David R. McDuff

The accuracy of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test in screening trauma center patients for alcoholism.

OBJECTIVE To evaluate the accuracy of questionnaire screening instruments to identify lifetime alcohol dependence among trauma center patients. METHODS The study was conducted at a Level I trauma center between September 1994 and November 1996. Patients meeting eligibility requirements (> or = 18 years old, admission from injury scene, > or = 2 days of hospitalization, intact cognition) were evaluated for alcohol abuse and dependence. Screening instruments consisted of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test. Screening results were compared with lifetime alcohol dependence diagnoses made using the in-depth Psychoactive Substance Use Disorders section of the Structured Clinical Interview. Accuracy was quantified as sensitivity, specificity, positive/negative predictive values, and receiver operating characteristic curves (used to calculate area under the curve). RESULTS Of the 1,118 patients studied, lifetime alcohol dependence was diagnosed by Structured Clinical Interview in 397 (35.5%), and abuse was diagnosed in 90 (8.1%) others. The CAGE was the best predictor of lifetime alcohol dependence, i.e., had the largest area under the curve (93%) and the highest sensitivity (84%), specificity (90%), positive predictive value (82%), and negative predictive value (91%). Among patients testing positive for alcohol, 63% had a lifetime alcohol dependence diagnosis. CONCLUSION The CAGE is an efficient screening test to detect alcohol dependence in trauma center populations. It should be used in combination with alcohol testing to identify patients at risk of alcohol use problems.

Engaging hospitalized heroin-dependent patients into substance abuse treatment.

The purpose of this study was to evaluate a 6-month outpatient program developed to improve abstinence and other health and social problems of heroin-addicted persons hospitalized in an urban academic medical centers medical or surgical unit and referred from the Substance Abuse Consult Service. Treatment intervention consisted of methadone therapy, daily group therapy, individual case management, medical and psychiatric consultation, and social services. The first 67 patients referred were followed for 6 months. Outcome measures were retention in treatment, urine drug screens, and health and social indicators. Patients averaged 19 weeks in treatment, with 52% of patients completing the 6-month program. Urine toxicology screens showed a reduction of illicit drug use. Patients improved deficits in health and social indicators by obtaining medical coverage, keeping outpatient medical appointments, and improving their housing conditions. Findings suggest that this combination of intensive psychosocial treatment with opioid substitution following an acute illness substantially impacts treatment outcomes. Implications for service delivery and health-care economics are discussed.

Alcoholism at the time of injury among trauma center patients: vehicular crash victims compared with other patients.

A structured in-depth interview employing standardized criteria was used to determine the prevalence of lifetime and current alcohol dependence (alcoholism) in unselected consecutive patients admitted to a regional Level I trauma center. Of 629 patients, 157 (25.0%) were current alcoholics at the time of injury. An additional 87 (13.8%) were diagnosed as lifetime non-current alcoholics. There was no significant difference in the rates of current alcohol dependence among patients injured in vehicular crashes (23.5%), other unintentional trauma victims (29.3%), and those injured as a result of violence (24.6%). Of BAC+ (blood alcohol concentration positive) patients, 54.5% were current alcoholics. However, 14.4% of alcohol-negative patients were also diagnosed as alcohol dependent.

Benzodiazepine Dependence And Withdrawal: Identification And Medical Management

Background: Primary care physicians prescribe benzodiazepines for the treatment of anxiety. Although most patients use the benzodiazepines appropriately, some patients experience benzodiazepine abuse, addiction, or physical dependence, each one of which is a distinct syndrome. Benzodiazepine dependence, which relates to the development of tolerance and an abstinence syndrome, can be produced by three disparate benzodiazepine use patterns. These distinct benzodiazepine use patterns can in turn create distinct withdrawal syndromes. High-dose benzodiazepine use between 1 and 6 months can produce an acute sedative-hypnotic withdrawal syndrome. In contrast, low-dose therapeutic range benzodiazepine use longer than 6 months can produce a prolonged, subacute low-dose benzodiazepine withdrawal syndrome. Daily, high-dose benzodiazepine use for more than 6 months can cause a combination of an acute high-dose benzodiazepine withdrawal and a prolonged, subacute low-dose withdrawal syndrome. In addition, patients may experience syndrome reemergence. Methods: A literature search was conducted using the medical subject headings benzodiazepines, substance abuse, substance dependence, substance withdrawal syndrome, and benzodiazepines adverse effects. The years 1970 to the present were reviewed. Results and Conclusions: Medical management for acute benzodiazepine withdrawal includes the graded reduction of the current benzodiazepine dosage, substitution of a long-acting benzodiazepine, and phenobarbital substitution. However, the medical management of benzodiazepine dependence does not constitute treatment of benzodiazepine addiction. Primary care physicians can accept complete, moderate, or limited medical responsibility regarding patients with substance use disorders. However, all physicians should provide diagnostic and referral services.

Outpatient Benzodiazepine Detoxification Procedure for Methadone Patients

Benzodiazepines are used by a substantial minority of opioid addicts on methadone maintenance. Alprazolam, now the most widely prescribed benzodiazepine in the United States, appears to have supplanted diazepam as the benzodiazepine drug of choice in this population. Its greater addiction liability, shorter half-life, and more intense withdrawal symptoms make addiction to alprazolam more likely and its management in methadone patients more complicated. This article describes a slow outpatient tapered reduction procedure that was utilized to detoxify benzodiazepine dependent methadone patients seen over a two-year period. The reduction procedure was offered to 22 opioid addicts on methadone maintenance who were regularly ingesting low to moderate amounts of benzodiazepines, primarily alprazolam. Of the 22 patients, 4 patients refused outpatient detoxification, and 18 were started on a reduction procedure. Twelve patients completed the detoxification procedure which averaged 7.8 weeks. Comparisons are made between completers and non-completers and essential design features of the procedure are discussed.

A Substance Abuse Consultation Service: Enhancing the Care of Hospitalized Substance Abusers and Providing Training in Addiction Psychiatry

The authors review the literature on the high prevalence but underrecognition of substance abuse among hospitalized patients and the general unavailability of hospital-based substance abuse consultation services. They describe the development, clinical operations, staffing, and teaching activities of a large substance abuse consultation service in one urban academic medical center and detail the services growth and changing utilization patterns over an 8-year period, reporting the clinical characteristics of 1,819 patients seen over a 1-year period. Differences in patient demographics, patterns of substance use, and diagnoses were highly significant from one referring service to another. The authors discuss the implications of such a service for patient care and teaching.

Sociodemographic Characteristics Associated with Substance Use Status in a Trauma Inpatient Population

Abstract Substance use is significantly associated with physical injury, yet relatively little is known about the prevalence of specific substance use disorders among trauma patients, or their associated sociodemographic characteristics. We evaluated these issues in an unselected sample of 1,118 adult inpatients at the University of Maryland Shock Trauma Center, Baltimore, MD, who were interviewed with the psychoactive substance use disorder section of the Structured Clinical Interview for DSM-III-R. Among trauma inpatients, lifetime alcohol users (71.8% of subjects) were more likely male; users of illegal drugs (45.3%) were also more likely to be younger, unmarried, and poor. Patients with current drug abuse/dependence (18.8%) were more likely to be non-white, less educated, and poor; those with current alcohol abuse/dependence (32.1%) were also more likely male, unmarried, and older. These findings highlight the need for screening for substance use disorders in trauma settings and referral of patients to substance abuse treatment programs.

Anxiety And Substance Use Disorders: The Treatment Of High-Risk Patients

Primary care physicians routinely treat patients with various anxiety disorders. These patients may have a substance use disorder or may be at high risk for abuse or addiction. Routine treatment of anxiety disorders with psychoactive drugs is successful in many patients, but it can lead to iatrogenic dependence in high-risk patients. This article describes addiction risk factors, drug pharmacodynamics, environment and environmental cues, and genetics. With these addiction risk factors in mind, the physician can apply a stepwise treatment protocol described in three progressive levels: conservative, nonpharmacological approaches; nonpsychoactive pharmacotherapy; and psychoactive pharmacotherapy. In addition, proper prescribing practices for high-risk patients are described in terms of diagnosis, dosage, duration, discontinuation, dependence, and documentation.

Anxiety and substance use disorders: a primer for primary care physicians.

Primary care physicians encounter many patients with primary and secondary anxiety and substance use problems. Some patients have a dual diagnosis of both an anxiety and a substance use disorder. Symptoms may be overdiagnosed, underdiagnosed, and misdiagnosed. This article provides the primary care physician with an overview of the relation between psychoactive substance use disorders and anxiety symptoms. Also described are drug use patterns and diagnostic criteria for psychoactive substance use disorders. A model for understanding the role of anxiety symptoms during drug use is provided.

Risk of Psychoactive Substance Dependence Among Substance Users in a Trauma Inpatient Population

Abstract One measure of a substances addictive risk is the proportion of users who become dependent. This study evaluates the lifetime and current risk of substance dependence among lifetime substance users among trauma inpatients and provides a relative ranking of addictive risk among the substances. Data on use of 8 substance groups (alcohol, opiates, cannabis, cocaines other stimulants, sedative-hypnotics, hallucinogens, other drugs) were obtained by interview (Structured Clinical Interview for the DSM-III-R) from 1,118 adult trauma inpatients. Prevalence of lifetime dependence among lifetime users ranged from 80.7% for opiates and 70.9% for cocaine to 33.3% for hallucinogens and 26.6% for sedative-hypnotics. The rank order of addictive risk was similar to that found in the general population. Trauma inpatients had a higher absolute addictive risk than the general population, comparable to the risk found in patients in treatment for substance use disorders, suggesting the importance of screening trauma inpatients for substance dependence.