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Update in Addiction Medicine
- Robert K. Schneider, MD;
- James L. Levenson, MD; and
- Sidney H. Schnoll, MD
- From Virginia Commonwealth University at the Campus of the Medical College of Virginia, Richmond, Virginia.
In 1978, Regier and colleagues (1) coined the term “de facto mental health and substance abuse system” after finding that most patients with mental illness and substance abuse are treated in the general medical sector, not in psychiatric settings. Despite the availability of this system, many patients with mental disorders and substance abuse do not receive a diagnosis, and many do not receive treatment or are treated for a “medical problem” instead of their underlying mental or substance abuse disorder. We polled journal editors from leading substance abuse, psychiatric, and general medical journals, as well as leaders in addiction medicine, to develop a list of important recent articles in this area. The literature described in this Update is intended to expand on and in some cases introduce information about addiction medicine that may not be readily available to internists. The information is broadly divided into categories of addiction medicine: nomenclature, alcohol, opioids, tobacco, cocaine, club drugs, marijuana, and psychogenetics.
Nomenclature
A Large Minority of Patients Have Substance Dependence without Physiologic Evidence
An important change in the definition of “dependence” occurred between the third and fourth editions of Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R and DSM-IV). According to DSM-IV, the presence of dependence is contingent on evidence of physiologic signs of tolerance or withdrawal. However, many patients are dependent without physiologic signs. Schuckit and colleagues classified study participants with substance dependence according to whether physiologic components of dependence were present. They performed two studies: The first study examined 3395 alcohol-dependent persons; the second study examined 1457 participants with a lifetime diagnosis of marijuana dependence, 1262 with cocaine dependence, 647 with amphetamine dependence, and 368 with opiate dependence. Diagnosis of dependence was based on structured interviews covering DSM-III-R and DSM-IV criteria.
Outcomes measured included evidence of dependence, characterized by withdrawal, tolerance, and psychological dependence as defined in DSM-III-R. Table 1 shows the …
