In the framework provided by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000), the problem of opioid misuse is divided into four categories, among which there may be some overlap. Opioid intoxication and opioid withdrawal are specifically defined in DSM-IV-TR. Facility in making these diagnoses requires a clear understanding of the clinical features associated with opioids, as discussed later in this chapter. In addition to intoxication or withdrawal, it is important to characterize the individual's relationship to the use of opioids over time.

Initial assessment always includes a thorough history of the individual's substance use over time, with corroboration from outside sources if possible. This corroboration of the individual's history is essential because of the nearly universal presence of denial in the nonrecovered substance abuser. Minimization of the frequency and amounts of opioid use is common, as is the illu sion of control characterized by the often-heard phrase, "I can stop anytime I want to." Progression in the pattern of usage is the rule, as the reinforcing qualities of the opioid and tolerance exert their powerful influence. Critical to the initial assessment is an accurate answer to this question: "When did you last use and how much did you use?" With this information, the clinician can begin to assess the impact of intoxication or withdrawal upon the immediate clinical presentation. It is also necessary to understand the crises or events precipitating contact with the health care system to assess whether the patient has truly "hit bottom" or merely experienced a temporary loss of ability to obtain opioids. This information may be useful in predicting readiness to accept treatment interventions.

A family history of substance abuse provides data reflective of the genetic influences in opioid dependence, as well as the contribution of learned behavior and sanction of substance abuse within the family structure. This information is particularly useful in planning a strategy for recovery and relapse prevention. Returning an individual to contact with family members and/or friends who are still using opioids and other drugs will virtually guarantee a quick relapse.

Also important are inquiries into the individual's functioning in the workplace, at home, and in the social arena. Trouble may occur in each area because of the competition between dependence-driven, drug-seeking behavior and the demands of everyday living. It is important to ask specifically about legal difficulties, arrests, convictions, or restrictions of freedom (e.g., loss of professional licensure).

A medical review of systems in tandem with a thorough physical examination, including a neurological examination and a mental status examination, may reveal signs of intoxication or withdrawal, as outlined later. Stigmata of opioid use, such as fresh or old needle marks (tracks) around superficial veins in the extremities and neck, are readily observed. These often appear as increased lines of pigmentation. There may be evidence of old and new skin abscesses, clotted or thrombosed veins, an enlarged and tender liver, swollen lymph nodes, a heart murmur caused by endocarditis, hypo- or hyperactive bowel sounds, and pupillary abnormalities, which depend on the stage of intoxication or withdrawal. Significant weight loss is common, though weight gain is occasionally reported.

Useful laboratory studies include serum liver function studies, which may show inflammation in the form of elevated serum aspartate aminotransferase (AST), serum alanine aminotransferase (ALT), bilirubin, alkaline phospha-tase, and reduction in total protein, clotting factors, and immunoglobulins. Blood urea nitrogen may also be elevated, though the meaning of this finding is unclear. Further testing may include hepatitis A, B, and C screening; human immunodeficiency virus (HIV) testing; complete blood count; and urine and/or serum analyses for the presence of opioids, cocaine metabolites, marijuana, alcohol, benzodiazepines, barbiturates, other stimulants, and hallucinogens. If possible, the collection of urine samples should be actively observed to ensure that the samples are not falsified in some manner by the individual. "Scams" for avoiding detection of illicit drugs in urine are diverse and imaginative: Some men have provided "clean" urine from a small tube alongside the penis, and some women have concealed a balloon of "clean" urine in the vagina to be lacerated with a fingernail, while apparently positioning the specimen cup near the urethral meatus as the sample is collected.

As evidence of opioid abuse or dependence grows, the clinician can mount a firm but respectful confrontation of the individual, who will frequently admit the problem because he or she now recognizes that there may exist an opportunity for treatment. The "addiction as an illness" concept can be useful at this critical juncture in the physician's interactions with an opioid-dependent person. If the patient's denial prevents engagement in treatment, leverage on his or her behavior may be gained by involving significant others, employers, or the legal system.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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