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Alcohol and Drug Abuse

I. Clinical Evaluation

A. Determine the amount and frequency of alcohol use and other drug use in the past month, week, and day. Ask about previous abuse of alcohol or other drugs.

B. If the patient currently uses alcohol, determine how many days per week, on average, the patient drinks, how much alcohol is usually consumed and whether the patient ever consumes five or more drinks.

C. Effects of the alcohol or drug use on the patient's life: Problems with health, family, job or financial status.

D. History of blackouts or motor vehicle crashes. Affect on family members or friends of the patient's drinking or drug use.

E. History:

1. Have you felt that you ought to cut down on your drinking or drug use?

2. Have people criticized your drinking or drug use?

3. Have you ever had a drink or used drugs first thing in the morning (eye opener) to steady your nerves, get rid of a hangover or get the day started?

F. Psychologic/behavioral Manifestations of Drug Disorders: Agitation, irritability, dysphoria, mood swings, hostility, violence, generalized anxiety, panic attacks, depression, psychosis.

G. Family Manifestations of Drug Disorders: Family dysfunction, marital problems, behavioral problems, abuse and violence.

H. Social Manifestations of Drug Disorders: Alienation and loss of friends, gravitation toward others with similar lifestyle.

I. Work/school Manifestations of Drug Disorders: Decline in performance, frequent job changes, cocaine, marijuana, crack, methamphetamine frequent absences (especially on Mondays), requests for work excuses.

J. Legal Manifestations of Drug Disorders: Arrests for disturbing the peace or driving while intoxicated, stealing, drug dealing, prostitution.

K. Financial Manifestations of Drug Disorders: Borrowing or owing money, selling of possessions.

II. Physical Examination

A. Alcohol abuse may be signaled by labile or refractory hypertension, or by mild upper abdominal tenderness.

B. Cocaine snorting may be identified by damaged nasal mucosa. Injection drug abuse may be evident by hypodermic marks.

C. Eye Examination:

1. Nystagmus is often seen in abusers of sedatives or hypnotics or cannabis.

2. Mydriasis (dilated pupils) is often seen in persons under the influence of stimulants or hallucinogens or in withdrawal from opiates.

3. Miosis (pin-point pupils) is a classic sign of opioid effect.

III. Laboratory Testing

A. Impaired liver function and hematologic disorders cocaine, marijuana should be sought with LFT's and CBC.

B. Spot checks of urine or breath may reveal the presence of undisclosed drugs or alcohol.

IV. Treatment

A. Outpatient Detoxification

1. Many drug-dependent patients can safely undergo withdrawal as outpatients.

2. To qualify for outpatient detoxification, the patient must clearly agree to abstain from using any mood-altering agent, and must also agree to participate in a treatment program. The patient also needs a sober and responsible family member or friend who will monitor the patient and assist with medications.

3. Evaluate the patient daily until he has started a treatment rehabilitation program and the risk of withdrawal is minimal. This interval may range from three days for alcohol abuse to 10 days for methamphetamines, opioids and cocaine.