Each year in the United States, approximately 8.2 million persons are dependent on alcohol and 3.5 million are dependent on illicit drugs, including stimulants (1 million) and heroin (750,000). In a sample from primary care practice, 15 percent of patients had either an “at-risk” pattern of alcohol use or an alcohol-related health problem, and 5 percent had a history of illicit-drug use. With rates of substance use so high, all patients should be carefully screened with validated instruments such as the CAGE questionnaire for alcohol dependence, which consists of the following questions: Can you cut down on your drinking? Are you annoyed when asked to stop drinking? Do you feel guilty about your drinking? Do you need an eye-opener drink when you get up in the morning? Physicians should be prepared to treat patients who have withdrawal syndromes. A carefully taken history should include the time of last use for each substance involved, and toxicologic screening should be performed to identify any additional substances used.
The substances abused must be determined early in treatment, because there are substantial differences in severe complications and in the management of withdrawal from alcohol and sedatives, opiates, and stimulants. Although the initial symptoms of withdrawal — for example, dysphoria, insomnia, anxiety, irritability, nausea, agitation, tachycardia, and hypertension — are similar for all three classes of drugs, complications and therefore treatment can differ greatly. For example, clonidine given to a patient withdrawing from an opioid can mask early symptoms of alcohol or sedative withdrawal and, without specific medication for sedative withdrawal, can lead to seizures. Detoxification is an important first step in substance-abuse treatment. It has three goals: initiating abstinence, reducing withdrawal symptoms and severe complications, and retaining the patient in treatment. Ongoing treatment is needed thereafter to maintain abstinence.
Pharmacologic treatment of drug withdrawal often involves substituting a long-acting agent for the abused drug and then gradually tapering its dosage. The desirable qualities for outpatient medications include administration by mouth, low potential for abuse and overdose, and low incidence of side effects. Adequate dosages of appropriate substitute medications are important. Patients often safely attain abstinence without pharmacologic interventions, however, and the threshold for pharmacotherapy differs among abused drugs. The need for medication is signaled by both symptoms and signs in patients withdrawing from alcohol, by severe objective signs in those withdrawing from stimulants, and by specific signs during withdrawal in those withdrawing from opioids. For patients addicted to heroin, sustained opioid stabilization is often a better treatment option than detoxification and abstinence.
Outpatient management is appropriate for patients with mild-to-moderate withdrawal symptoms who have no important coexisting conditions and have a support person willing to monitor their progress closely. The emergence of serious complications, including delirium tremens among patients dependent on alcohol or depression with suicidal ideation or psychotic symptoms among patients dependent on stimulants or opioids, demands inpatient treatment. In addition, coexisting psychiatric and medical disorders must be managed. Care must be supportive and nonjudgmental, yet assertive.
During detoxification, behavioral interventions for ongoing treatment of these chronic relapsing disorders may be started. Such interventions should be more sophisticated than simple referral to self-help groups. Effective treatments include contingency management, motivational enhancement, and cognitive therapies.
From the Departments of Psychiatry (T.R.K.) and Medicine (P.G.O.), Yale University School of Medicine, New Haven, Conn.; and Veterans Affairs Connecticut Healthcare System, West Haven, Conn. (T.R.K.).
Thomas R. Kosten, M.D., and Patrick G. O’Connor, M.D., M.P.H.