Recognition of substance abuse in adolescents, geriatric patients, and patients with mental illness provides special challenges.
Drug and alcohol use during adolescence differs from use in adults. The typical acting out of adolescents can be confused with the effects of drug and alcohol use. Adolescents' mistrust of adult authority frequently complicates the detection of substance abuse. A family physician who has interacted with an adolescent over time probably is trusted more than other adult authority figures. The best chance for the physician to detect problems is in the context of routine medical care. 15 Family physicians need to be aware of potential problems and modify the CAGE questionnaire to screen for both drugs and alcohol.
Older patients with alcoholism fall into two groups. The early-onset group had alcoholism earlier in life, while problems in the late-onset group begin after the age of 60. 16 Several studies have evaluated the efficacy of the CAGE questionnaire in elderly patients. While the overall sensitivity and specificity are quite good, this screening tool is not as effective in discriminating between current drinking and a past drinking problem. It is particularly important to modify the CAGE questionnaire to detect drug abuse, because elderly patients are prone to self-medication. The physician must be aware that cognitive impairment can affect the patient's ability to respond accurately to the questions.
The physician should be suspicious of substance abuse in patients with mental disorders. Results from the Epidemiologic Catchment Area study 17 demonstrated that 47 percent of patients with a lifetime diagnosis of schizophrenia or schizophreniform disorder met criteria for some form of substance abuse. In patients with antisocial personality disorder, the percentage was 83.6; in patients with anxiety disorders, the percentage was 23.7; and in patients with affective disorders, the percentage was 32. Suspicion of substance abuse is important not only because of the prevalence of this disorder, but also because it is very difficult to treat mental illness if concomitant substance abuse is unrecognized.
A detailed outline of the treatment of substance abuse is beyond the scope of this article. If problem drinking is identified, even brief physician advice can be helpful. 18 [Evidence level A, randomized controlled trial] These patients have experienced some negative consequences but have not yet experienced a major loss of control. The patient who has been diagnosed with substance abuse should be referred to an addiction-medicine specialist or an inpatient or outpatient treatment center. These steps give the patient a solid start on the recovery process.
If insurance problems or other factors prevent referral, it is possible to detoxify the patient on an outpatient basis. The patient then can be referred to Alcoholics Anonymous or Narcotics Anonymous for sustained follow-up support. Specific medical therapies are available for opioid addiction.
Whatever treatment the patient undergoes, it is important for the family physician to be supportive of the patient and the family in recovery and to be extremely careful about prescribing mood-altering drugs in the future. As a chronic disease, substance abuse tends to relapse. The family physician can play a pivotal role by dealing with the patient and family in a nonjudgmental manner.