Chapter 6

Substance Use Assessment

Outline

Subjective Data

Health History Questions

Objective Data

Abnormal Findings

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Alcohol Use and Abuse

In 2008, slightly more than half (51.6%) of Americans ages 12 and older reported being current alcohol drinkers.32 More than one fifth (23.3%) of persons ages 12 and older were binge drinkers (≥5 drinks/occasion) and 6.9% reported heavy drinking (binge drinking on at least 5 days in the past 30 days). Thus alcohol is the most used and abused psychoactive drug. People like to drink! Given the rates of alcohol use, it is not surprising that many patients in the hospital and in primary care offices find themselves with alcohol-related disorders.

Morbidity and mortality data reflect the adverse consequences of excessive alcohol use. Alcohol is involved in 40% of the 41,000 annual deaths due to traffic crashes.23 The number of emergency department (ED) visits attributable to alcohol from the period 1992 to 2000 was about 68.6 million,19 with an increasing trend of 18% during that time. In the general population, alcohol consumption of at least 4 standard drinks per day (each containing 12 g alcohol, see Table 6-1) is associated with increased rates of death from cirrhosis and alcoholism; cancers of the mouth, esophagus, pharynx, and liver combined; and injuries and other external causes in men.30 In women, alcohol consumption increases the risk for breast cancer in a dose-response relation, starting at an alcohol intake of 24 g (about 2 drinks) a day.15 The link between chronic alcohol use and alcohol liver disease is well known. Cirrhosis accounted for 27,000 deaths in the United States in 2004, or the 12th leading cause of death.6 There are multiple alcohol effects on the heart. Chronic heavy use increases the risk for alcoholic cardiomyopathy, with an increase in left ventricular mass, dilation of ventricles, and wall thinning.31 Hypertension is a common detrimental effect, with a causal association between consumption of 30 to 60 g alcohol per day (3 to 5 standard drinks) and blood pressure (BP) elevation in men and women.13 Finally, alcohol and illicit drugs are arrhythmogenic and are associated with the rapid heart rate of atrial fibrillation.14

Because of alcohol-related morbidity, many patients you encounter in primary care settings and in the hospital will have a significant drinking history. Persons visiting primary care providers have a significantly higher rate of past or present alcohol abuse (23%) than those in the general population (9%).17,21a Surveys of hospital ICU admissions show a range of 12% to 21% prevalence of alcohol dependence among their patients.18,24 Excessive alcohol use increases risk for ICU admissions due to trauma, hypothermia, and pancreatitis. Once in the hospital, heavy alcohol use can lead to respiratory failure from acute alcohol intoxication and alcohol withdrawal syndrome. Alcohol dependence increases risk for sepsis, septic shock, and hospital mortality among ICU patients.24

Defining Illicit Drug Use

In 2008, about 8% of Americans ages 12 years and older reported current (past month) illicit drug use.33 Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, and prescription-type drugs used nonmedically. Marijuana was the most commonly used illicit drug, with 6.1% of persons ages 12 years and older reporting past-month use. Among youth ages 12 to 17 years, between 2002 and 2008, the rates of use of illicit drugs in general declined significantly (from 11.6% to 9.3%). Still, that represents 1 out of 10 adolescents as illicit drug users. This warrants our attention and intervention. Any amount of illicit drug use has serious legal consequences, as well as consequences for health, relationships, and future jobs, school, and career.

The abuse of prescription drugs is the fastest growing drug problem in the United States. Between 2004 and 2008, visits to hospital EDs for the nonmedical use of narcotic pain relievers more than doubled, rising 111%.7 The three most frequently abused prescription opioid pain relievers were products using oxycodone, hydrocodone, and methadone. The misuse of prescription drugs has a huge impact not only on health and safety but also on burdens to the ED system.

Diagnosing Substance Abuse

The rate of Americans classified with substance abuse or dependence is 9.2 % of the population ages 12 years and older; of these persons, 68% were dependent on or abused alcohol but not illicit drugs and 14% used both alcohol and illicit drugs. There is a continuum of alcohol drinking ranging from special occasion use, through moderate drinking, to harmful drinking (Table 6-2). Alcohol dependence or alcoholism is a chronic progressive disease that is not curable but is highly treatable. Accurate diagnosis is needed in order to provide advice, brief intervention, appropriate treatment, and follow-up. The gold standard of diagnosis is well defined by the American Psychiatric Association (APA) in their Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV-TR). Tables 6-3 and 6-4 give the criteria for these diagnoses. Unfortunately, alcohol problems are underdiagnosed both in primary care settings and in hospitals. Excessive alcohol use often is unrecognized until patients develop serious complications.

TABLE 6-2

Categories and Definitions for Patterns of Alcohol Use

CategoryOrganizationDefinition
Moderate drinkingNIAAAMen, ≤2 drinks/day; women, ≤1 drink/day; >65 years, ≤1 drink/day
At-risk drinkingNIAAAMen, >14 drinks/wk or >4 drinks/occasion; women, >7 drinks/wk or >3 drinks/occasion
Hazardous drinkingWHOAt risk for adverse consequences from alcohol
Harmful drinkingWHOAlcohol is causing physical or psychological harm
Alcohol abuseAPA≥1 of the following events in a year: recurrent use resulting in failure to fulfill major role obligations; recurrent use in hazardous situations; recurrent alcohol-related legal problems (e.g., DUI); continued use despite social or interpersonal problems caused or exacerbated by alcohol
Alcohol dependenceAPA≥3 of the following events in a year: tolerance (increased amounts to achieve effect; diminished effect from same amount); withdrawal; a great deal of time spent obtaining alcohol, using it, or recovering from its effect; important activities given up or reduced because of alcohol; drinking more or longer than intended; persistent desire or unsuccessful efforts to cut down or control alcohol use; use continued despite knowledge of having a psychological problem caused or exacerbated by alcohol

APA, American Psychiatric Association; DUI, driving under the influence; NIAAA, National Institute on Alcohol Abuse and Alcoholism; WHO, World Health Organization.

image Developmental Competence

The Pregnant Woman

Among pregnant women ages 15 to 44 years, about 10.6% report current alcohol use, with 4.5% reporting binge drinking and 0.8% reporting heavy drinking.32 These rates are much lower than their age-matched counterparts who are not pregnant (54%, 24.2%, and 5.5%, respectively). However, no amount of alcohol has been determined safe for pregnant women. The potential adverse consequences of alcohol use to the fetus are well known. Thus all women contemplating pregnancy and who are pregnant should be screened for alcohol use, and abstinence should be recommended.

The Aging Adult

The prevalence of current alcohol use decreases with increasing age, from 67.4% among those ages 26 to 29 years; down to 50.3% in those ages 60 to 64 years; and to 39.7% in adults ages 65 years and older.32 However, older adults have numerous characteristics that can increase the risk for alcohol use. Liver metabolism and kidney function are decreased, which increases the bioavailability of alcohol in the blood for longer time periods. Aging people lose muscle mass; less tissue for the alcohol to be distributed to means an increased alcohol concentration in the blood. Older adults may be on multiple medications, which can interact adversely with alcohol (e.g., benzodiazepines, antidepressants, antihypertensives, aspirin, to name just a few). Drinking alcohol increases risk for falls, depression, and gastrointestinal problems. Finally, older adults may avoid detection of their alcohol problems; they may avoid alcohol-related consequences such as a DUI just because they no longer drive, or they may avoid job problems just because they no longer work.

Subjective Data

If the patient currently is intoxicated or going through substance withdrawal, collecting any history data is difficult and unreliable. However, when sober, most people are willing and able to give reliable data, provided that the setting is private, confidential, and nonconfrontational.

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Objective Data

Normal Range of FindingsAbnormal Findings
Clinical laboratory findings give objective evidence of problem drinking. These are less sensitive and specific than self-report questionnaires, but they are useful data to corroborate the subjective data. The serum protein gamma glutamyl transferase (GGT) is the most commonly used biochemical marker of alcohol drinking. Occasional alcohol drinking will not raise this measure, but chronic heavy drinking will. Be aware that nonalcoholic liver disease also can increase GGT levels in the absence of alcohol.Chronic alcohol drinking of ≥4 drinks/day for 4 to 8 weeks significantly raises GGT. It takes 4 to 5 weeks of abstinence for GGT levels to return to normal range.21
Serum aspartate aminotransferase (AST) is an enzyme found in high concentrations in the heart and liver. Months of chronic drinking increases AST.
From the complete blood count, the mean corpuscular volume (MCV) is an index of red blood cell (RBC) size. MCV is not sensitive enough to use as the only biomarker, but it can detect earlier drinking after a long period of abstinence.21 Heavy alcohol drinking for 4 to 8 weeks increases MCV.
Breath alcohol analysis detects any amount of alcohol in the end of exhaled air following a deep inhalation until all ingested alcohol is metabolized. This measure can be correlated with blood alcohol concentration (BAC) and is the basis for legal interpretation of drinking. Normal values indicating no alcohol are 0.00. A BAC ≥0.08% = legal intoxication in most states (3 standard drinks), with loss of balance and loss of motor coordination.
Clinical appearance and behavioral signs of commonly abused substances are presented in Table 6-7. Note that clinical signs are described both for the intoxicated person and for the person in withdrawal.

Promoting a Healthy Lifestyle

Prescription AD/HD Medication Abuse

Prescription attention-deficit/hyperactivity disorder (AD/HD) medications are among the most commonly abused prescription medications. In a recent study, Setlik et al. (2009) documented an 86% increase in the number of prescriptions written for AD/HD medications in 10- to 19- year-olds, as well as a 76% rise in poison center calls for adolescent abuse of AD/HD medication. They also noted the significant increase in prescription AD/HD medication abuse far exceeded other substance abuse in teens, suggesting a rising problem with teen and young adult AD/HD medication abuse.

Prescription AD/HD medication abuse occurs when an individual takes a medication that was prescribed for someone else OR takes their own prescription in a manner or dosage other than what was prescribed. These medications are known to health care providers by their chemical names, dextroamphetamine and methylphenidate, or by their brand names, Dexedrine or Adderall and Ritalin or Concerta. Among teens and young adults, these medications are also referred to by their street names, which include Skippy, Vitamin R, Cramming Drug, R-Ball, The Smart Drug, Bennies, Black Beauties, Roses, Speed, or Uppers. Methylphenidate and amphetamines are stimulant medications that are often prescribed to treat individuals with AD/HD. The therapeutic action of these stimulant medications is a slow and steady increase in dopamine—a neurotransmitter associated with attention. The prescription doses are typically started at low levels and increased gradually until a therapeutic effect is achieved for the individual that mimics levels in the brain unaffected by AD/HD and allows individuals with AD/HD to focus. When these medications are taken in doses and/or routes other than those prescribed, such as crushing the pill and snorting or injecting it, dopamine levels increase in a rapid, highly amplified manner, disrupting normal neurotransmission and often creating a state of euphoria. When prescription AD/HD medications are taken orally either in higher doses or by individuals without AD/HD, students report they can stay awake and maintain abnormally high levels of concentration for long nights of studying. However, continued abuse or an overdose of stimulants can cause anxiety, panic, tremors, irregular heartbeat, dangerously high body temperatures, and even heart attack. Further, teens and young adults who stop taking stimulants may suffer from fatigue and depression, which may set the stage for further medication use, abuse, and addiction.

The primary mission of the National Institutes of Health (NIH) National Institute on Drug Abuse (NIDA) is to lead the nation in bringing the power of science to bear on drug abuse and addiction. The NIDA InfoFacts: Stimulant ADHD Medications: Methylphenidate and Amphetamines provides an overview of current science on these prescriptions, including their use and abuse. It is available at www.nida.nih.gov/infofacts/ADHD.html.

The NIDA also has a site for teens about prescription medication abuse and the science behind addiction. It includes information aimed at teens, parents, and teachers, as well as an ongoing blog. It is available at http://teens.drugabuse.gov/facts/facts_rx1.php.

Resources

1. Setlik J, Bond RB, Ho M. Adolescent prescription ADHD medication abuse is rising along with prescriptions for these medications. Pediatrics. 2009;124(3):875–880.

Abnormal Findings

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