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Alcohol/Substance AbuseSYMPTOMSAbuse of alcohol or a substance is generally characterized by a maladaptive pattern of alcohol or substance use leading to significant impairment or distress, as manifested by one (or more) of the following, occurring within a one year period:
The symptoms must also have never met the criteria for Alcohol/Substance Dependence for this class of substance.
Criteria summarized from: |
Alcohol/Substance DependenceSYMPTOMSA 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: 1. tolerance, as defined by either of the following:
2. withdrawal, as manifested by either of the following:
3. the substance is often taken in larger amounts or over a longer period than was intended 4. there is a persistent desire or unsuccessful efforts to cut down or control substance use 5. 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 6. important social, occupational, or recreational activities are given up or reduced because of substance use 7. 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 exacerbated 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)
Criteria summarized
from: Alcohol Abuse & DependenceTREATMENTMedical TreatmentBasic PrinciplesDetoxification: It is impossible to treat alcohol dependence in patients who continue to use alcohol. The patient must be detoxified before any meaningful therapy can begin for other emotional problems. Usually this detoxification can be done as an outpatient. However, the following are the indications for inpatient detoxification:
Because of the many medical complications of alcohol withdrawal, a complete physical examination with appropriate laboratory tests is mandatory, with special attention to the liver and nervous system. Patients withdrawing from alcohol who exhibit any withdrawal phenomena should receive a benzodiazepine (such as chlordiazepoxide or diazepam). Anticonvulsant medication is not useful in preventing or treating alcohol withdrawal convulsions; the use of chlordiazepoxide or diazepam is generally effective. A high-calorie, high-carbohydrate diet supplemented by multivitamins is important. Dehydration must be corrected with fluids by mouth or intravenously. Alcoholic patients in severe withdrawal should never be physically restrained as they may fight the restraints to exhaustion. When patients are disorderly and uncontrollable, a seclusion room can be used. The need for warm verbal support is imperative in the treatment of severe alcohol withdrawal. Patients in severe withdrawal are very confused and frightened - yet can dramatically calm when given sufficient verbal support. Restrict access to addicting substances: Following detoxification, alcohol should be removed from the patient's home, and all prescriptions written by other physicians should be discontinued. Until the patient is stronger, all family or friends that drink heavily or use illicit drugs should be avoided. Teach the disease model of addiction: The patient and the family should be educated that addiction is an medical illness - not a moral failing. An alcoholic can never go back to drinking. In general, controlled drinking (e.g., one drink per weekend) carries a high risk of relapse. Any treatment for alcoholism must be based on total abstinence. Likewise, ALL addictive drugs should be avoided (unless they are clearly indicated for acute pain or time-limited acute anxiety). Addictions, like many other medical disorders, are relapsing conditions that require a long-term commitment to therapy. Thus progress in therapy is often "two-steps-forward-and-one-step-back", but the patient should not be abandoned because of a temporary "slip" back into addiction. Relapses should be dealt with in a nonjudgmental manner, and detoxification should be arranged rapidly. Treat associated psychiatric problems: Alcohol may have been a self-treatment for another psychiatric disorder. This is especially true of addicted patients who use alcohol to treat their Psychotic Disorder, Mood Disorder, Anxiety Disorder, or Personality Disorder. Many of these coexisting psychiatric disorders have effective medical treatments which should be given. Do unscheduled alcohol blood tests: Periodic blood tests for alcohol can be essential in identifying relapse. It is essential that these blood tests be unscheduled (to minimize the risk of "cheating"). Encourage exercise: It is important to stress the importance of regular exercise (lasting more than 20 minutes at a time) as an alternative to craving alcohol. It is hoped that the patient will develop a dependency on exercise to replace the former dependency on alcohol as a "stress reliever". Treatment Of Alcohol WithdrawalThe standard treatment regime for alcohol withdrawal is:
The chlordiazepoxide or diazepam may have to be prescribed for weeks or even months to control the anxiety, restlessness, and insomnia seen in the initial stage of abstinence. The physician must carefully monitor this antianxiety drug therapy to prevent over-medication or addiction. With careful monitoring, the risk of the alcoholic becoming addicted to an antianxiety drug is remote. DisulfiramDisulfiram (Antabuse) competitively inhibits the enzyme aldehyde dehydrogenase, so that even a single drink usually causes a toxic reaction due to acetaldehyde accumulation in the blood. Administration of the drug should not begin until 24 hours after the patient's last drink. The physician must warn the patient about the drug or for as long as 2 weeks thereafter. Those who drink while taking disulfiram turn purple, become severely ill for 30 to 60 minutes (or longer) and often vomit. Patients on disulfiram may also have this same response to alcohol ingested in mouthwash, wine sauces or vinegars, or even to inhaled alcohol vapors from aftershave lotions. Disulfiram may also exacerbate psychotic symptoms in schizophrenic patients (but this is uncommon). Disulfiram can be of critical importance in helping the alcoholic to make the essential decision to stop drinking. There should be nothing surreptitious about the use of disulfiram (i.e., no slipping the drug into the coffee by the spouse). It should be discussed with the patient, with full disclosure of its side effects and dangers. The initial dosage (after a minimum of 24 hours' abstention from alcohol) is 500 mg/d in a single dose in the morning. This can be decreased to a maintenance dose of 250 mg/d, continued indefinitely. Disulfiram frees the alcoholic from ruminating as to whether he should or should not have a drink and prevents the relapses that usually follow a sudden and impulsive first drink. Antidepressant DrugsStudies of alcoholic patients indicated that as many as 30 percent may suffer from a Major Depression beyond the detoxification period. These patients often benefit from antidepressant medication (in doses similar to those prescribed for other clinically depressed patients). The antidepressants can be used without difficulty in patients taking disulfiram. Lithium has also been used with some success. HospitalizationHospitalization is not usually necessary or even desirable unless there are serious medical complications during alcohol withdrawal. Most alcoholics can be safely withdrawn from alcohol at home or at a detoxification center. Antipsychotic DrugsAntipsychotic drugs are best avoided because they may increase the risk of alcohol withdrawal seizures. Antipsychotic drugs are only used for the rare cases of alcoholic hallucinosis that fail to respond to treatment with benzodiazepines. Psychosocial TreatmentBasic PrinciplesArrange follow-up treatment: If an alcoholic is to remain alcohol-free, follow-up treatment, usually with psychiatric help and resort to community resources, is often vital. The patient must be seen regularly to monitor continued abstinence and adjustment. Research is showing that patient factors such as having a stable family, stable job, less sociopathy, less psychopathology, and a negative family history for alcoholism are more powerful predictors of positive outcome that is the type of treatment (Frances et al. 1984). This research could be interpreted to mean that follow-up treatment is most needed for alcoholic patients with an unstable family, unstable job, more sociopathy, more psychopathology, and a positive family history for alcoholism. PsychotherapyConfront denial gradually: Aggressive confrontation too early in treatment may increase, rather than decrease, the patient's denial of having a problem. Initially, all that the patient has to agree to is detoxification (usually done to placate the family or the physician). The best way to confront the patient's denial of addiction is to challenge him to "prove" that he's not addicted by going on a one month trial period of abstinence. A successful trial period of abstinence may help the patient feel so much better that continued abstinence becomes easier. An unsuccessful trail period of abstinence proves that the alcohol use is out of control, and the therapist must then confront the patient's denial more vigorously. Focus psychotherapy on the patient's addiction: Psychotherapy is most successful when it focuses on the alcoholic's drinking. The drinking itself - past, present, and future consequences - must be given firm emphasis. Patients who insist that they need to solve their emotional problems before they stop using alcohol must be told that the alcohol is the main problem, and that other emotional problems can not be adequately treated until they first stop using alcohol. Involve family and friends: The therapist must involve the patient's family or friends as allies in the patient's treatment. Family and friends are often aware of relapses that are concealed by the patient. Research has shown that patients that are encouraged or even coerced into treatment by family or friends are more likely to remain in treatment and have a better outcome than those who are not so pressured. Alcoholics Anonymous (A.A.)Therapists should routinely refer alcoholics to A.A. as part of a multiple treatment approach. Although Alcoholics Anonymous does not appeal to all alcoholics, it is obvious that the AA approach has been extremely successful with many. A.A. meetings provide members with acceptance, understanding, forgiveness, confrontation, and a means for positive identification. New A.A. members are asked to admit to a problem, give up a sense of personal control over the disease, do a personal assessment, make amends, and help others. Telephone numbers are exchanged, and new members pick "sponsors" (more experienced members who guide them through their recovery). Al-Anon is an organization for the spouses of alcoholics that is organized along the same lines as Alcoholic Anonymous. Alateen has been developed for the children of alcoholics so that they may better understand their parents' alcoholism. Residential Centers And Halfway HousesA residential center or halfway house is an important treatment resource for the alcoholic newly discharged from inpatient care. The halfway house provides emotional support, counselling and progressive entry into society. Behavior TherapyBehavior therapy teaches the alcoholic other ways to reduce anxiety. Relaxation training, assertiveness training, self-control skills, and new strategies to master the environment are emphasized. Trials of aversive conditioning - apomorphine and emetine to induce vomiting, electrical stimulation to produce pain - are no longer widely used in the treatment of alcoholism. Reprinted from Internet Mental Health, Copyright © 1995 by Phillip W. Long, M.D. Substance Abuse & DependenceTREATMENTCocaine Abuse and DependenceMedical TreatmentBasic PrinciplesThe principles of cocaine rehabilitation are similar to treatment of alcoholism or sedativism. Detoxification is a prerequisite in the treatment of this disorder. Antianxiety DrugsSevere cocaine-induced agitation can be treated with diazepam (Valium) 5 to 10 mg every 3 hours IM or PO. Tachyarrhythmias can be treated with propranolol (Inderol) 10 to 20 mg PO every 4 hours. Antidepressant DrugsIn preliminary tests, imipramine and desipramine attenuated cocaine euphoria and craving. LithiumLithium has been reported to block cocaine euphoric effects, though recent evidence suggests lithium is effective only in bipolar or cyclothymic patients. Other DrugsVitamin C (0.5 g PO every 6 hours) may increase urinary excretion by acidifying urine. Methylphenidate has not been found to be useful in those cocaine abusers who do not have preexisting attention deficit disorder. HospitalizationUsually cocaine dependent patients are best treated as outpatients. Inpatient hospitalization may be needed for severe crash symptoms, suicide ideation, psychotic symptoms, or failure in outpatient treatment. Psychosocial TreatmentBasic PrinciplesIf a user is to remain drug-free, follow-up treatment, usually with psychiatric help and resort to community resources, is vital. Life-style changes such as avoiding people, places, and things related to cocaine use should be encouraged. Initial psychosocial treatment should focus on confronting denial, teaching the disease concept of addictions, fostering an identification as a recovering person, recognition of the negative consequences of cocaine abuse, avoiding situational and intrapsychic cues that stimulate craving, and formulation of support plans. Drug urine tests should be used to ensure compliance. Treatment outcome is affected more by such factors as employment status, family support, and degree of antisocial features than by initial motivation for treatment. PsychotherapyIt is likely that some heavy cocaine users, like other heavy drug users, suffer from chronic anxiety, depression, or feelings of inadequacy. In these cases, the drug abuse is a symptom rather than the central problem. These cases can benefit from psychotherapy. Psychotherapy is useful when it focuses on the reasons for the patient's drug abuse. The drug abuse itself - past, present, and future consequences - must be given firm emphasis. Involving an interested and cooperative parent or spouse in conjoint therapy is often very beneficial. The therapist must be watchful for return of cocaine-related activities, attitudes, friendships, and paraphernalia. Alcohol and other mood-altering drugs should be avoided, since they may disinhibit behavior and lead to relapse. Concurrent Axis I or II psychiatric disorders should be treated with attention to the interaction with cocaine disorder. Treatment of clearly defined attention deficit disorder or bipolar or unipolar depression should proceed along with attention to the addiction. Cocaine AnonymousA new self-help group, Cocaine Anonymous, has started. It is patterned after Alcohol Anonymous and Narcotics Anonymous. Cannabis Abuse and DependenceMedical TreatmentBasic PrinciplesUsually adverse effects of marijuana intoxication do not lead to professional attention. There is no adequately documented case of a fatality in a human being. Pure marijuana abuse rarely requires inpatient or pharmacological treatment, and detoxification is not necessary. Since marijuana may be one of many drugs abused, total abstinence from all psychoactive substances should be the goal of therapy. Periodic urine testing should be used to monitor abstinence. Cannabinoids can be detected in the urine up to 21 days after abstinence in chronic abusers due to fat redistribution; however, one to five days is the normal urine positive period. Thus, beginning drug monitoring needs to be interpreted accordingly. Antianxiety DrugsAntianxiety drugs are occasionally needed to treat severe cannabis-induced anxiety or panic. If the patient was using cannabis for anxiety reduction, an antianxiety drug should be considered as substitution therapy. Antipsychotic DrugsAntipsychotic drugs are occasionally needed to treat protracted, cannabis-induced psychosis. Antidepressant DrugsIf the patient was using cannabis for alleviation of depression, an antidepressant should be considered as substitution therapy. Psychosocial TreatmentBasic PrinciplesIf a user is to remain drug-free, follow-up treatment, usually with psychiatric help and resort to community resources, is vital. Life-style changes such as avoiding people, places, and things related to cannabis use should be encouraged. Initial psychosocial treatment should focus on confronting denial, teaching the disease concept of addictions, fostering an identification as a recovering person, recognition of the negative consequences of cannabis abuse, avoiding situational and intrapsychic cues that stimulate craving, and formulation of support plans. Drug urine tests should be used to ensure compliance. Educating patients about the amotivational syndrome and other complications of cannabis abuse may dissuade some from using cannabis. Often the patient does not realize the full extent of his amotivational syndrome until he stops using the drug and notices the improvement. PsychotherapyIt is likely that some heavy cannabis users, like other heavy drug users, suffer from chronic anxiety, depression, or feelings of inadequacy. In these cases, the drug abuse is a symptom rather than the central problem. These cases can benefit from psychotherapy. Psychotherapy is useful when it focuses on the reasons for the patient's drug abuse. The drug abuse itself - past, present, and future consequences - must be given firm emphasis. Involving an interested and cooperative parent or spouse in conjoint therapy is often very beneficial. In the adolescent, cannabis dependence often hides poor self-esteem, depression, severe family problems, and learning disorders. These issues must be addressed in therapy. Generally, a nonjudgmental, honest, steady, and firm approach is needed with adolescence. Behavior TherapyBehavior therapy teaches the cannabis drug user other ways to reduce anxiety. Relaxation training, assertiveness training, self-control skills, and new strategies to master the environment are emphasized. Reprinted from Internet Mental Health, Copyright © 1995 by Phillip W. Long, M.D.
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