Table Of ContentOXFORD MEDICAL PUBLICATIONS
Addiction Medicine
Oxford Specialist Handbooks published and forthcoming
General Oxford Specialist Parkinson’s Disease and Other Movement
Handbooks Disorders, 2e
A Resuscitation Room Guide Stroke Medicine, 2e
Day Case Surgery
Oxford Specialist Handbooks
Perioperative Medicine, 2e
Pharmaceutical Medicine in Oncology
Postoperative Complications, 2e Practical Management of Complex Cancer
Pain
Oxford Specialist Handbooks in
Accident & Emergency Medicine Oxford Specialist Handbooks
Retrieval Medicine in Paediatrics
Oxford Specialist Handbooks Paediatric Dermatology
Paediatric Endocrinology and Diabetes
in Anaesthesia
Paediatric Gastroenterology, Hepatology,
Anaesthesia for Medical and Surgical and Nutrition
Emergencies Paediatric Haematology and Oncology
Cardiac Anaesthesia Paediatric Intensive Care
Neuroanaesthesia Paediatric Nephrology, 2e
Obstetric Anaesthesia Paediatric Neurology, 2e
Ophthalmic Anaesthesia Paediatric Palliative Medicine, 2e
Paediatric Anaesthesia Paediatric Radiology
Regional Anaesthesia, Stimulation Paediatric Respiratory Medicine
and Ultrasound Techniques Paediatric Rheumatology
Thoracic Anaesthesia
Oxford Specialist Handbooks Oxford Specialist Handbooks
in Cardiology in Pain Medicine
Adult Congenital Heart Disease Spinal Interventions in Pain Management
Cardiac Catheterization and Coronary
Oxford Specialist Handbooks
Intervention
in Psychiatry
Cardiac Electrophysiology and Catheter
Ablation Addiction Medicine, 2e
Cardiovascular Computed Tomography Child and Adolescent Psychiatry
Cardiovascular Magnetic Resonance Forensic Psychiatry
Echocardiography, 2e Medical Psychotherapy
Fetal Cardiology Old Age Psychiatry
Heart Failure, 2e Oxford Specialist Handbooks
Hypertension in Radiology
Inherited Cardiac Disease
Nuclear Cardiology Interventional Radiology
Pacemakers and ICDs Musculoskeletal Imaging
Pulmonary Hypertension Pulmonary Imaging
Valvular Heart Disease Thoracic Imaging
Oxford Specialist Handbooks Oxford Specialist Handbooks
in Critical Care in Surgery
Advanced Respiratory Critical Care Cardiothoracic Surgery, 2e
Cardiothoracic Critical Care Colorectal Surgery
Gastric and Oesophageal Surgery
Oxford Specialist Handbooks Hand Surgery
in End of Life Care Hepatopancreatobiliary Surgery
End of Life Care in Cardiology Neurosurgery
End of Life Care in Dementia Operative Surgery, 2e
End of Life Care in Nephrology Oral and Maxillofacial Surgery, 2e
End of Life Care in Respiratory Disease Otolaryngology and Head and Neck
End of Life in the Intensive Care Unit Surgery
Paediatric Surgery
Oxford Specialist Handbooks Plastic and Reconstructive Surgery
in Infectious Disease Renal Transplantation
Infectious Disease Epidemiology Surgical Oncology
Urological Surgery
Oxford Specialist Handbooks Vascular Surgery, 2e
in Neurology
Epilepsy
Oxford Specialist
Handbooks
Addiction
Medicine
Second Edition
Edited by
John B. Saunders E. Jane Marshall
Professor and Consultant Physician in Consultant Psychiatrist, Alcohol Service,
Internal Medicine and Addiction Medicine, South London and Maudsley National
University of Queensland, University of Health Service Trust and the National
Sydney, and St. John of God Health Care, Addiction Centre, Institute of Psychiatry,
Wesley Health Care, and South Pacific King’s College London, UK
Private Hospital, Sydney, Australia
Walter Ling
Katherine M. Conigrave
Integrated Substance Abuse Program
Professor in Addiction Medicine and (ISAP), School of Medicine, University
Public Health, Sydney Medical School, of California at Los Angeles (UCLA),
University of Sydney, and Addiction and formerly Commissioner for
Specialist Royal Prince Alfred Hospital, Narcotics and Dangerous Drugs
Sydney, Australia Commission, Los Angeles, CA, USA
Noeline C. Latt Susumu Higuchi
Addiction Medicine Specialist, Royal Director, National Hospital
North Shore Hospital, and Sydney Medical Organization Kurihama Medical and
School, University of Sydney, Australia Addiction Center and Director of the
World Health Organization (WHO)
David J. Nutt Collaborating Centre on Research and
Training of Alcohol- Related Problems,
Professor of Psychopharmacology, Kanagawa, Japan
Division of Brain Science, Department
of Medicine, Hammersmith Hospital,
Imperial College London, UK, and
Founding Chair of DrugScience, UK
With a Foreword by Karl Mann
1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2016
The moral rights of the authors have been asserted
First Edition published 2009
First Edition, revised and updated 2011
Second Edition published 2016
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2015955010
ISBN 978– 0– 19– 871475– 0
Printed and bound in China by
C&C Offset Printing Co. Ltd
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-t o- date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-p regnant
adult who is not breast- feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
v
Preface
Origin of this handbook
This Oxford Specialist Handbook Addiction Medicine is the result of many
years, preparation by a group of colleagues who have been clinicians, teach-
ers, and researchers in the addictive disorders field for many years. The
present edition replaces the first edition, which was published in 2009. That
had its origins in a series of lecture notes produced for the University of
Sydney more than 30 years ago and clinical protocols developed separately
and in collaboration by the authors and constantly updated over this time.
The scope of the second edition has been expanded in several ways. It
now includes the behavioural addictions such as gambling and gaming and
includes a broader range of psychoactive substances. It aims to be interna-
tional in scope. The editors are drawn from the United Kingdom, Australia,
United States of America, and Japan and there are contributing authors
from 25 countries worldwide.
Our aim continues to be to offer a contemporary, broadly based, and
clinically grounded text that summarizes the scientific basis and the practice
of addiction medicine.
Evidence and practice
Evidence- based practice continues to increase in impact and there is an
expectation that the approaches made in management of addictive disor-
ders and the selection of medications, therapies, and overall strategy are
based on scientific data from controlled clinical trials and other relevant
studies. This applies in addiction medicine as much as it does in any other
field of healthcare. We recognize, however, that as in other areas the scien-
tific evidence base is not comprehensive, particularly when a person with an
addictive disorder has different co-m orbidities or when standard treatment
approaches have been exhausted, or simply where the evidence base does
not exist.
Our approach to the second edition has been to draw upon the follow-
ing sources:
1. Current guidelines developed according to prevailing international
standards for clinical guidelines and which include guidelines published
by the World Health Organization, government departments of health
and human services (e.g. from the US, UK, Australia, Japan, Germany,
France, Sweden, and other Nordic countries) and those produced by
relevant professional organizations, academies, and associations, which
have been based on systematic reviews of the literature and undergone
extensive processes of validation.
2. Publically accessible scientific evidence on the efficacy of treatment
(with an emphasis on systematic reviews, meta- analyses, and
vi PREFACE
randomized controlled trials), supplemented by other scientifically valid
clinical, psychometric, and epidemiological studies.
3. The clinical practice and experience of the authors, ensuring that the
recommendations are appropriate to many clinical practice settings and,
where there is an absence of evidence from scientific studies, that the
material published here represents a distillation of practice which we
consider to have international relevance and to be effective and safe.
It should be emphasized that in clinical practice, decisions need to be made
often in the absence of scientific evidence. This may be simply because
there is none or, very typically, the clinical situation develops beyond what
scientific evidence exists or could ever realistically be expected to exist. In
clinical practice, the focus is on the individual (or it may be on a couple, a
family, or a group) and individuals and groups of individuals are infinitely
variable. Scientific data will never exist to cover the multiple variations and
eventualities in terms of comorbid disorders, previous treatment expe-
rience, lack of response to an approved treatment, individual patient or
family preference, and some of the unknowns such as vital diagnostic or
background information not being available at the time the clinical decision
has to be made. These are the realities of the clinical life and in producing
this handbook we recognize these as realities. Clinical practice is not merely
the application of the evidence base to a particular person. Rather, the evi-
dence base informs and guides clinical practice.
Who is this book for?
This handbook is intended as a concise and practical guide for students and
practitioners of medicine, nursing, psychology, and other health profession-
als whose work brings them into contact with people with addictive dis-
orders. In particular, it is designed for students and post- graduate trainees
and fellows in addiction medicine, internal medicine, psychiatry, emergency
medicine, pain management, gastroenterology, and general medical (fam-
ily physician) practice. We believe it will be useful and relevant to nurses,
particularly those working as specialists in addictive disorders, clinical psy-
chologists, psychologists and counsellors, and social workers and for staff in
specialist multidisciplinary agencies which provide help, support, and treat-
ment for people with addictive disorders.
Why is this book important?
Alcohol and other substance use rank among the five top risk factors con-
tributing to the global burden of disease. In recent years, there has been a
rapid increase in non- substance forms of addiction such as gambling, inter-
net gaming, and various other behavioural or ‘process’ addictions. In Asia
and several other parts of the world, these latter disorders represent the
biggest burden of ill health and social problems of any of the addictions.
Substance use disorders can cause, mimic, underlie, or complicate a large
number of medical and psychiatric conditions. All addictive disorders can
PREFACE vii
cause immense personal suffering as well as harm and costs to families,
communities, and society as a whole. Often this is not recognized. People
with addictive disorders may be reticent about revealing their substance use
and may not see its relevance. The fact that many patients use more than
one substance, sometimes multiple substances and sometimes a substance
used in combination with a behavioural addiction, further adds to the com-
plexity. Making a correct diagnosis of an addictive disorder can greatly facili-
tate management, often avoid unnecessary tests and procedures, shorten
hospital stays, and make both the clinician’s and the patient’s life easier.
The ability to diagnose addictive disorders and initiate appropriate manage-
ment is a responsibility for all health professionals. Historically, however,
most have not been confident in their ability to diagnose and manage these
disorders, as they have often been omitted from student and postgradu-
ate courses. Recent years have seen the development of a comprehen-
sive knowledge base and an understanding of the skill set and professional
practice behaviour necessary for good professional practice in this field.
Addiction medicine now has a range of approaches that compare in their
effectiveness with those in other areas of medicine.
What is covered?
This handbook provides a practical guide to the management of people with
addictive disorders. The first chapters provide important background infor-
mation and summarize the overall principles of diagnosis and management.
There follow several chapters on specific types or groups of psychoactive
substance. The nature of the substances, their pharmacological properties,
and the clinical syndromes that result are described, together with specific
guidance on diagnosis and management which takes into account both their
generic addictive properties and their specific pathophysiological ones. The
latter part of the book is devoted to the management of specific groups of
patients and people seen in specific settings, together with an account of
relevant medicolegal and ethical issues. Following the main text, the final
chapter comprises a series of practical tools, such as questionnaires, which
assist in systematic clinical practice.
The handbook provides detailed guidelines on how to elicit a history
of substance use and other addictive activities, together with ways of
diagnosing the core clinical syndromes and the physical, psychiatric, and
social disorders that may flow from them. It includes practical guides to
brief intervention, management of intoxication, withdrawal management
(‘intoxication’), pharmacotherapies, and psychological therapies aimed at
relapse prevention, together with an account of support approaches and
the principles and practice of self- help.
viii
Foreword
Addictions are highly prevalent. They cause harm to the afflicted and their
families and are costly to society. While the clinical symptomatology in peo-
ple suffering from addictions is similar around the world, treatment and pre-
vention are not. Research in recent years has provided enormous progress
in our understanding of these disorders resulting in a multitude of new evi-
dence-based treatments. However, most conditions remain under-served
and treatment approaches vary substantially around the world. All of these
facts call for an up-to-date and universal appraisal of the current situation.
A comprehensive overview on emerging strategies would be instrumental
in this and could help to meet the actual challenges.
The Oxford Specialist Handbook—Addiction Medicine provides such a
global perspective. The editors and authors are eminent researchers and
clinicians in our field. They come from a large variety of areas such as
Australia, Asia, Europe, and North America. While the first edition of the
textbook in 2009 already provided a very broad view on addictions and
ways of dealing with them, the revised version gives an update of current
concepts and newly emanating strategies. Important extensions have been
made providing several new chapters and incorporating new fields such as
gambling and gaming as examples for behavioural addictions. The handbook
now also includes evidence-based recommendations from the most recent
clinical guidelines from around the world.
Prof. John Saunders of Sydney and Queensland Universities and his col-
leagues are to be congratulated for their enormous efforts. Their book
Addiction Medicine gives the necessary detail to understand and respond to
actual problems in an individual patient. The long standing teaching experi-
ence of most of its authors has resulted in a text which is well structured
and easy to read and thus offers information not only to the professional
but also to the patient and his or her family and to others in search of some
quick and valid information on the troublesome but also fascinating field of
addiction.
Karl Mann, MD
Emeritus Professor of Addiction Research
Central Institute of Mental Health
Medical Faculty Mannheim
University of Heidelberg
Germany
ix
Contents
Acknowledgements xi
Editors and authors xii
Contributors xv
Symbols and abbreviations xxiii
1 The nature of addictive disorders 1
2 Epidemiology and prevention 7
3 Pharmacology and pathophysiology 31
4 The scope of intervention 55
5 Establishing the diagnosis 67
6 Acute care 85
7 Ongoing management of substance use disorders 103
8 Tobacco 119
9 Alcohol 151
10 Cannabis 235
11 Opioids 249
12 Pain and opioids 295
13 Benzodiazepines and the other sedative- hypnotics 307
14 Psychostimulants 327
15 Hallucinogens and dissociative drugs 355
16 Other drugs 363
17 Polysubstance use 391
18 Injecting drug use 407
19 Gambling 427
20 Gaming 441
21 Other addictive disorders 449
22 Psychiatric co- morbidity 461
