Chemical Dependence: Substance Abuse

Among the chemical dependency groups, substances whose primary mode of action is a depressant effect have been gathered under the heading of Sedative-Hypnotics. Alcohol, benzodiazepines and barbiturates all belong to this category. Nonbarbiturate nonbenzodiazepine sedative-hypnotics are also included, such as buspirone, chloral hydrate, carisoprodol, and gamma-hydroxybutyrate (GHB).

Sedative-hypnotic use is common. Benzodiazepines for therapeutic use are one of the most frequently prescribed pharmaceuticals in the world. The wide availability by prescription for legitimate use creates ample opportunity to maintain an established long-duration chemical dependence.

The use of sedative-hypnotics also tends to accompany chemical dependency to both stimulants and opioids. Frequently in these individuals no dependency is present to a sedative-hypnotic, the depressant chemical is simply a tool used to help offset side-effects or withdrawal symptoms created by the substance they are dependent on (Cooper, 2009).

Chief amongst the sedative-hypnotic chemicals of dependence is alcohol, which is licit (socially accepted), and possesses predictable central nervous system depressant effects. Roughly two-thirds of Americans drink alcohol with around one in ten using it to significant abuse. Excessive alcohol use has been identified as the third leading preventable cause of death amongst Americans and comprises of a large number of emergency room visits each year (Gold & Aronson, 2009).
 

Alcohol Use Prevalence in the United States in 2004

Alcohol dependence = 2 to 9 percent of population Risky drinking = 4 to 29 percent of population Harmful drinking = 0.3 to 10 percent of population

(Gold, & Aronson, 2009)

Acute indicators, which may signal the presence of an alcohol or other depressant chemical dependence, range from suspicious circumstances in an accident to obvious disinhibition from the CNS depressant effect. Blood levels for acute use symptoms may be an effective tool to aid a person to realize that they have a problem that requires treatment.

Chronic physical symptoms specific to alcohol dependence range widely and are dependent to areas of physiologic vulnerability specific to each individual. They may include effects of chronic use such as the following (Cohagan, & Worthington, 2007);

Neurologic - Korsakoff psychosis, Wernicke encephalopathy, peripheral neuropathy, dementia resulting to structural changes in the brain
Psychiatric - Anxiety or depressive disorders
Immunologic - Neutrophil function suppression
Gastrointestinal - Liver cirrhosis, peptic ulcer disease, pancreatitis
Obstetric - Fetal alcohol syndrome, mental retardation, fetal deformities
Endocrine - Male testicular atrophy, impotence, gynecomastia

Assessment for alcohol or other depressant dependence requires personal history information in order to determine the presence of chemical use patterns and any negative consequences that may be related to use. Information either from the client or from family members is helpful, and often clients are very forthcoming concerning substance use as long as questions are framed in an open and nonjudgmental manner.

Even when being fully cooperative, clients frequently underestimate their own substance use. Tools such as the CAGE alcohol-screening questionnaire can help the health provider to gain the clearest understanding possible. A single positive response for any of the CAGE four questions is considered as suggestive of an alcohol dependence problem. Two or more positive responses increase probability of a dependence problem to around 90-percent. Please remember when using the CAGE tool that it is best utilized when not preceded by questions concerning types or numbers of drinks consumed.
 

CAGE Questionnaire for Alcohol Use Screening

C- Has anyone ever felt you should Cut down on your drinking? A - Have people Annoyed you by criticizing your drinking? G - Have you ever felt Guilty about your drinking? E - Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?

(Cohagan, & Worthington, (2007)

Making a dependency diagnosis with any of the sedative-hypnotics only requires meeting the criteria discussed earlier: tolerance, avoidance of withdrawal, consumption greater than intended and negative consequences of use. Health practitioners do not actually need to quantify consumption amounts to detail; however, learning amount of typical intake during both "normal" and "binge" episodes can be very helpful in both risk assessment for chronic health concerns and later in counseling for dependency.
 

CDC Excessive Alcohol Use Definitions

Heavy Drinking = More than two drinks per day for men, more than one drink per day for women  Binge Drinking = Five or more drinks during a single occasion for men, four or more drinks during a single occasion for women  Excessive Drinking = Includes BOTH heavy and binge drinking

A standard drink is defined as; 0.5 ounces of pure alcohol (1.2 tablespoons or 13.7 grams) 1.5 ounces of distilled (80 proof) spirits or distilled liquor (e.g. rum, vodka, gin, whiskey) 5 ounces of wine 8 ounces of malt liquor 12 ounces of regular beer or wine cooler

(CDC, Alcohol and Public Health, 2008)

Withdrawal symptoms are a red flag for any health professional that chemical dependency is an issue. An awareness of some key aspects of alcohol withdrawal is therefore essential in order to recognize and supply the best support and treatment.
 

Alcohol Withdrawal Characteristics

"The Shakes" 12 to 24 hours (times are approx., i.e., can begin manifesting within 6 hours) after the last drink. Tremor may be accompanied by anxiety, headache, tachycardia, diaphoresis, insomnia, or anorexia, and reflect an over-excitation of the CNS.

"Rum Fits" 24 to 72 hours after last drink. Generalized seizures may manifest, as may alcoholic hallucinations. Untreated alcohol withdrawal seizures progress to delirium tremens in about one-third of clients.

"DT's" 3 to 5 days after last drink. Delirium tremens (DT) is a condition characterized by fever, disorientation, and visual hallucinations. DT's are regarded as a medical emergency and warrant inpatient treatment.

(Cohagan, & Worthington, 2007), (Hoffman, & Weinhouse, 2009)

In our focus on alcohol as the most prevalent of the sedative-hypnotic chemicals of the dependence group please be aware that one of the commonly observed characteristics of alcohol dependence is a loss of control by the user concerning behaviors associated with alcohol use. This can be manifested in such things as drinking their alcohol more quickly than circumstances might dictate, or gulping their very first drink. Other indicators might include showing concern or worry when events interfere with planned drinking opportunities, or using alcohol as a primary mechanism to release stress. Frequent thoughts or talk about drinking and when they will be able to engage in their next drink can also be an indication of need to assess for dependence.

Blood alcohol levels may not be of great assistance in determining a diagnosis of alcohol dependence. The presence of detectable alcohol by breath test or in the bloodstream does not present the requisite information to determine the pattern of use present. Other laboratory tests may supply a clearer picture of use patterns (Gold, & Aronson, 2009).
 

• MCV or Mean Corpuscular Volume - Macrocytosis (MCV of between 100 and 110 fL in the complete blood count) is frequently associated with a pattern of alcohol use indicative of dependence. Regular ingestion of 80 grams of alcohol each day (equivalent to one bottle of wine) leads to this change in around 90-percent of individuals. Abstaining from alcohol allows the body to resolve macrocytosis within two to four months.
• Liver studies - A number of characteristic liver changes accompany consistent and extended alcohol use. Abnormalities in serum aspartate and alanine aminotransferases as well as gammaglutamyl transferase (GGT) are commonly associated with alcohol dependence or abuse.
• Serum Carbohydrate-deficient Transferrin (CDT) - is an intriguing blood assay that can be of great use identifying chronic heavy alcohol use. This test is actually a better biomarker for alcohol consumption than either MCV or GGT as its sensitivity for significant alcohol intake is between 60 to 70-percent while its specificity is between 80 to 90-percent. A rising CDT concentration can be an indication of relapse during treatment.

It is important for the health professional to remember that the presence of other chemicals in the sedative-hypnotic group will also tend to resemble alcohol intoxication. The use of both laboratory screening tools and interview skills are important. In cases of severe impairment, the following studies are recommended (Cooper, 2009):
 

• Complete blood count (CBC)
• Arterial blood gas (ABG)
• Chemistry profile with glucose
• Toxicology screen
  • Suspected intentional exposures should always include; Alcohol, Salicylate, and Acetaminophen
  • Quantitative serum drug concentration levels are recommended for clients with serious toxicity symptoms 

Stimulant use as a dependence issue is often an exercise in polysubstance use. While the stimulant dependent person will often have their favorite substance, many imbibe whatever is at hand that can be utilized to achieve the goal of renewed energy, a boost, or simply to help them maintain a feeling of control. Stimulants range from licit items such as caffeine, heavily sugared energy drinks, cigarettes, and even over-the-counter (OTC) decongestants, to illicit and illegal substances such as cocaine or methamphetamines.

Suspicion of stimulant use and perhaps dependence should occur on observing any of the following; an elevated mood in circumstances where that would not be warranted, an unusual level of alertness, reports of increased energy often accompanied with insomnia, and atypical weight loss similar to anorexia (Divadeenam, K., 2008).

The presentation for evaluation in office or emergency department with chest pain, tachypnea, abdominal pain, nausea, and headaches may indicate stimulant use. The long-term use of stimulants tends to show characteristic dependency indicators such as substance tolerance, and may also be manifested in weight loss as well as mood and mental instabilities such as heightened impulsivity, irritability, aggressiveness, hallucinations and even delusional thinking. The characteristics of stimulant dependence and overuse can be summarized as follows:
 

Stimulant Intoxication Mental Status Examination

Attitude – Tense Psychomotor Activity - Agitated, restless Speech – Talkative Mood/ Affect - Good, euphoric, labile Thought content or processes - Flight of ideas, paranoia, grandiosity, hypersexuality, hallucinations, homicidal ideation Orientation - Confused, delirium Insight or judgment – Impaired Memory - Varies, while small amounts of stimulants may improve alertness and task focus, heavy or prolonged use is detrimental to memory and can lead to coma

(Divadeenam, 2008)

A similar examination of an individual with long-standing stimulant use or stimulant dependence who has been without their substance of choice can also be characterized into a recognizable pattern.
 

Stimulant Withdrawal Mental Status Examination

Behavior – Sedated Psychomotor Activity – Retarded Speech – Nonspontaneous Mood/ Affect - Depressed, irritable Thought content or processes - Linear at times with suicidal content and substance cravings, homicidal potential as well as paranoia is often present Orientation - Close to normal Insight or judgment – Variable Memory - Likely to be impaired due to sleep deprivation and fatigue

(Divadeenam, 2008)

A clinical history that encompasses substance use is an important tool in establishing the presence of stimulant dependence. It has been suggested that the sequence of topics discussed can play a role in obtaining more and better information when chemical dependence is suspected. By preference, a layered substance questioning strategy has been recommended.
 

Substance Use Interview Sequence

First, ask concerning socially accepted substances such as nicotine or caffeine. This helps to establish a level of comfort for the client regarding questions about substance use. Next, inquire about alcohol. Be sure to specifically ask about wine, beer, and whiskey as many clients will not consider beer to be "alcohol", which some only associate with hard liquor. Inquire concerning use of over-the-counter drugs including caffeine pills, dextromethorphan and pseudoephedrine products, and "energy" products. Finally ask concerning illicit drug use. The client should be prepared by this time, having a sense that the practitioner is collecting information in a non-judgmental fashion for the purpose of helping. Marijuana is often regarded by users as a substance with little social stigma, so should be the first illicit substance asked about. Following that should be questions about cocaine and heroin use, as well as prescription pain medication use.  Be sure to ask clear questions concerning the quantity of each substance used as well as frequency of use. Please be aware, studies with alcohol abusers indicate that clients dealing with dependence issues are more open to discussion of them than most providers believe.

(Weaver, & Jarvis, 2009), (Gold, & Aronson, 2009)

Physical examination results may indicate suspicion of stimulant dependence especially when cocaine or methamphetamines have been the substance of choice. The presence of signs of metabolic acceleration or excitation such as being hyperthermic, tachycardic, and hypertensive are all suggestive of acute stimulant use. A manifestation of seizure activity in the absence of seizure history is also a diagnostic indicator to suspect stimulant use.

Laboratory screening for substances of abuse can be very helpful in these individuals. It is also important to conduct generalized electrolyte studies along with glucose levels as stimulants play havoc with these metabolic processes.
 

Narcotic is a generalized term that may incorporate a variety of classes of chemicals who share the properties of enhancing sleep and decreasing pain. Opioid chemicals consist of a more narrow range of pharmaceutical grade or street drug level substances than the general term narcotic. The common relationship opioids have with each other is that they either are derived from or chemically resemble active metabolites obtained from the opium poppy. Both prescription pain relievers and illicit opioids are chemicals that may be associated with dependence and as with the category stimulants, it is often not a single drug of choice involved but rather whatever related item is currently available. Therefore while the chemically dependent individual may have a drug of preference, it is important to inquire about related substances they have taken in the past as well as what they are currently utilizing, to get a better clinical picture.
 

Some of the more common Opioids
Natural Opioids (aka Opiates)	Synthetic Opioids
Opium Morphine	Codeine Oxycodone (OxyContin) Meperidine (Demerol) Fentanyl (Sublimaze) Hydromorphone (Dilaudid) Methadone Propoxyphene (Darvon) Pentazocine (Talwin) Nalbuphine (Nubain) Butorphanol (Stadol)
Heroin, perhaps the most abused opioid of all, is semisythetic and may be found in either category depending on the definitions used by various information sources.
(Opioids and Related Disorders, 2009), (Habal, 2008)

Pharmacologic pain management has relied extensively on opioid narcotics. This makes professional healthcare the number one means of initial exposure to a substance that in a few individuals triggers the brain reward system and sets up a cycle that may lead toward chemical dependence. Awareness of the potential for developing a dependency is crucial to the delivery of care, as is the early identification of dependency before negative consequences creates irreparable damage.

Chemical dependence to an opioid follows the diagnostic pattern outlined in the DSM-IV. The establishment of a tolerance to the substance leads to a higher dosage being required in order to achieve the desired effect. Active avoidance of feelings or symptoms associated with stopping the use of the substance, and a continuing persistence of usage despite evidence of growing negative consequences are also needed to establish a dependence diagnosis.

Please be aware! Substance abuse and chemical dependency are not the same thing and recognition with follow-up needs to be congruent with the individual client. Quantities of use in the opioid groupings cannot be utilized as a definitive diagnostic differential between abuse and dependence as individuals who ingest opioids for the purpose of abuse typically use them less frequently, and may also use lesser single dosages than do those who have developed tolerance in an ongoing dependency (Opioids and Related Disorders 2009).

Signs of recent opioid use include facial flushing which is the result of vascular changes induced by the drug, and the presence of drowsiness or lethargy that is unusual in that person or not congruent with the current situation. Dry mouth and slurred speech along with a positive affect or mood and seeming indifference to pain are symptoms that can support the suspicion of active opioid use. Complaints concerning constipation can also provide suspicion of both current and ongoing opioid use as this side effect is consistent across the spectrum of therapeutic as well as non-therapeutic usage.

In clients who have developed a dependency for opioids it can quite literally be true that the amounts of drug they are taking could kill another person who is opioid naive (e.g., has never before been exposed to them). Opioid tolerance can develop quickly and regular users adjust by incrementally increasing the amounts taken, at times to staggering quantities. The manner in which our metabolism adjusts can create a situation where in the dependent person only feels "normal" when they actively have adequate opioids in their system. This means that a disruption in supply of the desired chemical can have significant effect on emotional, physical, and mental problem solving abilities.

Symptoms of opioid withdrawal are a red flag that opioid dependency may be a factor. Withdrawal begins in as little as six to eight hours from the time that an effective drug level leaves the system, and depending on the opioid currently being used can last from several days to an extended withdrawal of six months or longer. Methadone withdrawal symptoms for example are notoriously prolonged. In part this is due to the extended half-life of the drug and the length of time it takes for the built-up metabolites of methadone to clear the system.

High on the list of withdrawal symptoms with which a client may present to a physician's office, clinic or emergency department is insomnia. Sleeping difficulties are frequently accompanied by generalized feelings of anxiety and a loss of interest in activities or functions that they would normally enjoy.

So well recognized are the symptoms associated with stopping the use of an opioid that the DSM-IV paints a clear picture of what manifestations to be aware of in order to confirm or rule out withdrawal.
 

Opioid Withdrawal

Opioid-specific withdrawal syndrome: Three or more of the following symptoms which are not due to another known condition and which develop after abstinence from or reducing the amount of an opioid; Insomnia (often accompanied by fatigue), Dysphoric (negative) mood, Nausea or vomiting, Muscle aches, Runny nose or watery eyes, Dilated pupils, Sweating with or without fever Diarrhea, Yawning (with or without reports of fatigue)  Please note that in order to be used as diagnostic evidence the withdrawal symptoms must cause significant distress, and that restlessness and anxiety such as that seen in opioid withdrawal may be seen in withdrawal from sedatives, hypnotics, and anxiolytic chemicals.

(Opioids and Related Disorders, 2009)

Diagnostic procedures in the acute setting rely heavily on clinician experience and clinical interview. Laboratory drug screening is a good confirmation of suspicion for opioid presence yet will not replace the depth of information that comes from a thorough diagnostic workup and interview. One interview tool that has been shown to be useful is the RAFFT questionnaire for substance abuse.
 

RAFFT Questionnaire

R (relax) - Does the client drink or take drugs to Relax, improve a self-image, or to fit in? A (alone) - Does the client ever drink or take drugs while Alone? F (friends) - Do any close Friends drink or use drugs? F (family) - Does a close Family member have a problem with alcohol or drugs? T (trouble) - Has the client ever gotten into Trouble for drinking or taking drugs?

(Weaver & Jarvis, 2009)

 

Promoting awareness of the negative consequences of chemical dependency is the purpose of feedback in brief intervention. Utilize laboratory results such as abnormal liver function tests or connect chemical use to encounters with law enforcement, job loss, and family problems. Pull from your client's life to find the correct feedback that captivates their attention to the dependency problem and solidify the link that it is their dependency behaviors that are putting their happiness at risk. The use of a daily journal or self-monitoring diary can be of assistance in this phase.

This is about the client. This is about the client's life, the client's behaviors. Personal responsibility is the core concept to their control of their life and happiness. Work to clarify goals that are important to your client. Goals should be reasonable and achievable. Anticipate the client will need assistance to form realistic, incremental goals.

Offer clear suggestions on reaching personal goals that are important to your client. Support here consists of suggestions and encouragement as well as providing the opportunity for the client to voice their concerns and frustrations in a climate free of condemnation.

Offer options on how to reach newly set goals. Be aware that some helps, methods or means to obtain those goals will be unknown to your client. Allow the opportunity for your client to discuss and consider what strategies appeal to them and their circumstances. Reinforce the concept of personal choice and personal responsibility in their personal treatment. Should there be concerns that too many options may overwhelm the client, carefully consider which two or three to promote and offer information on.

The pivotal component to success in brief intervention therapy revolves around empathy. Utilize skillful listening to offer suggestions or responses that validate client's feelings while supporting their efforts toward success. Be ever vigilant not to smother a client's progress by imposing your own life experiences or values onto them.

Success in any given venture centers on the belief that it can be achieved. Self-efficacy is about building up your client' sense of ability to succeed in this task. Promote optimism, celebrate incremental success, and assist your client to maintain a clear vision of the positive gains that will be achieved once their dependency is under control. Specific helps consist of strategies such as assisting the setting of early, easily accomplished goals and eliciting or reinforcing self-motivating statements.
 

Case Study: Margaret

Margaret is a 26 y/o female, married, with two children ages 3 and 5. She was admitted for trauma workup after driving through the front window of a convenience store in an SUV. To first responders she presented with slowed responses and slurred speech though no odor of alcohol was present. Of immediate concern was the possibility of head trauma, which was later ruled out. Blood alcohol was negative. Present to toxicology screening was benzodiazepines for which she has a valid prescription due to generalized anxiety disorder. In the back seat of the SUV at the time of the accident were both children, safely secured in car seats.

During the admission interview with the emergency room nurse, Margaret, reveals that she has come to depend on her prescription medication, Ativan, to help her feel "normal". Recently her medication has ceased to be effective and her general practitioner unwilling to increase her dosage. She has been "borrowing" from her mother's Valium, which she indicates her mother rarely uses. The interview also indicates that Margaret values the health and safety of her children very highly and would never willingly put them at risk for danger.

Assignment: Initiating the FRAMES Component - Feedback Using the Feedback component of Brief Intervention, what awareness could you offer to Margaret concerning a behavior that is putting her happiness at risk.