Substance abuse and dependence causes physical, mental, emotional, or social harm. Examples of abused drugs include opioids, stimulants, depressants, antianxiety agents, and hallucinogens. (See Understanding commonly abused substances, pages 432 to 436.) Chronic drug abuse, especially I.V. use, can lead to life-threatening complications, such as cardiac and respiratory arrest, intracranial hemorrhage, acquired immunodeficiency syndrome, tetanus, subacute infective endocarditis, hepatitis, vasculitis, septicemia, thrombophlebitis, pulmonary emboli, gangrene, malnutrition and GI disturbances, respiratory infections, musculoskeletal dysfunction, trauma, depression, increased risk of suicide, and psychosis. Materials used to “cut” street drugs also can cause toxic or allergic reactions.
Psychoactive drug abuse can occur at any age. Experimentation with drugs commonly begins in adolescence or even earlier. In many cases, drug abuse leads to addiction, which may involve physical or psychological dependence or both. The most dangerous form of abuse occurs when users mix several drugs simultaneously — including alcohol.
Psychoactive drug abuse commonly results from a combination of low self-esteem, peer pressure, inadequate coping skills, and curiosity. Most people who are predisposed to drug abuse have few mental or emotional resources against stress, an overdependence on others, and a low tolerance for frustration. Taking the drug gives them pleasure by relieving tension, abolishing loneliness, allowing them to achieve a temporarily peaceful or euphoric state, or simply relieving boredom.
Drug dependence may follow experimentation with drugs in response to peer pressure. It also may follow the use of drugs to relieve physical pain, but this is uncommon.
The signs and symptoms of acute intoxication vary, depending on the drug. The drug user seldom seeks treatment specifically for his drug problem. Instead, he may seek emergency treatment for drug-related injuries or complications, such as a motor vehicle accident, burns from freebasing, an overdose, physical deterioration from illness or malnutrition, or symptoms of withdrawal. Friends, family members, or law enforcement officials may bring the patient to the hospital because of respiratory depression, unconsciousness, acute injury, or a psychiatric crisis.
Examine the patient for signs and symptoms of drug use or drug-related complications as well as for clues to the type of drug ingested. For example, fever can result from stimulant or hallucinogen intoxication, from withdrawal, or from infection caused by I.V. drug use.
Inspect the eyes for lacrimation from opiate withdrawal, nystagmus from central nervous system (CNS) depressants or phencyclidine intoxication, and drooping eyelids from opiate or CNS depressant use. Constricted pupils occur with opiate use or withdrawal; dilated pupils, with the use of hallucinogens or amphetamines.
Examine the nose for rhinorrhea from opiate withdrawal and the oral and nasal mucosa for signs of drug-induced irritation. Drug sniffing can result in inflammation, atrophy, or perforation of the nasal mucosa. Dental conditions commonly result from the poor oral hygiene associated with chronic drug use. Also inspect under the tongue for evidence of I.V. drug injection.
Inspect the skin. Sweating, a common sign of intoxication with opiates or CNS stimulants, also accompanies most drug withdrawal syndromes. Drug use sometimes induces a sensation of bugs crawling on the skin, known as formication; as a result, the patient’s skin may be excoriated from scratching.
Needle marks or tracks are an obvious sign of I.V. drug abuse. Keep in mind that the patient may attempt to conceal or disguise injection sites with tattoos or by selecting an inconspicuous site such as under the nails. In addition, self-injection can sometimes cause cellulitis or abscesses, especially in the patient who also is a chronic alcoholic. Puffy hands can be a late sign of thrombophlebitis or of fascial infection due to self-injection on the hands or arms.
Auscultation may disclose bilateral crackles and rhonchi caused by smoking and inhaling drugs or by opiate overdose. Other cardiopulmonary signs of overdose include pulmonary edema, respiratory depression, aspiration pneumonia, and hypotension. CNS stimulants and some hallucinogens may precipitate refractory acute-onset hypertension or cardiac arrhythmias. Withdrawal from opiates or depressants also can provoke arrhythmias and, occasionally, hypotension.
During opiate withdrawal, the patient may report abdominal pain, nausea, or vomiting. He may also complain of hemorrhoids, a consequence of the constipating effects of these drugs. Palpation of an enlarged liver, with or without tenderness, may indicate hepatitis.
Neurologic symptoms of drug abuse include tremors, hyperreflexia, hyporeflexia, and seizures. Abrupt withdrawal may precipitate signs of CNS depression (ranging from lethargy to coma), hallucinations, or signs of overstimulation, including euphoria and violent behavior.
Carefully review the patient’s medical history. Suspect drug abuse if he reports a painful injury or chronic illness but refuses a diagnostic workup. In his attempt to obtain drugs, the dependent patient may feign illnesses, such as migraine headaches, myocardial infarction, and renal colic; claim an allergy to over-the-counter analgesics; or even request a specific medication. Also be alert for a history of overdose or a high tolerance for potentially addictive drugs. An I.V. drug user may have a history of hepatitis or human immunodeficiency virus (HIV) infection from sharing dirty needles. A female drug user may report a history of amenorrhea.
A patient who abuses drugs may give you a fictitious name and address, be reluctant to discuss previous hospitalizations, or seek treatment at a medical facility across town rather than in his own neighborhood. If possible, interview family members to verify his responses.
If the patient admits to drug use, try to determine the extent to which this behavior interferes with his normal functioning. Note whether he expresses a desire to overcome his dependence on drugs. If possible, obtain a drug history consisting of substances ingested, amount, frequency, and last dose. Expect incomplete or inaccurate responses. Drug-induced amnesia, a depressed level of consciousness, or ignorance may distort the patient’s recollection of the facts; he also may fabricate answers to avoid arrest or to conceal a suicide attempt.
The hospitalized drug abuser is likely to be uncooperative, disruptive, or even violent. He may experience mood swings, anxiety, impaired memory, sleep disturbances, flashbacks, slurred speech, depression, and thought disorders. He may resort to plays on sympathy, bribery, or threats to obtain drugs, or he may try to pit one caregiver against another.
Psychoactive substances may be used in cultural practices. For instance, some Native Americans use hallucinatory drugs to help achieve spiritual experiences. Therefore, use and abuse must be carefully distinguished.
For characteristic findings in patients with this condition, see Diagnosing substance dependence and related disorders, page 430. Various tests can confirm drug use, determine the amount and type of drug taken, and reveal complications. For example, a serum or urine drug screen can detect recently ingested substances.
Characteristic findings in other tests include elevated serum globulin levels, hypoglycemia, leukocytosis, liver function abnormalities, positive Venereal Disease Research Laboratory test results, positive rapid plasma reagin test results due to elevated protein fractions, an elevated mean corpuscular hemoglobin level, elevated uric acid levels, and reduced blood urea nitrogen levels.
The patient with acute drug intoxication should receive symptomatic treatment based on the drug ingested. Measures include fluid replacement therapy and nutritional and vitamin supplements, if indicated; detoxification with the same drug or a pharmacologically similar drug (exceptions include cocaine, hallucinogens, and marijuana, which aren’t used for detoxification); sedatives to induce sleep; anticholinergics and antidiarrheal agents to relieve GI distress; antianxiety drugs for severe agitation, especially in cocaine abusers; and symptomatic treatment of complications. Depending on the dosage and time elapsed before admission, additional treatment may include gastric lavage, induced emesis, activated charcoal, forced diuresis and, possibly, hemoperfusion or hemodialysis.
Treatment of drug dependence commonly involves a triad of care: detoxification, short- and long-term rehabilitation, and aftercare; the latter means a lifetime of abstinence, usually aided by participation in Narcotics Anonymous (NA) or a similar self-help group.
Detoxification, the controlled and gradual withdrawal of an abused drug, is achieved through substituting a drug with a similar action. Such gradual replacement of the abused drug controls the effects of withdrawal, thereby reducing the patient’s discomfort and associated risks.
Depending on which drug the patient has abused, detoxification may be managed on an inpatient or outpatient basis. For example, withdrawal from depressants can produce hazardous adverse reactions, such as generalized tonic-clonic seizures, status epilepticus, and hypotension. The severity of these reactions determines whether the patient can be safely treated as an outpatient or if he requires hospitalization. Withdrawal from depressants usually requires detoxification because abrupt or poorly managed withdrawal from barbiturates can cause death.
Opioid withdrawal causes severe physical discomfort and can be life threatening. To minimize these effects, chronic opioid abusers commonly are detoxified with methadone.
To ease withdrawal from opioids, depressants, and other drugs, useful nonchemical measures may include psychotherapy, exercise, relaxation techniques, and nutritional support. Sedatives and tranquilizers may be administered temporarily to help the patient cope with insomnia, anxiety, and depression.
After withdrawal, the patient needs to participate in a rehabilitation program to prevent a recurrence. Rehabilitation programs are available for inpatients and outpatients; they usually last a month or longer and may include individual, group, and family psychotherapy. During and after rehabilitation, participation in a drug-oriented self-help group may be helpful. The largest such group is NA.
Focus on restoring the patient’s physical health, educating him and his family about drug abuse and dependence, providing support, and encouraging participation in drug treatment programs and self-help groups.
During an acute episode:
❑ Continuously monitor the patient’s vital signs, and observe for complications of overdose and withdrawal, such as cardiopulmonary arrest, seizures, and aspiration.
❑ Based on standard hospital policy, institute appropriate measures to prevent suicide attempts.
❑ Give medications, as ordered, to decrease withdrawal symptoms; monitor and record their effectiveness.
❑ Maintain a quiet, safe environment during withdrawal from any drug because excessive noise may agitate the patient.
❑ Remove harmful objects from the patient’s room, and use restraints only if you suspect that he might harm himself or others. Institute seizure precautions.
After an acute episode:
❑ Learn to control your reactions to the patient’s undesirable behaviors — commonly, psychological dependency, manipulation, anger, frustration, and alienation.
❑ Set limits for dealing with demanding, manipulative behavior.
❑ Promote adequate nutrition and monitor the patient’s nutritional intake.
❑ Administer medications carefully to prevent hoarding by the patient. Check the patient’s mouth to ensure that he has swallowed the medication. Closely monitor visitors who might supply the patient with drugs.
❑ Refer the patient for detoxification and rehabilitation, as appropriate. Give him a list of available resources.
❑ Encourage family members to seek help whether or not the abuser seeks it. You can suggest private therapy or community mental health clinics.
If the patient refuses to participate in a rehabilitation program, teach him how to minimize the risk of drug-related complications, as follows:
❑ Review measures for preventing HIV infection and hepatitis. Stress that these infections are readily transmitted by sharing needles with other drug users and by having unprotected sexual intercourse.
❑ Advise the patient to use a new needle for every injection or to clean needles with a solution of chlorine bleach and water.
❑ Emphasize the importance of using a condom during intercourse to prevent disease transmission and pregnancy. If necessary, teach the female drug abuser about other methods of birth control. Explain the devastating effects of drugs on the developing fetus.
Read excerpts from these other book chapters related to Laxative abuse:
Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X 
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