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Substance M Isuse: Classifi Cation and D Iagnosis
Substance M Isuse: Classifi Cation and D Iagnosis
Substance M Isuse: Classifi Cation and D Iagnosis
11
Classification and diagnosis, 165 Risk assessment, 172 Clinical features and management,
Alcohol, 166 Management and prognosis, 172 177
Epidemiology, 166 Illicit drugs, 174 Recommended reading, 180
Aetiology, 168 A brief history of illicit drugs, 174 Summary, 180
Clinical features and complications, Epidemiology, 175 Self-assessment, 181
169 Aetiology, 176
● The recommended limits for alcohol consumption ● Role and limitations of blood tests in alcohol misuse
● Features of alcohol dependence ● Management of alcohol dependence, including
● Symptoms of alcohol withdrawal detoxification and maintenance treatment
● Key features of delirium tremens and Wernicke–Korsakov ● Routes of administration, mechanism of action, sought-
syndrome after effects, and undesired effects of commonly used illicit
● Other complications of alcohol misuse and dependence drugs
● Alcohol risk assessment
ICD-10 DSM-IV
F10 Alcohol Alcohol
F11 Opioids Opioids
F12 Cannabinoids Cannabis
F13 Sedatives or hypnotics Sedatives, hypnotics, or anxiolytics
F14 Cocaine
F15 Other stimulants, including caffeine
Cocaine
Amphetamines
11
F16 Hallucinogens Caffeine
F17 Tobacco Hallucinogens
F18 Volatile solvents Phencyclidine
F19 Multiple drug use and other Nicotine
Inhalants
Polysubstance
Other
165
166 Chapter 11 Substance misuse
ICD-10 DSM-IV
.0 Acute intoxication Intoxication
.1 Harmful use Abuse
.2 Dependence syndrome Dependence
.3 Withdrawal state Withdrawal
.4 Withdrawal state with delirium Withdrawal delirium
.5 Psychotic disorder Psychotic disorders
.6 Amnesic syndrome Amnestic disorder
.7 Residual and late-onset psychotic disorder Dementia
.8 Other mental and behavioural disorders Mood disorders
Anxiety disorders
Sexual dysfunctions
Sleep disorders
11
Figure 11.2 A bottle of claret or burgundy typically contains about 12 units of alcohol, but a bottle of red wine from the New World
(right) is likely to contain more. Photo by Neel Burton.
168 Chapter 11 Substance misuse
4–8 3–6
0–4 0–3
0 0
0 10 20 30 40 0 10 20 30 40
% %
Adult males exceeding the daily recommended Adult females exceeding the daily recommended
limits for alcohol consumption limits for alcohol consumption
65+ 65+
Age group
Age group
45–64 45–64
25–44 25–44
16–24 16–24
0 10 20 30 40 50 0 10 20 30 40 50
% %
Figure 11.3 Alcohol consumption among people aged 16 and over in England by sex; and adults exceeding daily recommended
limits for alcohol consumption in Great Britain on their heaviest drinking day in the last week by age and sex. In studying these charts
it should be remembered that alcohol consumption is typically under-reported. (Source: General Household Survey 2001–02, ONS).
flushing, nausea, palpitations, and headache (this is the can be controlled through three factors: price, availabil-
so-called ‘flushing reaction’). ity, and social attitudes to alcohol.
Alcohol has a variety of effects on a number of neurotrans- Other psychiatric disorders – especially depressive dis-
mitters, including GABA, dopamine, serotonin, and orders, anxiety disorders, and stress-related disorders –
glutamate. The euphoriant and reinforcing effects of and medical disorders (e.g. chronic pain and terminal
alcohol are mediated by GABA, dopamine, and serotonin. illness) commonly lead to alcohol misuse and depen-
In alcohol dependence there is a compensatory upregula- dence. Equally, alcohol misuse commonly leads to other
tion of glutamate to compensate for the (GABA- psychiatric disorders and medical disorders (see Table
ergic) CNS depressant effects of alcohol. Suddenly 11.1). The term dual diagnosis refers to the co-occurrence
withdrawing alcohol therefore leads to symptoms of CNS of both a psychiatric disorder and substance misuse
hyperexcitability. (alcohol or illicit drugs), although it does not strictly
speaking encompass psychiatric states that result directly
from, or are fully contingent upon, substance misuse (e.g.
Psychological theories paranoid ideation or hallucinations that occur after taking
There is no such thing as an ‘alcoholic personality’, cocaine). The failure to recognise comorbid substance
although anxiety disorders, borderline personality dis- misuse in a patient can lead to an incorrect diagnosis and
order, antisocial personality disorder, and a history of to an inappropriate management plan.
childhood conduct disorder are particularly associated
with alcohol misuse. According to cognitive-behavioural
theories, alcohol dependence may result from positive Clinical features and complications
reinforcement (seeking out the pleasant effects of alcohol)
and negative reinforcement (avoiding the negative effects Key features of alcohol dependence
of alcohol withdrawal), from a conditioned response to The following are seven key features of alcohol
one or more circumstances (e.g. a pub or nightclub), or dependence:
from modelling the drinking behaviour of relatives, peers, 1. Compulsion to drink
and ‘celebrities’. According to psychodynamic theories, 2. Primacy of drinking over other activities
alcohol dependence may result from maternal depriva- 3. Stereotyped pattern of drinking
tion, childhood sexual abuse, or unconscious gains result- 4. Increased tolerance to alcohol
ing from intoxication and personal damage caused. 5. Repeated withdrawal symptoms
6. Relief drinking to avoid withdrawal symptoms
Social factors/other 7. Reinstatement after abstinence.
For a diagnosis of alcohol dependence to be made,
● Life events: life events such as separation, bereave- DSM-IV requires at least three from a similar list of
ment, or loss of employment may lead to alcohol misuse seven features occurring at any time during a 12-month
and dependence. period.
● Occupation: certain occupational groups are at a
higher risk of alcohol dependence, e.g. publicans and
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Withdrawal symptoms
bar staff, salesmen, entertainers, journalists, and
doctors. Generally speaking, alcohol dependence is Withdrawal symptoms usually occur after several years of
more prevalent in the unskilled manual social class and heavy drinking and range from mild anxiety and sleep dis-
in the unemployed. turbance to life-threatening delirium tremens. They are
● Population levels of alcohol consumption: the most likely to occur first thing in the morning, which is
average level of alcohol consumption in a given popula- why some people with alcohol dependence sleep with a
tion is closely related to the level of alcohol-related dis- straw in their mouth. Common symptoms include agita-
orders, e.g. to the number of deaths from cirrhosis. The tion, tremor (the ‘shakes’), sweating, nausea, and retch-
average level of alcohol consumption in a population ing. If these symptoms are not relieved by alcohol or
170 Chapter 11 Substance misuse
Psychiatric ● Mood and anxiety disorders – may be either complications or, less commonly, aetiological factors
● Suicide and deliberate self-harm
● Alcoholic hallucinosis – auditory hallucinations, first of fragmentary sounds then of derogatory voices, usually
in the third person. These auditory hallucinations can persist even after several months of abstinence, in some
cases leading to secondary delusions. They are notoriously unresponsive to antipsychotic medication
● Othello syndrome (pathological jealousy, delusions of infidelity) – often compounded by sexual problems and
the spouse’s lack of interest in a drunken partner. If treatment is failing it may be necessary for the couple to
separate so as to protect the spouse
● Cognitive impairment – may be partially reversible if drinking is stopped
● Pathological intoxication (manie à potu) – an uncommon idiosyncratic reaction to alcohol marked by
maladaptive changes in behaviour
Neurological ● Episodic anterograde amnesia
● Seizures
● Perhipheral neuropathy
● Cerebellar degeneration
● Optic atrophy (rare)
● Central pontine myelinosis (rare)
● Marchiafava–Bignami disease – demyelination of corpus callosum, optic tracts, and cerebral peduncles
manifesting as dysarthria, ataxia, seizures, and impaired consciousness, and eventually dementia and limb
paralysis (rare)
Gastrointestinal ● Oesophagitis
● Oesophageal varices
● Gastritis
● Peptic ulceration
● Acute and chronic pancreatitis
● Alcoholic hepatitis
● Cirrhosis: 10–20% of alcohol-dependent people develop cirrhosis
● Cancer of the oesophagus, stomach, and liver
Cardiovascular ● Hypertension – increased risk of stroke and ischaemic heart disease
● Cardiac arrhythmias
● Cardiomyopathy
Other medical ● Episodic hypoglycaemia
● Vitamin deficiencies and anaemia
● Accidents, especially head injury
● Hypothermia
● Respiratory depression
● Aspiration pneumonia
● Increased susceptibility to infections
● Sexual problems: decreased libido, impotence
11 Social ● Family and marital difficulties
● Employment difficulties
● Accidents
● Financial problems
● Vagrancy and homelessness
● Crime and its repercussions
Substance misuse Chapter 11 171
thalamus. The remainder go on to develop Korsakov’s lead to foetal alcohol syndrome (FAS). FAS affects 1–2 live
syndrome (amnestic syndrome), an irreversible syndrome births per 1000 and is characterised by growth retarda-
of prominent impairment of recent memory and, to a tion, dysmorphology (particularly midfacial anomalies),
lesser extent, remote memory resulting from neuronal and CNS involvement (cognitive impairment, learning
loss, gliosis, and haemorrhage in the mamillary bodies and disabilities, and impulsiveness). Milder forms of FAS,
damage to the dorsomedial nucleus of the thalamus. Con- sometimes referred to as foetal alcohol effects (FAE), are
fabulation – the falsification of memory in clear conscious- thought to be more common and principally circum-
ness – may be a marked feature, but immediate recall, scribed to CNS involvement.
perception and other cognitive functions are usually
intact. ‘The Lost Mariner’ is a case study of Korsakov’s syn-
Management and prognosis
drome recounted by Oliver Sacks in The Man Who Mistook
His Wife for a Hat. Alcohol misuse is common and clinicians in all specialties
should maintain a high index of suspicion for it and rou-
tinely ask about alcohol intake. Rapid screening question-
Alcohol in pregnancy
naires such as the CAGE questionnaire may be useful in
The amount of alcohol that can be safely drunk in preg- this context, although they are not as sensitive as a com-
nancy is uncertain, so it is probably best to avoid it alto- prehensive alcohol risk assessment. If drinking habits are
gether. Drinking alcohol in pregnancy increases the rate of difficult to assess, take an informant history or ask the
stillbirths and other obstetric complications. It can also patient to keep an alcohol diary.
Clinical skills: CAGE questionnaire ! Antidepressant and antipsychotic drugs may be used to
treat associated psychiatric disorders, but it is also impor-
C Have you ever felt you should Cut down on your tant to remember that symptoms of anxiety and depres-
drinking? sion often resolve with the cessation of drinking.
A Have people Annoyed you by criticising your drinking?
G Have you ever felt bad or Guilty about drinking?
E Have you ever taken a drink first thing in the morning
(Eye opener)? After detoxification the patient should be advised to
Two or more positive replies are said to identify alcohol abstain from alcohol as abstention has a better prognosis
misuse. than controlled drinking, especially if the patient has suf-
fered physical damage from alcohol or is aged 40 or over.
Abstention can be encouraged by maintenance treatments
such as the opiate antagonist naltrexone (not currently
licensed in the UK), acamprosate (Campral), and disulfi-
ram (Antabuse). Acamprosate is an ‘anticraving’ drug
Blood tests may be helpful in augmenting the findings that enhances GABA neurotransmission and therefore
of screening questionnaires such as the CAGE question- mimics the CNS depressant effects of alcohol. Disulfiram
naire, and in monitoring progress. Gamma-glutamyl- on the other hand is an alcohol-sensitising deterrent drug
transferase (GGT) is raised in about 80% of heavy that blocks the oxidation of alcohol by irreversibly inhibit-
drinkers, alkaline phosphatase (ALP) in about 60%, and ing the enzyme aldehyde dehydrogenase, leading to an
mean corpuscular volume (MCV) in about 50%. Of the accumulation of acetaldehyde and associated symptoms
three tests, MCV has the highest specificity for alcohol of flushing, palpitations, headache, nausea, and a choking
misuse but, due to the long half-life of red blood cells (120 sensation (it can be thought of as a chemical form of aver-
days), may remain elevated for a long time after the patient sion therapy). For this reason, it should not be started
has stopped drinking. Carbohydrate-deficient transferrin until the breath alcohol has returned to zero. It is contra-
(CDT) has an even higher specificity than MCV, but is not indicated in hypertension, coronary artery disease, and
commonly available in the UK. The sensitivity and speci- cardiac failure as it can cause cardiac arrhythmias; other
ficity of GGT, ALP, and MCV can be improved by order- side-effects include sedation, constipation, and halitosis
ing them in combination. (bad breath).
Early treatment of alcohol misuse is often delivered in Maintenance treatments require close supervision,
primary care and involves simple advice and support, and often by a nominated ‘supervisor’ such as the patient’s
appraisal of current medical, psychological, and social spouse, and are not a substitute to psychosocial interven-
problems. It may also be useful to devise a goal-oriented tions. These latter include attendance at groups run by
management plan that is tailored to the patient’s needs local community alcohol services or Alcoholics Anonym-
and that can be mutually agreed upon. ous, supportive psychotherapy (including supportive psy-
If alcohol misuse has already reached the stage of chotherapy for carers), cognitive-behavioural therapy,
dependence, detoxification is required. This involves a and marital and family therapy. Social skills training is an
reducing course of a benzodiazepine in lieu of alcohol, e.g. effective component of substance misuse treatment pro-
chlordiazepoxide 20 mg QDS reducing daily over 5–7 days
and supplemented by thiamine 200 mg OD (often in the
grammes that aims to impart the skills needed to function
more effectively in social situations, and involves a variety
11
form of a multivitamin preparation). Detoxification can of interventions such as role playing in groups (e.g. declin-
usually be carried out in the community either by the GP ing the offer of an alcoholic drink, or going to a bar and
practice or the local substance misuse service, but hospital ordering a non-alcoholic drink), assertiveness training,
admission should be considered if the patient has a and problem solving skills.
comorbid medical or psychiatric disorder (including drug Alcohol dependence is a chronic relapsing condition
misuse), a history of convulsions or delirium tremens, or a and only 20–50% of patients remain abstinent one year
lack of social support. Note that a similar drug regimen to after detoxification. Predictors of relapse include poor
the one outlined above can also be used for the early stages motivation, lack of employment and social support, and
of alcohol withdrawal. comorbid mental illness.
174 Chapter 11 Substance misuse
Scenario A Doctor: That’s right, but it doesn’t just damage our body, it
Doctor: According to your blood tests, you’re drinking too also damages our lives: our work, our finances, our
much alcohol. relationships.
Patient: I suppose I do enjoy the odd drink. Patient: Funny you should say that. My wife’s been at my
Doctor: You’re probably having far more than just the odd neck …
drink. Alcohol is very bad for you, you need to stop (…)
drinking. Doctor: So, you’ve told me that you’re currently drinking
Patient: You sound like my wife. about 16 units of alcohol a day. This has placed
Doctor: Well, she’s right you know. Alcohol can cause liver severe strain on your marriage and on your
and heart problems and many other things besides. relationship with your daughter Emma, not to
So you really need to stop drinking, OK? mention that you haven’t been to work since last
Patient: Yes, doctor, thank you. Tuesday and have started to fear for your job. But
(Patient never returns.) what you fear most is ending up lying on a hospital
bed like your friend Tom. Is that a fair summary of
11 Scenario B (using motivational interviewing) things as they stand?
Doctor: We all enjoy a drink now and then, but sometimes Patient: Things are completely out of hand, aren’t they?
alcohol can do us a lot of harm. What do you know If I don’t stop drinking now, I might lose everything
about the harmful effects of alcohol? I’ve built over the past 20 years: my job, my
Patient: Quite a bit, I’m afraid. My best friend, well, he used marriage, even my daughter.
to drink a lot. Last year he spent three months in Doctor: I’m afraid you might be right.
hospital. I visited him often, but most of the time he Patient: I really need to quit drinking.
wasn’t with it. Then he died from internal bleeding. Doctor: You sound very motivated to stop drinking. Why
Doctor: I’m sorry to hear that, alcohol can really do us a lot don’t we make another appointment to talk about
of damage. the ways in which we might support you?
Patient: It does a lot of damage to the liver, doesn’t it?