Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page i SUBSTANCE USE DISORDERS A Practical Guide Second Edition Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page ii Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page iii SUBSTANCE USE DISORDERS A Practical Guide Second Edition Stuart Gitlow M.D.,M.P.H.,M.B.A. Director, Annenberg Physician Training Program in Addictive Disease Assistant Clinical Professor of Psychiatry Mount Sinai School of Medicine New York, New York Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page iv Publisher and Executive Editor: Charles W. Mitchell Senior Managing Editor: Lisa R. Kairis Project Manager: Jennifer Harper Manufacturing Coordinator:Kathleen Brown Associate Director of Marketing:Adam Glazer Creative Director: Doug Smock Production Services: International Typesetting & Composition Printer:R.R. Donnelley, Crawfordsville ©2007 by LIPPINCOTT WILLIAMS & WILKINS, a Wolters Kluwer business 530 Walnut Street Philadelphia,PA 19106 USA LWW.com 1stedition, ©2001 Lippincott Williams & Wilkins All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in the USA Library of Congress Cataloging-in-Publication Data Gitlow, Stuart. Substance use disorders : a practical guide / Stuart Gitlow.—2nd ed. p. ; cm.—(Practical guides in psychiatry) Includes bibliographical references and index. ISBN-13: 978-0-7817-6998-3 ISBN-10: 0-7817-6998-1 1.Substance abuse—Treatment—Handbooks, manuals, etc. I.Title. II.Series. [DNLM: 1.Substance-Related Disorders—Handbooks. WM 34 G536s 2006] RC564.15.G58 2006 616.86—dc22 2006019921 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner. The author and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800)638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams&Wilkins on the Internet:at LWW.com. Lippincott Williams&Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1 Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page v To my father, who along with Drs. Marvin Block, Max Weisman, LeClair Bissell, and many other experts in the field, helped form my initial impressions and opinions about substance use. To my wife, Heather, who was again willing to watch me sit at my Macintosh into the wee hours of the morning for so many months. To my son, Jaden, who despite the traditional two-year-old’s repeated efforts to firmly push every button on the keyboard simultane- ously, managed to fail in his attempts to delete this entire textbook. And to Bill and Cathy, thank you for teaching me so much about the successes and failures that are both possible while treating any substance use disorder. v Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page vi Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page vii Contents Foreword by Mark S. Gold . . . . . . . . . . . . . . . . . . . . . . . . ix Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Read Me First . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix SECTIONI GENERAL PRINCIPLES OF SUBSTANCE USE DISORDERS . . . .1 1. An Initial Approach . . . . . . . . . . . . . . . . . . . . . . . 2 2. Types of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3. The Substance Use Disorders . . . . . . . . . . . . . . . . 20 4. Screening Techniques . . . . . . . . . . . . . . . . . . . . . . 44 5. The First Interview . . . . . . . . . . . . . . . . . . . . . . . 50 6. Outpatient Logistics . . . . . . . . . . . . . . . . . . . . . . . 64 7. Laboratory Studies . . . . . . . . . . . . . . . . . . . . . . . . 73 SECTIONII SUBSTANCE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . .85 8. Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 9. Other Sedatives . . . . . . . . . . . . . . . . . . . . . . . . . .100 10. Sedative Detoxification . . . . . . . . . . . . . . . . . . . . .113 11. Medications During Sedative Recovery . . . . . . . . .124 12. Nicotine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 13. Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 14. Opiates/Opioids . . . . . . . . . . . . . . . . . . . . . . . . . .164 15. Opioid Detoxification . . . . . . . . . . . . . . . . . . . . . .173 16. Opioid Maintenance Programs . . . . . . . . . . . . . . .178 17. Marijuana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186 18. LSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195 19. Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200 20. Substance-Induced Disorders . . . . . . . . . . . . . . . .207 vii Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page viii viii Contents SECTIONIII SUBSTANCE USE TREATMENT . . . . . . . . . . . . . . . . . . .215 21. Treatment Settings . . . . . . . . . . . . . . . . . . . . . . . .216 22. Twelve-Step Programs . . . . . . . . . . . . . . . . . . . . .224 23. Relapse Prevention . . . . . . . . . . . . . . . . . . . . . . . .234 24. Who Treats Substance Use? . . . . . . . . . . . . . . . . .244 25. Treatment Dilemmas . . . . . . . . . . . . . . . . . . . . . .248 26. Patient Placement Criteria . . . . . . . . . . . . . . . . . .260 27. Spirituality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .271 ENDNOTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .279 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .281 A. Standardized Examinations . . . . . . . . . . . . . . . . . . . .282 • CAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 • AUDIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 • MAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 • CIWA-Ar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 • CIWA-B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 • CINA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 • CRAFFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 • Fagerstrom Test for Nicotine Dependence . . . . . . . . . . . . . 293 • CAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 B. Published Resources . . . . . . . . . . . . . . . . . . . . . . . . .297 C. Alcoholism and Drug Abuse Counselor State Certification and Licensing Boards . . . . . . . . . . . . . .299 D. Controlled Substances Act . . . . . . . . . . . . . . . . . . . .308 E. Useful Web Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . .311 SuggestedReadings&Citations . . . . . . . . . . . . . . . . . . . .313 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .319 Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page ix Foreword Alcohol and the American experience began at the beginning of European colonization. With imported alcohol, widespread locally brewed beer, spirits, an active trade in rum, ciders, moonshine and so on, the colonists were regularly drinking to excess. John Adams, during the 1760s, expressed fears about abusive consumption of alcohol, but it was Dr. Benjamin Rush, an ardent republican, revolutionary, signer of the Declaration of Independence, Pennsylvania delegate, and Continental army surgeon general who defined the problem. His publications earned him the title of “Father of Psychiatry,” but he was best known for “Inquiry,” an essay on alcohol consumption. In this radical piece, Dr. Rush did not actually call for total abstinence, but he did call for temperance. He went on to clearly report that alcohol abuse could destroy health and cause death. He also described addiction and identified alcohol as an addictive substance. Rush clearly described alcohol as an acquired appetite with persistent craving and preoccupation. He made the case that addiction was like a disease and that the alcohol victim was helpless to resist due to the loss of control over alco- hol. Rush made a clear association between a substance and the disease of addiction. He accurately described and anticipated the DSM-IV description of alcohol dependence. Currently, the American Psychiatric Association and the American Medical Association recognize alcohol dependence as a chronic and progressive disease that if left untreated often results in death. Physicians are in the ideal position to identify the substance use disorder or disorders, diagnose and facilitate the treatment process including intervention, group and other therapy, and use relapse preventing strategies and medications. Failure to diagnose and offer an appropriate clinical response to the patient is commonly attributed to lack of physician time or interest. However, we have recently presented data that demonstrates that physicians are interested in making an early diagnosis but lack competency in alcohol-related issues. Columbia University’s CASA has also recently reported that physicians fail to identify the simplest of drug abuse and dependence scenarios. Recent studies suggest that primary care physicians miss problem drinkers and treat chief complaints and symptoms 98% of the time. Dr. Gitlow has put together a practical guide that speaks to physicians in a language that they can understand. With an easy style and years of experience from early childhood dinner conversations to the present day, Gitlow has developed a visceral understanding of abuse and ix Gitlow-fm-i-xxii.qxd 8/21/06 17:21 Page x x Foreword addiction so compelling that he can actually explain it to col- leagues without jargon and in a form that can be used from day one. His guidebook or manual should be kept handy and referred to often. Each chapter can be read as a stand-alone synopsis of current thinking and practical tips for evaluation, treatment, or management. Alcohol is clearly the model addic- tive illness and serves as the anchor for much of this excep- tional text. However, sedative detoxification, tobacco smoking, stimulants, opiates, marijuana, LSD, and club drugs are easily summarized by him on the basis of a firm understanding of the literature and practical experiences with each. Alcohol depen- dence or alcohol addiction, like other drug dependencies, is a primary and chronic disease. As in the first edition, this edition does not overestimate the effects of medications in the treat- ment of alcohol dependence or other addictions. Dependence on alcohol is not a symptom of another physical or mental con- dition, but a disease in itself, like cancer or heart disease, with a very recognizable set of symptoms that are shared by people with alcoholism and that separates them from others without the disease and places them at a great disadvantage in daily liv- ing. The common features of addictive diseases are emphasized in the way that makes his descriptions of medical treatments, treatment settings, patient placement, relapse, legal issues, and spirituality apply to all addicts and those who try to help them. The addiction psychiatrist has a special place in evaluating substance-related and independent mood disorders. Depres- sion can result from alcoholism, exacerbate alcoholism, and be unrelated to alcoholism. Depression can also cause alcohol problems to increase. Alcohol use can make depression worse and can provoke a relapse in depressed patients who had been successfully treated. Psychiatric symptoms in patients with alcoholism may be temporally or medically related to acute intoxication, active disease, withdrawal, detoxification, and recovery. Depressive symptoms can be caused by alco- holism or drug addiction. Depression can be exacerbated by alcoholism or drug addiction. Most alcoholics entering treat- ment will exhibit significant depressive symptoms. The con- cept of depression as a primary cause for alcoholism is not new. However, no studies have shown that depressive disor- ders actually cause alcoholism. Clinicians suggest that alco- holism and depression are among the most common psychi- atric diseases and most commonly seen in the same patients at the same time. Major depression and alcoholism are the most commonly diagnosed psychiatric disorders in patients who commit suicide.