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Vanderbilt Core Clinical Curriculum

Substance Use and 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.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with SUBSTANCE USE AND ABUSE can include:

Medical Knowledge Learning Topics related to SUBSTANCE USE AND ABUSE

1. Signs, and symptoms of:

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

2. Risk factors for alcohol and drug abuse (social, genetic)
3. Morbidity and mortality associated with substance use (e.g., trauma, motor vehicle accidents, homicide, overdose, cirrhosis, endocarditis, HIV, hepatitis B, and suicide)
4. Differences of substance use, dependency, and addiction
5. Diagnostic criteria for alcohol, and drug abuse, dependency, and addiction, based on a history, physical examination, and laboratory testing
6. 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. Utility of diagnostic tests in the evaluation of substance use, including indications and contraindication, limitations, and cost:

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

8. Management of common causes of substance use
9. Critical pathway for substance use
10. Biopsychosocial etiology of addictions
11. Prevalence of addictions and the need to consistently include substance abuse in the history
12. Availability of community referral sources (e.g., Alcoholics Anonymous, Narcotics Anonymous)
13. Key health benefits that accrue with cessation

Diagnostic Evaluation Learning Topics related to SUBSTANCE USE AND ABUSE

1. 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. 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

3. Differential diagnosis that recognizes specific history and physical exam findings

4. 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

5. Utility and interpretation of laboratory and clinical tests both prior to and after initiating treatment, based on the differential diagnosis. Consideration of 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

6. Diagnosis of substance abuse of drugs or alcohol

Management Plan Learning Topics related to SUBSTANCE USE AND ABUSE
1. Indications, mechanisms of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with substance use
2. Treatment for the patient with substance use based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences. Including:
o assessment of a patient’s motivation for achieving sobriety/abstinence
o delivery of a directed, non-judgmental message to a substance-abusing patient urging him/her to quit
o appropriate community referral for a substance-abusing patient
o appropriate fluid and medication orders for the treatment of acute alcohol and/or drug withdrawal
o management of comorbid illness
3. Prognosis for the patient with substance use based on the diagnosis, the treatment plan, and the patient’s characteristics
4. Communication of the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring, compassionate, and nonjudgmental manner. Consideration of the patient’s knowledge and ability to comprehend new information. Understanding of the emotional impact of a diagnosis of substance abuse and its potential effect on lifestyle (work performance, sexual functioning, etc.)
5. Education for the patient about his or her treatment plan
6. Counseling to patients when indicated about issues related to prevention
7. Refer for psychological support
8. Follow-up planning

Potential Differential Diagnosis Topics Include:

  • 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