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Rationale

Alcohol and drug abuse are associated with many of the interactions internists have with patients in a given day. The effects of substance abuse 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 abuse can, through appropriate therapy, treatment, and/or referral, help the patient return to a healthy lifestyle.

Prerequisites

Basic courses in physiology, pathology, and pharmacology, and introductory required preclinical course in physical diagnosis

Specific Learning Objectives

  1. Knowledge: Students should be able to describe:
    1. presenting signs and symptoms of abusing the following substances: alcohol, opiods, cocaine, amphetamines, hallucinogens, barbiturates, and other related medications and benzodiazipines.
    2. presenting symptoms of alcohol and drug intoxication.
    3. presenting symptoms of alcohol and drug overdose.
    4. presenting symptoms of acute alcohol and drug withdrawal.
    5. key risk factors for alcohol and drug abuse (social, genetic).
    6. the major causes of morbidity and mortality associated with substance abuse (e.g., trauma, motor vehicle accidents, homicide, overdose, cirrhosis, endocarditis, HIV, hepatitis B, and suicide).
    7. discuss the differences among substance abuse, dependency, and addiction.
    8. the diagnostic criteria for alcohol and drug abuse, dependency, and addiction, based on a history, physical examination, and laboratory testing.
    9. 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]?”)*.
    10. list the key laboratory tests useful in evaluating substance abuse (e.g., blood alcohol level, liver function tests, complete blood count, amylase, urine and serum drug screens)
    11. list available community referral sources (e.g., Alcoholics Anonymous, Narcotics Anonymous) and where to obtain telephone numbers.
    12. list the key health benefits that accrue with cessation.
    13. describe the management strategies for acute alcohol and drug withdrawal.
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease including:
      1. eliciting a social history in a nonjudgmental, supportive manner, using appropriate questioning (CAGE questions, etc.).
      2. evaluating a patient using the Diagnostic and Statistical Manual of Psychiatric Disease (DSM III-R) criteria for substance or alcoholic dependence.
    2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including assessing in a substance-abusing patient for:
      1. fever
      2. hypertension
      3. tachycardia
      4. skin for jaundice, needle tracks, manifestations of endocarditis, HIV infection, and cirrhosis
      5. eyes for pupil size and icterus, fundus exam (roth spots)
      6. nose for nasal septum perforation
      7. mouth for odor of alcohol and parotid enlargement
      8. breasts for gynecomastia
      9. lymph nodes for adenopathy
      10. heart for murmurs
      11. abdomen for hepatomegaly
      12. genital exam for testicular atrophy
      13. neurologic exam for tremor and cognitive impairment
      14. Dupuytren’s contractures
    3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings to determine the diagnosis of substance abuse of drugs or alcohol.
    4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment, based on the differential diagnosis, including consideration of test cost and performance characteristics, as well as patient preferences
      1. 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
    5. communication skills: Students should be able to explain the results of the evaluation to the patient.
    6. basic and advanced procedure skills: None
    7. management skills: Students should be able to:
      1. assess a patient’s motivation for achieving sobriety/abstinence.
      2. deliver a directed, non-judgmental message to a substance-abusing patient urging him/her to quit.
      3. make an appropriate community referral for a substance-abusing patient
      4. write appropriate fluid and medication orders for the treatment of acute alcohol and/or drug withdrawal.
      5. access and utilize appropriate information systems and resources to help delineate issues related to substance abuse.
  3. Attitudes and Professional Behaviors: Students should be able to:
    1. recognize the biopsychosocial etiology of addictions
    2. appreciate the prevalence of addictions and the need to consistently include substance abuse in the history.
    3. appreciate the power of simple directed messages in stimulating behavior change.
    4. recognize that substance abuse affects the community and family, as well as the patient.
    5. demonstrate a commitment to non-judgmental care of substance-abusing patients

      * [Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 252: 1905, 1984.]