You’re sure to see substance abuse questions on the Physician Assistant Exam (PANCE). Substance abuse is a form of substance-related disorder. An excessive or off-purpose use of a substance can be classified as abuse. In many cases, the result is dependence or addiction. In some cases, the result is degeneration of the abuser, leading to illness and death.
Drug abuse is an important topic because of its frequent occurrence and negative impacts. It’s not just an individual clinical problem but a societal issue as well.
Dependence and addiction
Make sure you understand the difference between dependence and addiction. Physical dependence refers to how a person’s body gets used to or handles a particular drug. For any medication you prescribe, whether it’s pain medication or diabetes medication, the person’s body needs to be able to adapt to it. For example, a person on insulin depends on that medication to keep his or her blood sugar low.
The hot topic for drug dependence is pain medication, more so than street drugs. People on pain meds come to physically depend on them to help relieve their pain. They may even develop a tolerance to the meds and require a higher dose.
Addiction is more of a psychological issue. The addicted person may take the pain medication even when it’s not scheduled. He or she may sneak extra doses and begin to crave the medication. His or her whole life starts to revolve around the medication. The addiction can take over the person’s life.
Common forms of substance abuse
Recognizing signs of substance abuse is important. The person who “uses” may often miss work, miss family obligations, and neglect others in the family. He or she may have a police record for recurrent substance use.
Alcohol abuse
Alcohol — that is, the relatively nonpoisonous ethanol — is America’s favorite legal addictive drug.
You can use questionnaires to gauge someone’s use of alcohol. A popular one you should know about is the CAGE questionnaire. Ask your patients four questions to screen for alcohol abuse:
C — cut down: Has the affected person — or anyone else — ever felt the need to reduce the amount that person drinks?
A — angry or annoyed: Does the person become angry or annoyed when asked about his or her drinking habits?
G — guilt: Does he or she feel guilty about excessive drinking?
E — eye-opener: Does the person need an eye-opener, the famous first drink in the morning to help with a hangover?
If a person answers two or more of these questions in the positive, he or she may have a problem with alcohol.
You need to be aware of several points concerning alcohol use, especially overuse. As a clinician, you often first meet the person who is abusing alcohol in the emergency room. Here are some high-yield facts:
Usually a blood alcohol level greater than 80 mg/dL is a pretty good indicator that the person is intoxicated.
If a patient presents with the odor of alcohol, you need to be guarded in your diagnosis and treatment plan. The history of the presenting illness may not be reliable. Further, don’t be too swift to blame findings on the alcohol. Your findings may actually be related to another condition.
Patients who abuse alcohol may present to the hospital with a change in mental status. Besides inebriation, other differential diagnoses include hypoglycemia and electrolyte abnormalities, alcoholic hepatitis, hepatic encephalopathy, Wernicke’s encephalopathy, infection/sepsis, and/or a subdural hematoma. If a person with suspected alcohol abuse is found down and is unresponsive, the person may have hit his or her head and could have a subdural hematoma.
The initial treatment for alcohol intoxication includes the banana bag, an IV solution that includes magnesium, thiamine, folic acid, and a multivitamin. Many people suffering from alcohol abuse have multiple nutritional deficiencies.
Do not give glucose without first giving thiamine. You could precipitate Wernicke’s encephalopathy.
Other meds can be used to treat alcoholism, although they’re rarely used anymore. One example is disulfiram (Antabuse). Anyone taking it experiences violent nausea and vomiting after drinking alcohol. You should be aware that other medications can cause a disulfiram-like reaction; these include oral sulfonylureas used to treat diabetes and the antibiotic metronidazole (Flagyl).
Nicotine abuse
You can get a sense of how much someone smokes — and that person’s subsequent risk of smoking-related conditions — by estimating pack years. If someone has been smoking 1 pack a day for 30 years, he or she has 30 pack years. If you talk with someone who smokes a pipe, ask whether the pipe is filtered or unfiltered. Also, ask whether the person smoked cigarettes before starting on the pipe.
Stopping smoking can be very hard, and the treatment is often multidimensional. For the purposes of the PANCE, be aware of the five a’s of quitting smoking:
Ask: Talk to your patient about his or her smoking with every interaction.
Advise: Encourage your patient to quit smoking.
Assess: Does your patient really want to quit?
Assist: For example, help the patient pick a “quit day.”
Arrange: For example, help the patient pick a smoking cessation class.
Some sort of nicotine replacement is often required to prevent withdrawal. Note that the person isn’t supposed to smoke while using the nicotine patch or the gum. Nicotine is a vasoconstrictor, and the combination can cause chest pain and/or hypertension.
Drug abuse
You should be able to recognize some of the main side effects and potential risks of many drugs that are commonly abused, especially stimulants. Here we’re talking about both prescribed medications and illegal substances. Realize that drug abuse is a widespread problem, especially among younger generations and teenagers.
In many cases, the person who abuses drugs needs some form of inpatient treatment for substance use, especially given all the medical comorbidities with the condition.