Drs : Muniagurria, AJ; Pizzuto, Gloria;
Clinical Semiology, Medical Cience Faculty; RNU

Addictions are defined as the compulsive use of a substance and the impossibility of controlling its intake despite knowing the negative effects it produces. The term addiction is somewhat imprecise and has pejorative meanings. The American Psychiatric Association began using the term "drug dependence" instead of "addiction" in the Diagnostic and Statistical Manual of Mental Illness in 1987 (DSM III R).

Fragmento de la película "El hombre del brazo de oro"

The primary care physician through the anamnesis, established during the clinical interview, should develop the following skills:

• Identify (screen) the addict, establish the frequency and quantity of substance consumed.
• Type of substance, legal or illegal
• Clinically intervene (Prevention 1st, 2nd or 3rd)

For an individual to meet the criteria for drug addiction, they must have at least three of the following characteristics:

1. Consume large amounts or for long periods of time.
2. Persistent desire or one or more failed attempts to stop or control intake.
3. Much time wasted in activities to get the substance, take it or recover from its effects.
4. Frequent intoxications or withdrawal symptoms at times when it is expected to fulfill its obligations (eg family, work, etc.) or when it is dangerous (eg driving).
5. Abandon or decrease social, occupational, or recreational activities for substance abuse.
6. Continued use despite knowledge of having physical, mental, occupational or social problems caused or exacerbated by the use of a psychoactive substance.
7. Marked tolerance with the need to increase the amounts of substance to achieve the desired effect or decrease the effect with the same amount of substance.
8. Characteristic withdrawal symptoms when discontinuing the substance.
9. The addictive substance controls or prevents withdrawal.

Once the screening is done, the frequency and quantity of substance consumed will be established. Accordingly, they are classified in two patents:

1) Substance abuse

A subject is an Abuser when he meets at least one criterion of the parameters granted by the DSM in a period of 12 months:

• Continued use despite the harm caused by the addict.
• Recurrent use in situations of physical risk (eg driving).
• Repeated legal problems from abuse.
• Repeated social problems from abuse.
• It does not depend on the substance.

2) Substance dependence

A subject is Dependent when he meets at least three criteria of the following according to the DSM in a period of 12 months:

• Tolerance or abandonment.
• Excessive addiction rather than abandonment attempt.
• Frequent poisonings or withdrawal symptoms.
• Much time wasted in obtaining, ingesting and recovering from the effects.
• Abandon or decrease social, occupational, or recreational activities.
• It depends on the substance, despite knowing the problems it suffers.

The effects of a drug dependency originates from a complex interaction:

1. The "brand" or emotional attitude of the drug user.
2. The "preparation" or environment within which the drug is taken.
3. The "dose" or amount of drug taken.
4. The "personality" of the user.
5. The "chemical variability" of the user.

Knowing the type of substance that is consumed, legal or illegal, allows the doctor to establish his intervention.

Substances can be classified according to their accessibility into:

 According to the injury that they produce in the central nervous system, the physical examination may be oriented in the search for signs or symptoms caused as a consequence of the different substances.

 Other adverse effects that can be considered in "heavy" or dependent users are:

• Cocaine: cardiovascular complications, arrhythmias, myocardial infarction, cerebral hemorrhage, seizures, respiratory diseases.
• Crack: highly addictive.
• Marihuana: chronic use is associated with respiratory diseases.

The most common effect of smoking is euphoria, decreased motor function, and time-space disorientation. The psychological effects produced by its active components, such as decreased anxiety and sedation, are probably the determinants of its potential therapeutic value. This value refers to terminally ill or HIV patients in which it began to be used in the USA in 1999, to treat pain, nausea and general weakness (more clinical trials are yet to be carried out).

Although the use of illegal ones decreased in the general population from 1979 to 1992; Drug use has increased in the population among children and adolescents. Marijuana is smoked regularly at least once a week and cocaine-heroin or other intravenous drugs throughout the year.

Another classification according to price is:

• Caraches: inhalants
• Moderated: dagga
• Faces: heroin
• Very expensive: Cocaine

Early medical intervention has the potential to ward off some of the serious consequences of substance abuse, including physical, psychological, legal and social injury.

The performance of urinary tests to determine the presence of metabolites of the substances is sensitive and specific for the recent user. But it has limitations in the case of "heavy" users who do it routinely. In these cases, these tests fail to distinguish occasional users, abusers, or dependents.

The sensitivity and specificity of the tests varies with the time of drug use and the effectiveness of an early intervention, has not been evaluated in asymptomatic users detected by toxicological screening.

When performing routine screening in asymptomatic individuals, the following should be taken into account:

-The testing cannot be carried out without informed consent, since the autonomy and confidentiality to which everyone is entitled is violated.

-The predictive value of the test decreases if it is carried out in a population with a low prevalence of drug use.

-Patients can be discriminated if the confidentiality of the result is not ensured

-In pregnant women, the tests are justified by the adverse effects on the development of the fetus; for the safety and prosperity of the child.

There is not enough scientific evidence to routinely recommend or recommend drug abuse screening. Some questions about drug use or abuse are included when building the medical history of a child, adolescent, or young adult. In all pregnant women should be advised for the potential effect on the development of the fetus and subsequent growth of the child.

Be alert to the signs and symptoms of drug abuse and question about the use of illegal drugs and abuse of legal drugs (sedatives, stimulants), as well as consideration of the use of inhalants in children, adolescents and young adults.

The quantity, frequency, consumption patterns and adverse consequences of drug use should be questioned; interference with school and work; they should be taken into account because it shows dependence.

The physician must establish a doctor-patient relationship based on trust; discuss drug use; not to judge and respect the concepts of the patient and their confidentiality.

All women should be counseled about the potential risks to the fetus and its transmission through breast milk.

Patients identified as addicts (drug dependency) should be informed of the risks to which they are exposed and should be advised to decrease or abandon. The treatment plan must be made according to the needs of the patient and will be referred to community rehabilitation programs.

In the case of injecting drug users, they should be periodically tested for the detection of HIV infections, hepatitis B and advised with measures to reduce risks of infections (use of new syringes for each application; change of needle; do not share equipment ; prepare the drug with sterile water; clean the application area with alcohol and use safety devices to discard the needles).

Bibliography:

- Sanca Durban Society Alcohol and Drug Centres, South África
- Profam tomo III, cap. 18, pág. 221. (Programa de Educ. a Distancia de Medicina Familiar y Ambulatoria). Unidad Medicina Familiar y Preventiva (UMFyP); Departamento de Docencia e Investigación (DDI); Hospital Italiano de Bs. As.
- Marijuana and Medicine: assessing the Science Base, Institute of Medicine, 1999, Nacional Academy of Sciences.