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Table 41–1 • COMMONLY ABUSED ILLICIT AND PRESCRIPTION
DRUGS
Category and
Name
Opioids and Morphine Derivatives
Codeine Codeine with Empirin or
Heroin Diacetyl-morphine and
Fentanyl and
analogs
Morphine Roxanol, Duramorph,
Opium Laudanum, paregoric,
Oxycodone HCl Oxycontin and Oxy, OC,
Hydrocodone
acetaminophen
Hallucinogens
LSD Lysergic acid
Mescaline Buttons, cactus, mesc,
Psilocybin Magic mushroom,
continued
Commercial and
Street Names
Fiorinal, Robitussin A-C,
Tylenol with Codeine
and Captain Cody,
doors and fours, loads,
pancakes and syrup
brown sugar, dope, H,
horse, junk, skag, skunk,
smack, white horse
Actiq, Duragesic,
Sublimaze and Apache,
China girl, China white,
dance fever, friend,
goodfella, jackpot,
murder 8, TNT, Tango
and Cash
MS-Contin and M, Miss
Emma, monkey, white
stuff
big O, black stuff, block,
gum, hop
killer
Vicodin, Anexsia, Lorcet,
Lortab, Norco, and Vike,
Watson-387
diethylamide and acid,
blotter, boomers,
cubes, microdot, yellow
sunshines
peyote
purple passion,
shrooms
Route of
Administration
Injected,
swallowed
Injected,
smoked, snorted
Injected,
smoked, snorted
Injected,
swallowed,
smoked
Swallowed,
smoked
Swallowed,
injected
Swallowed
Swallowed,
absorbed
through mouth
tissues
Swallowed,
smoked
Swallowed
Intoxication Effects
and Potential Health
Consequences
Common features: pain relief,
euphoria, drowsiness, miosis,
and nausea, constipation, confusion, sedation, respiratory
depression and arrest, toler-
ance, addiction, unconsciousness, coma, death. Also, for
Codeine: less analgesia, sedation, and respiratory depression than morphine. Also, for
Heroin: staggering gait
Common features: altered
states of perception and feeling; nausea; persisting perception disorder (flashbacks).
Also, for LSD and Mescaline:
increased body temperature,
heart rate, blood pressure;
loss of appetite, sleeplessness,
numbness, weakness, tremors;
persistent mental disorders.
Also, for Psilocybin: nervousness, paranoia
(Continued)
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Table 41–1 • COMMONLY ABUSED ILLICIT AND PRESCRIPTION
DRUGS
Category and
Name
Stimulants
Amphetamines Biphetamine, Dexedrine
Cocaine Cocaine hydrochloride
MDMA Methylenedioxy-
Methamphetamine Desoxyn and chalk,
Methylphenidate Ritalin and JIF, MPH,
Nicotine cigarettes, cigars,
continued
Commercial and
Street Names
and bennies, black
beauties, crosses,
hearts, LA turnaround,
speed, truck drivers,
uppers
and blow, bump, C,
candy, Charlie, coke,
crack, flake, rock, snow,
toot
methamphetamine and
Adam, clarity, ecstasy,
Eve, lover’s speed,
peace, STP
crank, crystal, fire, glass,
go fast, ice, meth, speed
R-ball, Skippy, the smart
drug, vitamin R
smokeless tobacco,
snuff, spit tobacco,
bidis, chew
Route of
Administration
Injected,
swallowed,
smoked, snorted
Injected,
smoked, snorted
Swallowed
Injected,
swallowed,
smoked, snorted
Injected,
swallowed,
snorted
Smoked,
snorted, taken
in snuff and spit
tobacco
Intoxication Effects
and Potential Health
Consequences
Common features: increased
heart rate, blood pressure,
metabolism; feelings of exhilara-
tion, energy, increased mental
alertness and rapid or irregular
heartbeat; reduced appetite,
weight loss, heart failure, ner-
vousness, insomnia. Also, for
Amphetamines: rapid breathing
and tremor, loss of coordina-
tion; irritability, anxiousness,
restlessness, delirium, panic,
paranoia, impulsive behavior,
aggressiveness, tolerance,
addiction. Also, for Cocaine:
increased temperature and chest
pain, respiratory failure, nausea,
abdominal pain, strokes, sei-
zures, headaches, malnutrition,
panic attacks, mydriasis. Also,
for MDMA: mild hallucinogenic
effects, increased tactile sen-
sitivity, empathic feelings and
impaired memory and learning,
hyperthermia, cardiac toxic-
ity, renal failure, liver toxicity.
Also, for Methamphetamine:
aggression, violence, psychotic
behavior and memory loss,
cardiac and neurological dam-
age; impaired memory and
learning, tolerance, addiction.
Also, for Nicotine: additional
effects attributable to tobacco
exposure; adverse pregnancy
outcomes; chronic lung disease,
cardiovascular disease, stroke,
cancer, tolerance, addiction
(Continued)
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Table 41–1 • COMMONLY ABUSED ILLICIT AND PRESCRIPTION
DRUGS
Category and
Name
Other Compounds
Anabolic steroids Anadrol, Oxandrin,
Dextromethorphan Found in some cough
Inhalants Solvents (paint thinners,
continued
Commercial and
Street Names
Durabolin, DepoTestosterone, Equipoise,
roids, juice
and cold medications;
Robotripping, Robo,
Triple C
gasoline, glues); gases
(butane, propane,
aerosol propellants,
nitrous oxide); nitrites
(isoamyl, isobutyl,
cyclohexyl); laughing
gas, poppers, snappers
Intoxication Effects
Route of
Administration
Injected,
swallowed,
applied to skin
Swallowed Common features: distorted
Inhaled through
nose or mouth
and Potential Health
Consequences
Common features: no intoxica-
tion effects and hypertension,
blood clotting and cholesterol
changes, liver cysts and cancer,
kidney cancer, hostility and
aggression, acne; in adoles-
cents, premature stoppage
of growth; in males, prostate
cancer, reduced sperm pro-
duction, shrunken testicles,
breast enlargement; in females,
menstrual irregularities, devel-
opment of beard and other
masculine characteristics, hir-
sutism, virilization
visual perceptions to complete
dissociative effects and at
higher doses see “dissociative
anesthetics”
Common features: stimulation,
loss of inhibition; headache; nau-
sea or vomiting; slurred speech,
loss of motor coordination;
wheezing and unconsciousness,
cramps, weight loss, muscle
weakness, depression, memory
impairment, damage to cardio-
vascular and nervous systems,
sudden death
Data from Commonly Abused Drugs. (Revised March 2020). Retrieved from the National Institute on Drug Abuse (NIDA).
https://www.drugabuse.gov/drugs-abuse/commonly-used-drugs-charts. Accessed May 26, 2020.
and are at high risk for AUD. The definitions for the different levels of drinking
include the following:
Moderate drinking: Up to one drink per day for women and up to two drinks
per day for men.
Binge drinking: Drinking four to five or more alcoholic drinks on the same
occasion on at least 1 day in the past 30 days. Binge drinking produces blood
alcohol concentrations of greater than 0.08 g/dL. This usually occurs after
four drinks for women and five drinks for men over a 2-hour period.
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Heavy drinking: Drinking five or more drinks on the same occasion on each of
5 or more days in the past 30 days.
Cannabis Use Disorder. Marijuana is the most-used drug after alcohol and tobacco
in the United States. In 2017, there were 26 million people ages 12 and up who
reported using marijuana during the previous month. In 2014, based on marijuana
use, 4.2 million people ages 12 and up met criteria for an SUD. Cannabis use disorder is defined as continued use despite impairment in psychological, physical, or
social functioning. About 10% of users experience addiction. As adult use increases
due to state legalization, the use increases in children and adolescents.
Stimulant Use Disorder. Stimulants increase alertness, attention, and energy, as
well as elevate blood pressure, heart rate, and respirations. They include a wide
range of drugs that have historically been used to treat conditions such as obesity,
attention deficit hyperactivity disorder, and depression. Like other prescription
medications, stimulants can be diverted for illegal use. The most commonly abused
stimulants are amphetamines, methamphetamine, and cocaine. Stimulants can be
synthetic (eg, amphetamines) or can be plant derived (eg, cocaine). They are usually
taken orally, are snorted, or are delivered intravenously. In 2017, an estimated
1.8 million people ages 12 and older misused stimulants, and 2.2 million were users
of cocaine. Withdrawal symptoms that occur after stopping or reducing use include
fatigue, vivid and unpleasant dreams, sleep problems, increased appetite, and irregular problems in controlling movement.
Hallucinogen Use Disorder. Hallucinogens can be chemically synthesized (as
with lysergic acid diethylamide, also known as LSD) or may occur naturally (as
with psilocybin mushrooms, peyote). These drugs can produce visual and auditory
hallucinations, feelings of detachment from one’s environment and oneself, and distortions in time and perception. In 2017, approximately 1.4 million Americans had
recent hallucinogen use.
Clinical Presentation
Some findings on the physical examination may aid in the diagnosis of illicit drug
use. Eye examination is crucial, especially in an unconscious patient suspected to be
under the influence of drugs. Dilated pupils may indicate stimulant or hallucinogen
use or withdrawal from opioids. Constricted pupils are a hallmark of opioid use.
Physical examination can also reveal signs such as damage to nasal mucosa, septum
perforation due to nasal inhalation, or injection “track marks.” Sequelae of cirrhosis, including spider angiomas, caput medusa, hepatomegaly, and/or ascites, due to
viral hepatitis or alcohol abuse, may also be found.
Laboratory Values. Several laboratory tests are available for determining the presence of alcohol and other drugs in body fluids and other substances, such as urine,
hair, and blood. Urine drug toxicology tests measure recent substance use rather than
chronic use or dependence. These tests can have false negatives since synthetic substances ingested are often not detected in point-of-care urine drug toxicology tests.
These tests can also have false positives and should be interpreted with caution.
There is no conclusive test to determine SUDs. Useful laboratory tests may include
breath or blood alcohol tests, urine toxicology, liver enzymes, electrolytes, renal
function, CBC, PT/INR and PTT, and vitamin-deficiency screening.
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Treatment
Substance use disorder is challenging and requires an understanding of the natural history of recovery, including high rates of relapse with the need for multiple
long-term interprofessional interventions to achieve optimal outcomes. Although
initial symptoms from withdrawal may not be very different from one class of drug
to another, there are significant differences in complications and management of
withdrawal from different substances. Therefore, it is crucial to identify the abused
substance early in the treatment. The treatment is a long-term process, regardless
of the substance being abused, and it often requires many behavioral changes and
multiple attempts to quit.
Medication and behavioral therapy, especially when combined, are important
elements of an overall therapeutic process that often begins with detoxification.
This includes management of the withdrawal symptoms, followed by treatment
and relapse prevention. A key to preventing relapse is to minimize the withdrawal
symptoms, which is often the first step of treatment in a patient who acknowledges
addiction. Tapering doses of long-acting agents for the abused drugs is frequently
used to treat drug withdrawal. Antidepressants, anxiolytics, mood stabilizers, and
antipsychotic medications may be critical for treatment success when patients have
co-occurring psychiatric disorders.
Collaboration With Patients. Treatment of drug addiction is provided in various settings with different medication and behavioral therapy options, which
should be discussed with the patient at the initiation of the treatment. Considering the wishes and readiness of the patient to acquire treatment, the provider
should recommend a comprehensive plan, preferably including both medication
and behavioral therapy. General categories for drug treatment programs include
detoxification and medically managed withdrawal, long-term residential treatment,
short-term residential treatment followed by long-term outpatient treatment, or
exclusively outpatient treatment.
Pharmacotherapy. Detoxification is an important first step in substance abuse
treatment with three goals: initiating abstinence, reducing withdrawal symptoms
and severe complications, and retaining the patient in treatment. Ongoing treatment is needed thereafter to maintain abstinence. The aims are to restore normal
cognitive and emotional function, to diminish cravings, and to prevent relapse.
Medication helps make patients more receptive to the behavioral treatment and
to avoid drug-seeking and related criminal behavior. See Table 41–2 for substance
withdrawal symptoms, medications used to treat withdrawal symptoms, long-term
treatment, and relapse prevention.
Behavioral Therapies. Behavioral treatment is an important adjunct to addiction treatment. Clinicians help by providing motivational interviewing to encourage behavior change, reduce relapse, modify lifestyles related to drug abuse, and
help develop coping mechanisms to handle stressful situations. Additional behavioral therapy models include group therapy, cognitive behavioral therapy, and the
12-step model, which is used by organizations such as Alcoholics Anonymous and
Narcotics Anonymous.
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Table 41–2 • ADDICTION: WITHDRAWAL SYMPTOMS AND PHARMACOLOGY
FOR DRUG WITHDRAWAL AND RELAPSE PREVENTION
Addictions
(Brand Name) Treatment
Withdrawal Symptoms Generic Name
Opioids
Muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise,
drug seeking, mydriasis, piloerection, diaphoresis, rhinorrhea,
lacrimation, diarrhea, insomnia,
elevated blood pressure and
pulse
Naltrexone (Revie) Long-acting synthetic opioid
Tobacco
Headaches, irritability, craving,
depression, anxiety, cognitive
and attention deficits, sleep disturbances, and increased appetite
Bupropion ( Wellbutrin, Zyban) Mild stimulant
Vareniciline (Chantix) Partial agonist/antagonist at
Methadone (Dolophine, Methadose) Long-acting
Buprenorphine (Subutex, Suboxone) Partial agonist
Nicotine replacement therapies
Characteristics
synthetic opioid; given in dosage sufficient to prevent opioid withdrawal,
block the effects of illicit opioid use,
decrease opioid craving.
at opioid receptors, lowers the risk
of overdose, reduces or eliminates
withdrawal symptoms, no euphoria
and sedation caused by other opioids
(including methadone).
antagonist; used in outpatient settings;
prevents an addicted individual from
feeling the effects associated with
opioid use, which is the notion behind
this treatment; diminished craving and
addiction.
(Gums, patch, spray, lozenges) Used in
maintaining low levels of nicotine in
the body and reduce the withdrawal
symptoms.
effects, blocks reuptake of norepinephrine and dopamine, marketed initially
as antidepressants, showed efficacy in
reducing tobacco craving, promoting
cessation without concomitant weight
gain.
nicotinic receptors; minimal stimulation
of nicotine receptor but not enough to
stimulate dopamine release, which is
related to the rewarding effects of nicotine; reduces craving.
(Continued)
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Table 41–2 • ADDICTION: WITHDRAWAL SYMPTOMS AND PHARMACOLOGY
FOR DRUG WITHDRAWAL AND RELAPSE PREVENTION
Addictions
(Brand Name) Treatment
Withdrawal Symptoms Generic Name
Alcohol
<12 hours: insomnia, tremulous-
ness, mild anxiety, gastrointestinal upset, headache, diaphoresis,
palpitations, anorexia
12 to 24 hours: visual, auditory,
or tactile hallucinations
24 to 48 hours: Generalized
tonic-clonic seizures
48 to 72 hours: Delirium
Tremens; hallucinations
(predominantly visual), disorientation, tachycardia, hypertension, low-grade fever, agitation,
diaphoresis
Topiramate ( Topamax) Thought to have similar
Chlordiazepoxide,
Carbamazepine,
Atenolol,
Clonidine (Catapres) Alpha-agonists; used as
Naltrexone (Revie) Used to reduce relapse in heavy
Acamprosate (Campral) Reduces withdrawal by act-
Disulfiram (Antabuse) Causes retention of acet-
diazepam,
lorazepam
valproate
propranolol
Characteristics
drinkers (defined as 4 or more drinks/
day in women and 5 or more drinks/
day in men), relapse reduction up to
36% in first 3 months, not very effective
in maintaining abstinence.
ing on GABA and glutamate pathway;
very effective in maintaining abstinence in dependent drinkers, even
in severe cases, for several weeks to
months.
aldehyde by interfering with the degradation of alcohol; flushing, nausea,
and vomiting experienced on alcohol
intake; nonadherence is common.
mode of action as acamprosate, not
FDA approved for alcohol addictions
treatment.
(Librium, Valium, Ativan) Benzodiazepines (preferably long acting);
decreased severity of withdrawal
symptoms; reduced risk of seizures and
delirium tremens.
(Tegretol, Depakote) Anticonvulsants;
decreased severity of withdrawal
symptoms.
(Tenormin, Inderal) Beta-blockers; used
as adjunctive agents, improvement in
vital signs; reduction in craving.
adjunctive agents, decreased severity
of withdrawal symptoms.
continued
(Continued)
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Table 41–2 • ADDICTION: WITHDRAWAL SYMPTOMS AND PHARMACOLOGY
FOR DRUG WITHDRAWAL AND RELAPSE PREVENTION
Addictions
(Brand Name) Treatment
Withdrawal Symptoms Generic Name
Stimulants
Paranoia, depression,
somnolence, anxiety, irritability,
difficulty to concentrate,
psychomotor retardation,
increased appetite
Desipramine,
Methylphenidate,
amantadine
Propranolol (Inderal) Adrenergic antagonists; treat-
bupropion
Characteristics
(Ritalin, Symmetrel) Indirect dopamine
agonists; treatment retention was
improved in one study of each agent;
data are very limited.
ment retention was improved and
cocaine use was reduced in patients
with severe withdrawal symptoms.
(Norpramin, Wellbutrin) Antidepressants;
medications are well tolerated but
do not appear to be effective during
stimulant withdrawal.
continued
CASE CORRELATION
See Case 7 (Tobacco Use and Cessation) and Case 59 (Opioid Use Disorder
and Chronic Pain Management).
COMPREHENSION QUESTIONS
41.1 An 18-year-old young woman who is captain of her high school cheerleading squad presents to the clinic with her mother, who is concerned about
her daughter’s erratic behavior and emotional outbursts. She states that her
daughter rarely sleeps on the weekends but sleeps heavily at the beginning
of the week and is frequently late for school. She has no significant medical
or psychiatric history. Her mother states that she has tried to discuss these
issues, but her daughter gets angry and leaves home. She wants to have her
daughter tested for drug use. You speak to the patient alone, and she endorses
the symptoms her mother reports. Her vital signs are within normal limits,
and the physical examination is unremarkable. She consents to a urine toxicology screen, which is positive for methamphetamine. The patient admits
she last used about 1 week ago and has only used twice in her life. What is the
most appropriate next step in managing this patient?
A. Confront the patient in the presence of her mother about her addiction
problem.
B. Refer the patient for an immediate psychiatry evaluation.
C. Prescribe oral propranolol to prevent withdrawal symptoms.
D. Offer behavioral therapy and drug rehabilitation to the patient alone.
E. Obtain an ECG, comprehensive panel, and CBC.
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41.2 A 40-year-old woman presents to the clinic complaining of feeling depressed
and jittery. She has been feeling this way on and off for the last year since her
husband passed away in a car accident. She reports a recent increase in headaches, insomnia, loss of appetite, and increased irritability. When asked about
substance use, she says she drinks wine at night to help her sleep. Further questioning leads her to disclose that she started drinking more after her husband’s
death, and she currently drinks, on average, 1.5 bottles of wine each evening.
She denies previous history of psychiatric disorder. The patient’s physical
examination is unremarkable with the exception an elevated blood pressure of
140/90 mm Hg. A comprehensive metabolic panel reveals an alanine aminotransferase (ALT; also known as SGPT) of 30 U/L (normal 10-40) and an
aspartate aminotransferase (AST; also known as SGOT) of 84 U/L (normal
10-30). The remaining laboratory studies are negative. There is no family history of liver disease. Which one of the following pharmacologic agents could
help reduce this patient’s alcohol consumption and increase abstinence?
A. Acamprosate
B. Amitriptyline
C. Paroxetine
D. Promethazine
E. Venlafaxine
41.3 Which one of the following is effective in preventing seizures associated with
alcohol withdrawal syndrome?
A. Carbamazepine (Tegretol)
B. Chlordiazepoxide
C. Clonidine (Catapres)
D. Gabapentin (Neurontin)
E. Phenytoin (Dilantin)
ANSWERS
41.1 D. This patient should be presented with the results of the urine toxicology
screen and options about substance abuse treatment. This should be done
with the patient alone and not in the presence of her parent (answer A). She
appears reasonable and psychologically stable during the appointment and thus
does not require an immediate psychiatry evaluation (answer B). An ECG and
serologic evaluation (answer E) will not likely add to the investigation of this
patient since she is asymptomatic upon presentation. Similarly, she does not
appear acutely intoxicated, and propranolol has no role in the prevention of
withdrawal symptoms for methamphetamine intoxication (answer C).
41.2 A. Pharmacological treatment is used as an adjunct in treatment of alcohol
dependence. Naltrexone, disulfiram, and acamprosate are approved by the
Food and Drug Administration (FDA) for this indication. Consistent, goodquality, patient-oriented evidence has found naltrexone or acamprosate to
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be the most effective treatment of alcohol dependence when used in conjunction with behavioral therapy. Antidepressants (answer C, paroxetine; answer
B, amitriptyline; and answer E, venlafaxine) may be beneficial in patients with
coexisting depression. The antiemetic ondansetron (not promethazine, answer
D) may also help decrease alcohol consumption in patients with AUD. An AST
to ALT ratio greater than 2:1 suggests alcoholic liver disease, and a ratio of 3:1
or higher is highly suggestive of alcoholic liver disease. With most hepatocellular disorders, including nonalcoholic fatty liver disease, viral hepatitis, and iron
overload disorder, the patient will have an AST to ALT ratio < 1.
41.3 B. Benzodiazepines can prevent alcohol withdrawal seizures. Anticonvulsants such as carbamazepine (answer A), gabapentin (answer D), and phenytoin (answer E) have less abuse potential than benzodiazepines but do not
prevent seizures. Clonidine (answer C), an alpha-adrenergic agonist, reduces
the adrenergic symptoms associated with withdrawal but does not prevent
seizures.
CLINICAL PEARLS
» No single treatment for SUD is appropriate for all individuals.
» Individual and/or group counseling and other behavioral therapies are
critical components of effective treatment for SUD.
» Medications are an important element of treatment for many patients,
especially when combined with counseling and other behavioral
therapies.
» Individuals with SUD with coexisting mental disorders should have both
disorders treated in an integrated way.
» Medical detoxification is only the first stage of SUD treatment and by
itself does little to change long-term drug use.
» Recovery from SUD is often a long-term process and frequently requires
interprofessional care management and multiple episodes of treatment.
REFERENCES
Illicit Drug Use, Including Nonmedical Use of Prescription Drugs: Screening. US Preventive Services Task
Force draft recommendation statement. https://www.uspreventiveservicestaskforce.org/uspstf/
draft-recommendation/drug-use-in-adolescents-and-adults-including-pregnant-women-screening.
Accessed May 26, 2020.
Muncie HL, Yasinian Y, Oge L. Outpatient management of alcohol withdrawal syndrome. Am Fam
Physician. 2013;88(9):589-595.
Phillips KA, Bonci A. Cocaine and other commonly used drugs. In: Jameson J, Fauci AS, Kasper DL,
Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 20th ed. New York,
NY: McGraw Hill; 2018: Chap. 447. http://accessmedicine.mhmedical.com/content.aspx?bookid=
2129§ionid=192534128. Accessed January 21, 2019.
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