Alcohol and substance abuse

Explaining socioeconomic inequalities in illicit drug use disorders in Iran

Background: Drug use disorders are one of the major health problems in societies, which cause physical, psychological, and social damages to individuals. Socioeconomic status is often inversely associated with drug use disorders. The present study aimed at determining the effect of socioeconomic inequality on the prevalence of drug use disorders and identifying its determinants in Iran.

Methods: Data of 7886 individuals aged 15 to 64 years were collected from Iran Mental Health Survey (IranMHS). Initially, the socioeconomic status of the participants was determined by principal component analysis. Later, socioeconomic inequality was measured using the concentration index, and the factors influencing the gap between the high and low socioeconomic groups were identified using the Oaxaca-Blinder Decomposition.

Results: The concentration index for drug use disorders in Iran was -0.29 (standard error= 0.06). The results of decomposition technique revealed that 1.14% and 2.7% of the participants with high and low socioeconomic status were affected by drug use disorders, respectively. In addition, the gap between these 2 groups was found to be 1.65%. Among the studied variables, occupation, marital status, and gender accounted for the highest contribution to inequality, respectively.

Conclusion: There is inequality in the prevalence of drug use disorders in Iran; these disorders are more common in lower socioeconomic group. Based on the findings, it is suggested that improvement in the socioeconomic status of the households, especially for males, the divorced or widowed individuals, and the unemployed may lead to a reduction in inequality in drug use disorders.

Gender, occupational, and socioeconomic correlates of alcohol and drug abuse among U.S. rural, metropolitan, and urban residents

OBJECTIVE

To estimate the prevalence and correlates of alcohol and drug abuse and dependence among rural, urban, and metropolitan U.S. residents.

METHODS

The National Comorbidity Survey (NCS) (1990-1992) yielded lifetime risks of psychiatric disorders in a probability sample of 8098 respondents in the 48 contiguous states using DSM-III-R for diagnosis. Logistic regressions of alcohol and drug disorders were performed to compare their correlates in rural, urban, and metropolitan areas after stratifying by demographic and socioeconomic variables.

RESULTS

Household income was protective only in rural areas. High occupation strata were positively associated with alcohol disorders. Urban and metropolitan women were less likely to report drug disorders. There was no gender difference in rural drug abuse and dependence. Also, high occupation strata were positively associated with drug disorders.

CONCLUSION

Lack of gender differences in rural drug disorders may indicate an increase in drug availability, access, and use among rural women. Workplace alcohol and drug disorders, especially among metropolitan sales, crafts, and service workers should be of concern to policymakers. These results underline the usefulness of using multiple indicators of socioeconomic positions in epidemiologic studies of substance use disorders.

Substance Use Disorders and Neurologic Illness

Because of the high rates of substance use disorders among the general and clinical populations, and the abuse potential of many medications commonly used in the treatment of neurologic illnesses, the treating neurologist must deal with drug misuse and abuse in practice. The most important tool neurologists must have in their arsenal is the ability to assess for and recognize substance use disorders in their patients. Any treatment plan developed for such patients must include ongoing management of substance abuse issues. After a substance use disorder is diagnosed, the neurologist must make proper referrals to adjunctive support interventions (Alcoholics Anonymous or Narcotics Anonymous) and chemical dependency specialists, and work closely and in collaboration with these components of the patient's overall treatment. The treating neurologist should be aware of the myriad neurologic sequelae of drug use, because most drugs of abuse, including alcohol, can have neurologic manifestations resulting from acute intoxication, acute withdrawal, or chronic use. Drug use (past and present) should be included in the differential diagnosis for any patient with an atypical constellation of symptoms or with isolated neurologic deficits. If the treatment of a neurologic condition requires the use of a potentially addictive substance, particularly when the patient has a history of substance use disorders, then the clinician must minimize the risk of addiction by giving the least addictive substances and developing a plan to manage the use of the drug throughout the treatment period.

Pain management in the ED

Recent regulatory and legal scrutiny has raised concerns about the over- and undertreatment of pain in the hospital. This debate stems from either the overly aggressive approach to the management of pain with opioids or, alternatively, to the barriers preventing the appropriate prescribing of these medications. The media attention on diversion of controlled substances for illicit purposes has intensified this debate, highlighting the possible overuse of these medications in the treatment of nonmalignant pain. Because pain is a highly common presenting complaint in the ED, EPs are pivotal players in these controversies. Accordingly, they must apprise themselves of pain management skills and continue to help those in need of appropriate medications while thwarting inappropriate prescribing. This review offers a synopsis of the pitfalls associated with ED pain management and provides recommendations for selected conditions.

Specific roles of the obstetrician-gynecologist

Obstetrician-gynecologists can play a major role in the prevention, identification, and treatment of substance abuse in women. Maintaining cognizance of abuse potential and consistently using office-screening techniques will identify patients who need assistance. Employing brief interventions at frequent office visits is an effective means of treating many of these patients. Those who do not respond to brief interventions may benefit from referral to an addictionologist. The US Supreme Court recently verified the Fourth Amendment rights of pregnant women by deciding that consent must be obtained to perform drug screening in pregnancy. Obstetrician-gynecologists will need to stay abreast of the changes that occur in their state laws as a result of this decision.

Cyproheptadine for intrathecal baclofen withdrawal

OBJECTIVE

To evaluate the efficacy of cyproheptadine in the management of acute intrathecal baclofen (ITB) withdrawal.

DESIGN

Descriptive case series.

SETTING

University hospital with a comprehensive in- and outpatient rehabilitation center.

PARTICIPANTS

Four patients (3 with spinal cord injury, 1 with cerebral palsy) with implanted ITB infusion pumps for treatment of severe spasticity, who had ITB withdrawal syndrome because of interruption of ITB infusion.

INTERVENTIONS

Patients were treated with 4 to 8mg of cyproheptadine by mouth every 6 to 8 hours, 5 to 10mg of diazepam by mouth every 6 to 12 hours, 10 to 20mg of baclofen by mouth every 6 hours, and ITB boluses in some cases.

MAIN OUTCOME MEASURES

Clinical signs and symptoms of ITB withdrawal of varying severity were assessed by vital signs (temperature, heart rate), physical examination (reflexes, tone, clonus), and patient report of symptoms (itching, nausea, headache, malaise).

RESULTS

The patients in our series improved significantly when the serotonin antagonist cyproheptadine was added to their regimens. Fever dropped at least 1.5 degrees C, and heart rate dropped from rates of 120 to 140 to less than 100bpm. Reflexes, tone, and myoclonus also decreased. Patients reported dramatic reduction in itching after cyproheptadine. These changes were associated temporally with cyproheptadine dosing.

DISCUSSION

Acute ITB withdrawal syndrome occurs frequently in cases of malfunctioning intrathecal infusion pumps or catheters. The syndrome commonly presents with pruritus and increased muscle tone. It can progress rapidly to high fever, altered mental status, seizures, profound muscle rigidity, rhabdomyolysis, brain injury, and death. Current therapy with oral baclofen and benzodiazepines is useful but has variable success, particularly in severe cases. We note that ITB withdrawal is similar to serotonergic syndromes, such as in overdoses of selective serotonin reuptake inhibitors or the popular drug of abuse 3,4-methylenedioxymethamphetamine (Ecstasy). We postulate that ITB withdrawal may be a form of serotonergic syndrome that occurs from loss of gamma-aminobutyric acid B receptor-mediated presynaptic inhibition of serotonin.

CONCLUSION

Cyproheptadine may be a useful adjunct to baclofen and benzodiazepines in the management of acute ITB withdrawal syndrome.