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Prevalence of patients in primary care that have a problem related to alcohol use


Prevalence of hospital in-patients with a history of alcohol abuse or alcohol dependence


Low-risk drinking (men)

Total of 12 in the entire week
Single occasion no more than 4
Days each week when you don't drink alcohol
No alcohol when driving, when a health problem could be made worse, when alcohol could interact with a medication

Low-risk drinking (women)

Total of 9 in the entire week
Single occasion no more than 3
Days each week when you don't drink alcohol
No alcohol when pregnant, driving, when a health problem could be made worse, when alcohol could interact with a medication

Percent of men who meet criteria for alcohol/illicit drug dependence


Percent of women who meet criteria for alcohol/illicit drug dependence



A primary, chronic disease characterized by impaired control over the use of a psychoactive substance or behaviour
Clinically the manifestations occur along biological, social and spiritual dimensions
Like other chronic diseases, it can be progressive, relapsing and fatal
Common features are change in mood, relief from negative emotions, provision of pleasure
Preoccupation with the use of substances or ritualistic behaviour
Continuted use of substances and/or engagement in behaviour despite adverse physical, psychological and/or social consequences

Substance abuse

Maladaptive pattern of use leading to clinically significant distress - at least one of:
-Failure to fulfill major role obligations at work, school or home
-Use in situations where it is physically hazardous
-Recurrent substance-related legal problems
-Continued use despite social or interpersonal problems caused by the effects of substance use

Substance dependence

Maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by 3 or more of the following over a 12 month period:
-Taken in larger amounts over a longer period of time
-Persistent desire or unsuccessful efforts to cut down or control substance use
-Great deal of time is spent in activities necessary to obtain substances, use substances, or recover from their effects
-Important activities are given up or reduced because of alcohol
-Substance use is continued despite knowledge of having a problem is likely have been caused or exacerbated by it

3 Cs of addiction

Loss of control
Compulsion to use or preoccupation with using or craving
Continued use despite consequences

When to screen for substance dependence or abuse

At annual physical
When a patient presents with any symptom which could be related to drug or alcohol use

CAGE screening tool

Felt you should Cut down?
Feel Annoyed by people criticizing you about your drinking?
Felt bad or Guilty about drinking?
Ever had an Eye-opener drink?


For pregnancy
T - tolerance (how many drinks until you are drunk? +ve if >2)
A - annoyed by people criticizing your drinking?
C - felt like you should Cut down?
E - eyeopener to steady nerves

Inquiries about drug use

Don't make assumptions based on age.
Ask about marijuana, cocaine/crack, valium, T3s and other opiates
E, Meth

Taking a consumption history

Frequency and quantity
Drug use
Pattern of use
Consequence of use

Obstacles to admitting dependence

Denial, minimalization, rationalization (delusional?)
Shame, guilt, fear
Blackouts and dementia (collateral information useful)

Symptoms of substance abuse

Gastritis, ulcers, GI bleeds, pancreatitis, liver disease
Heachages, codeine dependence, peripheral neuropathy, seizures
Hypertension, palpitations due to tachycardia or arrhymia, cardiomyopathy, endocarditis, MI
Pneumonia, chronic cough or rhinitis (cocaine)
Menstrual irregularities

Psychiatric symptoms

Hallucinations (from withdrawal)
Paranoia (cocaine at met-amphetamines)

Substance abuse cycles

Euphoric when using, but withdrawn when going through withdrawal.
Use to escape life problems, but then leads to more problems and can't quit

Determining comorbid psychiatric disorders

Best assessed when at least 3-4 weeks abstinent

Prevalence of comorbid conditions with alcoholism

37% people with SA had current or previous psych disorder
21% lifetime prevalence drug disorder

Prevalence of comorbid conditions with drug disorder

53% prevalence of psych disorder
47% lifetime prevalence of alcohol disorder

Signs of substance abuse

Track marks, abscess at injection site
Damaged nasal cartilage
Skin excoriations with met-amphetamines
Signs of liver disease
Signs of withdrawal

Signs of mild alcohol withdrawal

Agitation, tremor, tachycarida, hypertension, nausea, elevated temp and sweating
Onset within a few hours of last drink peak at 24-36 hours

Moderate alcohol withdrawal

More severe symptoms of sympathetic NS activity plus seizures (onset 7-48 hours, occur in 5-15%)
alcoholic hallucinosis (onset 24 hours - several days, 3-10%

Severe alcohol withdrawal

Delirium tremens. Occurs in up to 5%. Onset 3-4 days
Severe sympathetic system hyperactivity plus agitation, disorientation, confusion and hallucinations

Alcohol withdrawal mortality rate

1-5%, up to 10% for those with severe

Treating alcohol withdrawal

Symptoms monitored hourly, treatment given according to severity
Thiamine 100 mg to prevent Wernike-Korsakoff syndrome
Haloperidol (for psychosis)


Must be given prior to any glucose

BZD withdrawal

Tremour, anxiety, insomnia, tachycardia
Severe - seizure, psychosis

Treating BZD withdrawal

Gradual tapering off with long-acting BZD - Diazepam or clonazepam (reduce by 10-25% per week)

Opiate withdrawal

Headache, nausea, vomiting, cramps and diarrhea
Bone pain
Chills, sweats, piloerection
Anxiety, emotional liability, craving
Not fatal!

Treating opiate withdrawal

Tapering does of long-acting opiate
Methadone maintenance long term

Stimulant withdrawal

Fatigue, hypersomnia, agitation, depression, increased appetite, drug craving

Stimulant withdrawal treatment

Emotional support, avoidance of triggers for cravings, antidepressants

Treatment for SA

Rehab programs are effective
-Motivational enhancement therapy, CBT
-Long term programs

Treating alcoholism



Shows reduced rate of relapse, better tolerated than naltrexone (fewer side effects)

Use of SSRIs

Might just be treating comorbid depression

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