M05.07.04 Pregnancy and substance abuse

Substance use disorders encompass a range of problematic patterns of drug and alcohol use that can significantly impact health, relationships, and daily functioning. This section provides medical students with a foundation for diagnosing and managing these disorders.

Self-Awareness in Substance Use Disorders

One of the biggest challenges in addressing substance use disorders is a lack of self-awareness among those struggling with addiction. Here’s why:

• Denial and rationalization: People with substance use disorders often deny they have a problem, justifying their behavior through various explanations.
• Functional addiction: Many individuals can maintain a semblance of normalcy in their daily lives despite addiction, making it difficult for them to acknowledge the issue.
• “Rock bottom”: A significant negative consequence can sometimes be the wake-up call needed to recognize the problem and seek help.

Screening Tools: The CAGE Questionnaire

The CAGE questionnaire is a simple and widely used tool to screen for potential alcohol abuse and dependence. It consists of four yes-or-no questions:

• C: Cut down on drinking? (Have you ever felt you needed to cut down on your drinking?)
• A: Annoyed by criticism of your drinking? (Have people annoyed you by criticizing your drinking?)
• G: Guilty about your drinking? (Have you ever felt bad or guilty about your drinking?)
• E: Eye-opener drinks in the morning? (Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?)

Stages of Change in Substance Use Disorders

Understanding the stages of behavior change can be crucial in guiding interventions for substance use disorders. These stages include:

• Precontemplation: The individual is unaware of or in denial about having a problem.
• Contemplation: The individual becomes aware of the problem but is ambivalent about making changes.
• Preparation: The individual decides to change and begins taking small steps toward that goal.
• Action: The individual actively implements changes and may experience setbacks.
• Maintenance: The individual works to maintain the new behaviors and prevent relapse.
• Relapse: The individual reverts to old patterns of substance use. This is a common occurrence, and the cycle may repeat until sustained sobriety is achieved.

Medical Complications of Alcohol Abuse

Chronic alcohol abuse can lead to a variety of medical problems, including:

• Liver disease: Cirrhosis, alcoholic hepatitis
• Pancreatitis
• Gastrointestinal ulcers
• Esophageal varices
• Diabetes
• Cancers (gastrointestinal, esophageal)
• Hypertension
• Peripheral neuropathies
• Myopathies (muscle weakness)
• Cardiomyopathy (heart disease)
• Cerebrovascular accidents (strokes)
• Erectile dysfunction
• Vitamin deficiencies (thiamine)
• Pernicious anemia
• Wernicke-Korsakoff syndrome (brain disorder)
• Cognitive decline

Laboratory Findings

Several laboratory tests can be used to support a diagnosis of substance use, including:

• Increased liver enzymes (AST/ALT) – typically in a 2:1 ratio
• Increased bilirubin
• Increased gamma-glutamyl transferase (GGT) – indicates recent alcohol intake
• Breathalyzer or blood alcohol level (BAL) tests

Diagnosis

The diagnosis of substance use disorders is often based on clinical presentation, patient history, and physical examination. Confirmation can be obtained through urine and blood toxicology screens. Diagnoses typically fall into two categories:

• Intoxication: Impairment in cognitive and motor skills due to recent drug or alcohol use.
• Withdrawal: Symptoms that occur when someone who has developed tolerance to a substance stops using it or significantly reduces their intake.

Substance Use and Legal Ramifications

Driving under the influence of drugs or alcohol (DUI/DWI) can have serious legal consequences.

Treatment Options

A comprehensive treatment plan for substance use disorders typically involves a combination of approaches:

• Medications: Medications like naltrexone or acamprosate can help reduce cravings and relapse risk for alcohol use disorders.
• Psychotherapy: Individual therapy, group therapy programs (e.g., Alcoholics Anonymous [AA] or Narcotics Anonymous [NA]), and family therapy can provide support, address underlying issues, and teach coping mechanisms.
• Behavioral Modification Techniques: Techniques like aversive conditioning can be used to discourage alcohol use. Disulfiram, for example, causes unpleasant side effects when alcohol is consumed.
• Support Groups: Support groups like AA and Al-Anon (for families of those with substance use disorders) provide a network of understanding and encouragement.

Disulfiram Treatment

Disulfiram is a medication used as an adjunct to therapy for alcohol use disorders.