Drug Abuse Medical Examination

This is how to take a medical examination for drug abuse, including legal and illegal drugs.
Two terms to note are Substance Dependence and Substance Abuse.

Substance dependence

                        - 3 or more are required to fulfill the diagnosis of substance dependence:
                                    - tolerance (physical dependence)
                                    - withdrawal (physical dependence)
                                    - use more than intended
                                    - inability to cut down
                                    - preoccupied with use
                                    - responsibilities and activities, such as work are neglected
                                    - continued use despite consequences

Substance abuse

           
Substance abuse occurs when there is an impact on the patient’s life and functioning, but the dependence criteria have not yet been met.

                        1. maladaptive behaviour leading to:
                                    - recurrent use
                                    - recurrent legal problems
                                    - social and personal problems
                                    - neglect of obligations
                        2. never met criteria of dependence

Commonly Abused Substances

Legal Abused Substances: alcohol, sedatives, hypnotics, anxiolytics, caffeine, nicotine, opiods
            Illegal Abused Substances: cannabis, hash, amphetamines, hallucinogens, cocaine, opiods, pcp

Drug Presentations

Withdrawal symptoms: intense drug craving and drug seeking behaviour, nausea, vomiting, sweating, myalgias, abdominal pain, headache, rhinorrhea, fever, tremor, tachycardia, hypertension, and emotional disturbances such as depression, mania

Seizures, disorientation, slurred speech, poor mental functiong, poor concentration, sleep disturbances can also been seen.
           
Infectious manifestations: lung abscess, bacterial endocarditis, skin infections, and hiv and hepatitis signs and symptoms

The first presenting sign is often TRAUMA.

Medical Examination of Drug Abuse History

Identifying data
Chief complaint
OPPQRS mnemonic
Add portions of Review of Systems that could help with drug abuse history, such as general review, for nausea and vomiting, headaches, neurological and cardiovascular review of systems, etc…

Social history
Family situation, employment and work situation, living situation, finances, education, legal problems, the presence of friends and/or a support network

Family History
Family history of abuse, psychiatric disorders

Past Psychiatric History

Screen for
- depression
- suicidal ideation
- safety issues (immediate risk of danger of patient as well as others)
- anxiety
- other high risk behaviours (intravenous drug use and needle sharing, hiv, prostitution, safe sex acts)

In depth medication and drug use history, such as

Drug Abuse History

Ask about use of
            - medications
            - alcohol
            - smoking
- recreational drug use

Asking about recreational drug use can be difficulty. One easy way is by asking, “Have you ever used drugs other than those required for medical reasons?”

Try to get more information on the drug use, such as:
“What types of drugs used?
Age started using?
When was your period of heaviest use?

Did this coincide with any part of your life?

Ask about the current pattern of use?
Who with?
What drugs?
Where used?
When and how often?
Why do you take the drugs (motivations)?
When last used?
Are larger doses needed to get same effect (tolerance)?
What happens when you don’t take the drug (withdrawal)?
Have you ever tried to quit? How willing are you to consider treatment?

Physical Examination for Drug Abuse:

General Appearance: malnutrition, track marks on arms,
- vitals
- head and neck
- cardiovascular
- pulmonary
- abdominal
- neurological

Investigations:

- labs: cbc, liver function tests, renal function tests, tsh, hiv and hepatitis serology, toxicology  screen
- urine toxicology screen

Management:

Complex and depends on drug being used, pattern of use, patient characteristics, desire to change.

Options include:

- self-help groups
- harm reduction e.g. methadone clinics
- cognitive behavioural therapy
- aversion therapy
- medical
- naloxone (narcan) – immediate opiate antagonist e.g. respiratory depression
- flumazenil – immediate benzodiazepine antagonist
- naltrexone – long acting opiate antagonist
- blocks positive reinforcement from opiods, alcohol also.
- long-acting benzodiazepine (diazepam) – for alcohol withdrawal symptoms
- substitution pharmacotherapy
- nicotine patch, methadone
- antidepressants