flat affect (BZD, barbiturates), paranoia (cocaine), psychosis (cocaine, cannabis, hallucinogens)
- Social: Marital discord, family violence, work/school absenteeism & poor performance
5 Consider and look for substance use or abuse as a possible factor in problems not responding to appropriate intervention (e.g., alcohol abuse in patients with hypertriglyceridemia, inhalational drug abuse in asthmatic patients).
6 Offer support to patients and family members affected by substance abuse. (The abuser may not be your patient.)
Summary of recommended messages for persons who use drugs illicitly to reduce drug use and infectious disease–related risks |
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7 In patients abusing substances, determine whether or not they are willing to agree with the diagnosis.
8 In substance users or abusers, routinely determine willingness to stop or decrease use.
9 In patients who abuse substances, take advantage of opportunities to screen for co-morbidities (e.g., poverty, crime, sexually transmitted infections, mental illness) and long-term complications (e.g., cirrhosis)
Principles for managing health-care relationships between providers and persons who use drugs illicitly |
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References:
- TN2013
- CDC 2011: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm?s_cid=rr6105a1_w
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