Substance-Related and Addictive Disorders

Abstract

Multiple illnesses comprise the substance use disorder spectrum. The management of any illness within the spectrum relies heavily on the availability of diagnostic and treatment resources and upon the level of participation by the patient. The two cases in this chapter demonstrate different problems and approaches to these challenging disorders.

Appendices

Appendix A: Tables with Possible Answers to the Vignettes

19.1.1 Vignette 19.1: Benton Bentham

Learning Issue Table 19.1

Facts	Hypotheses	Information needed	Learning issues
“Good drinker”, daily heroin use	Alcohol withdrawal, delirium likely	Comprehensive medical and psychiatric evaluation	Which of these substances in intoxication or withdrawal may be producing his symptoms?
History of cellulitides from injecting drugs	Tobacco use disorder	Comprehensive physical and neurological examination	It is critical to identify the intoxication or withdrawal syndrome that is the most life-threatening and requires the most urgent treatment
Smokes cigarettes	Liver damage	Monitoring of pain control	It is important to review the treatment of intoxication and withdrawal of the major substances
Temperature 99.8 °	Some sort of encephalopathy	Monitoring of vital signs	It is important to review the treatment of intoxication and withdrawal of the major substances
HR 112/min BP 146/92	Anemia from nutritional deficiency?	Screen for HIV and hepatitis B and C	Is the patient at risk for Korsakoff’s syndrome typically also associated with Wernicke’s encephalopathy?
Hard time following questions, gives the wrong name of the hospital, unable to give the date, unable to repeat more than 3 digits forward and 2 digits backward		Electrocardiogram was obtained to rule out cardiovascular sequelae of cocaine and alcohol use; and neuroimaging was obtained in order to rule out intracranial pathology	Consider the biological, psychological, and social/cultural/spiritual elements of comprehensive treatment management
Liver edge appreciated 2 fingerbreadths below the ribcage\tremors of outstretched hands difficulty with finger-to-nose testing, diaphoretic
Mild anemia with a mildly elevated mean corpuscular volume, elevated gamma glutamyl transferase and other liver function tests

1. HR heart rate, BP blood pressure

19.1.2 Vignette 19.2: Dr. Caleb

Learning Issue Table 19.2

Facts	Hypotheses	Information needed	Learning issues
55-year-old male physician dragged into your office	Alcohol use disorder	Comprehensive history and examination	Consider the biological, psychological, and social/cultural/spiritual elements of comprehensive treatment management
Would be worried about what people think	Prescription medication use disorder	Appropriate laboratory studies	Physicians in need of addiction treatment should be referred to an addiction specialist
Reclusive, unfriendly, judgmental, and sometimes punitive	Other medical condition
Licensing Board complaint	Suffered headaches most of his adult life
Constantly paged; he manages most of his practice by calling in medications	Marital stressors
Has gained weight
Father was alcoholic

Appendix B: Answers to Review Questions

• 1. d

• 2. a

• 3. b

• 4. c

• 5. a

Appendix C: CAGE Questionnaire (Ewing 1984)

(High sensitivity and specificity in most medical populations. Manner of questioning influences outcome, questioner should avoid leading the answer with affect. Recommended that more neutral risk screening be conducted first—e.g., diet/exercise/seat belts/smoking.)

Has the patient any of these responses, to the suggested questions?

Cut Down (or discontinued) Use

• Because symptoms worsened

• Because a doctor or therapist or advisor suggested

Angry when Using or Annoyed when Drug or Alcohol Use Discussed

• Anger or altercation during use

• Hostile defensiveness surrounding use

Guilt Surrounding Use

• Guilt or shame regarding behaviors while using

• Any suicidal gesture

Eye-Opener

• Effort to medicate withdrawal, e.g., alcohol or sedatives to suppress hangover symptoms or to permit function at work

Appendix D: Michigan Alcohol Screening Test (MAST)

A score of two or more positive responses suggests an alcohol use disorder corresponding to dependence (DSM4TR) (Buschbaum et al. 1991) and warrants re-screening with MAST (Michigan Alcohol Screening Test) or S-MAST (Short MAST), or full diagnostic review with the SCID (Structured Clinical Interview for DSM-4TR).

Appendix E: Short MAST (Seltzer et al. 1975)

Do you feel you are a normal drinker?	Yes	No
Do your spouse or parents worry or complain about your drinking?	Yes	No
Do you ever feel bad about your drinking?	Yes	No
Do friends or relatives think you are a normal drinker?	Yes	No
Are you always able to stop drinking when you want to?	Yes	No
Have you ever attended a meeting of Alcoholics Anonymous?	Yes	No
Has drinking ever created problems between you and your spouse?	Yes	No
Have you ever gotten into trouble at work because of drinking?	Yes	No
Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?	Yes	No
Have you ever gone to anyone for help about your drinking?	Yes	No
Have you ever been in the hospital because of drinking?	Yes	No
Have you ever been arrested even for a few hours because of drinking?	Yes	No
Have you ever been arrested for drunk driving or driving after drinking?	Yes	No

Scoring:

1 point for each of answers in italics.

2 points = possible problem in use of alcohol

3 points = probable problem in use of alcohol

Appendix E: Alcohol Use Disorders Identification Test (AUDIT) Public Domain, http://pubs.niaaa.nih.gov/publications/arh28-2/78-79.htm