Drug and alcohol abuse

410 Pages·2002·2.39 MB·English

by  Carlson

'
: 4 1
e
l I I à ' *
l ' ' i : 1 1 l '' '
à Iï : ' ' (I. g.j -) 1.-
'l: - ' :1: -1111171. .lli
t:1.. s5- *!* 1. 7-. .6-VZ1V2<=Q
N ' ' g
j
j
,. . t,v j
û
.
. h
( .. '
=< k
II11 ' . ., .., 2 '
. s s* 1. tk<' '. ; .' . ,
.
. ' s x
t ?, .b. .. z . . ..
.,k/. 'z p . 2 ----)( 't....-- , ,
.
zp,
/ /'' 1 '
f . ? j .
. .
. l (. /
.
j t'1 .1 1 / '.
'kt '
-,- u-. ..
Drug and
Alcohol Abuse
AClinical Guide to Diagnosis and Treatment
Sixth Edition
Drug and
Alcohol Abuse
A Clinical Guide to Diagnosis and Treatment
Sixth Edition
Marc A. Schuckit
University of California Medical School and
Veterans Administration Hospital
San Diego, CA, USA
Library ofCongress Control Number:2005924429
ISBN-10:0-387-25732-2 0-387-25733-0 (eBook)
ISBN-13:978-0387-25732-7
Printed on acid-free paper.
© 2006 Springer Science+Business Media,Inc.
All rights reserved.This work may not be translated or copied in whole or in part without the written
permission ofthe publisher (Springer Science+Business Media,Inc.,233 Spring Street,New York,NY
10013,USA),except for brief excerpts in connection with reviews or scholarly analysis.Use in con-
nection with any form ofinformation storage and retrieval,electronic adaptation,computer software,
or by similar or dissimilar methodology now known or hereafter developed is forbidden.
The use in this publication oftrade names,trademarks,service marks and similar terms,even ifthey
are not identified as such,is not to be taken as an expression ofopinion as to whether or not they are
subject to proprietary rights.
Printed in the United States ofAmerica. (SPI/SBA)
9 8 7 6 5 4 3 2 1
springeronline.com
Preface
This book uses a clinically oriented approach for working with patients and
clients with substance-use disorders. The material represents a blending
together of my three major professional roles as a clinician, teacher, and
researcher. The overall goal is to help the busy clinicians feel comfortable
with their level of understanding of alcohol and other drug-related disorders,
and to offer the best clinical care possible.
The first edition of this text,published in 1979,grew out of my need to
place the 200 or so drugs of abuse into a clinically useful perspective. There
was no way I could remember each and every drug, and I faced a challenge
when a new drug (or perhaps an old substance with a new name) was intro-
duced. I learned that I can place these substances into a limited number of
categories based on the usual clinical effects,thereby creating groups similar
in the quality of intoxication,associated physiological changes,and patterns
of problems likely to be observed in the context of intoxication and with-
drawal.This clinically oriented and pragmatic approach remains the core of
this book, continuing to be as useful to me today as when the first volume
was published.
Of course, over the years, many details have changed. First, the diag-
nostic criteria have evolved from DSM-II to DSM-III in 1980,DSM-III-R in
1987,and DSM-IV in 1994.I was fortunate to hold the Chair of the DSM-
IV Substance Use Disorders Workgroup, and to participate in one of the
committees leading to DSM-V.Therefore,each edition of the text has had the
opportunity to offer some perspectives on the most recent diagnostic systems.
Over the years, the patterns of substance use in populations have gone up,
come down,and sometimes gone up again,while our understanding of phar-
macology, physiology, and genetic influences has continued to expand at a
rapid rate. These historical issues and background on epidemiology and
physiology have formed the basis for the first half of each chapter dedicated
to a category of drugs (e.g., depressants, opioids, stimulants, cannabinoids,
v
vi PREFACE
and so on) and have been updated with each new edition.The second half of
each current substance-oriented chapter offers a clinically oriented presenta-
tion of recent developments in the treatment of substance-related conditions,
many of which represent expansions of our understanding of the cognitive
behavioral core of treatment,along with the development of new pharmaco-
logical approaches. Chapter 14 is dedicated to reviewing the current status
of rehabilitation approaches in an effort to pull together much of the
information presented within the previous drug category-oriented chapters.
Therefore, the structure of the book reflects my background as both a
clinician and teacher. The specifics, however, rest with my training as a
researcher.About 80% of the references in this sixth edition have been pub-
lished since 2000.The Refrences for each chapter give the reader the oppor-
tunity to learn more about specific topics offered within the text, with
references given as more of a general background,rather than a highly linked
statement based on each reference.
In addition to a thorough updating of the References, the sixth edition
incorporates another important change. In the course of developing the five
previous editions, and as a consequence of the consistent and impressive
increase in knowledge in our field, the number of chapters and pages
increased across the five editions.As I looked at the version of this book pub-
lished in 2000,I felt that if the length of the text continued to expand,it would
do so at the potential cost of limiting the usefulness and clinician-oriented
emphasis of the work. Therefore, the sixth edition has been streamlined by
deleting two previous chapters (the section on phencyclidine has been folded
into the overall chapter on hallucinogens and the thoughts on prevention have
now been incorporated into Chapter 1). At the same time, efforts have been
made to shorten each of the remaining chapters whenever possible.
Finally, this remains a single-author text. This facilitates consistency
across chapters in both philosophy and writing style. Having said that, this
work has been strongly influenced by many people in this field,including,but
not limited to, authors cited in the References for the various chapters. In
addition,this text could not have been accomplished without the help of the
wonderful people in my office.Emily Wick worked day and night to help me
place the chapters into a final form, and has been indispensable regarding
pinning down references.Lynnette Fleck transcribed the initial changes in the
first several drafts of the updated chapters, putting up with my awful hand-
writing and, at times, my inability to sit still long enough explaining things.
Finally, everything that comes out of my office reflects the dedication,
warmth,and support of Marcy Gregg and Tom Smith.I would be lost with-
out any of them.
MARCA.SCHUCKIT,M.D.
Contents
1. An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. Depressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3. Alcoholism:An Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
4. Alcoholism:Acute Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
5. Stimulants:Amphetamines and Cocaine . . . . . . . . . . . . . . . . . . . 137
6. Opioids and Other Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
7. Cannabinols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
8. Hallucinogens and Related Drugs . . . . . . . . . . . . . . . . . . . . . . . . 210
9. Glues,Inhalants,and Aeorsols . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
10. Over-the-Counter (OTC) Drugs and Some Prescription Drugs . . 248
11. Xanthines (Caffeine) and Nicotine . . . . . . . . . . . . . . . . . . . . . . . . 277
12. Multidrug Abuse and Dependence . . . . . . . . . . . . . . . . . . . . . . . . 304
13. Emergency Problems:A Quick Overview . . . . . . . . . . . . . . . . . . . 320
14. Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
vii
CHAPTER 1
An Overview
1.1. INTRODUCTION
1.1.1. Some General Thoughts About Alcohol and Drugs
People have used mind-altering substances (from nicotine to heroin and
beyond) for thousands of years.1,2 These drugs (using that term to include
alcohol as well) help us to concentrate,offer a diversion from our usual way
of feeling (even if the change is from good to just different,not always from
bad to good), and help us to feel as if we fit in with those around us. Some
substances,like alcohol,have distinct healthful effects at low doses,including
increased appetite,lowered risks for some forms of heart disease and stroke,
and possibly even a mild protective effect against some forms of dementias.3,4
Other drugs (e.g., cannabinols, cocaine, amphetamines, and opioids) have
medicinal properties that can be useful in treating a variety of medical
conditions.5
So, it is not surprising to discover that a large proportion of men and
women in western countries have used such substances.For example,in 2002
and 2003,51% of high school seniors and 59% of young adults admitted to
ever having used an illicit substance, including about 45% of each who had
used a cannabinol (e.g.,marijuana),11 and 20%,respectively,who have ever
taken a hallucinogen and,almost 15% of each who have ever taken amphet-
amines.6While the rates of substance-use disorders (e.g.,abuse and depend-
ence) are harder to determine, these figures are also substantial. It has been
estimated that approximately 25% of men and women in the United States
regularly smoke cigarettes (and presumptively have dependence), while the
lifetime risk for abuse or dependence on alcohol is at least 15% for men and
8% for women,with an estimated 10 and 5% of the two sexes ever having met
criteria for abuse or dependence on an illicit drug.
As described later in this chapter,repeated heavy use of substances has
serious implications for health,interpersonal functioning,legal difficulties,as
1
2 CHAPTER 1
well as job and school performance.7,8Intoxication or withdrawal from many
substances can temporarily mimic almost any major psychiatric syndromes,
most drugs of abuse can exacerbate preexisting medical conditions, and
almost all of these substances are metabolized by the liver where they
can interfere with the breakdown and subsequent blood levels of most pre-
scribed medications.2,9 Therefore, healthcare deliverers need to understand
the impact that these substances and associated substance-use disorders are
having on the symptoms, syndromes, and treatment of disorders in their
clients and patients.
Unfortunately,schools that teach clinicians how to deliver optimal treat-
ment rarely include substance-related topics in their busy schedules. The
emphasis tends to be on the more straightforward medical and psychiatric
disorders,with little time reserved in the curriculum to teach about the highly
prevalent conditions associated with substance use.10,11In one recent survey,
40% of general medical practitioners could not remember having received
any training regarding substance-use disorders, and an additional quarter
(i.e., adding up to almost three quarters of those surveyed) noted having
received less than 4 h of continuing education regarding these conditions.11It
has been estimated that the average medical school graduate has received less
than 1 h per year of substance-use disorder training. The end result is that
few of us enter healthcare-related practices having been adequately educated
to understand how the use of both legal and illicit substances might impact
those we treat,and even fewer have received adequate training on how to rec-
ognize and treat related abuse and dependence conditions.
Recently,a series of papers have offered important insights into how the
basic elements of treatment of substance-related conditions are similar to
approaches used for other long-term disorders that tend to wax and wane
over time, including optimal steps required in the treatment of diabetes and
hypertension.12,13Using adult onset diabetes as an example,while useful med-
ications have been identified, their effectiveness depends upon helping the
patient to develop and maintain relatively high levels of motivation regarding
compliance with prescriptions, as well as changes in diet, improvement in
exercise, and cessation of smoking. Elements similar to those used in the
treatment of substance-related conditions are also employed in medicine to
enhance levels of motivation,and to help patients recognize and address their
disorder and associated treatments on both emotional and cognitive lev-
els.14,15When these techniques are applied appropriately to substance-related
conditions, one can expect a high proportion of patients to modify their
behaviors,with absolute abstinence from substances for extended periods of
time likely to be seen in as many as 70% of patients who have relatively sta-
ble life styles, and more than 50% for those without immediate resources
regarding jobs and families.16
This book has been written to help to bridge the gap that exists in most
healthcare providers regarding substances of abuse and related problems.Itis
AN OVERVIEW 3
written for the medical student, the physician in practice, the psychologist,
the social worker, and other health professionals or paraprofessionals who
need a quick,handy,clinically oriented reference on alcohol and other drug
problems. A parallel text, entitled Educating Yourself About Alcohol and
Drugs,presents a similar message in terms useful to patients and clients and
their friends and families.17Similar to the approach used in major diagnostic
manuals, the emphasis here is on substances of abuse and related disorders,
and does not include discussion of “compulsive”behavioral syndromes such
as gambling and compulsive shopping.18
1.1.2. Changes Incorporated into this Sixth Edition
The first edition of this text was published in 1979, and received com-
plimentary reviews.Each subsequent edition has incorporated new develop-
ments in the field,and updated more than half of the references.
This sixth edition is the first to use information from the new millen-
nium. In addition, it is the first being developed entirely under the auspices
of our current publisher. Both transitions (i.e., time and publisher) con-
tributed to the decision to thoroughly revise what is offered here. This has
involved a number of changes.
First,an effort has been made to update about 80% of the references so
as to primarily reflect citations published since 2000.Second,in order to opti-
mize the ease of use for the reader,and to keep the cost of the text as low as
possible,the material has been streamlined.This includes attempts to list key,
most salient references, and keeping the length of each chapter as short as
possible while still covering all the material that needs to be presented.
A third,related step has been to combine chapters whereever appropri-
ate. For example, prior editions of the text were based on the increasing
prevalence of the use of phencyclidine (PCP) and related drugs such as keta-
mine.However,in recent years the prevalence of use of these substances has
remained relatively low and stable,and their pattern of use on the streets has
continued to greatly overlap with the more classical hallucinogens.Therefore,
what was previously known as Chapter 9 on PCP has been combined with the
traditional hallucinogens in Chapter 8.As a result,Chapter 10 from the prior
texts has become Chapter 9,Chapter 11 has become Chapter 10,and so on.
The previous edition was the first to prepare a separate section (Chapter
16) dealing with prevention. While I recognize the great importance of this
topic,the feedback we received regarding the fifth edition indicates that read-
ers have focused primarily on the specific drug-related chapters,as well as the
descriptions of treatment approaches, but may have found the information
on prevention less directly useful to their clinical work.Therefore,Chapter 16
has been deleted and the most salient information incorporated into a sub-
section of Chapter 1.
Another important development in recent years is the beginning of the
process of planning for the fifth edition of the Diagnostic and Statistical