A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 13: Management of Substance Abuse
Chapter 13:
Management of Substance Abuse
Henry Francis, MD
ASSESSMENT OF SUBSTANCE ABUSE PROBLEMS
TREATMENT OF SUBSTANCE ABUSE PROBLEMS
MEDICAL AND PAIN MANAGEMENT ISSUES
HIV/AIDS ISSUES
KEY POINTS
SUGGESTED RESOURCES
REFERENCES
ASSESSMENT OF
SUBSTANCE ABUSE
PROBLEMS
What is the definition of a substance abuser?
A substance abuser is an individual who repeatedly
uses an addictive substance or performs a certain
behavior even with the knowledge of its negative health
consequences. A person is drug dependent or addicted
if he or she uses drugs repeatedly despite the social,
interpersonal, or other problems associated with their
use and has a physical or psychological tolerance to the
drug and experiences withdrawal symptoms after the
effects of the drug wear off. Long-term drug abuse can
interfere with normal brain activity and metabolism and
can become a chronic, relapsing condition characterized
by compulsive drug craving and drug seeking. There are
other kinds of addiction that may not involve the use of
substances, such as gambling, sex, and eating-related
disorders, all of which involve a range of dysfunctional
behaviors with undesirable social, medical, and
economic consequences (see Table 13-1).
Table 13-1: Range of Substances and
Behaviors That Can Be Abused
Addictive substances
• Marijuana
• Cocaine
• Heroin
• Amphetamines, other
stimulants
• Tranquilizers
• Hallucinogens
• Steroids and
recreational drugs
Behaviors
• Eating disorders:
anorexia, bulimia,
binging
• Sex disorders:
compulsive sexual
activity
• Gambling
• Internet addictions:
compulsive use of the
internet
How should primary care providers address
substance use problems in their patients?
The first task is to consciously look for behavioral and
physical signs of maladaptive drug use and to use a
simple screening tool such as the CAGE examination
(described below) to detect it. Common indicators of
drug abuse are frequent absence from work or school,
recurrent injuries, motor vehicle accidents, depression,
anxiety, labile hypertension, sleep problems, sexual
dysfunction, or abdominal symptoms. Physical signs of
drug abuse such as tremor, liver disorders, and physical
changes such as nasal irritation caused by cocaine are
well known to health care providers.
The second task is to tell the patient his or her diagnosis
of drug abuse or dependence. Providers are often
concerned about upsetting a patient with a stigmatizing
diagnosis. Giving a concise, objective description
of clinical findings without making judgments is
important. Common pitfalls for providers to avoid
during this discussion are listed as the DEATH Glossary
(Table 13-2).
The third task before sending a patient to treatment
is to try a brief intervention in the office. It has
clearly been shown that brief interventions given in
community centers, hospitals, and ambulatory clinics
decrease the morbidity and mortality associated with
drug abuse (see Suggested Resources). For physicians
who have received training on buprenorphine treatment
for opiate addicts, there is the added opportunity to
treat opiate drug users in the private practice setting
without referring the individuals to drug use centers
(see section on Treatment of Substance Abuse below).
13
U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
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