Knowledge - Students should be able to describe the:

1. Presenting symptoms, signs and risk factors for alcohol and drug abuse, intoxication, overdose and withdrawal.
2. Diagnostic criteria for substance abuse, dependency, and addiction based on history, physical examination and appropriate laboratory testing.
3. Major causes of morbidity and mortality associated with substance abuse and addiction:
   1. trauma
   2. motor vehicle accidents
   3. homicide
   4. domestic violence
   5. overdose
   6. endocarditis
   7. Hepatitis B
   8. cirrhosis
   9. HIV
4. Screening techniques for alcoholism:
   1. CAGE
   2. MAST (Michigan Alcohol Screening Test)
   3. Skinner Trauma Scale
   4. AUDIT
5. Predictive value, sensitivity and specificity of laboratory confirmatory tests, and screening instruments in predicting alcohol abuse and dependency.
6. Health benefits of substance abuse cessation.
7. Management strategies for acute alcohol and drug withdrawal, cocaine and alcohol dependence.
8. Community referral sources (Alcoholics Anonymous, Cocaine Anonymous).
9. Medical complications of alcohol and cocaine abuse.

Skills - Students should be able to:

1. History: elicit a social history in a nonjudgmental, supportive manner using appropriate questioning (CAGE questions*, etc.) and demonstrate knowledge of the Diagnostic and Statistical Manual of Psychiatric Disease (DSM) criteria for substance and alcohol dependence.
   
   *Questions in the CAGE questionnaire:

   1. Have you ever felt you should Cut down on your drinking?
   2. Have people Annoyed you by criticizing your drinking?
   3. Have you ever felt bad or Guilty about your drinking?
   4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang-over [Eye-opener]?
2. Physical Exam: perform a physical exam to establish the diagnosis and severity of disease, including accurate recognition of withdrawal, stigmata of drug and alcohol use, chronic disease states and acute complications secondary to substance abuse:
   1. fever
   2. hypertension
   3. tachycardia
   4. jaundice, needle tracks, stigmata of endocarditis, HIV, telangiectasias
   5. pupil size, icterus
   6. nasal septum perforation
   7. mouth odor of alcohol
   8. parotid enlargement
   9. gynecomastia
   10. lymphadenopathy
   11. heart murmurs
   12. hepatomegaly, splenomegaly
   13. testicular atrophy
   14. tremor, asterixis
   15. cognitive impairment
   16. Dupuytren's contractures
       
       
3. Differential Diagnosis: generate a differential diagnosis recognizing specific history and physical exam findings to determine the diagnosis of substance abuse of alcohol and drugs and their sequelae.
   
   
4. Laboratory:  order and interpret diagnostic and confirmatory laboratory tests prior   to and after initiating treatment based on the differential diagnosis:
   1. blood alcohol level
   2. urine and serum toxicology screens
   3. complete blood count
   4. liver enzymes
   5. amylase and lipase levels
   6. tests for detecting HIV
      
      

5. Communication: explain the evaluation and treatment plan to the patient; counsel cessation and available community referral resources.

6. Management:

   1. Assess a patient's motivation for achieving sobriety/abstinence
   2. Deliver a directed, non-judgmental message to a substance-abusing patient
   3. Develop an appropriate evaluation and treatment plan
   4. Make an appropriate community referral for a substance-abusing patient
   5. Write appropriate fluid and medication orders for the treatment of alcohol and/or drug withdrawal.

Attitudes and Professional Behaviors  - Students should be able to:

1. Recognize the biopsychosocial etiology of addictions, and feel comfortable with the rejection of the notion that addictions are a "sign of moral weakness."
2. Appreciate the prevalence of addictions and the need to consistently include substance abuse detection as a prominent part of history-taking.
3. Realize the power of simple, direct messages in stimulating behavior change.
4. Recognize that substance abuse affects the community and family in addition to the patient.
5. Demonstrate a commitment to non-judgmental care of substance-abusing patients.

Recommended Readings:

1. Fauci AS, et al. (eds.): Harrison's Principles of Internal Medicine. 14th edition, NY: McGraw-Hill, 1998: pp. 2503-2508, 2512-2516.
2. Lieber CS. Medical Disorders of Alcoholism. NEJM 1995. 333(16):1058-1065.
3. Mendelson JH, Mello NK. Management of Cocaine Abuse and Dependence. NEJM 1996. 334(15):965-972.
4. O"Connor PG, Schottenfeld RS. Patients with Alcohol Problems. NEJM 1998. 338(9):592-602.
5. Warner, EA. Cocaine Abuse. Annals of Internal Medicine 1993. 119(3):226-235.

Where to go for additional information on Substance Abuse:

1. The National Institute on Alcohol Abuse and Alcoholism (NIAA)
   Office of Scientific Affairs
   Willco Building
   6000 Executive Boulevard, Suite 409
   Bethesda, MD 20892-7003
   301-443-3860
   
   

2. American Society of Addiction Medicine (ASAM)
   4601 North Park Avenue
   Suite 101, Upper Arcade
   Chevy Chase, MD 20815
   301-656-3920

3. National Council on Alcoholism and Drug Dependence (NCADD)
   12 West 21st Street
   New York, NY 10010
   212-206-6770