Definitions
As with disorders of alcohol use, The American Psychiatric Associations
DSM-IV identifies two primary disorders of drug use: drug abuse and drug dependence. The
diagnostic criteria for drug abuse and dependence parallel those for alcohol abuse and
dependence. Drug abuse is defined as continued use of a psychoactive substance in
spite of clinically significant impairment or distress. Drug dependence is defined
as abuse along with evidence of addiction, including tolerance, withdrawal, inability to
quit or cut down, and/or use of the drug becoming increasingly important in the
individuals life.
Comparison between
Alcohol and Drugs
Although similar, drug and alcohol use disorders also differ in a number of
important ways. First, drug use disorders are a more heterogeneous group, depending on
which particular psychoactive substances are used pathologically. Second, most drugs of
abuse are illegal, while alcohol use is legal (>21 years of age). Finally, the Navy has
a policy of "zero tolerance" toward drug abuse, which greatly differs from its
stance toward alcohol use disorders. Because of these differences, disorders of drug use,
particularly in the Navy, tend to be more difficult to identify and manage, and their
prognosis is generally poorer.
Drug Types
Commonly abused psychoactive substances include sedatives/hypnotics/anxiolytics,
opioids, cocaine, amphetamines, phencyclidine, hallucinogens, cannabis, and inhalants.
Nicotine is also an important drug of abuse and addiction, but it is managed differently
given its (waning) social sanction. Among adolescents, marijuana is the most frequent
substance of abuse after alcohol and tobacco. The next most common, perhaps, but certainly
of greater medical consequence is the use of amphetamines, including "crystal"
methamphetamine. Cocaine abuse and dependence are declining in some populations, and
problems related to the use of hallucinogens, PCP, and inhalants are rare. Sedative abuse
and dependence are often iatrogenic.
Concurrent Conditions
Consider drug abuse and dependence in patients with personality or other
psychiatric disorders, criminal behavior, drug-seeking behavior, or factitious illness.
Most drug abusers also abuse alcohol and tobacco. Patients with sexually transmitted
disease, hepatitis, pneumonia, tuberculosis, and HIV disease should be questioned
regarding drug use. Always remember to assess and document potential for suicide and
homicide.
Physical Manifestations
The physical manifestations of intoxication with, and withdrawal from substances of
abuse, are summarized in the October 5, 1990 issue of The Medical Letter.
Sedative/hypnotics cause slurred speech, an unsteady gait, and nystagmus. Opiates cause
respiratory depression, coma, and hypotension, while withdrawal provokes marked agitation,
dilated pupils, and upper respiratory infection symptoms. Cocaine is extremely addicting,
producing intense euphoria and hallucinations within minutes of IV use or when smoked
(crack). It can also produce severe dysphoric states, with extremes of depression,
paranoia, hyperactivity, or suicidal behavior. Patients may have seizures, fever,
hypothermia, and arrhythmias. Death from myocardial infarction, aortic rupture,
hypertensive emergency, or placental abruption has been described. Phencyclidine (PCP)
causes acute psychosis with agitation, violence, and disorientation. Marijuana rarely
causes any detectable physical symptoms other than conjunctival injection.
History and Physical Exam (HPI)
Every patient suspected of a drug use disorder should receive a complete history,
physical exam (including neurologic exam), and mental status exam. Date of first use,
heaviest use, longest period of abstinence, amount, frequency, time of last use, route of
administration, circumstances of use, and reactions to use are all important elements of
the HPI. Sexual and legal histories, family histories of drug use, and histories of
exposure to HIV and other infectious agents should also be obtained. Cognitive function
should always be assessed in someone suspected of a drug use disorder since some abusable
substances impair memory and other higher cortical functions.
Ancillary evaluation
Few laboratory findings (other than toxicology
screen) are associated with primary
disorders of drug use. However, a CBC, chest x-ray, and liver functions should be checked
for anyone suspected of having an infection (e.g., septicemia, local vasculitis),
hepatitis, or a pulmonary problem (e.g., pulmonary embolus, emphysema) secondary to
psychoactive substance use.
Final notes
Your job as a GMO is to diagnose the abuse or dependence, manage any
acute toxicity or withdrawal, and recommend long-term treatment. The Navy or Marine Corps
will decide whether to retain the sailor for treatment (rarely) or to separate him or her
administratively or legally after NJP or court martial.
Reference
-
The American Psychiatric Press Synopsis of Psychiatry
, edited by Robert Hales and
Stuart
Yudofsky, published by American Psychiatric Press, Washington, DC, 1996.
Revised by CAPT William P. Nash, MC, USN, Psychiatry Specialty Leader, Naval
Medical Center San Diego (1998).