Substance Use Disorders: A Guide for the Primary Care Provider

362 Pages·2018·7.88 MB·English

by  H. Thomas Milhorn (auth.)

H. Thomas Milhorn, MD, PhD
Substance
Use Disorders
A Guide for the
Primary Care Provider
123
Substance Use Disorders
H. Thomas Milhorn
Substance Use Disorders
A Guide for the Primary Care
Provider
H. Thomas Milhorn, MD, PhD
Director, Didactics Section
East Central HealthNet Family Medicine Residency Program
Meridian, Mississippi
Formerly Professor of Family Medicine, Professor of Physiology and Biophysics,
and Associate Professor of Psychiatry and Human Behavior
University of Mississippi School of Medicine
Jackson, Mississippi
ISBN 978-3-319-63039-7 ISBN 978-3-319-63040-3 (eBook)
DOI 10.1007/978-3-319-63040-3
Library of Congress Control Number: 2017947158
© Springer International Publishing AG 2018
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Preface
This book was written for primary care physicians, who almost daily come
into contact with substance-dependent individuals and their families.
However, it also should be helpful to primary care nurse practitioners and
physician assistants, as well as medical students, primary care residents,
emergency medicine physicians, ASAM- and APA-certified addictionists and
those studying for certification in those specialties, psychiatrists, psycholo-
gists, and alcohol/drug counselors.
Primary care physicians are in excellent position to diagnose substance
use disorders and to help the families of these patients get them into treat-
ment. In addition, primary care physicians can detoxify patients as needed.
On return from treatment, they can participate in the patients’ recovery pro-
grams to help prevent relapse.
The book is divided into four parts: (1) The Basics; (2) Psychoactive
Substance Dependencies; (3) Diagnosis, Treatment, Recovery, Relapse, and
the Family; and (4) Special Groups.
Part 1 (The Basics) consists of an overview, the various definitions of sub-
stance dependence, and the pharmacology of addictive substances. Chapter 1
“Overview” is an introductory chapter that covers material common to the
entire field of substance dependence, such as classification of psychoactive
substances based on their effects on the central nervous system, primitive
survival brain concept, criteria for substance dependence, addiction medicine
specialists, denial, abstinence syndromes, 12-step programs, prescription
drug addiction, and DEA drug schedules. Chapter 2 covers the various defini-
tions of substance dependence, and Chap. 3 covers the pharmacology of
addictive substances.
Part 2 (Psychoactive Substance Dependencies) covers the various drug
dependencies—alcohol dependence, sedative-hypnotic dependence, opioid
dependence, stimulant dependence, nicotine dependence, cannabis depen-
dence, dissociative dependence, inhalant dependence, hallucinogen depen-
dence, and anabolic steroid dependence.
Part 3 covers diagnosis, treatment, recovery, relapse, and the family.
Part 4 (Special Groups) covers women, adolescents, the elderly, ethnic
minority groups, co-occurring disorders, LGBT patients, HIV-positive
patients, and the impaired physician.
To keep from repeatedly saying “his or her,” I have used the generic “he”
to mean all addicts regardless of sex.
v
vi Preface
I would like to thank Toby Milhorn who did some of the typing and put the
references into the appropriate format, my wife Kay for her patience and
understanding while I worked on the manuscript, and the residents in the
EC-HealthNet Family Medicine Residency Program for giving me the inspi-
ration to write the book.
Meridian, MS, USA H. Thomas Milhorn
Abbreviations
AA Alcoholics Anonymous
ACOA Adult Children of Alcoholics
ADH Alcohol dehydrogenase
ADM Addiction medicine
AIDS Acquired immune deficiency syndrome
ALDH Aldehyde dehydrogenase
ALS Amyotrophic lateral sclerosis
ALT Alanine aminotransferase
AMA American Medical Association
ASAM American Society of Addiction Medicine
AST Aspartate aminotransferase
AUDIT Alcohol Use Disorders Identification Test
BAC Blood alcohol concentration
BAL Blood alcohol level
BBB Blood-brain barrier
C Zero concentration
o
cAMP Cyclic adenosine monophosphate
CBD Cannabidiol
CDT Carbohydrate-deficient transferrin
CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol—Revised
Version
CMRO Certified medical review officer
CNS Central nervous system
CT Computed tomography
D Initial dose
o
DAST Drug Abuse Screening Test
DEA Drug Enforcement Administration
DHHS Department of Health and Human Services
DSM Diagnostic and Statistical Manual of Mental Disorders
DUI Driving under the influence
ED Emergency department
EEG Electroencephalogram
EMIT Enzyme multiplied immunoassay technique
EtG Ethyl glucuronide
FAE Fetal alcohol effects
FAS Fetal alcohol syndrome
FDA US Food and Drug Administration
vii
viii Abbreviations
GABA Gamma-aminobutyric acid
GBL Gamma-butyrolactone
GC/MS Gas chromatography/mass spectrometry
GGT Gamma-glutamyl transpeptidase
GHB Gamma-hydroxybutyrate
HALT Hungry, angry, lonely, or tired
HIV Human immunodeficiency virus
HPPD Hallucinogen persisting perception disorder
KCl Potassium chloride
LAAM Levo-alpha-acetylmethadol
LSD Lysergic acid diethylamide
MAO Monoamine oxidase
MAST Michigan Alcoholism Screening Test
MCV Mean cell volume
MDMA 3,4-Methylenedioxymethamphetamine
MEOS Microsomal ethanol oxidizing system
MME Morphine milligram equivalents
MRI Magnetic resonance imaging
NAD Nicotinamide adenine dinucleotide
NADPH Nicotinamide adenine dinucleotide phosphate
NIAAA National Institute on Alcohol Abuse and Alcoholism
NIDA National Institute on Drug Abuse
NMDA N-Methyl-D-aspartate
NSAID Nonsteroidal anti-inflammatory drug
OBOT Office-based opioid therapy
OTC Over the counter
PAWS Post-acute withdrawal syndrome
PCP Phencyclidine
PDMP Prescription drug monitoring program
PT Prothrombin time
REM Rapid eye movement
SAMHSA Substance Abuse and Mental Health Services Administration
SIDS Sudden infant death syndrome
SMAST Short Michigan Alcoholism Screening Test
T Time zero
o
THC Tetrahydrocannabinol
V Volume of distribution
d
VTA Ventral tegmental area
Contents
Part I The Basics
1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
The Financial Cost of Substance Dependence . . . . . . . . . . . . . . . 4
Substance Use Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Emergency Department Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Treatment Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Substance Use Disorders and the Primary Care Physician . . . . . . 5
How Psychoactive Substances Differ from Other Drugs . . . . . . . . . 5
Classification of Psychoactive Substances Based
on Their Effects on the Central Nervous System . . . . . . . . . . . . . . . 5
Club Drugs and Date Rape Drugs . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Primitive Survival Brain Concept of Substance
Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Normal Response to Substance Use . . . . . . . . . . . . . . . . . . . . . . . 7
Development of Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Tools of Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Addicted Versus Addict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Abstinence Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Severity of Abstinence Syndromes . . . . . . . . . . . . . . . . . . . . . . . . 9
The Beginning of All 12-Step Programs . . . . . . . . . . . . . . . . . . . . . . 10
The Prescription Drug-Dependent Patient . . . . . . . . . . . . . . . . . . . . 10
Patient Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Characteristics of Overprescribing Physicians . . . . . . . . . . . . . . . 11
Addiction Medicine Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
American Society of Addiction Medicine . . . . . . . . . . . . . . . . . . . 12
American Psychiatric Association . . . . . . . . . . . . . . . . . . . . . . . . 12
DSM-5 Criteria for Substance Dependence . . . . . . . . . . . . . . . . . . . 12
DEA Drug Schedules and Prescribing Regulations . . . . . . . . . . . . . 13
DEA Drug Schedules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Prescribing Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ix
x Contents
2 Definitions of Substance Dependence . . . . . . . . . . . . . . . . . . . . . . 17
The Biopsychosocial Definition of Substance Dependence . . . . . . . 17
Biological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Psychological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Sociological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Disease Concept Definition of Substance Dependence . . . . . . . . . . 20
Genetic Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Conclusions About Genetic Studies . . . . . . . . . . . . . . . . . . . . . . . 20
Natural Course of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
The Disease Concept and the Primary Care Physician . . . . . . . . . 22
AMA’S Definition of Substance Dependence . . . . . . . . . . . . . . . . . . 22
ASAM’S Definition of Substance Dependence . . . . . . . . . . . . . . . . 22
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 Pharmacology of Psychoactive Substances . . . . . . . . . . . . . . . . . . 25
Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Synapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Reward Center of the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Neurotransmitters Affected by Psychoactive Substances . . . . . . . 29
Upregulation and Downregulation . . . . . . . . . . . . . . . . . . . . . . . . 29
Dose-Response Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Kindling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Route of Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Enzymatic Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Steady-State Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Cross-Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Physical Dependence and Abstinence Syndrome . . . . . . . . . . . . . . . 36
Set and Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Part II Psychoactive Substance Dependencies
4 Alcohol Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Forms of Alcoholic Beverages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Prevalence of Alcohol Use and Dependence . . . . . . . . . . . . . . . . . . 42
Prevalence of Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Prevalence of Binge Drinking and Heavy Drinking . . . . . . . . . . . 42
Prevalence of Alcohol Use Disorder . . . . . . . . . . . . . . . . . . . . . . . 42
Treatment Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Alcohol-Related Liver Problems . . . . . . . . . . . . . . . . . . . . . . . . . 42
Alcohol-Related Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
The Financial Cost of Alcohol Dependence . . . . . . . . . . . . . . . . . 43