Alcoholism and Substance Abuse
Donald Warne, MD, MPH
Overview: Alcoholism and Substance Abuse
Alcoholism, or alcohol dependence, is a disease characterized by four key components":
Craving: a strong urge to drink alcohol
Loss of control: being unable to stop drinking once one has started
Physical dependence: symptoms such as sweating, shaking, and anxiety after one stops drinking
Tolerance: the need for greater quantities of alcohol to feel intoxicated
In addition to alcohol, there are numerous drugs of abuse, including opiates, marijuana, cocaine, methamphetamines, and tobacco. See Box 81-1 for a simple three-question screening tool for alcohol disorders (AUDIT-C).
Alcoholism and substance abuse have a negative impact on other chronic diseases managed in the primary care setting by the direct effects of the substances abused and issues related to compliance and self-care.
Acute injury and illness resulting from alcohol and substance abuse are analogous to exacerbations of chronic conditions and therefore constitute issues of extreme importance in the arena of primary care. Unfortunately, many physicians do not routinely address these issues, and few conventional allopathic interventions are easily accessible and efficacious.
This chapter examines the treatment options available to the primary care physician and also provides a source of information for appropriate referrals.
A multitude of both illicit and prescribed sub-stances are abused; the focus of this chapter is primarily on alcohol, tobacco, opiates, cocaine, and marijuana.
Important points to consider
Mind-body therapies, including meditation, biofeedback, hypnosis, guided imagery, yoga, and prayer, use the power of the mind to influence the body. Relaxation and reduced physiologic responses to stress are helpful in the recovery process
Prevention Prescription
Encourage patients to make a connection with something that gives life deeper meaning and
purpose
Treat depression and anxiety. Work with a spiritual care provider or other health care providers before vymptoms result in self-medication with alcohol or other substances.
Encourage patients to avoid the use of illicit drags Be aware of a patient's alcohol intake. If he or she displays any of the following traits, begin an integrative approach for treatment of the addiction:
Craving a strong urge to drink alcohol Loss of control: being unable to stop drinking once your patient has started Physical dependence: symptoms such as sweating, shaking, and anxiety after your patient stops drinking Tolerance: the need for greater quantities of alcohol to feel intoxicated.
Integrative therapeutics review
The following is a summary of options for treatment of alcoholism and substance abuse. If a patient presents with a history and symptoms consistent with alcohol or substance abuse withdrawal, immediate referral to a detoxification center is warranted.
Laboratory
Laboratory testing is not helpful in screening, but liver assessment can help in monitoring of the toxic effects of heavy drinking and be a tool in motivating behavior change.
Alanine aminotransferase, gamma-glutamyltransferase, and carbohydrate-deficient transferrin (CDT): CDT is least affected by nonalcoholic liver disease and thus is a specific indicator for heavy ethanol use. It can be elevated if four or five drinks have been consumed at one time in the previous 2 weeks.
Consider complete blood count and determination of levels of B, folate, electrolytes, magnesium, uric acid, lipase, and prealbumin in chronic alcohol users.
Pharmaceutical Agents
Alcohol
Benzodiazepines are commonly used for detoxification and withdrawal symptoms:
Consider clonazepam, I mg three times daily. with a gradual taper during 10 to 14 days
To reduce the high sensation associated with alcohol:
Naltrexone (ReVia): 50 mg/day orally
To reduce the craving of alcohol:
Acamprosate (Campral): 333 to 666 mg
three times a day
Topiramate (Topamax): titrate 25 to 300 mg weekly during & weeks (see Table 81-2)
To create unpleasant side effects with use of alcohol: Disulfiram (Antabuse): 250 to 500 mg/day
Tobacco
Tapered nicotine replacement: oral, patch, or inhaled over 3 to 4 weeks
Bupropion (Zyban): 150 mg twice a day x 6 weeks. The patient should set a quit date after taking the medication for 2 weeks. It is effective in managing symptoms of withdrawal and cravings.
Varenicline (Chantix) is started 7 days before the quit date: days 1 to 3: 0.5 mg daily; days 4 to 7: 0.5 mg twice daily; subsequent 11 weeks: Img twice daily. It can be used for up to 24 weeks if needed to prevent relapse.
Opiates
Methadone. 15 to 20 mg/day orally for opiate addiction, is the most commonly used pharmaceutical agent in relapse prevention and management of cravings.
Buprenorphine (Subutex) is an opioid partial agonist that reduces cravings and helps prevent relapses, It also has a lower potential than methadone for dependence. Extra training is required to prescribe it.
Cocaine
Antidepressant medications (selective serotonin reuptake inhibitors and tricyclic antidepressants)
Amantadine. 100 mg orally twice daily, has been used to decrease cravings and to prevent relapse. with varying success.
Botanicals
For anxiety, insomnia, and depression associated with substance abuse, consider the following:
Valerian: for anxiety, 300 to 450mg three times. daily or 400 to 900 mg 2 hours before sleep. It must be used for 2 to 3 weeks before an effect can be seen.
Kava kava extract standardized to 70% kava-lactones: 100 mg three times a day for anaiety. Avoid in patients with liver disease because of the potential for hepatic toxicity.
St. John's wort, 300 mg three times daily or 450 to 600 mg twice daily, is used for depression, but its role in alcohol and substance abuse recovery is yet to be determined.
Kudzu is a traditional Chinese herb that has been used in alcohol recovery. The recommended dose is 1.2g twice daily.
Acupuncture
Acupuncture is effective in producing relaxation and minimizing cravings for most substances of abuse.
Treatment protocols typically involve five needles placed in each ear several times a week and are most effective as part of a comprehensive treatment program.
Not all treatment facilities offer acupuncture, and referring practitioners should be aware of the treatment options available in their geographic area.
Mind-Body Therapies
Meditation, biofeedback, hypnosis, guided imagery, yoga, and I prayer have been shown to be effective adjunctive therapies in treatment programs, but most of the studies conducted to assess them have not been well controlled.
Spirituality
Numerous studies have shown a benefit in the recovery process in persons who have a strong spiritual connection or actively participate in various religious practices. There is no correlation between a specific religion or belief system and recovery, the important factor appears to be the presence of a spiritual connection or practice.
Twelve-Step Programs
Alcoholics Anonymous has proved to be successful in the alcoholism recovery process. The Twelve Steps are rooted in spirituality and social support.
Other programs, such as Narcotics Anonymous, Cocaine Anonymous, and Al-Anon, use similar principles and focus on other substances of abuse and their effects on the abuser's family
Primary care physicians should be aware of the programs available in their geographic area.
Culturally Specific Interventions
Various cultural and ethnic groups have been affected by alcoholism and substance abuse to different degrees. In many cultures, including Native American cultures, culture-specific interventions and practices can aid in the recovery process.
Physicians should be aware of the patient's cultural background and belief system when making referrals to treatment facilities.
Key Web Sources
http://www. niaaa.nih.gov
http://rethinkingdrinking.niaaa.nih.gov/Tools Resources/Calculators_Main.asp
http://www.acodetox.com/
www.az.org
http://www.aa.org/lang/en/meeting_finder.cfm?origpage=29
www.nida.nih.gov
www.PCSSmentor.org
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