Alcohol & Illicit Drugs

Substance abuse is a major public health problem in the United States and is estimated to be a factor in 41% of highway fatality accidents. The lifetime prevalence of alcoholism is estimated to be between 12% and 16%. Approximately two-thirds of high school seniors are regular users of alcohol. Underdiagnosis of alcohol abuse is substantial, both because of patient denial and lack of detection of clinical clues. A substantial decline in alcohol-related fatalities testifies to the success of educational and law-enforcement efforts to stop drinking and driving. Even so, alcohol-impaired driving remains prevalent, especially among men aged 18–34 years.
Binge drinking among college students has recently increased. As with cigarette use, clinician identification and coun seling about alcoholism may improve the chances of recovery. About 10% of all adults seen in medical practices are problem drinkers. An estimated 15–30% of hospitalized patients have problems with alcohol abuse or dependence, but the connection between patients’ presenting complaints and their alcohol abuse is often missed. The CAGE test is both sensitive and specific for chronic alcoholism. However, it is less sensitive in detecting heavy or binge drinking in elderly patients and has been criticized for being less applicable to minority groups or to women. Others recommend asking three questions:
(1) How many days per week do you drink (frequency)?
(2) On a day when you drink alcohol, how many drinks do you have in one day (quantity)?
(3) On how many occasions in the last month did you drink more than five drinks (binge drinking)?
The Alcohol Use Disorder Identification Test (AUDIT) consists of questions on the quantity and frequency of alcohol consumption, on alcohol dependence symptoms, and on alcohol-related problems.It has been found to accurately detect hazardous drinking, harmful drinking, and alcohol dependence and does not seem to be affected by ethnic or gender bias. Choice of therapy remains controversial. However, use of screening procedures and brief intervention methods can produce a 10–30% reduction in longterm alcohol use and alcohol-related problems. However, brief advice and counseling without regular follow-up and reinforcement cannot sustain significant long-term reductions in unhealthy drinking behaviors.
Several pharmacologic agents are effective in reducing alcohol consumption. In acute alcohol detoxification, standard treatment regimens use long-acting benzodiazepines, the preferred medications for alcohol detoxification, because they can be given on a fixed schedule or through “frontloading” or “symptom-triggered” regimens. Adjuvant sympatholytic medications can be used to treat hyperadrenergic symptoms that persist despite adequate sedation. Three drugs are FDA approved for treatment of alcohol dependence—disulfiram, naltrexone, and acamprosate. Disulfiram, an aversive agent, has significant adverse effects and consequently, compliance difficulties have resulted in no clear evidence that it increases abstinence rates, decreases relapse rates, or reduces cravings. Persons who receive shortterm treatment with naltrexone have a lower chance of Reproduced, with permission, from the United States Department of Health Human Services, U.S. Public Health Service, Office of Disease Prevention Health Promotion. Clinician’s Handbook of Preventive Services: Put Prevention Into Practice. U.S. Government Printing Office, 1994. alcoholism relapse. Compared with placebo, naltrexone can lower the risk of treatment withdrawal in alcohol-dependent patients. Compared with placebo, long-acting intramuscular formulation of naltrexone has been found to be well-tolerated and to reduce drinking significantly among treatment seeking alcoholics over a 6-month period. In a randomized, controlled trial, patients receiving medical management with naltrexone, a combined behavioral intervention, or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy with or without combined behavioral intervention.
Use of illegal drugs—including cocaine, methamphetamine, and so-called “designer drugs”—either sporadically or episodically remains an important problem. Disturbing trends include an increase in use of marijuana and inhalants among eighth graders and high school students and an increase in abuse of prescription pain medications. Many drug users are employed, and many use drugs during pregnancy. Cocaine or tobacco use during early pregnancy substantially increases the risk of miscarriage.Abuse of anabolic-androgenic steroids has been associated with use of other illicit drugs, alcohol, and cigarettes and with violence and criminal behavior. As with alcohol abuse, the recognition of drug abuse presents special problems and requires that the clinician actively consider the diagnosis.
Currently, evidence does not support the use of carbamazepine, disulfiram, mazindol, phenytoin,nimodipine, lithium, antidepressants, or dopamine agonists in the treatment of cocaine dependence. In a methadone maintenance population, the combination of contingency management with bupropion is more effective than bupropion alone for the treatment of cocaine addiction.
Buprenorphine has potential as a medication to ameliorate the symptoms and signs of withdrawal from opioids and has been shown to be effective in reducing concomitant cocaine and opiate abuse. Slow tapering with temporary substitution of methadone and buprenorphine—accompanied by medical supervision and ancillary medications—can reduce withdrawal severity, but most patients relapse to heroin use. Cessation of methadone maintenance is possible using buprenorphine by transfer from methadone to buprenorphine and subsequent buprenorphine reductions. Evidence does not support the use of naltrexone in maintenance treatment of opioid addiction.
Rapid opioid detoxification with opioid antagonist induction using general anesthesia has emerged as an approach to treat opioid dependence. However, a randomized comparison of buprenorphine-assisted rapid opioid detoxification with naltrexone induction and clonidine-assisted opioid detoxification with delayed naltrexone induction found no significant differences in rates of completion of inpatient detoxification, treatment retention, or proportions of opioid-positive urine specimens, and the anesthesia procedure was associated with more potentially lifethreatening adverse events. Finally, cognitive behavior therapy, contingency management, couples and family therapy, and other types of behavioral treatment have been shown to be effective interventions for drug addiction.