Brain and Behavior Substance Abuse Charles P. O’Brien, M.D., Ph.D. Charles Dackis, M.D.

Teaching Points Substance abuse is under recognized and under treated. For diagnosis, specific questions about the onset of this disorder need to be asked

Outline Course rationale Prevalence Course Objectives Topic areas: drug types Diagnostic questions for clinical interview

Why a course on Substance Abuse ? Very common disorder Poorly treated in clinical practice From 1971 to 1989 this was an elective course. During faculty/student retreat meetings in the late 1980s, recent Penn med graduates asked to have more about substance abuse in the main curriculum because so many of their patients suffered from this problem and if they did not take the elective, they knew very little about it. Indeed all medical students in all medical schools should be required to learn about this problem because it is so common and it is confronted by physicians in all specialties. A second reason is that problems with alcohol and other drugs are at least as common among physicians as they are in the general population. Drug problems have developed among Penn graduates and in some cases among Penn medical students and residents. Even though treatment of physicians with addiction problems have been generally successful, we hope to reduce the likelihood that Penn medical students having experienced this course will be as likely to be entrapped by this problem during the course of their medical careers.

Prevalence Substance Use Disorders* Lifetime New Haven Baltimore St. Louis 15.0% 17.0% 18.1% Six Months New Haven Baltimore St. Louis 6.6% 7.9% 6.5% *not including nicotine Studies in general population samples in three different cities stratified to include representatives of different socio economic groups find that the lifetime prevalence ranges between 15 and 18%, not including nicotine addiction, and the six months prevalence is between 6 and 8%. Lee Robbins et al, ECA (Epidemiological Catchment Area) Study

Course Objectives Early recognition Distinguish addiction from normal tolerance, physical dependence and withdrawal Pharmacology of drugs of abuse Prevent progression from use to abuse to addiction Refer to appropriate specialists The objectives of the course are not to produce addiction specialists but rather to help the general physician to recognize substance abuse early and refer for treatment if it is too complicated for the individual physician. Early treatment is much more effective than late treatment.

Drug Types Alcohol, Benzodiazepines, and other hypnotics Nicotine Sedatives Alcohol, Benzodiazepines, and other hypnotics Stimulants Opioids Cannabinoids Hallucinogens LSD, PCP, and Ecstasy Above is a listing of drug categories and this is the way the course is organized.

Diagnostic Questions for Clinical Interview How did this occur ? Early signs or clues Effects on performance Trajectory What would you have said to patient if you had been his significant other? What caused him to get help ? Addiction is essentially a loss of control over drug use. The questions refer to the history on the video given by the patient who at the time was a recent Penn med graduate. He began his cocaine use as a first year Penn medical student. His description of his loss of control over drug use is graphically described.