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Diagnosis and Treatment of Drug Abuse in Family Practice

Introduction
 

Abuse of drugs (including alcohol and tobacco) is the number one cause of preventable illness and death in the United States [1]. In the past 15 years, the ever-increasing number of cases of acquired immunodeficiency syndrome (AIDS) has forced the medical consequences of substance abuse into the public's consciousness. Yet AIDS is only the highly visible tip of an enormous iceberg. Each year, more than 500,000 deaths - or over one in four - in the United States are attributable to abuse of alcohol, tobacco or other drugs [2].

Equally devastating is the morbidity caused by the use of illegal and legal drugs (Table 1 below). In terms of demands on health care resources and loss of productivity, the cost of substance abuse is tremendous, whether attributable to cancer and cardiopulmonary disease from tobacco, cirrhosis and vehicular crashes from alcohol, falls and oversedation from misuse of prescription drugs, or bacterial and viral infections (including human immunodeficiency virus) associated with injection of illicit drugs.

Fortunately, treatment can be effective, probably to a greater degree when substance abuse disorders are identified early. In this regard, family physicians can play a pivotal role. They are well positioned to make the diagnosis because patients frequently seek medical care for the complications of drug and alcohol abuse. In addition, family physicians have an expanding role in the treatment of substance abuse as a result of recent advances in the understanding and pharmacologic management of addictive disorders.

This monograph highlights the lessons derived from the past 20 years of research concerning the diagnosis and treatment of drug abuse and addictive disorders. Because a great deal remains to be learned, however, family physicians must continue to use their best clinical judgment in areas where definitive answers are not established. In drug abuse, it is especially important to remain abreast of new developments that substantiate or refute current clinical practice.




TABLE 1: Complications of Injection Drug Use


Pulmonary complications

  • HIV-related or increased in incidence with HIV infection
    • Pneumocystis
    • Bacterial pneumonias
    • Opportunistic infections, e.g., Rhodococcus equi, Nocardia
    • Tuberculosis, especially involving strains resistant to multiple drugs
  • Cocaine-related
    • Focal air-space disease
    • Atelectasis
    • Alveolar hemorrhage
    • Pneumothorax and mediastinum
    • Bronchiolitis obliterans
    • Pulmonary edema
  • Focal infections and injection complications
  • Pneumothorax
    • Hemothorax and pyopneumothorax
    • Cellulitis, abscess, or pseudoaneurysm
    • Septic thrombophlebitis with pulmonary emboli or endocarditis
  • Microemboli, due to nonsoluble additives
    • Starch, talc-producing pulmonary granuloma and angiothrombosis and emphysema
  • Complications of inhalation
    • Reduced pulmonary function in intravenous drug users who are cigarette smokers
    • Pulmonary aspergillosis in users of contaminated marijuana

Cardiovascular complications

  • Cocaine-associated
    • Coronary artery constriction with angina and myocardial infarction
    • Cardiomyopathy
    • Rhabdomyolysis with chest pain mimicking anginal pain
  • Endocarditis

Musculoskeletal

  • Rheumatologic prodrome of hepatitis B antigenemia
  • Chronic amyloidosis
  • Bone and joint infections in injecting drug users (IDUs), especially due to Candida and gram-negative bacilli (particularly Pseudomonas)
  • Muscle and skin infarction
  • Rhabdomyolysis, sometimes accompanied by shock and renal failure
  • Small-vessel angiitis

Septicemia and disseminated infections

  • Group A, beta-hemolytic streptococci
  • Candida albicans fungemia syndrome
  • Fungal ophthalmitis
  • Fungal brain abscess
  • HIV-related
    • Aspergillosis
    • Rhodococcus equi infection
    • Listeriosis
    • Nocardiosis
    • Salmonellosis
    • Pyomyositis
    • Borrelia infection
    • Pericarditis due to Bacillus careus
  • Cocaine sinusitis
    • Clostridium botulinum infection
    • Pott puffy tumor
  • Syphilis
  • Hepatitis
  • Renal disease

Adapted from Cherubin CE and Sapira JD. The medical complications of drug addiction and the medical assessment of the intravenous drug user: 25 years later. Ann Intern Med 1993;119:1017-46. Used with permission.


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Illustration of a stimulant drug causing an increase of dopamine in the nucleus accumbens
Cover illustration by
Carol Donner, Tucson, Arizona




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