Initial evaluation of the cocaine abuser begins with a medical, psychiatric, and psychosocial history, as well as a physical examination. Confirming and augmenting the patient's history through collateral reports of family members and significant others is often helpful. On an emergency basis, the following laboratory tests need to be considered, based on the patient's clinical presentation: complete blood count, chemical profile (SMA-12), urinalysis, urine and/or blood toxicology, electrocardiogram, and chest X-ray. Indications for acute hospitalization include (1) serious medical or psychiatric problems either caused by the stimulant drugs or independently coexisting, and (2) concurrent dependence on other drugs, such as alcohol or sedative hypnotics, necessitating a more closely supervised withdrawal. A validated, widely accepted tool to assess addiction severity specifically to cocaine has not yet been developed. However, DSM-IV-TR (American Psychiatric Association, 2000) diagnostic criteria for cocaine intoxication, withdrawal, delirium, delusional disorder, dependence, and abuse are based on the symptoms described in this chapter. Evaluation to guide addiction treatment needs to address a variety of issues, including the dosage, patterns, chronicity, and method of cocaine use; other drug use; antedating and drug-related medical, social, and psychological problems; the patient's cognitive ability and social skills; and the patient's knowledge, motivation, attitude, and expectations of treatment (Washton, Stone, & Hendrickson, 1988). Additional factors indicating increased severity of addiction that may necessitate inpatient treatment include chronic smoking of freebase or intravenous cocaine use, the demonstrated inability to abstain from use while in outpatient treatment, and the lack of family and social supports.
Once the patient is stabilized and assigned to an appropriate level of care, a more detailed medical, psychiatric, and psychosocial history and physical examination should be performed. Patient motivation and readiness for change may enhance retention and positive treatment outcomes. The search for evidence of medical, neuropsychological, and psychiatric sequelae should be stressed, as well as consequences of self-neglect. The following laboratory tests should be considered supplements to those obtained previously on an acute care basis: pulmonary function testing with diffusing capacity of carbon monoxide (DLCO, DCO) in smokers of freebase and crack cocaine, and purified protein derivative (PPD) tubercular skin testing with controls; rapid plasma reagin agglutination test (RPR; syphilis serology); hepatitis B surface antigen and hepatitis C antigen; and HIV serology in intravenous users. Because these patients generally have poor follow-up rates, immunizations should be given, and general preventive health maintenance should be performed at this time as well.
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