Christine A. Pace, MD, MSc; Jeffrey H. Samet, MD, MA, MPH
CME Objective: To review current evidence for epidemiology, prevention, diagnosis, complications, and management of substance use disorders.
Funding Source: American College of Physicians.
Acknowledgment: The authors thank Julia Canfield, MPH; Dan Alford, MD, MPH; Lee Ellenberg, LICSW; David Fiellin, MD; Tim Naimi, MD, MPH; Richard Saitz, MD, MPH; and Alexander Walley, MD, MSc for their assistance.
With the assistance of additional physician writers, the editors of Annals of Internal Medicine develop In the Clinic using MKSAP and other resources of the American College of Physicians.
In the Clinic does not necessarily represent official ACP clinical policy. For ACP clinical guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.
Disclosures: Dr. Pace and Dr. Samet, ACP Contributing Authors, have disclosed no conflicts of interests. Forms can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2657.
This issue provides a clinical overview of substance use disorders, focusing on epidemiology, prevention, diagnosis, complications, and management. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.
Unhealthy substance use.
Appendix Table 1. Clinical Opiate Withdrawal Scale (COWS)
Appendix Table 2. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
Table. Medical Treatment for Substance Use Disorders
Use large amounts of drugs or alcohol or for a longer amount of time than you planned
Have trouble cutting down on your use of drugs or alcohol
Spend a lot of time trying to get drugs or alcohol
Take a long time to recover from drug or alcohol use
Have strong cravings or urges to use drugs or alcohol
Have trouble at work, school, or home because of drugs or alcohol
Continue to use drugs or alcohol even if it causes problems for you
Feel like you need to use more drugs or alcohol than before to get the same effects
Have withdrawal when you don't use drugs or alcohol
Your doctor will ask questions about your substance use.
You may fill out a series of questions. This can help your physician make a diagnosis.
You may have blood tests to check for health problems caused by drugs or alcohol.
Some medicines can be helpful in treating substance use disorder. These medicines may be prescribed by your doctor or another health care provider.
Group or one-on-one counseling can help you better manage your substance use disorder.
Self-help groups, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), and day programs are helpful for many people.
Some choose an overnight treatment program to get more support.
Talk to your doctor about how to get the care you need. If you are not ready to stop using drugs or alcohol, talk to your doctor. They can help you learn about ways to reduce the effect of substance use on your health.
Is my substance use affecting my health?
What is the best treatment for me?
If I don't get treatment, what will happen?
Are there medicines that could help me? Which ones might be right for me?
Should I go to a long-term treatment program?
I need emotional support. Where can I turn?
Clinical Slide Set. Substance Use Disorders
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Alain Braillon , MD
University Hospital, Amiens, France
April 22, 2016
Tobacco plus other Substance Use Disorders: leaping the chasm in two jumps
Why tobacco is excluded from the CME about Substance Use Disorders (SUD)?(1) Only two sentences with low expectations, without references: “Finally, physicians should address tobacco use in patients with substance use disorders, just as they would with other patients. Tobacco is a major cause of morbidity and mortality among patients who are actively using drugs and alcohol, as well as those in recovery; no evidence convincingly suggests that tobacco cessation worsens substance use outcomes or causes relapse.”(1)Robust evidence has been available since 2004. A systematic review of 17 studies showed tobacco cessation treatment does not compromise other SUD treatment and does improve other substance uses (alcohol and illicit drugs) outcomes, predicting more favourable long-term outcomes.(2) This is confirmed by more recent studies.(3-4) Even during acute state, nicotine replacement therapy allows to reduce agitation and aggression in patients with severe mental disorders.(5)Having low expectations about smoking cessation treatment is flying in the face of evidence and a reminder of the paternalistic nature of too much of medicine’s past, it harms the most vulnerable.The most dangerous thing in the world is to leap a chasm in two jumps.(David Lloyd George, British Prime Minister during World War I)1 Pace CA, Samet JH. Substance Use Disorders. Ann Intern Med 2016 5;164:ITC49-ITC64.2 Prochaska J J, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. J Consult Clin Psychol 2004;72: 1144-1156.3 Mannelli P, Wu LT, Peindl KS, Gorelick DA. Smoking and opioid detoxification: behavioral changes and response to treatment. Nicotine Tob Res 2013;15:1705-13.4 Weinberger AH, Platt J, Jiang B, Goodwin RD. Cigarette smoking and risk of alcohol use relapse among adults in recovery from alcohol used. Alcohol Clin Exp Res 2015;39:1989-96.5 Allen MH, Debanné M, Lazignac C, Adam E, Dickinson LM, Damsa C. Effect of nicotine replacement therapy on agitation in smokers with schizophrenia: a double-blind, randomized, placebo-controlled study. Am J Psychiatry 2011;168:395-9
Pace CA, Samet JH. Substance Use Disorders. Ann Intern Med. 2016;164:ITC49-ITC64. doi: 10.7326/AITC201604050
Download citation file:
Published: Ann Intern Med. 2016;164(7):ITC49-ITC64.
Tobacco, Alcohol, and Other Substance Abuse.
Results provided by:
Copyright © 2017 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only