HEALTH CARE * LES SOINS
Addiction can take many Addilct*ion can take niany forins, forms,
experts warn MDs
at conference
Sidney Katz
T he 36-year-old stranger came to the small Ontario town looking for a seasonal job. Disappointed that none was available, he spent the afternoon drinking in local pubs. After several hours he became belligerent and abusive and was beaten up by two men. The police found him lying on the road and drove him to hospital. Hostile and uncooperative, he refused admission. A physician summoned from the hospital examined the patient, as best he could, in the back seat of the police cruiser. The man was then driven to the police station, where he was put in a cell. Some hours later, he was found dead. The autopsy revealed an abnormally high blood-alcohol content, extensive fractures and internal injuries. Death was caused by hypovolemic shock. This history was cited by Dr. James Rankin, chief of the medical staff at Ontario's Addiction Research Foundation (ARF), during the opening session of a 3-day fall meeting of the Canadian Medical Society on Alcohol and Other Drugs (CMSAOD). "The point of this story is that this person need not have died," said Rankin, who ex-
One patient referred to the Homewood Health Centre was taking 45 tablets containing codeine every day. He was supplementing that intake with over-the-counter acetaminophen. -Dr. Graeme
Cunningham Sidney Katz is a freelance writer living in Toronto. MARCH 1, 1992
plained that CMSAOD, which he currently heads, was created 2 years ago to prevent needless drug-related deaths. "We want to change the way we physicians work so that people are helped to recover from alcohol and drug problems and, where possible, are prevented from getting into trouble in the first place." But certain factors, such as a busy physician's shortage of time, may slow the achievement of these goals. Dr. William Barakett, a family physician from Cowansville, Que., 80 km from Montreal, delivers babies, makes house calls and sees 40 patients a day. With his limited time, it is not easy to identify substance-abuse addicts, who usually go to great lengths to conceal their habit. A diagnostic shortcut that Barakett has found effective is the CAGE questionnaire, which asks only four probing questions: Have you ever tried to Cut down on your drinking? Have you ever been Annoyed by criticism made by others about your drinking? Have you ever felt Guilty about your drinking? Have you ever needed an Eye-opener to get going the morning after a drinking bout? To be effective as a therapist, advises Barakett, a physician must approach the patient with a proper mind-set and be neither critical nor judgemental. "The patient has CAN MED ASSOCJ 1992; 146(5)
755
been repeatedly criticized and condemned for his excessive drinking and urged to straighten out, all to no avail. We must appreciate that the destructive habit is not the patient's fault. These patients are suffering from a disease and, while they're not responsible for having the disease, they are responsible for having it treated," explained Barakett. He confronts patients about their condition "in a blunt but caring way." He explains the nature of an addictive illness, describes the adverse effects it has on health and predicts dire consequences if behaviour does not change: further deterioration of the patient's health and possible loss of his family, friends and career. Barakett may supplement his own efforts by referring his patient to an addiction-treatment service and encouraging him to join a self-help group such as Alcoholics Anonymous. Some speakers argued that physicians should include patients' families in the treatment program. "We should call in the members of the family and talk to them," advised Wayne Skinner, an ARF social worker. He said family members can supply valuable information about the addicted patient and knowledge of the
maint tr m of u 1IS. e 10 1. d ra nial esemia. 2. 31 Co sure. 4. Myocardial i 5. Hypotension. 6. Known hypersensitivity troglycerin or previous idiosyncratic reaction to organic nitrates. Warnings: Nitroglycerin use in patients with congestive heart failure or with acute myocardial infarction requires careful clinical and/or hemodynamic monitoring. Precautions: Headaches or symptoms of hypotension, such as weakness or dizziness, particularly when arising suddenly from a recumbent position, may be due to overdosage. When they occur, the dose or frequency should be reduced. Nitroglycerin, a potent vasodilator, causes a slight decrease in mean blood pressure (approximately 10-15 mm Hg) in some patients when usedin therapeutic dosages. Exercise caution in patients who are prone to, or who might be affected by hypotension. Alcohol may enhance sensitivity to the hypotensive effects of nitrates. Tolerance to this drug and cross-tolerance to other nitrates or nitrites may occur. Physical dependence has also been described. With the chronic use of nitrates, there have been reports of anginal attacks being more easily provoked as well as reports of rebound in hemodynamic effects, occurring soon after nitrate withdrawal. Animal reproduction studies have nOt been done with NITROLINGUAL SPRAYS. As with all medication, nitroglycerin should only be given to a pregnant woman if 1
: T
"We want to change the way we physicians work so that people are helped to recover from alcohol and drug problems and prevented from getting into trouble in the first place." Dr. James Rankin family will also make it possible to assess what strengths exist in the home to contribute to the addict's rehabilitation. Conversely, conflicts that would impede the patient's progress would be revealed. Physicians should also be on the lookout for possible physical or psychologic damage suffered by families as the result of an addict's antisocial behaviour. Many families have benefitted from participation in selfhelp groups such as Al AnonAlateen. Improper use of prescribed drugs also contributes to the problem of addiction. Two cases of "prescribed" drug dependency
were described by Dr. Graeme Cunningham, director of alcohol and drug services at the Homewood Health Centre in Guelph, Ont. * A 35-year-old optometrist received 50 mg of meperidine hydrochloride (Demerol) intramuscularly to relieve his severe migraine headaches. A year later, when the migraine attacks returned and persisted, he was prescribed oral doses of oxycodone (Percodan). Because the relief of pain was accompanied by a pleasant, euphoric sensation, he began taking several a day - they were prescribed to him by an overly permissive and obliging physician. Because of his increasing dependency on oxycodone, the physician switched him to 4 mg of hydromorphone hydrochloride (Dilaudid). After receiving a warning about the drug from the Bureau of Dangerous Drugs, the physician withdrew it, which caused the patient to experience withdrawal symptoms. He was admitted to the Homewood for treatment. * Another patient, a 34year-old construction worker who had a history of alcoholism, developed low-back pain after lifting a heavy load. He was given a prescription for an analgesic (aceta-
5 vertical with ehe p. cilyindi ca tw g dbe cretedi m I Se uti Ekeps clos t outh p nto uld w ring tona asi t fet nd ect in fa arize th 5 wi t osition th pray children has not been estabished. Adverse Elfects: Use orifice, identified bythefnerrest on tog of the valve, in has been associated with headache, faintness, giddi- order to facilitate administration at night. Av'ailbility: ness, lightheadedness, pallor, feeling cold, numbness of Supplied in aerosol bottles delivering 200 metered doses the legs. Nitroglycerin may also cause flushing, of 0.4 mg each, in an aromatized oily solution. Nontachycardia, nausea, vomiting, restlessness, retroster- flammable, non-toxic propellant. Specil Cain: do re. bove nal discomfort, postural hypotension or dermatitis. An not expose the aerosol uni to occasional individual may exhibit marked sensitivity to 49°C and do not open. Preduct monraph avaibe on the hypotensive effects of nitrates. Clinically significant request. methemoglobinemia is rare at conventional doses, but Refnrenees: 1. WightLJ etal. Experiencewith NITROLINGUALSPRAYin general may occur especially in patients with genetic hemo- practice. BJCP 1990; 44 (2): 55-7. 2. Vandenburg MJ et al. Sublingual nitroalobin abnormalities. Dosage and Adminstataion: Not glycerin or spray in the treatment of angina. BJCP 1986; 40: 524-527 or Inhalation. Each metered dose contains 0.4 mg nitroglycerin in an aromatized solution. Upon initiating therapy, especially when changing from another form of nitroglycerin administration, patients should be followed closely in order to determine the minimal effective dose for each patient. With the onset of an acute attack of angina pectoris, 1 or 2 metered doses (0.4 or 0.8 mg of (0.4mg nitroglycerin per metered dose) nitroglycerin), as determined by experience, may be 1 AV 4ngre r administered onto or underthe tongue, withoutinhalUng. .0 I The optimal dose may be repeated.twice at 5-10 minute Made in Gnrnany by. G. PohI-Boskan GmnbH and Co. intervals. Dosage must be individualized and should be _ __________ PAAB sufficient to provide relief without producing untoward reactions. During administration the patent should be at R^N O CANAD the canister MONTREAL and in the kept sitting position, warsdemak rest, ideally } Registered
minophen, with 30 mg of codeine), which was to be taken three times a day. After 6 months the patient was taking 45 tablets containing codeine every day, and was supplementing this with overthe-counter acetaminophen. CMAJ contributing editor Brian Goldman, an emergency physician at Toronto's Mount Sinai Hospital, urged doctors to help curb the flow of prescription drugs to the illicit drug market. Goldman estimated that about 15% of prescribed drugs end up being sold on the street, where they sustain the habits of drugaddict sellers. Here's how the scam works. Goldman says hundreds of con artists - he calls them "entrepreneurial drug seekers" - work full time trying to procure prescription drugs. They prefer to deal in "legal" drugs because the strength and purity of the product are known, they're relatively safe to possess, and they are obtained through contact with respectable physicians and pharmacists, not shady drug dealers. The scam artists travel from town to town, making the rounds of medical offices. They wheedle prescriptions from physicians by faking symptoms and telling fanciful hard-luck stories. Some of them steal prescription pads from medical offices or print up their own. Drugs in heavy demand are narcotics, stimulants and sedatives. Black market prices for prescription drugs are highly inflated, Goldman said - a single Dilaudid tablet can fetch $120. He offered pointed advice for foiling the efforts of con artists. "You should temper your mercy with suspicion," he said.- Ask questions, establish the patient's background, check his story when possible, and examine him to confirm his complaints when this is feasible. "Think like a detective in order not to be scammed," Goldman warned. (Last June the Ontario MediMARCH 1, 1992
cal Association recommended establishing a province-wide computer-tracking system for prescriptions. This would make it possible to identify patients who were simultaneously obtaining prescriptions from more than one physician and, if appropriate, have these patients investigated.) Since physicians are part of both the addiction problem and the addiction solution, a special workshop was devoted to "the medical practitioner with alcohol and drug problems." There are varying estimates about the incidence of substance abuse among physicians - some observers place the figure as high as 10%. However, based on her studies, Joan Brewster, a researcher with the ARF, concluded that "the proportion of physicians who have been treated for problems
"You should temper your mercy with suspicion. Think like a detective in order not to be scammed by drug seekers." Dr. Brian Goldman
with alcohol or other drugs is no greater than the proportion in the general population." That would put the incidence at about 1.3%. Several case histories involving physician addicts were presented at the workshop. * A 30-year-old resident in internal medicine was apprehended with a vial of Demerol and syringes in her pocket. She was first introduced to the drug in a hospital emergency room, where she was treated for migraine headaches. Since then, she had selfinjected herself 10 times. * A 43-year-old general practitioner is married and has five children. On four occasions during the past 4 years he had alcohol on his breath when he arrived for duty in the hospital emergency room, where he proceeded to treat patients in a loud, abusive manner. In interviews he admitted to consuming a bottle of liquor every day, along with 40 mg of diazepam. He dismissed the complaints against him as trivial and said they were being pressed by colleagues who wish to harm him. He has suffered liver damage, his gait is somewhat shuffling, he complains of neuritis in his lower limbs and he has more than 40 spider nevi on his chest. * A 58-year-old anesthetist was apprehended injecting himself with the narcotic analgesic fentanyl. An assessment revealed that he has had intermittent problems with various drugs over the past 30 years. One month after completing a 4-week treatment program, he was again caught selfinjecting the same drug. He refuses to take further treatment. Literature distributed during the meeting emphasized that physicians are responsible for seeking help for impaired colleagues. Rehabilitation programs, which are available in every province, function in a discreet and confidential manner to prevent jeopardizing the professional career of a physician who seeks help.a CAN MED ASSOC J 1992; 146 (5)
757
Addiction can take many Addilct*ion can take niany forins, forms,
experts warn MDs
at conference
Sidney Katz
T he 36-year-old stranger came to the small Ontario town looking for a seasonal job. Disappointed that none was available, he spent the afternoon drinking in local pubs. After several hours he became belligerent and abusive and was beaten up by two men. The police found him lying on the road and drove him to hospital. Hostile and uncooperative, he refused admission. A physician summoned from the hospital examined the patient, as best he could, in the back seat of the police cruiser. The man was then driven to the police station, where he was put in a cell. Some hours later, he was found dead. The autopsy revealed an abnormally high blood-alcohol content, extensive fractures and internal injuries. Death was caused by hypovolemic shock. This history was cited by Dr. James Rankin, chief of the medical staff at Ontario's Addiction Research Foundation (ARF), during the opening session of a 3-day fall meeting of the Canadian Medical Society on Alcohol and Other Drugs (CMSAOD). "The point of this story is that this person need not have died," said Rankin, who ex-
One patient referred to the Homewood Health Centre was taking 45 tablets containing codeine every day. He was supplementing that intake with over-the-counter acetaminophen. -Dr. Graeme
Cunningham Sidney Katz is a freelance writer living in Toronto. MARCH 1, 1992
plained that CMSAOD, which he currently heads, was created 2 years ago to prevent needless drug-related deaths. "We want to change the way we physicians work so that people are helped to recover from alcohol and drug problems and, where possible, are prevented from getting into trouble in the first place." But certain factors, such as a busy physician's shortage of time, may slow the achievement of these goals. Dr. William Barakett, a family physician from Cowansville, Que., 80 km from Montreal, delivers babies, makes house calls and sees 40 patients a day. With his limited time, it is not easy to identify substance-abuse addicts, who usually go to great lengths to conceal their habit. A diagnostic shortcut that Barakett has found effective is the CAGE questionnaire, which asks only four probing questions: Have you ever tried to Cut down on your drinking? Have you ever been Annoyed by criticism made by others about your drinking? Have you ever felt Guilty about your drinking? Have you ever needed an Eye-opener to get going the morning after a drinking bout? To be effective as a therapist, advises Barakett, a physician must approach the patient with a proper mind-set and be neither critical nor judgemental. "The patient has CAN MED ASSOCJ 1992; 146(5)
755
been repeatedly criticized and condemned for his excessive drinking and urged to straighten out, all to no avail. We must appreciate that the destructive habit is not the patient's fault. These patients are suffering from a disease and, while they're not responsible for having the disease, they are responsible for having it treated," explained Barakett. He confronts patients about their condition "in a blunt but caring way." He explains the nature of an addictive illness, describes the adverse effects it has on health and predicts dire consequences if behaviour does not change: further deterioration of the patient's health and possible loss of his family, friends and career. Barakett may supplement his own efforts by referring his patient to an addiction-treatment service and encouraging him to join a self-help group such as Alcoholics Anonymous. Some speakers argued that physicians should include patients' families in the treatment program. "We should call in the members of the family and talk to them," advised Wayne Skinner, an ARF social worker. He said family members can supply valuable information about the addicted patient and knowledge of the
maint tr m of u 1IS. e 10 1. d ra nial esemia. 2. 31 Co sure. 4. Myocardial i 5. Hypotension. 6. Known hypersensitivity troglycerin or previous idiosyncratic reaction to organic nitrates. Warnings: Nitroglycerin use in patients with congestive heart failure or with acute myocardial infarction requires careful clinical and/or hemodynamic monitoring. Precautions: Headaches or symptoms of hypotension, such as weakness or dizziness, particularly when arising suddenly from a recumbent position, may be due to overdosage. When they occur, the dose or frequency should be reduced. Nitroglycerin, a potent vasodilator, causes a slight decrease in mean blood pressure (approximately 10-15 mm Hg) in some patients when usedin therapeutic dosages. Exercise caution in patients who are prone to, or who might be affected by hypotension. Alcohol may enhance sensitivity to the hypotensive effects of nitrates. Tolerance to this drug and cross-tolerance to other nitrates or nitrites may occur. Physical dependence has also been described. With the chronic use of nitrates, there have been reports of anginal attacks being more easily provoked as well as reports of rebound in hemodynamic effects, occurring soon after nitrate withdrawal. Animal reproduction studies have nOt been done with NITROLINGUAL SPRAYS. As with all medication, nitroglycerin should only be given to a pregnant woman if 1
: T
"We want to change the way we physicians work so that people are helped to recover from alcohol and drug problems and prevented from getting into trouble in the first place." Dr. James Rankin family will also make it possible to assess what strengths exist in the home to contribute to the addict's rehabilitation. Conversely, conflicts that would impede the patient's progress would be revealed. Physicians should also be on the lookout for possible physical or psychologic damage suffered by families as the result of an addict's antisocial behaviour. Many families have benefitted from participation in selfhelp groups such as Al AnonAlateen. Improper use of prescribed drugs also contributes to the problem of addiction. Two cases of "prescribed" drug dependency
were described by Dr. Graeme Cunningham, director of alcohol and drug services at the Homewood Health Centre in Guelph, Ont. * A 35-year-old optometrist received 50 mg of meperidine hydrochloride (Demerol) intramuscularly to relieve his severe migraine headaches. A year later, when the migraine attacks returned and persisted, he was prescribed oral doses of oxycodone (Percodan). Because the relief of pain was accompanied by a pleasant, euphoric sensation, he began taking several a day - they were prescribed to him by an overly permissive and obliging physician. Because of his increasing dependency on oxycodone, the physician switched him to 4 mg of hydromorphone hydrochloride (Dilaudid). After receiving a warning about the drug from the Bureau of Dangerous Drugs, the physician withdrew it, which caused the patient to experience withdrawal symptoms. He was admitted to the Homewood for treatment. * Another patient, a 34year-old construction worker who had a history of alcoholism, developed low-back pain after lifting a heavy load. He was given a prescription for an analgesic (aceta-
5 vertical with ehe p. cilyindi ca tw g dbe cretedi m I Se uti Ekeps clos t outh p nto uld w ring tona asi t fet nd ect in fa arize th 5 wi t osition th pray children has not been estabished. Adverse Elfects: Use orifice, identified bythefnerrest on tog of the valve, in has been associated with headache, faintness, giddi- order to facilitate administration at night. Av'ailbility: ness, lightheadedness, pallor, feeling cold, numbness of Supplied in aerosol bottles delivering 200 metered doses the legs. Nitroglycerin may also cause flushing, of 0.4 mg each, in an aromatized oily solution. Nontachycardia, nausea, vomiting, restlessness, retroster- flammable, non-toxic propellant. Specil Cain: do re. bove nal discomfort, postural hypotension or dermatitis. An not expose the aerosol uni to occasional individual may exhibit marked sensitivity to 49°C and do not open. Preduct monraph avaibe on the hypotensive effects of nitrates. Clinically significant request. methemoglobinemia is rare at conventional doses, but Refnrenees: 1. WightLJ etal. Experiencewith NITROLINGUALSPRAYin general may occur especially in patients with genetic hemo- practice. BJCP 1990; 44 (2): 55-7. 2. Vandenburg MJ et al. Sublingual nitroalobin abnormalities. Dosage and Adminstataion: Not glycerin or spray in the treatment of angina. BJCP 1986; 40: 524-527 or Inhalation. Each metered dose contains 0.4 mg nitroglycerin in an aromatized solution. Upon initiating therapy, especially when changing from another form of nitroglycerin administration, patients should be followed closely in order to determine the minimal effective dose for each patient. With the onset of an acute attack of angina pectoris, 1 or 2 metered doses (0.4 or 0.8 mg of (0.4mg nitroglycerin per metered dose) nitroglycerin), as determined by experience, may be 1 AV 4ngre r administered onto or underthe tongue, withoutinhalUng. .0 I The optimal dose may be repeated.twice at 5-10 minute Made in Gnrnany by. G. PohI-Boskan GmnbH and Co. intervals. Dosage must be individualized and should be _ __________ PAAB sufficient to provide relief without producing untoward reactions. During administration the patent should be at R^N O CANAD the canister MONTREAL and in the kept sitting position, warsdemak rest, ideally } Registered
minophen, with 30 mg of codeine), which was to be taken three times a day. After 6 months the patient was taking 45 tablets containing codeine every day, and was supplementing this with overthe-counter acetaminophen. CMAJ contributing editor Brian Goldman, an emergency physician at Toronto's Mount Sinai Hospital, urged doctors to help curb the flow of prescription drugs to the illicit drug market. Goldman estimated that about 15% of prescribed drugs end up being sold on the street, where they sustain the habits of drugaddict sellers. Here's how the scam works. Goldman says hundreds of con artists - he calls them "entrepreneurial drug seekers" - work full time trying to procure prescription drugs. They prefer to deal in "legal" drugs because the strength and purity of the product are known, they're relatively safe to possess, and they are obtained through contact with respectable physicians and pharmacists, not shady drug dealers. The scam artists travel from town to town, making the rounds of medical offices. They wheedle prescriptions from physicians by faking symptoms and telling fanciful hard-luck stories. Some of them steal prescription pads from medical offices or print up their own. Drugs in heavy demand are narcotics, stimulants and sedatives. Black market prices for prescription drugs are highly inflated, Goldman said - a single Dilaudid tablet can fetch $120. He offered pointed advice for foiling the efforts of con artists. "You should temper your mercy with suspicion," he said.- Ask questions, establish the patient's background, check his story when possible, and examine him to confirm his complaints when this is feasible. "Think like a detective in order not to be scammed," Goldman warned. (Last June the Ontario MediMARCH 1, 1992
cal Association recommended establishing a province-wide computer-tracking system for prescriptions. This would make it possible to identify patients who were simultaneously obtaining prescriptions from more than one physician and, if appropriate, have these patients investigated.) Since physicians are part of both the addiction problem and the addiction solution, a special workshop was devoted to "the medical practitioner with alcohol and drug problems." There are varying estimates about the incidence of substance abuse among physicians - some observers place the figure as high as 10%. However, based on her studies, Joan Brewster, a researcher with the ARF, concluded that "the proportion of physicians who have been treated for problems
"You should temper your mercy with suspicion. Think like a detective in order not to be scammed by drug seekers." Dr. Brian Goldman
with alcohol or other drugs is no greater than the proportion in the general population." That would put the incidence at about 1.3%. Several case histories involving physician addicts were presented at the workshop. * A 30-year-old resident in internal medicine was apprehended with a vial of Demerol and syringes in her pocket. She was first introduced to the drug in a hospital emergency room, where she was treated for migraine headaches. Since then, she had selfinjected herself 10 times. * A 43-year-old general practitioner is married and has five children. On four occasions during the past 4 years he had alcohol on his breath when he arrived for duty in the hospital emergency room, where he proceeded to treat patients in a loud, abusive manner. In interviews he admitted to consuming a bottle of liquor every day, along with 40 mg of diazepam. He dismissed the complaints against him as trivial and said they were being pressed by colleagues who wish to harm him. He has suffered liver damage, his gait is somewhat shuffling, he complains of neuritis in his lower limbs and he has more than 40 spider nevi on his chest. * A 58-year-old anesthetist was apprehended injecting himself with the narcotic analgesic fentanyl. An assessment revealed that he has had intermittent problems with various drugs over the past 30 years. One month after completing a 4-week treatment program, he was again caught selfinjecting the same drug. He refuses to take further treatment. Literature distributed during the meeting emphasized that physicians are responsible for seeking help for impaired colleagues. Rehabilitation programs, which are available in every province, function in a discreet and confidential manner to prevent jeopardizing the professional career of a physician who seeks help.a CAN MED ASSOC J 1992; 146 (5)
757
