Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Substance Abuse

Alcohol and drug abuse are associated with many of the interactions physicians have with patients in a given day. The effects of substance use extend beyond the individual to include family, co-workers, and friends, yet can often be hidden from the observer who is unaware of their ubiquity. The physician who knows how to observe and ask about substance use can, through appropriate therapy, treatment, and/or referral, help the patient return to a healthy lifestyle.

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Prerequisites

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Describe and discuss:

  • basic physiology
  • basic pathology 
  • basic neuroanatomy

Demonstrate:

  • ability to take a medical history
  • ability to perform a physical exam
  • ability to perform a mental status exam
  • basic communication skills

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe presenting signs, and symptoms of:

  • abusing alcohol, opiods, cocaine, amphetamines, hallucinogens, barbiturates, and other related medications, and benzodiazepines
  • alcohol and drug intoxication
  • alcohol and drug overdose
  • acute alcohol and drug withdrawal

2.     Describe key risk factors for alcohol and drug abuse (social, genetic).

3.     Describe morbidity and mortality associated with substance use (e.g., trauma, motor vehicle accidents, homicide, overdose, cirrhosis, endocarditis, HIV, hepatitis B, and suicide).

4.     Describe the differences among substance use, dependency, and addiction.

5.     Describe the diagnostic criteria for alcohol, and drug abuse, dependency, and addiction, based on a history, physical examination, and laboratory testing.

6.     Know the questions in the CAGE questionnaire. (“Have you ever felt you should Cut down on your drinking?”, “Have people Annoyed you by criticizing your drinking?”,  Have you ever felt bad, or Guilty about your drinking?”, “Have you ever had a drink first thing in the morning to steady your nerves, or get rid of a hang-over [Eye Opener]?”)

7.     Describe how diagnostic tests would help in the evaluation of substance use, including their indications and contraindication, limitations, and cost:

  • blood alcohol level
  • liver function tests
  • complete blood count
  • amylase, urine, and serum drug screens

8.     Describe principles of management of common causes of substance use.

9.     Describe steps in a critical pathway for substance use.

10.  Describe the biopsychosocial etiology of addictions.

11.  Describe the prevalence of addictions and the need to consistently include substance abuse in the history.

12.  Know the available community referral sources (e.g. Alcoholics Anonymous, Narcotics Anonymous) and where to obtain phone numbers.

13.  List the key health benefits that accrue with cessation. 

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Diagnose

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1.     Obtain document and present an age-appropriate medical history that differentiates among etiologies of disease including;

  • eliciting a social history in a nonjudgmental, supportive manner, using appropriate questioning (CAGE questions, etc)
  • evaluating a patient using the Diagnostic and Statistical Manual of Psychiatric Disease (DSM IV-TR) criteria for substance or alcoholic dependence

2.     Perform a physical exam, including mental status exam, to establish the diagnosis, and severity of disease including assessing patient who is suspected of substance abuse for:

  • fever
  • hypertension
  • tachycardia
  • skin for jaundice, needle tracks, manifestations of endocarditis, HIV infection, and cirrhosis
  • eyes for pupil size and icterus, fundus exam (roth spots)
  • nose for nasal septum perforation
  • mouth for odor of alcohol and parotid enlargement
  • breasts for gynecomastia
  • lymph nodes for adenopathy
  • heart for murmurs
  • abdomen for hepatomegaly
  • genital exam for testicular atrophy
  • neurologic exam for tremor, and cognitive impairment
  • Dupuytren’s contractures

1.     Generate a prioritized differential diagnosis that recognizes specific history and physical exam findings.

2.     Complete review of systems and evaluation to rule out primary medical problem(s), history of seizures, history of most recent use to guide differential between intoxication and withdrawal states, degree of chronic use and history of prior adverse toxicity or withdrawal episodes.

3.     Recommend when to order diagnostic, laboratory tests, and clinical tests both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering tests and interpret the results (with consultation). Consider test cost and performance characteristics as well as patient preferences.  Laboratory, and diagnostic tests should include, when appropriate:

  • blood alcohol level
  • urine and serum toxicology screens
  • complete blood count
  • liver enzymes
  • amylase and lipase
  • HIV

4.     Determine the diagnosis of substance abuse of drugs or alcohol.

5.     Record, present, research, critique, and manage clinical information.                                                                   

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Develop and Implement a Management Plan

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6.     Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with substance use.

7.     Design an approach to treatment for the patient with substance use based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences. Include:

  • assessing a patient’s motivation for achieving sobiety/abstinence
  • delivering a directed, non-judgmental message to a substance-abusing patient urging him/her to quit
  • making an appropriate community referral for a substance-abusing patient
  • writing appropriate fluid and medication orders for the treatment of acute alcohol and/or drug withdrawal
  • managing comorbid illness 

8.     Formulate a prognosis for the patient with substance use based on the diagnosis, the treatment plan, and the patient’s characteristics.

9.     Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring, compassionate, and nonjudgmental manner. Take into consideration the patient’s knowledge and ability to comprehend new information and reflect an understanding of the emotional impact of a diagnosis of substance abuse and its potential effect on lifestyle (work performance, sexual functioning, etc.).

10.  Provide education for the patient about his or her treatment plan.

11.  Provide counseling to patients when indicated about issues related to prevention.

12.  Refer for psychological support.

13.  Access and utilize appropriate information systems to ascertain information about health system and community resources.

14.  Plan for follow-up.

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Differential Diagnosis

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Be able to recognize the diagnosis, and associated comorbid biological/psychological, and social issues concerning the following substance related disorders: 

  • alcohol intoxication, withdrawal, abuse, and dependence
  • amphetamine intoxication, withdrawal, abuse and dependence
  • cannabis abuse and dependence
  • cocaine intoxication, withdrawal, abuse and dependence
  • hallucinogen use disorders
  • inhalant use disorders
  • nicotine dependence and withdrawal
  • opioid intoxication, withdrawal, abuse, and dependence
  • sedative-hypnotic intoxication, withdrawal, abuse, and dependence