Psychoactive substance use disorders are most accurately diagnosed by history. The "CAGE-B" questionnaire (Table 7.2), which has been adapted from the CAGE to include all classes of psychoactive drugs rather than alcohol alone, can be used to elicit such a history. The physician should always ask other informants for their observations or concerns about a patients alcohol and drug use. The physician should ask some patients for whom he or she prescribes controlled substances for permission to contact their pharmacy and other physicians to make sure that multiple prescriptions are not being written. The physician should assume that any patient who regularly inhales, smokes, or injects any agent has a dependency syndrome until proven otherwise.
Not all patients are readily forthcoming with history or permit contact with other informants. Thus, the physician should remember that certain signs on the physical examination can indicate psychoactive substance use. Multiple tattoos or body piercings may reflect a disregard for societal norms, including those that limit drug taking. Facial or digital edema, cigarette-stained fingers, palmar erythema, and spider nevi suggest alcohol dependence, and any odor of beverage alcohol is more than a little suggestive of the same. Tremor, tachycardia, elevated blood pressure, and dilated pupils may indicate repeated ingestion of alcohol, barbiturates, benzodiazepines, or other sedatives. Nasal septal necrosis suggests repeated cocaine use, while dilated pupils and multiple scars and keloids on the extremities suggest intravenous drug use, usually heroin or cocaine. Miosis, decreased bowel sounds, flaccid muscles, and urinary retention can be due to opioids.
Laboratory studies may also be helpful in the diagnosis of psychoactive substance use disorders. Thus, thrombocytopenia, high mean corpuscular volume, and elevations of serum uric acid, aspartate aminotransferase, and gamma glutamyltransferase suggest heavy drinking. Liver function studies, especially alkaline phosphatase, are often elevated in chronic opioid users.
Dependence on Alchohol or Drugs ■ 103 Table 7.2. CAGE-B
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