AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

Physicians in the emergency department (ED) regularly encounter patients seeking treatment for alcohol or substance abuse problems. The initial evaluation may seem routine, yet these patients have multiple physical and emotional issues that should be addressed. The emergency physician (EP) should strive to identify patients who might benefit from appropriate referrals for drug and alcohol problems. The ED may be the initial or only point of contact with the health care system for these patients.

Substances of abuse include alcohol, cocaine, opiates, amphetamines, and hallucinogens. This article provides a brief review of the physiologic effects of these substances as well as the signs and physiologic effects of withdrawal with which the caregiver should be familiar. More detailed information can be obtained from the specific articles on each substance (see Toxicity, Alcohols; Toxicity, Cocaine; Toxicity, Amphetamine; Toxicity, Hallucinogen; Toxicity, Narcotics).

Alcohol

Alcohol is a CNS depressant. In low doses, alcohol acts primarily on inhibitory centers. Resultant disinhibition may lead to out-of-character activities (eg, dancing with a lampshade on the head, blurting out a long-held confidence). At higher doses, alcohol inhibits excitatory centers. People may show effects ranging from impairment of rational thinking to absence of motor coordination. Physiologic effects of chronic alcohol use include the following:

• Gastrointestinal - Cirrhosis of the liver, peptic ulcer disease, gastritis, pancreatitis, and carcinoma
• Cardiovascular - Hypertension and cardiomyopathy
• Neurological - Peripheral neuropathy leading to ataxia, Wernicke encephalopathy, Korsakoff psychosis, and structural changes in the brain leading to dementia
• Immunologic - Suppression of neutrophil function and cell-mediated immunity
• Endocrine - In males, increase in estrogen and decrease in testosterone, leading to impotence, testicular atrophy, and gynecomastia
• Obstetric - Fetal alcohol syndrome (ie, mental retardation, facial deformity, other neurologic problems)
• Psychiatric - Depression or anxiety disorders

Opiates

Heroin is by far the most commonly abused opiate. Other drugs of abuse in this category include methadone, morphine, codeine, oxycodone, fentanyl (China white), and black tar (a potent form of heroin). Signs of intoxication are decreased respiratory rate and pinpoint pupils. Complications of chronic use are primarily infectious and include skin abscess at an injection site, cellulitis, mycotic aneurysms, endocarditis, talcosis, noncardiogenic pulmonary edema, HIV, and hepatitis. Snorting of heroin is a recent trend that has expanded its user base in many areas.

Cocaine

Cocaine may be smoked, inhaled, used topically, or injected. Acute cocaine intoxication may present with tachycardia, tachypnea, hypertension, and diaphoresis. Complications of acute and chronic use can include myocardial ischemia or infarction, stroke, pulmonary edema, and rhabdomyolysis.

Amphetamines

Acute intoxication with amphetamines presents with signs of sympathetic nervous system stimulation, tachycardia, hypertension, anorexia, insomnia, and occasionally seizures.

Hallucinogens

Different hallucinogens present with a variety of organ system effects. Phencyclidine (PCP) has been known to cause muscle rigidity, seizures, rhabdomyolysis, and coma. Anticholinergics have been associated with delirium, supraventricular tachycardia, hypertension, and seizures. Other hallucinogens (eg, lysergic acid diethylamide [LSD], peyote, marijuana, nutmeg) rarely cause significant physical complications.

EPIDEMIOLOGY

Section 3 of 9  

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

Quantitative information on the prevalence of substance abuse is difficult to obtain because of the unwillingness of abusers to accurately disclose consumption. Surveys are taken routinely in high schools and door-to-door in communities, but complete figures are not available.

Alcohol use reportedly has been on the decline in recent years. Reports indicate that roughly two thirds of all adults drink alcohol occasionally. Approximately 13% of people in the US are alcoholics, and 1 person in 5 who uses alcohol for recreational purposes becomes dependent for some period of time. Studies performed in urban EDs indicate that up to 20% of patients may have problems with alcohol, with the highest rate in patients who present late at night.

In contrast to alcohol use, heroin use is rising. Estimates place the number of heroin users in the US at 750,000.

Heavy cocaine use has remained fairly steady since its peak in the late 1980s and early 1990s, with an estimated 600,000-700,000 regular users.

On the rise in rural communities is methamphetamine, also knows as crystal meth. It is easily manufactured as the base ingredient is over the counter cold medication. It is found to be abused most often in the 15- to 25-year-old age bracket.

CLINICAL

Section 4 of 9  

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

The 3 components of ED evaluation for persons seeking treatment for a substance abuse problem or those confirmed to have such a problem while in the ED are (1) assessment of the need for treatment, (2) placement into appropriate treatment, and (3) determination of physical suitability for treatment.

Assessment

In assessing need for treatment, keep in mind that patients frequently underestimate their consumption. This underestimation may be attributed to denial, one of the hallmarks of the disease process of substance abuse. Question patients about their drug or drugs of choice and the frequency, amount, and method of use. Obtain information on prior detoxifications, concomitant use of other substances, date of first use, and time interval from last use. Most physicians know and employ the CAGE questioning technique as follows:

• 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 to get rid of a hangover?

A single positive response to the CAGE questions is considered suggestive of an alcohol problem, and 2 or more positive responses indicate the presence of such a problem with a sensitivity and specificity approximately 90% in most studies. One report indicated that the CAGE questions are best applied if not preceded by questions attempting to quantify alcohol intake.

These questions may not accurately indicate abuse problems when universally applied across gender and cultural lines. For example, the CAGE score has been shown less accurate in white females; therefore, attempt to gather a complete picture of the patient rather than completely relying on this questioning technique. Several other screening methods exist, with the brief Michigan Alcohol Screening Test (MAST) the most widely used screen suitable for ED use.

One very brief modification of the MAST, which has a reported sensitivity of 91%, requires a positive response to 1 of the following 2 questions:

• Have you ever had a drinking problem?
• When was your last drink? (<24 h = positive response)

The TWEAK screen has been recommended for white females, and a score of 3 or higher indicates an alcohol problem. The TWEAK involves the following questions:

• Tolerance (2 points): How many drinks can you hold? (Six or more indicates tolerance.)
• Worried (2 points): Have close friends or relatives worried or complained about your drinking in the past year?
• Eye openers (1 point): Do you sometimes take a drink in the morning when you first get up?
• Amnesia (1 point): Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
• [K] Cut down (1 point): Do you sometimes feel the need to cut down on your drinking?

Frequent injury and injury while drinking also should prompt screening for alcohol abuse.

Placement

Placement into the appropriate treatment program ultimately is the responsibility of the detoxification specialist who follows the patient during rehabilitation. The specialist's initial decisions may be based in large measure on the information gathered by the EP's assessments.

The physical examination should be a complete assessment of the patient; this population is much less likely to have regular medical care than the general population. The EP must be aware of the specific symptoms of withdrawal from various substances.

• Alcohol withdrawal
  
  
  • Many alcoholics experience "the shakes" approximately 12-24 hours after their last drink. The shakes are tremors caused by overexcitation of the CNS.
  • Tremor may be accompanied by tachycardia, diaphoresis, anorexia, and insomnia.
  • After 24-72 hours, the alcoholic may have rum fits (ie, generalized seizures).
  • Delirium tremens (DT) begins 3-5 days after the last drink. DT is characterized by disorientation, fever, and visual hallucinations.
  • DT is a medical emergency and should be treated on an inpatient basis.
• Opioid withdrawal
  • Withdrawal symptoms from opioids may begin just a few hours after last use.
  • Along with a strong craving for the drug, opioid withdrawal produces yawning, tears, diarrhea, abdominal cramping, piloerection, and rhinorrhea.
  • Symptoms of withdrawal usually peak around 48 hours and again at 72 hours.
  • Withdrawal usually subsides after 1 week, but some heavily dependent users may have mild symptoms for up to 6 months.
  • Although physically uncomfortable, opioid withdrawal is not life threatening.
• Amphetamine withdrawal
  • Withdrawal is fairly mild.
  • Patients may complain of depression, increased appetite, abdominal cramping, diarrhea, and headache.
• Cocaine and hallucinogen withdrawal
  • Cocaine and hallucinogens do not have a typical withdrawal pattern.
  • These drugs are considered psychologically addicting rather than physically addicting.

DIFFERENTIAL DIAGNOSIS

Section 5 of 9  

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

Myocardial Infarction

Congestive Heart Failure and Pulmonary Edema

Other Problems to be Considered

Seizure disorder

WORKUP

Section 6 of 9  

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

No specific laboratory studies are indicated for the patient seeking detoxification, unless interview or examination suggests the need. In the patient with acute intoxication, a screen for substances of abuse and a blood or breath alcohol level may be considered, but these generally do not alter management. Consider electrolytes, glucose, BUN, and creatinine because of the dehydration and poor nutrition observed in this population. A CBC may be sent if GI bleeding, anemia, bone marrow suppression, or infections are concerns. Complications of cocaine intoxication may require a cardiac or CNS evaluation that may include an ECG and brain CT scan.

Dependence on laboratory abnormalities (eg, elevated mean corpuscular volume of red blood cells, abnormal liver enzymes) to confirm the diagnosis of alcoholism causes the physician to miss the majority of patients with the disease; therefore, the physician should query patients with such abnormalities to determine if substance abuse is an issue.

A patient with an alcohol addiction may require vitamin supplementation with thiamine (200 mg), folic acid (1 mg), and a multivitamin. If the patient develops agitation or tremulousness, benzodiazepines may be needed.

TREATMENT AND REHABILITATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

Personnel in a detoxification center perform definitive treatment. Substance abuse is a life-long disease that only can be controlled, not cured. In the detoxification center, treatment initially consists of managing the varied symptoms of withdrawal, which can range from a longing to reuse to hallucinations and seizures. Once physical withdrawal is complete, group and individual counseling begins and continues on an inpatient, outpatient, and group support basis (eg, Alcoholics Anonymous, Narcotics Anonymous).

For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center and Substance Abuse Center. Also, see eMedicine's patient education articles Alcoholism, Alcohol Intoxication, Drug Dependence and Abuse, Narcotic Abuse, and Substance Abuse.

ACKNOWLEDGMENTS

Section 8 of 9  

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Michael C Plewa, MD, to the development and writing of this article.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Epidemiology
• Clinical
• Differential Diagnosis
• Workup
• Treatment and Rehabilitation
• Acknowledgments
• References

• Alcoholism and Drug Addiction Research Foundation, Toronto. ARF: Facts About Opiates. 1991.
• Bates ME. Stability of neuropsychological assessments early in alcoholism treatment. J Stud Alcohol. Nov 1997;58(6):617-21. [Medline].
• Bradley KA, Boyd-Wickizer J, Powell SH, Burman ML. Alcohol screening questionnaires in women: a critical review. JAMA. Jul 8 1998;280(2):166-71. [Medline].
• Cherpitel CJ. Comparison of screening instruments for alcohol problems between black and white emergency room patients from two regions of the country. Alcohol Clin Exp Res. Nov 1997;21(8):1391-7. [Medline].
• Coleman P. Overview of substance abuse. Prim Care. Mar 1993;20(1):1-18. [Medline].
• Cyr MG, Wartman SA. The effectiveness of routine screening questions in the detection of alcoholism. JAMA. Jan 1 1988;259(1):51-4. [Medline].
• Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. Oct 12 1984;252(14):1905-7. [Medline].
• Havranek EP, Spertus JA, Masoudi FA, et al. Predictors of the onset of depressive symptoms in patients with heart failure. J Am Coll Cardiol. Dec 21 2004;44(12):2333-8. [Medline].
• Ivis FJ, Bondy SJ, Adlaf EM. The effect of question structure on self-reports of heavy drinking: closed-ended versus open-ended questions. J Stud Alcohol. Nov 1997;58(6):622-4. [Medline].
• Lamberg L. New tactics help curb adolescent substance abuse and dependence. JAMA. Aug 15 2007;298(7):729-30. [Medline].
• Lapham SC, C'de Baca J, McMillan G, Hunt WC. Accuracy of alcohol diagnosis among DWI offenders referred for screening. Drug Alcohol Depend. Nov 11 2004;76(2):135-41. [Medline].
• Luttrell S, Watkin V, Livingston G, et al. Screening for alcohol misuse in older people. Int J Geriatr Psychiatry. Dec 1997;12(12):1151-4. [Medline].
• Pokorny AD, Miller BA, Kaplan HB. The brief MAST: a shortened version of the Michigan Alcoholism Screening Test. Am J Psychiatry. Sep 1972;129(3):342-5. [Medline].
• Rund DA, Summers WK, Levin M. Alcohol use and psychiatric illness in emergency patients. JAMA. Mar 27 1981;245(12):1240-1. [Medline].
• Schuckit MA, Smith TL, Danko GP, et al. Prospective Evaluation of the Four DSM-IV Criteria for Alcohol Abuse in a Large Population. Am J Psychiatry. Feb 2005;162(2):350-60. [Medline].
• Steinweg DL, Worth H. Alcoholism: the keys to the CAGE. Am J Med. May 1993;94(5):520-3. [Medline].
• Volk RJ, Cantor SB, Steinbauer JR, Cass AR. Item bias in the CAGE screening test for alcohol use disorders. J Gen Intern Med. Dec 1997;12(12):763-9. [Medline].

Article Last Updated: Nov 1, 2007