Drug Abuse Diagnosis

  • Diagnosis

    Drug abusers use substances to modify their mood or state of mind, even when doing so causes difficulties at work, school, or with relationships, health, or the law. Substance abuse contributes to many social ills, including crime, accidents, and family violence. For example, substance abuse causes impaired judgment, which may lead to the spread of HIV through needle-sharing and trading sex for drugs. Drug-related problems cost an estimated $160 billion or more annually.

    Drug dependence and tolerance are different from drug abuse or addiction. Physical tolerance occurs when a person needs additional amounts of a drug to achieve the same effect as a lower dose had previously caused. Dependence occurs when a person becomes adapted to a drug, and experiences symptoms of withdrawal if the drug is not taken. A dependent person may not be able to control the amount of substance they consume, or be able to stop using the drug. In addition, the unpleasant physical and behavioral withdrawal symptoms often drive them back to using the substance. People can be addicted to drugs, such as cocaine, that do not produce physical dependence. In addition, cancer patients who require increasing amounts of narcotic pain relievers may develop a tolerance, but are not considered to be addicted if they do not exhibit the behavioral symptoms of addiction.

    Tolerance, dependence, abuse, and addiction can occur with over-the-counter, prescription, or illegal substances. Multiple substances are often used in tandem. Drug abusers tend to deny substance-related problems, under-report their intake, and attempt to hide their addictions.

    Drugs that are commonly abused include alcohol and nicotine, marijuana, opiates (heroin and Talwin), psychostimulants (cocaine), sedative-hypnotics (benzodiazepines and barbiturates), hallucinogens (LSD), phencyclidine (PCP), designer drugs (Ecstasy), and inhalants.

    People who abuse one drug are at high risk for abusing other chemical agents. Often drug abusers will use multiple drugs simultaneously. A tolerance for one drug usually causes a tolerance for other drugs in the same class.

    Patients who abuse prescription drugs may take the drugs for different purposes, or more frequently than the doctor prescribed.

    While many people experiment with drugs, not as many make drug use a regular habit.A report by the Substance Abuse and Mental Health Association found that overall illicit drug use, particularly use of marijauna, ecstasy, and heroin has decreased from 11.6% in 2002 to 9.9% in 2005 in youth aged 13-17 years old. Though this shows improvement, it is still alarming to talk about heroin use in teen-agers. The same report showed a very high overall use of prescription drugs, such as tranquilizers and narcotic pain relievers, in teen-agers. The study showed that 6.4 million people aged 12 and older abused prescription drugs in the month that the survey was taken.

    Drug abusers suffer from an array of medical and mental illnesses Table 01. Untreated abusers—health care costs are about twice those of users who have received treatment.

    Anxiety, depression, insomnia, phobias, and emotional and behavioral problems frequently coexist with drug abuse or result from the substance use. Drug abusers are two to four times more likely than non-drug users to have a psychiatric disorder. Patients with a mental illness often use drugs to self-medicate in hopes of limiting their symptoms.

    Table 1.  Medical Illness Associated With Chronic Drug Dependence

    Substance Illness
    Cannabis Respiratory disorders, decreased pulmonary function, possible increased risk of emphysema and pulmonary cardiac arrest, cardiac conduction abnormalities, premature ventricular contractions, decreased sperm count and motility, menstrual abnormalities
    Stimulants Sudden death, cardiac arrhythmias, fibrillation, infarction, hypertensive crisis, hyperthermia, pulmonary edema, physical exhaustion, epistaxis, nasal septum perforation, chronic rhinitis, chronic pulmonary infections, and pulmonary alveolar damage (smoking) with nasal use, systemic infection, endocarditis, central nervous system abscess, granulomas, injection site cellulitis, and blood-borne virally transmitted disease (HIV, hepatitis) with intravenous use
    Opiates Increased risk of tuberculosis, generalized malnutrition, transmission of blood-borne viruses (HIV, Epstein-Barr virus, hepatitis), staphylococcal endocarditis, systemic bacterial infections, foreign body emboli, pulmonary fibrosis, abscess, and injection site fibrosis or abscess with intravenous use

    Neurochemical changes resulting from drug use contribute to addiction and abuse. Addictive drugs create complex changes in the brain's reward system, contributing to physical and psychological dependence, fear of withdrawal, and memory alteration. Cues from this altered reward system stimulate desire for another hit of the drug. Wanting a cigarette after a large meal or after sex are two such examples.

    Some substances possess reinforcing qualities that make them more addictive. Smoking or injecting a drug, for example, typically produce more powerful results than swallowing a pill, making those drugs that are smoked or injected more reinforcing and addicting. However, substances with low-reinforcing qualities frequently become a problem for people with a biological or genetic predisposition to them, or for those who use the substance regularly.

    Easy access, and environmental, psychological, and cultural factors play a role in who starts or continues to abuse drugs. People who become addicted frequently exhibit immaturity, frustration, and difficulty solving problems or relating to people of the opposite sex. These people often lack self-esteem. Addicts frequently have a dependent personality, seeking support from others. Some are prone to rage and uncontrolled behavior.

    Drug abusers and addicts have cravings, and are unable to control their drug use. People with drug problems may hide their drug use and deny its connection to any social, legal, and medical difficulties.Caring family members often push patients to receive treatment.

    Physical and behavioral symptoms depend on the drug taken Table 02. Marijuana (cannabis) creates a sense of well-being and relaxation. It depresses brain activity, making thoughts seem disconnected and uncontrolled. Colors, time, and spatial relations may be distorted during the dreamy state that ensues. Users can feel high or a sense of excitement, often depending on expectations and where and with whom the drug is used. Severe anxiety, panic attacks, disorientation, depression, and auditory hallucinations can occur. Marijuana can also cause an increase in heart rate.

    Opiates such as heroin, Talwin, and other prescription drugs slow breathing and heart rate, lower blood pressure, produce drowsiness, constrict pupils, and cause constipation. They can also produce euphoria. Prescription narcotics relieve pain and can suppress coughs, and are frequently ordered to manage those symptoms.

    Psychostimulants like cocaine produce agitation, restlessness, fast speech, grandiose feelings, irritability, insomnia, dilated pupils, and disordered thoughts. Psychosis, agitation, and paranoia can occur with chronic use. The drug increases blood pressure and heart rate, which can precipitate a heart attack. Seizures, nerve damage, and intestinal damage are also possible.

    Sedative-hypnotics, including benzodiazepines, barbiturates, chloral hydrate, and other drugs cause drowsiness, decreased alertness, disorientation, lowered inhibitions, unsteady gait, and slurred speech. The drugs can cause reactions opposite of their intended action, resulting in irritability, combativeness, destructive behavior, and rapid emotional shifts. Doctors prescribe benzodiazepines to treat anxiety and insomnia; however, barbiturates are rarely ordered anymore.

    Hallucinogens such as LSD distort users' perceptions, and can cause extreme anxiety, agitation, and a feeling of losing control. The drug can cause psychosis, especially in users with an underlying psychiatric problem. Days, months, or years after ingestion, hallucinogen users may suffer from flashbacks—brief alterations in perception similar to those experienced while on the drug.

    Phencyclidine, known as PCP or angel dust, produces strange behavior, confusion, delirium, and an agitated, violent state. Users' blood pressure may increase, and muscle tremors can occur.

    Designer drug MDMA, or Ecstasy, can cause hallucinations. It is thought to be toxic to the nervous system. Produced by altering amphetamine compounds, designer drugs can also cause increased alertness and a feeling of euphoria.

    Inhaling fumes from common household products can produce intoxication, dizziness, drowsiness, confusion, an unsteady gait, and slurred speech that lasts for a few minutes or longer. Inhaling fumes can be deadly because of resulting changes in breathing and heart rate.

    Table 2.  Symptoms of Substance Abuse By Drug

    Substance Intoxication symptoms Withdrawal symptoms Long-term effects
    Cocaine Tachycardia, hypertension, pyrexia, euphoria, hyperactivity, rapid speech, hallucinations, agitation Dysphoria, agitation, insomnia, fatigue Impotence, gynecomastia, menstrual irregularities
    Cannabis Euphoria, conjunctival injection, dry mouth, impaired motor function, increased appetite, paranoia, anxiety, derealization, hallucinations Tremor, nystagmus, sweating, vomiting, diarrhea, decreased appetite Depression, anxiety, amotivational syndrome, memory impairment, decreased sperm count and impaired motility, decreased pulmonary capacity
    Phencyclidine Psychomotor agitation, amnesia, tachycardia, hypertension, incoordination, derealization, depersonalization, sweating, nystagmus, catatonic-like behavior ? Psychosis
    Sedatives Sedation, euphoria, slurred speech, disorientation, irritability, nystagmus Anxiety, dysphoria, agitation, insomnia, nausea, sweating, depression Depression, delusions
    Opiates Nausea, vomiting, miosis, anorexia, constipation, sedation, euphoria, respiratory depression, orthostatic hypotension Yawning, lacrimation, irritability, anxiety, insomnia, papillary dilation, muscle cramps, nausea, vomiting, hot/cold flashes, tachycardia, tachypnea, fever Endocarditis, hepatitis
    Hallucinogens Tachycardia, sweating, pyrexia, hypertension, dry mouth, decreased appetite, hallucinations ? Schizophrenia, depression, anxiety, flashbacks, memory problems

    Gender, a history of mental problems, and a family history are risk factors for drug abuse. Men are more likely to abuse drugs than are women. Women and older adults use more benzodiazepines, and young adults may take Ecstasy at "rave" dance parties. Patients in chronic pain and those in medical professions tend to be at higher risk for opiate addiction. Illegal drug use is higher in the Western states than in the Northeast.

    Experimentation with drugs typically begins during or before adolescence. Some experts believe that marijuana, alcohol, and nicotine serve as a gateways to the use of heroin, cocaine, and other "harder" drugs.

    Your physician will ask questions to determine if you are having difficulty controlling drug use, if you are timing prescription doses inappropriately, or if you are having problems with productivity, family relationships, physical dependence, or tolerance.

    Your doctor will perform a physical examination, looking for signs of nervousness, irritability, tremors, incoordination, poor personal hygiene, and other signs that might indicate drug abuse. Murmurs and other abnormal heart sounds may indicate the presence of or potential for endocarditis secondary to intravenous drug use. Your doctor will also listen for abnormal chest sounds, as substance users are at risk for pneumonia. Abnormal lung sounds may also result from chronic cannabis use. The doctor will also examine a patient for sexually transmitted diseases, as drug abusers may participate in risky behavior such as unprotected sexual intercourse.

    Routine toxicology screenings are sometimes helpful in identifying drug use. Toxicology screening sometimes aids in detecting drug use, but is helpful only while the drug or its byproducts remain in the system. Some drugs leave the body within 24 hours. Therefore, a toxicology report may not identify substance use.

  • Prevention and Screening

    Routine toxicology screenings are sometimes helpful in identifying drug use. Toxicology screening sometimes aids in detecting drug use, but is helpful only while the drug or its byproducts remain in the system. Some drugs leave the body within 24 hours. Therefore, a toxicology report may not identify substance use.

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