Sunday, May 14, 2017

Drug Abuse and Dependence

The National Institute on Drug Abuse defines drug abuse and dependence as the use of a legal or an illegal drug that causes physical, mental, emotional, or social harm. 

Examples of abused drugs include narcotics, stimulants, depressants, anxiolytics, and hallucinogens.
Chronic drug abuse, especially I.V. use, can lead to life-threatening complications, such as cardiac and respiratory arrest, intracranial hemorrhage, acquired immunodeficiency syndrome, tetanus, subacute infective endocarditis, hepatitis, vasculitis, septicemia, thrombophlebitis, pulmonary emboli, gangrene, malnutrition and GI disturbances, respiratory infections, musculoskeletal dysfunction, trauma, depression, increased risk of suicide, and psychosis. Materials used to “cut” street drugs can also cause toxic or allergic reactions.

Drug abuse can occur at any age. Experimentation with drugs commonly begins in adolescence or even earlier. Drug abuse commonly leads to addiction, which may involve physical or psychological dependence or both. The most dangerous form of abuse occurs when users mix several drugs simultaneously—including alcohol.

Drug abuse commonly results from a combination of low self-esteem, peer pressure, inadequate coping skills, and curiosity. There is also evidence of familial patterns of addiction.
Most people who are predisposed to drug abuse have few mental or emotional resources against stress, an overdependence on others, and a low tolerance for frustration. Taking the drug gives them pleasure by relieving tension, abolishing loneliness, allowing them to achieve a temporarily peaceful or euphoric state, or simply relieving boredom.
Drug dependence may follow experimentation with drugs in response to peer pressure. It may also follow the use of drugs to relieve physical pain, but this is uncommon.

Signs and symptoms

Indications of acute intoxication vary, depending on the drug.
Friends, family members, or law enforcement officials may bring the patient to the hospital because of respiratory depression, unconsciousness, acute injury, or a psychiatric crisis.

Physical examination
Examine the patient for signs and symptoms of drug use or drug-related complications as well as for clues to the type of drug ingested. For example, fever can result from stimulant or hallucinogen intoxication, from withdrawal, or from infection from I.V. drug use.
Inspect the eyes for lacrimation from opioid withdrawal, nystagmus from central nervous system (CNS) depressants or phencyclidine intoxication, and drooping eyelids from opioid or CNS depressant use. Constricted pupils occur with opioid use or withdrawal; dilated pupils, with the use of hallucinogens or amphetamines.
Examine the nose for rhinorrhea from opioid withdrawal and the oral and nasal mucosa for signs of drug-induced irritation. Drug sniffing can result in inflammation, atrophy, or perforation of the nasal mucosa. Dental conditions commonly result from the poor oral hygiene associated with chronic drug use. Also inspect under the tongue for evidence of I.V. drug injection.
Inspect the skin. Sweating, a common sign of intoxication with opioids or CNS stimulants, also accompanies most drug withdrawal syndromes. Drug use sometimes induces a sensation of bugs crawling on the skin, known as formication; as a result, the patient’s skin may be excoriated from scratching.
Needle marks or tracks are an obvious sign of I.V. drug abuse. Keep in mind that the patient may attempt to conceal or disguise injection sites with tattoos or by selecting an inconspicuous site, such as under the nails.
In addition, self-injection can sometimes cause cellulitis or abscesses, especially in patients who also are chronic alcoholics. Puffy hands can be a late sign of thrombophlebitis or of fascial infection from self-injection on the hands or arms.
Auscultation may disclose bilateral crackles and rhonchi caused by smoking and inhaling drugs or by opioid overdose. Other cardiopulmonary signs of overdose include pulmonary edema, respiratory depression, aspiration pneumonia, and hypotension.
CNS stimulants and some hallucinogens may precipitate refractory acute-onset hypertension or cardiac arrhythmias. Withdrawal from opioids or CNS depressants can also provoke arrhythmias and, occasionally, hypotension.
During opioid withdrawal, the patient may report abdominal pain, nausea, or vomiting. Opioid abusers also commonly complain of hemorrhoids, a consequence of the constipating effects of these drugs. Palpation of an enlarged liver, with or without tenderness, may indicate hepatitis.
Neurologic symptoms of drug abuse include tremors, hyperreflexia, hyporeflexia, and seizures. Abrupt withdrawal may precipitate signs of CNS depression (ranging from lethargy to coma), hallucinations, or signs of overstimulation, including euphoria and violent behavior.

Medical history
Carefully review the patient’s medical history. Suspect drug abuse if he reports a painful injury or chronic illness but refuses a diagnostic workup. In his attempt to obtain drugs, the dependent patient may feign illnesses, such as migraine headaches, myocardial infarction, and renal colic; claim an allergy to over-the-counter analgesics; or even request a specific medication.
Also, be alert for a previous history of overdose or a high tolerance for potentially addictive drugs. I.V. drug users may have a history of hepatitis or human immunodeficiency virus (HIV) infection from sharing dirty needles. Female drug users may report a history of amenorrhea.
A patient who abuses drugs may give you a fictitious name and address, be reluctant to discuss previous hospitalizations, or seek treatment at a medical facility across town rather than in his own neighborhood. If possible, interview family members to verify his responses.
If the patient admits to drug use, try to determine the extent to which this behavior interferes with his normal functioning. Note whether he expresses a desire to overcome his dependence on drugs.
If possible, obtain a drug history consisting of substances ingested, amount, frequency, and last dose. Expect incomplete or inaccurate responses. Drug-induced amnesia, a depressed level of consciousness, or ignorance may distort the patient’s recollection of the facts; he also may deliberately fabricate answers to avoid arrest or to conceal a suicide attempt.
The hospitalized drug abuser is likely to be uncooperative, disruptive, or even violent. He may experience mood swings, anxiety, impaired memory, sleep disturbances, flashbacks, slurred speech, depression, and thought disorders.
Some patients resort to plays on sympathy, bribery, or threats to obtain drugs. They may also try to manipulate caregivers by pitting one against another.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition – Text Revision, gives characteristic findings for patients with drug dependence.
Various tests can confirm drug use, determine the amount and type of drug taken, and reveal complications.

For example, a serum or urine drug screen can detect recently ingested substances.
Characteristic findings in other tests include elevated serum globulin levels, hypoglycemia, leukocytosis, liver function abnormalities, positive rapid plasma reagin test results because of elevated protein fractions, elevated mean corpuscular hemoglobin levels, elevated uric acid levels, and reduced blood urea nitrogen levels.

The patient may first need treatment for drug intoxication, followed by long-term therapy to combat drug dependence.

Drug intoxication
The patient with acute drug intoxication should receive symptomatic treatment based on the drug ingested. Measures include fluid replacement therapy and nutritional and vitamin supplements, if indicated, and detoxification with the same drug or a pharmacologically similar drug. (Exceptions include cocaine, hallucinogens, and marijuana, which aren’t used for detoxification.)
Medications include sedatives to induce sleep; anticholinergics and anti-diarrheals to relieve GI distress; anti-anxiety drugs for severe agitation, especially in cocaine abusers; and symptomatic treatment of complications.
Depending on the dosage and time elapsed before admission, additional treatments may include gastric lavage, induced vomiting, activated charcoal, forced diuresis and, possibly, hemoperfusion or hemodialysis.

Drug dependence
Treatment of drug dependence commonly involves a triad of care: detoxification, short- and long-term rehabilitation, and aftercare. The latter means a lifetime of abstinence, usually aided by participation in Narcotics Anonymous or a similar self-help group.
Detoxification, the controlled and gradual withdrawal of an abused drug, is achieved through substitution of a drug with similar action, which is then gradually decreased. Such gradual replacement of the abused drug controls the effects of withdrawal, thereby reducing the patient’s discomfort and associated risks.
Depending on which drug the patient has abused, detoxification may be managed on an inpatient or outpatient basis. For example, withdrawal from CNS depressants can produce hazardous adverse reactions, such as generalized tonic-clonic seizures, status epilepticus, and hypotension.
The severity of these reactions determines whether the patient can be safely treated as an outpatient or requires hospitalization. Withdrawal from CNS depressants usually doesn’t require detoxification.
Opioid withdrawal causes severe physical discomfort and can even be life-threatening. To minimize these effects, chronic opioid abusers commonly are detoxified with methadone.
To ease withdrawal from opioids, depressants, and other drugs, useful nonchemical measures may include psychotherapy, exercise, relaxation techniques, and nutritional support. Sedatives and tranquilizers may be administered temporarily to help the patient cope with insomnia, anxiety, and depression.
After withdrawal, the patient needs to participate in a rehabilitation program to prevent a recurrence of drug abuse. Rehabilitation programs are available for both inpatients and outpatients; they usually last a month or longer and may include individual, group, and family psychotherapy. During and after rehabilitation, participation in a drug-oriented self-help group may be beneficial. The largest such group is Narcotics Anonymous.

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