Online Medical Reference

Drug Abuse and Addiction

Gregory B. Collins

Mark S. McAllister

Kamala Adury

Published: August 2010

Definition and Etiology

A diagnosis of either substance abuse or addiction is made when symptoms indicate a maladaptive pattern of substance use resulting in clinically significant impairment or distress. Substance abuse manifests with social, interpersonal, physical, and legal problems, whereas addiction is characterized by (1) physical dependence, manifested through tolerance and withdrawal, and (2) behavioral manifestations, evidenced by an inability to control use, continued use despite adverse consequences, and social dysfunction (Boxes 1 and 2).1 Current thinking favors the view that chemical dependency is a result of complex genetic, environmental, psychological, physical, and social factors.

Box 1 DSM-IV-TR Criteria for Substance Abuse
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
  • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use, substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  • Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  • Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
  • Continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)The symptoms have never met the criteria for substance dependence for this class of substance.

Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC. American Psychiatric Association, 2000.

Box 2 DSM-IV-TR Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
  • Tolerance, as defined by either of the following:
  • A need for markedly increased amounts of the substance to achieve intoxication or desired effect
  • Markedly diminished effect with continued use of the same amount of the substance
  • Withdrawal, as manifested by either of the following:
  • The characteristic withdrawal syndrome is demonstrated for the substance.
  • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
  • The substance is often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control substance use.
  • A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects.
  • Important social, occupational, or recreational activities are given up or reduced because of substance use.
  • The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacer-bated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).The diagnosis should specify “With Physiologic Dependence” (either item 1 or 2 is present) or “Without Physiologic Dependence” (nei-ther item 1 nor item 2 is present).

Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC. American Psychiatric Association, 2000.

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Prevalence and Risk Factors

The Substance Abuse and Mental Health Services Administration indicated that 22.5 million Americans, or 9.4% of the population older than 12 years, met criteria for substance abuse or dependence in 2004.2 Although alcohol-related disorders account for the majority of these individuals, illicit drug use or a combination of alcohol and illicit drug use is responsible for a significant proportion. Despite recent declines in use, marijuana remains the most commonly used illicit drug. There has been a significant increase in the nonmedical use of prescription opioids among young adults in recent years. Over this same period, the use of other illicit drugs by young adults has either decreased or remained stable. From 1993 to 2003, the number of substance abuse treatment admissions increased by almost 14%.3 Increases in the number of admissions for marijuana, opioid, and stimulant use are largely responsible for this finding. In 1993, the largest proportion of admissions was in the 25- to 34-year-old age group (40%).3 By 2003, that age group accounted for only 25% of admissions. In the same time period, the proportion of admissions increased for all other age groups, with the largest increase seen among admissions older than 45 years. Substance abuse often starts in adolescence. Several factors have been identified that may be of predictive value in determining risk for the development of substance-related disorders.4 These risk factors fit into four categories, or domains, that consist of community, family, school, and individual/peer (Table 1).

Table 1 Risk Factors for Adolescent Drug Use
Individual Community
Alienation and rebelliousness Availability of drugs
Friends who engage in the problem behavior Community laws and norms favorable toward drug use
Favorable attitudes toward the problem behavior Transitions and mobility
Early initiation of the problem behavior Low neighborhood attachment and community disorganization
Constitutional factors Extreme economic deprivation
Family School
Family history of the problem behavior Early and persistent antisocial behavior
Family management problems Academic failure beginning in late elementary school
Family conflict Lack of commitment to school
Favorable parental attitudes and involvement in the problem behavior

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Signs and Symptoms

Drug addiction can be regarded as having psychological and physical components, but the exact pathophysiology has not yet been entirely elucidated. Currently, the only practical way to diagnose drug addiction is to observe its consequences or symptoms. Usually, these symptoms are reflected in the deterioration of marital, occupational, emotional, spiritual, legal, financial, or physical well being. If the drug use repeatedly causes problems in one or more of these areas, the diagnosis of chemical dependency can be made, even though the patient may believe that he or she can stop using drugs. Because of the complex nature of the etiology of chemical dependency, most professionals pay little attention to how the chemically dependent person came to be addicted. Looking for underlying problems or causes before a period of stable abstinence has been achieved may at times be fruitless and even detrimental. Often, a better approach is to direct treatment at eliminating the use of psychoactive substances, while recognizing that the patient is suffering from a compulsion to return to active substance use.

Chemical dependency is a great masquerader, often disguising itself as a medical or psychiatric complaint. Patients rarely seek treatment for substance-related disorders. Usually they are in the physician’s office for one or more secondary disorders, such as seizures, systemic or local infections, accidents, trauma, burns, or other organ pathology. The presenting complaint also may be psychiatric with the appearance of anxiety, depression, personality disorder, or paranoid ideation. Complaints of chronic pain may be present, such as fibromyalgia, arthritis, disk disease, or other painful conditions “requiring” opioid medication. The role of the physician is to see through the manifesting symptoms and diagnose the chemical problem. If drugs have anything to do with the problem, the possibility of chemical abuse should be investigated further.

Problems often arise because physicians tend to recognize only late-stage physical complications and withdrawal symptoms as indicative of chemical dependency. They should, however, cultivate the skill of diagnosing substance dependence at a much earlier point in this progressive disability, when manifestations are subtle. The earliest symptoms are generally adverse effects on marriage and job, which often antedate by many years any detectable physical consequences. It is, therefore, a good idea to ask, “Did this problem have anything to do with your drug use?” or “Were you using drugs when the problem occurred?” If the answer is yes, the physician should explore the possibility of a chronic, serious, or incipient problem with substance abuse.

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Diagnosis

The diagnosis of chemical dependency is usually made on the basis of information obtained from the medical history, physical examination, psychological assessment, laboratory tests, and reports of concerned others. In addition, several empirically validated screening tools are available that require little time or training to use during an initial assessment. Examples include the CAGE5 screen for alcohol abuse or the Drug Abuse Screening Test6 for other commonly abused substances.

The medical history should survey recent drug use, including alcohol, tobacco, analgesics, sedatives, tranquilizers, cocaine, marijuana, and any others. Has there been a pattern of increasing the dosage or frequency of these drugs? Has the patient received treatment from numerous doctors or hospitals? Is the patient unwilling to reveal the names or places of the previous treatment? Does the individual have a vague physical problem such as back pain without radiologic changes, or conversely, does he or she present with an exotic chronic disease that causes intermittent bouts of pain? Is there any deception or major omission in the medical or psychiatric history? Does the patient acknowledge an earlier alcohol problem or previous drug treatment? Are other risk factors present such as easy access to drugs (e.g., with health care professionals) or peer pressure (e.g., in sports or entertainment figures)? Has the patient been arrested for driving while intoxicated or under the influence? Have there been any other drug- or alcohol-related arrests? Is there a history of drug-involved marital discord or job trouble? Has there been any drug-related trauma, violence, explosion, or burns? Is there a history of any drug withdrawal symptoms, such as sweating, nausea, vomiting, or seizures?

Any elicited acknowledgment of substance use deserves further inquiry including the onset, quantity, frequency, and duration of use. Patterns of escalating use including the most recent dose of each substance used and the time elapsed since last use should be ascertained. Because many patients are using more than one substance, the history should routinely include questions regarding the use of substances other than the patient’s drug of choice. Specifically, use of over-the-counter medications and prescription medications should be examined because many patients do not consider these agents to be prone to abuse. Any attempts to limit, control, or cease substance use are also important to discuss as well as the circumstances surrounding relapse.

The physical examination should be comprehensive because chronic substance abuse can adversely affect virtually any organ system. The physician should look for signs of drug use, such as residual white powdery substance (cocaine or heroin) around the nares or alcohol on the breath. Clothing and personal effects may reveal an interest in drugs or the drug culture. Check for the presence of medications or drugs, as well as administering paraphernalia including syringes, needles, cellophane bags, paper wrappers, crack pipes, volatile ether, sodium bicarbonate, quinine, razor blades, and tiny spoons. The patient may wear drug-related insignias on belts, shirts, and rings. Physical signs of chronic drug administration may be present (Table 2).

Table 2 Physical Findings and Complications of Chronic Drug Addiction
Organ or Organ System Complication
Skin Needle marks, injection "tracks" over veins, scars, ulcerations, cellulitis, necrotic tissue, jaundice
Eyes Pupillary constriction (opiates) or dilation (stimulant, opiate or benzodiazepine withdrawal), scleral icterus
Respiratory Nasal mucosal inflammation or septal perforation, coarsened voice or chronic bronchitis from cocaine freebasing or marijuana smoking
Cardiovascular "No veins" limiting intravenous access and blood for laboratory sampling, bacterial endocarditis
Autonomic nervous system Elevated blood pressure, abnormal heart rate (bradycardia or tachycardia), tremor, diaphoresis, brisk reflexes
Liver Tenderness or enlargement
Neuromuscular Seizures, aseptic necrosis of large muscle masses causing scarring, fibrosis, and boardlike rigidity of affected muscles

Psychological manifestations may include a recent drug-related personality change of any type. There may be evidence of intoxication: staggering gait, slurred speech, nodding off, nonsensical conversing, or forgetfulness. Anxiety and nervousness may be present with anger, irritability, and impatience. Agitation or even hostility may require emergency protective precautions. The patient may be confused or disoriented and may have evidence of hallucinations or paranoid delusions. Conversely, behavior may be dull, apathetic, and listless. Drug seeking may be in evidence. It is also important to ascertain the presence of any coexisting psychiatric disorders because management of such disorders may profoundly affect the success of substance-related treatment. The evaluation of psychiatric symptoms may be aided by repeated, longitudinal assessments taking into account the presence or absence of concurrent substance use.

Laboratory testing may help to confirm the presence of alcohol or drugs, may establish evidence of organ damage, or may suggest the presence of a drug or alcohol problem. Negative or normal laboratory studies, however, do not rule out a substantial drug problem. A toxicology screen for substance abuse is warranted in any suspicious circumstance. A supervised urine collection is best for drugs. Alcohol requires testing of the blood or breath. Blood studies may indicate effects on internal organs, toxicity, or related infections. A tuberculosis (TB) skin test is advisable. The electrocardiogram may reflect arrhythmia or ischemia (cocaine), and a chest radiograph may show infectious granulomas, diffuse fibrosis, TB, or pneumonia.

It is always helpful for a physician to receive confirmation about a patient’s substance abuse from concerned others, such as the spouse or persons close to the patient. In this regard, physicians must be discreet in their inquiries so as not to reveal privileged information or jeopardize the patient’s reputation. Generally, eliciting information from the family is the best way to proceed. If family members reveal serious concerns because of substance use, the physician can support these concerns and assist the family to motivate the patient to accept help. It is equally as important to discern whether household members or friends may interfere with the patient’s efforts at abstinence. In this regard, the substance use status of those close to the patient should be considered and their willingness to quit at the same time or refrain from use around the individual should be assessed.

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Summary

  • Substance abuse is often diagnosed by observing its consequences or symptoms.
  • Continued use of drugs in spite of serious consequences is a hallmark of addiction.
  • Chronic substance abuse can adversely affect virtually any organ system.
  • Assessment and treatment of coexisting psychiatric disorders profoundly affect the success of substance abuse treatment.
  • Collateral information obtained from individuals close to the patient can aid in the assessment and diagnosis.

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Treatment

Physician management of drug abuse consists of two fairly distinct processes that should be implemented concurrently for optimal benefit. These are detoxification, where a patient withdrawing from the effects of illicit drugs is stabilized, and the psychological component, which generates motivation to maintain abstinence. These processes vary with the specific drugs of abuse and the patterns of behavior exhibited by the substance abuser.

Detoxification

Opioids

Treatment for opioid dependence has two alternative approaches: detoxification or maintenance therapy. Detoxification involves the short-term pharmacologic management of the physical symptoms of opioid withdrawal and is designed to bring patients to an opioid-free state while engaging them into drug-free, relapse prevention therapy. Symptoms of withdrawal from opioids can be quite severe, depending on the potency of the abused opioid, route of administration, and duration of use. Manifestations of opioid withdrawal include muscle and joint pains, restlessness, irritability, nausea, vomiting, diarrhea, insomnia, mydriasis, diaphoresis, rhinorrhea, piloerection, tachycardia, and hypertension. In general, seizures are not associated with opioid withdrawal, but can be present during withdrawal from meperidine (Demerol) or propoxyphene (Darvon).

Management of the opioid withdrawal syndrome can be accomplished through various pharmacologic methods. One approach is to use long-acting opioid agonists, such as methadone or buprenorphine (Subutex). For cases of street heroin use, usually 20 to 30 mg/day of methadone, in divided doses four times daily, will suffice to start. For recently acquired addictions or for patients abusing less potent opioids such as codeine or propoxyphene, 2 to 10 mg of methadone per day in divided doses will usually suffice. Addicts tolerant to large daily doses of potent pharmaceutical opioids such as hydrocodone and oxycodone may need 40 to 100 mg/day or more of methadone, usually given in divided doses, with respiratory status closely monitored. Naloxone should be kept on hand in the event of inadvertent methadone overdose. Once stabilized on a consistent dose, methadone can be tapered while titrating for the patient’s comfort level. Federal law restricts use of methadone for opioid dependence to specially licensed hospitals and clinics. Physicians may not prescribe methadone or other opioids for the treatment of opioid dependence outside of these specially licensed settings.

At times, α2-adrenergic agonists, such as clonidine, are used with or without methadone detoxification. Clonidine helps to ameliorate withdrawal symptoms, particularly anxiety, by reducing secretion of norepinephrine from the locus coeruleus, but this drug is often an inadequate replacement for potent opioids. One should observe for any hypotensive episodes with clonidine. The initial dose of clonidine is 0.1 mg one to four times daily, and the dose is tapered as tolerated.

Buprenorphine is a partial agonist at the mu opioid receptor and an antagonist at the kappa receptor and has been used for opioid detoxification and initial stabilization in recent years.7 Slow dissociation from the receptor sites results in a long duration of action. Although buprenorphine produces mild subjective reinforcement, a ceiling effect exists because of its partial agonist activity so that increasing doses do not produce similarly increasing euphoria or respiratory depression. This offers a distinct advantage over methadone, which at higher doses produces not only greater euphoric effect, but also greater abuse liability and more intense withdrawal symptoms as well as higher risks for respiratory depression and death by overdose. Like methadone, however, buprenorphine has abuse potential if used parenterally. Because of this liability, a combination tablet of buprenorphine and naloxone (Suboxone) was developed to deter the possibility of diversion and improper use. The combination product is currently marketed in a buprenorphine to naloxone ratio of 4 : 1.

It is advisable that patients be experiencing mild to moderate withdrawal symptoms before initiating therapy with buprenorphine. This may occur as little as four hours from the time of last use if the patient is abusing short-acting opioids such as street heroin, or significantly longer, 48 hours or more, for patients on long-acting opioids such as methadone or oxycodone. It is recommended that patients taking long-acting opioids reduce their dose to a methadone-equivalent dose of 30 mg/day or less before changing to buprenorphine.

Start-up doses of buprenorphine are typically 2 to 4 mg every 6 hours, with supplemental doses of 2 mg given every 2 to 4 hours as needed. When the patient is comfortable, the dosage can be tapered down over ensuing days or weeks. Physicians who prescribe buprenorphine in the treatment of opioid addiction must obtain a waiver from federal methadone regulations through the Substance Abuse and Mental Health Services Administration. Physicians obtaining such a waiver may prescribe buprenorphine for inpatient or outpatient management and no special hospital license is required. It should be noted that all opioid detoxification and drug-free approaches enjoy limited success in terms of treatment retention and prevention of relapse.8

Maintenance therapy for opioid dependence, on the other hand, involves the replacement of abused opioids with medically prescribed slow-onset, long-acting opioids that have reduced abuse potential. Such medications exhibit cross-tolerance at the opioid receptor thus preventing opioid withdrawal and they compete with opioid receptor binding sites, thereby blocking the effects of self-administered exogenous opioids such as heroin. Contrary to the detoxification process, no attempt at weaning the medication is performed once stabilization is achieved. Maintenance treatment is sustained as long as the patient continues to benefit, is at continued risk of relapse, has no serious side effects, and the clinician believes such treatment is still required. In contrast to detoxification therapy, multiple controlled studies clearly support the effectiveness of maintenance therapy on treatment retention9 as well as on reduction of illicit opioid use, criminal activities, and human immunodeficiency virus seroconversion.10 We prefer to use either methadone (available to outpatients only through federally regulated methadone clinics), buprenorphine, or the combination of buprenorphine and naloxone for maintenance therapy. As noted above, physicians obtaining a waiver from federal methadone regulations can prescribe both preparations of buprenorphine for opioid dependence.

Initial maintenance dosing of buprenorphine is 4 mg or buprenorphine/naloxone 4/1 mg. Subsequent daily dosing should be increased by 2 to 4 mg to achieve a maintenance dose in the range of 12 to 16 mg of buprenorphine. Rarely do patients require dosages exceeding 32 mg. It should be noted that because of the partial agonist nature of the drug, increases in dose are not necessarily reflected by increases in subjective effect. Higher doses do, however, provide more effective blockade of the effects of illicit opioids. All patients, unless they have significant contraindications such as pregnancy or hypersensitivity to naloxone, should be maintained on the combination product to minimize the possibility of diversion and abuse.11 Switching from buprenorphine alone to the combination product is done maintaining the same dosage of buprenorphine. Usually buprenorphine can be administered once daily, although many patients prefer divided doses.

Tramadol (Ultram) is an analgesic that works through modulation of the GABAergic, noradrenergic, and serotonergic systems. Its analgesic and dependence properties stem from its action at the mu opioid receptor. Even though it has liability for dependence, it is not currently scheduled by the U.S. Drug Enforcement Administration. It may cause seizures while being abused in doses of more than 500 mg (10 tablets) daily but not in the withdrawal phase. Signs and symptoms of withdrawal may include typical opioid withdrawal and/or atypical withdrawal symptoms such as severe anxiety and panic attacks, confusion, delusions, hallucinations, depersonalization, derealization, paranoia, and unusual sensory phenomena such as numbness, tingling, paresthesia, and tinnitus. Detoxification consists of gradual dose reduction, low-dose benzodiazepines, or both, especially in the case of atypical withdrawal.

Benzodiazepines

Signs and symptoms of benzodiazepine withdrawal are more or less similar to alcohol withdrawal. In milder forms these include anxiety, insomnia, tremors, brisk reflexes, dilated pupils, progressive weakness, dizziness, and nausea or vomiting. A more severe form may also include tonic-clonic seizures, delirium, confusion, disorientation, agitation, hypertension, tachycardia, and visual hallucinations.

Generally, a longer-acting benzodiazepine such as chlordiazepoxide (Librium) is used for detoxification because it can be tapered more easily without risk of abrupt withdrawal. Also, it is less likely to be used illicitly. Chlordiazepoxide must be used cautiously in individuals with liver dysfunction because its psychoactive metabolites can build up quickly to toxic levels. The initial dosage depends on the pattern of illicit use and manifestation of symptoms, such as elevation of blood pressure or pulse rate, temperature, tremor, and hyper-reflexiveness. Patients with delirium or with a history of seizures associated with benzodiazepine withdrawal should be treated with a much slower taper. Antipsychotics may be helpful for agitation and psychotic symptoms associated with delirium. Anticonvulsant medications such as phenytoin in addition to the benzodiazepine should be used if deemed necessary for seizures or seizure prophylaxis.

Withdrawal from benzodiazepines may last several weeks and often requires a gradual taper of medication. The dosage of chlordiazepoxide is anywhere between 10 and 100 mg orally every 6 hours plus additional doses of 10 to 50 mg every 6 hours as needed. The total requirement in the initial 24 hours is the starting dose, which is tapered subsequently. Many physicians outside of the setting of addiction medicine are not familiar with chlordiazepoxide and prefer to use the same benzodiazepine that the patient used illicitly for detoxification. This approach works well for mild addiction but the longer-acting benzodiazepines are still preferable for more severe forms. Dosage conversions for benzodiazepines are shown in Table 3.

Table 3 Benzodiazepine Dose Equivalency
Generic Drug Brand Name Equivalent Dose (mg)
Alprazolam Xanax 1
Chlordiazepoxide Librium 25
Clonazepam Klonopin 2
Diazepam Valium 10
Flurazepam Dalmane 15
Lorazepam Ativan 1
Oxazepam Serax 10
Temazepam Restoril 15

Some physicians avoid medications with abuse potential for detoxification and rely on gabapentin (Neurontin) because it acts on the GABA receptors similar to the benzodiazepines and has anticonvulsant properties. The dosage range of gabapentin is between 300 and 3600 mg daily in three divided doses. The initial dosing depends on the extent of daily benzodiazepine use and manifestations of withdrawal. Neurontin is tapered as tolerated.

Barbiturates and Sedative-Hypnotics

The recognition of sedative addiction comes about by observing a pattern of increasingly heavy use of sedatives, such as carisoprodol (Soma), whose breakdown product, meprobamate, is a powerful sedative, or barbiturate analgesics, such as butalbital (Fiorinal). Barbiturates tend to produce rapid sedation and tolerance. These drugs can cause withdrawal convulsions if the dosage is reduced too rapidly. Because of this, the detoxification process should be done on an inpatient basis. For barbiturate detoxification, an initial challenge dose of 200 mg of pentobarbital sodium (Nembutal) is used to assess patient tolerance. If the patient becomes drowsy or ataxic or presents with nystagmus, tolerance is mild and only a modest dosage schedule is indicated, such as 100 to 200 mg of pentobarbital by mouth four times daily. If no effect is seen 2 hours after the initial challenge dose, a stronger regimen may be required, such as 300 to 400 mg by mouth four times daily. A slow taper of the dosage from these starting levels and supplementation with anticonvulsants such as phenytoin, should then be undertaken.

Cocaine

Cocaine withdrawal causes symptoms of autonomic arousal such as palpitations and sweating along with anxiety and dysphoria. It also causes intense craving, which has been postulated to be due to the β-adrenergic system, involved in augmenting the memory related to emotionally arousing systems. Propranolol, which is a nonselective β-adrenergic antagonist, has been shown to reduce the anxiety and symptoms of autonomic arousal associated with cocaine craving. Also, propranolol may decrease the reinforcing effects of cocaine and reduce cocaine desirability. This may lead to improved treatment adherence and abstinence. In a recent 10-week double-blind study, 199 patients dependent on cocaine with severe withdrawal symptoms were assigned to propranolol, amantadine, or placebo. It was found that, among patients who were highly compliant with treatment medication, propranolol treatment was associated with better treatment retention and higher rates of cocaine abstinence compared with placebo.12 These data are consistent with previous studies with propranolol on similar subsets of cocaine addicts.

Some studies have involved the use of antidepressants for cocaine dependence, especially for dysphoria associated with cocaine withdrawal, with varying results. These studies indicate that tricyclic antidepressants, such as imipramine or desipramine may reduce craving for cocaine and at the same time exert antidepressant action for general dysphoria. We recommend the use of a combination of propranolol and imipramine. The dosing of propranolol is 20 mg three times daily and that of imipramine is 25 mg three times daily.

Cocaine-induced delusions, which mostly occur during intoxication, usually cease in a few hours without the use of pharmacotherapy. It may be helpful to use antipsychotics or benzodiazepines if the delusions are severe or causing distress to the patient. For cocaine-induced vasospasm, which may involve the coronary arteries producing angina or cerebral vasculature producing stroke, appropriate treatment should be given, preferably in the intensive care setting.

Amphetamines

After prolonged heavy use of amphetamines, a withdrawal syndrome may occur. Often referred to as “crashing,” this phenomenon is characterized by depressed mood, fatigue, disturbed sleep, and pronounced dreaming. Amphetamines suppress REM sleep and can cause a rebound increase in REM sleep after the drug is withdrawn. Beginning within 24 hours after the last dose, the patient may sleep for increasing periods, up to 18 to 20 hours per day for the next 72 hours. Other symptoms include irritability, impulsivity, insatiable hunger, headaches, profuse sweating, and muscle or stomach cramps. The depression generally peaks 48 to 72 hours after the last dose and persists for several weeks. Suicidal ideation occasionally occurs during this period. If depression persists longer, an underlying disorder should be considered and antidepressant therapy should be instituted. There is no generally accepted detoxification agent, although dextroamphetamine, methylphenidate, imipramine, and bupropion have been used.13-15

Treatment of patients presenting with amphetamine-induced psychosis, in an acutely intoxicated, agitated, or delusional state requires inpatient supervision. These patients should be placed in a quiet room and provided with reassurance. Intramuscular haloperidol (Haldol) 1 to 5 mg three times daily for the first day, and as needed thereafter, should be started if necessary for the control of agitation. Diazepam (Valium) 10 to 20 mg orally or intramuscularly may be substituted, especially if the patient has seizures. It is also vital to establish a follow-up relationship with the patient, explaining that episodes of depression, apathy, and lack of initiative may occur over the next 2 to 4 months and that this may tempt the patient to resume amphetamine use.

Behavioral Approach

Treatment Setting

There are three kinds of treatment settings available to patients, depending on the severity of their addiction.16 The first is inpatient hospitalization, wherein patients who are intoxicated or withdrawing from drugs have serious medical or psychiatric comorbid conditions or uncontrolled drug use with previous failed treatments. The second one is residential treatment, wherein people having significant deficits in social or vocational skills are placed and specially trained in such areas and other strategies to help them stay sober. The third option involves either partial hospitalization, where patients are not at risk for withdrawal or other clinical comorbid conditions, or intensive outpatient programs that meet three to five times weekly for a few months. Outpatient aftercare visits on a weekly basis in individual or group settings are strongly advised.

Follow-up

During hospitalization for detoxification, the patient and physician should establish a plan for a long-term follow-up program and other specialized treatments. Appropriateness for a residential chemical dependency rehabilitation program should be considered. Such programs provide an intense educational and motivational experience, overcoming denial and resistance in a supportive milieu. Outpatient aftercare programs are appropriate when reasonable abstinence and emotional and physical stability are achieved.

Urine Monitoring

We suggest frequent randomized urine testing for a minimum of 1 to 2 years for most patients. Most of these urine checks are obtained randomly, approximately once a week, and are collected under supervision.

Self-Help Groups

These include Alcoholic Anonymous (AA), Narcotic Anonymous (NA), Cocaine Anonymous (CA), and others. Such groups provide frequent and powerful therapeutic reinforcement for recovering patients. As a rule, patients are mandated to attend these self-help groups, and attendance usually begins during the initial treatment episode.

Psychotherapy

There have been much data to suggest that psychotherapy is an important tool in promoting sobriety. It includes cognitive-behavioral therapy, individual therapy, interpersonal therapy, group therapy, and other modalities. The main goal of any of these modalities is to motivate the patient to remain abstinent from drugs, to teach coping mechanisms, to improve interpersonal and social skills, to build a support system, and to teach stress management. All of these assist the patient in forgoing perceived rewards of resuming substance use as well as tolerating the withdrawal symptoms which can be prolonged in some cases.

Recovering patients need to be given respect and praise for maintaining an abstinence program and for participating in treatment modalities. They have to sacrifice much in the way of time, energy, and expense to conquer this illness. Understanding, praise, and firm support are a physician’s most important tools.

Aftercare

It is important to continue the physician-patient relationship following the detoxification period. Patients should be encouraged to bring all their requests for medications and other medical consultations to the treating physician’s attention first. We recommend prohibiting the ingestion of any medication other than ibuprofen without prior approval. We also check periodically for intravenous injection tracks on our needle-using patients. Urine toxicology screens should be performed regularly. It is important to avoid prescribing any psychoactive drugs especially sedatives, analgesics, and tranquilizers. These medications carry a substantial risk of inducing medical dependency. One should strongly recommend to medication-dependent patients that they abstain from drinking alcohol. In many such patients, drinking escalates rapidly to full-blown alcoholism, whereas in other people, drinking leads to relapse of drug use. It is important to maintain close contact with patient’s spouse or family for at least 1 to 2 years.

It is best to regard addiction as a chronic, relapsing condition that is never cured, only held in remission. It requires lifelong commitment on the part of the patient and appropriate support from the physician to treat this potentially fatal illness.

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Prevention

Effective prevention of substance-related disorders begins with an appreciation that abuse can easily become dependence and that patients who are chemically dependent are addicted to the substance that is destroying their lives. Primary prevention for physicians involves premorbid educational efforts, particularly those directed at adolescents, as well as cautious prescribing practices when administering addictive medications. Medication abuse can be difficult to detect because the addicted person often offers plausible reasons for needing the medications. The clinician should be wary of the signs of addiction and always obtain a substance abuse history before prescribing controlled drugs. It is important to remember that dependence is chronic and lifelong, and that patients with a history of drug dependence are always at high risk of addictive relapse if mood-altering drugs are reintroduced to them. Secondary prevention involves early recognition and treatment of developing cases and very often depends on the physician’s awareness of the prevalence of substance abuse in any patient population, recognition of classic behavioral signs and patterns suggesting addiction, and discretion and judgment in refusing to prescribe addictive medications. Substance-related behaviors, including noncompliance, denial, or even hostility can place formidable obstacles in the path of the treating physician and challenge even the most experienced clinicians.

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Summary

Pharmacotherapy

  • Opiates: Although complete abstinence is desirable, maintenance therapy with methadone or buprenorphine is of proven benefit.
  • Benzodiazepines: Withdrawal may be prolonged and detoxification with long-acting agents is preferred.
  • Barbiturates: Detoxification should be performed on an inpatient basis because of a risk of seizures.
  • Cocaine: Combination of propranolol and imipramine might be helpful for dysphoria and craving.
  • Amphetamines: Depressive symptoms accompany withdrawal and require ongoing support and occasionally medication to prevent relapse.

Behavioral Approach

  • Behavior modification should be used early on in the treatment process to help teach skills needed for long-term sobriety.

References

  1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association, 2000.
  2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies: Results from the 2004 National Survey on Drug Use and Health: National Findings (NSDUH Series H-28, DHHS Publication No. SMA 05-4062). Rockville, Md: Department of Health and Human Services, 2005.
  3. Substance Abuse and Mental Health Services Administration, Office of Applied Studies: Treatment Episode Data Set (TEDS): 1993–2003. National Admissions to Substance Abuse Treatment Services (DASIS Series: S–29, DHHS Publication No. SMA 05-4118). Rockville, Md: Department of Health and Human Services, 2005.
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