Q: What signs or symptoms should alert the PCP to a possible problem?
Ms. Becker:
Marijuana users may have red, puffy eyes. People injecting cocaine or heroin may have skin abscesses, endocarditis, and/or infectious disease (e.g., hepatitis B or C, or HIV). Methamphetamine users frequently have scratch marks from chronic pruritus, as well as transient hypertension and anxiety. It can be hard to identify drug use on physical exam. That’s why screening is so important.
Ms. Waters: All PCPs should be familiar with both the overt signs of intoxication by various drugs as well as the more subtle signs and symptoms, such as mild-to-moderate hypertension, generalized abdominal pain, and rhinorrhea. Signs and symptoms often are not consistent because of the variability of dosage, adulteration of the drugs, and common use of drugs in combination. Further, the intoxication syndrome is activating for some drugs and sedating for others, so the signs and symptoms vary greatly depending on the drug. It’s vital for providers to understand the dynamic neurotransmitter actions and interactions with various drugs and to use this knowledge when evaluating signs and symptoms. Also important are the distinct withdrawal syndromes associated with the various drugs. Remember that the withdrawal syndrome is generally opposite to the intoxication syndrome. This is logical, but many providers fail to think of the two syndromes in this way. For example, while an opiate-intoxicated patient may be calm or lethargic with midpoint or constricted pupils and dry, warm skin, the patient withdrawing from opiates may be agitated with dilated pupils, diaphoresis, flushed skin, and rhinorrhea.
Ms. Becker: Physical problems are frequently the reason a patient seeks out the PCP (e.g., a cocaine user who presents with chest pain). It is especially challenging when the patient presents with a health problem that is a result of the drug abuse and the provider is unaware of the abuse. Say you’re treating a patient for hypertension, but that patient is a methamphetamine abuser. It’s difficult to make the right decision about the medication dose if you are unaware of the meth abuse. Psychological problems often include dysfunctional relationships, mood swings, depression, or financial, legal, or job difficulties.

Q: Are illicit drugs addictive?
Ms. Becker: There is behavioral tolerance and physical tolerance. Behavioral tolerance is a learned condition response. After repeated drug exposure, the body reflexively learns to anticipate the drug’s effects. Physical tolerance involves neuroadaptation, as more and more of the substance is required to achieve pleasurable effects; with abstinence or decreasing amounts of the substance, the patient will experience very unpleasant physical withdrawal symptoms. Opiates, such as heroin or oxycodone, and sedative-hypnotics, such as the benzodiazepines or barbiturates, cause both physical and behavioral dependence. Patients who are physically dependent on a substance need to be supported and safely withdrawn from the drug. Physical tolerance is reversed during periods of abstinence; however, behavioral tolerance is far more persistent and is the reason that patients continue to “crave” the drug. Interestingly, marijuana users don’t develop physical tolerance, but they do experience significant behavioral tolerance.

Continue Reading

Q: Are patients usually willing to discuss drug use?
Ms. Waters:
Yes, provided it is asked about in a nonjudgmental manner during a medical encounter. I preface my questions with “I ask all of my patients about alcohol and drug use because it can impact your health.” Research tells us that patients expect to be asked these questions in the medical setting.
Ms. Becker: Patients who present for the rare health encounter may be less likely to disclose illicit drug use. Some patients are in such denial that they can’t recognize the severity of their problem and minimize the amount of use. While there is no truth to the old adage “Take what they tell you they use and double it,” it came about in response to the denial and minimization so prevalent in most substance abusers.