Professional Documents
Culture Documents
i ai d e
ea a i
ed i i a d i a
f
be
e icae ia d e
hia ide di e ic
d e
ic c ic a ide e
T e A eac i
a e d e-de e de .
T e B eac i
a e b defi i i Bi arre. The eac i
ae
E a
e i c de he a
ici a d b d d c a ia .
edic ab e f
e ie
f he d g.
e c ibi g a
d g he
e c ibe
I he d g ea
ece a ?
Wha i ha e if i i
ed?
Wha g d d I h e achie e?
Wha ha
a e
f
hi ea
dc
ide he f
i g
e :
e ?
a ai e, d
CVS
a iai
GIT
S i
a h,
chia ic/E
be
a i
ca ed b d g a
ide effec i c de:
i e
, fa ig e/ i ed e
, e i he a
ea,
i i g, d
i
,f
, headache, di
ede a, h
e
ide effec
i e ac i
ha a e
i e
ia, cha ge i b
i ai
hi g
ia, i i abi i , a
ie , de e
, agi a i
1/12
12/15/11
A i ic bia
e ici
h
e ac
e
e c
A ic
i /ce ha
a ide
ci e
ci
a e
a
ca ba a e i e
he ba bi e
he
i
di
a
ae
A ide e
ic c ic
MAO i hibi
A i-i f a
ie a d a a ge ic
a i i / a ic a e
c dei e/
hi e, e c.
NSAID
g d a
A ih
e e
i e age
( e e a)
Ca diac age
dig i
i idi e
a i da e
he a ia h h ic
Di e ic
hia ide
f e ide
Ta
i i e
he hia i e
be
dia e i e
ba bi a e
ch dia e
ide
O he d g i c de
c
h
a
ic
e
i
a fa i
Nico ine
'S
i gi g df
bad; hie e
i
d age beca e
T bacc
i gi
', acc di g a
b
a igh beca
i die he
ae
he a ge
i g e, e
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
d A ab
e b. 'The d g
i
bi e
e
c gh i
ee a d
i
ea i e
g.'
e ab e ca e f dea h a d di ea e i A
beca e
e
ffe he i dig i ie
a ia. I ha bee
2/12
12/15/11
estimated to have caused approximately 20 000 deaths in 1991, over six times the number of deaths from
road accidents. 2 Diseases attributed to smoking are summarised in Figure 18.1 .
Ge ing pa ien
oq i
Several studies have highlighted the value of opportunistic intervention by the family doctor. It is important not
only to encourage people to quit but also to organise a quitting program and follow-up. In Australia 80% of
smokers (representing about 30% of the adult population) have indicated that they wish to stop smoking.
Point out that it is not easy and requires strong will power. As Mark Twain said, 'Quitting is easy I've done it
a thousand times.'
Me hod
Educate patients about the risks to their health and the many advantages of giving up smoking, and
emphasise the improvement in health, longevit , mone savings, look s and se ualit .
The extent of nicotine dependence can be assessed using a questionnaire (based on the Fagerstrom
Test) and scoring system. 3
Fac
o poin o
Advantages
Food tastes better.
Sense of smell improves.
Exercise tolerance is better.
Sexual pleasure is improved.
Bad breath improves.
Risk of lung cancer drops: after 10-15 years of quitting it is as low as someone who has never
smoked.
Early COAD can be reversed.
Decreases URTIs and bronchitis.
Chance of premature skin wrinkling and stained teeth is less.
Removes effects of passive smoking on family and friends.
Removes problem of effects on pregnancy.
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
3/12
12/15/11
A contract to quit
'I ...................... agree to stop smok ing on .................... I understand that stopping smok ing is the single
best thing I can do for m health and that m doctor has strongl encouraged me to quit.'
........................................ (Patient's signature)
........................................ (Doctor's signature)
These motivated patients will require educational and behavioural strategies to help them cope with
quitting. Ongoing support by their GP is very important.
Organise joining a support group.
Arrange follow-up (very important), at least monthly, especially during first 3 months.
Going 'cold turk e ' (stopping completely) is preferable but before making the final break it can be made
easier by changing to a lighter brand, inhaling less, stubbing out earlier and reducing the number.
Changing to cigars or pipes is best avoided.
Wi hd a al effec
The initial symptoms are restlessness, cravings, hunger, irritability, poor concentration, headache,
tachycardia, insomnia, increased cough, tension, depression, tiredness and sweating. After about 10 days
most of these effects subside but it takes about three months for a smoker to feel relatively comfortable with
not smoking any more. Nicotine replacement therapy certainly helps patients cope.
4/12
12/15/11
Useful points
Chew each piece slowly for about 30 minutes.
Ensure all the nicotine is utilised.
Chew at least 6 pieces per day, replacing at regular intervals (not more than 1 piece per hour)
Use for 3 months, weaning off before the end of this period.
Transdermal nicotine 3
This is available as 16-hour or 24-hour nicotine patches in three different strengths. The patients should stop
smoking immediately on use.
Recommendations
Moderate dependence: 14 mg patch; change to 7 mg patch after 4-6 weeks
High dependence: 21 mg patch; change to 14 mg patch after 4-6 weeks
Apply to non-hairy, clean, dry section of skin on upper outer arm or upper chest and leave in place for 24
hours. Rotate sites with a 7-day gap for reuse of a specific site.
Contraindications
These are pregnancy and breast-feeding, children, severe myocardial ischaemia, arrhythmias or recent CVA.
Adverse reactions
Gum: hiccoughs, orodental problems, jaw pain, gastrointestinal including exacerbation of peptic ulcer
Patches: local reaction, sleep disturbances (use 16-hour patch for this)
Both: nervousness, sweating, dry mouth, dyspepsia, abdominal cramps, angina and arrhythmias
Alcohol
Excessive drinking of alcohol can cause several clinical manifestations. Identification of the alcohol-affected
person is complicated by the tendency of some to hide, underestimate or understate the extent of their
intake.
In order to diagnose and classify alcohol-dependent people, the family doctor has to rely on a combination of
parameters that include clinical symptoms and signs, available data on quantity consumed, clinical intuition,
personal knowledge of the social habits of patients, and information (usually unsolicited) from relatives, friends
or other health workers.
A checklist of pointers to the adverse effects of chronic alcohol abuse is presented in Table 18.1 . In a study
by the author the outstanding clinical problems are the psychogenic disorders (anxiety, depression and
insomnia) and hypertension. 4 Susceptibility to work and domestic accidents were also significant findings.
The challenge to the family doctor is early recognition of the alcohol problem. This is achieved by developing a
special interest in the problem and a knowledge of the early clinical and social pointers, and being ever alert
to the tell-tale signs of alcohol dependence (refer to Chapter 106 ).
Table 18.1 Checklist of pointers of alcohol abuse
Ps chosocial features
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
5/12
12/15/11
characteristic facies
hand tremor
alcohol foetor by day
morning nausea and vomiting
traumatic episodes
dyspepsia gastritis/ulcer
obesity
palpitations
impotence
insomnia/nightmares
anxiety/depression
hypertension
hepatomegaly
gout
pancreatitis
personal neglect, 'vagabond' look
LSD
Ph sical s mptoms
Look for
Dangers
Suicidal tendencies.
Unpredictable behaviour.
Chronic exposure causes
brain damage. LSD causes
chromosomal breakdown.
6/12
12/15/11
Barbiturates
(b) cocaine
Powder: in microwave
ovens
Phencyclidine
(angel dust)
Marijuana
Inducement to take
stronger narcotics. Recent
medical findings reveal that
prolonged usage causes
cerebral lesions.
Glue sniffing
Lung/brain/liver damage.
Death through suffocation
or choking.
Narcotics
(a) opiates,
e.g. heroin
Needle or hypodermic
syringe. Cotton.
Tourniquet string. Rope,
belt, burnt bottle, caps or
spoons. Glassine
envelopes.
Narcotic dependence
This section will focus on heroin dependence.
Methods of intake
Oral ingestion
Inhalation
intranasal
smoking
Parenteral
subcutaneous
intramuscular
intravenous
Withdrawal effects
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
7/12
12/15/11
These develop within 12 hours of ceasing regular usage. Maximum withdrawal symptoms usually occur
between 36 and 72 hours.
anxiety and panic
irritability
chills and shivering
excessive sweating
'gooseflesh' (cold turkey)
loss of appetite, nausea (possibly vomiting)
lacrimation/rhinorrhoea
tiredness/insomnia
muscle aches and cramps
abdominal colic
diarrhoea
A secondary abstinence syndrome is identified 5 at 2 to 3 months and includes irritability, depression and
insomnia.
Complications
Medical
Acute heroin reaction: respiratory depression may include fatal cardiopulmonary collapse. There is
an alarming increase in opioid deaths (including methadone).
Injection site: scarring, pigmentation, thrombosis, abscesses, ulceration (especially with barbiturates).
Distal septic complications: septicaemia, infective endocarditis, lung abscess, osteomyelitis,
ophthalmitis.
Viral infections: hepatitis B, hepatitis C, HIV infection.
Neurological complications: transverse myelitis, nerve trauma.
Physical disability: malnutrition.
Table 18.3 A street drug dictionar
Amphetamines or uppers
Benzedrine:
Dexedrine:
Methedrine:
Drinamyl:
Hallucinogens
LSD: acid, blue cheer, strawberry fields, barrels, sunshine, pentagons, purple haze, peace pills, blue
light.
Cannabis (Indian hemp)
1. Hashish (the
resin):
hash, resin
2. Marijuana (from pot, tea, grass, hay, weed, locoweed, Mary Jane, rope, bong, jive, Acapulco gold.
leaves):
Cigarettes:
Smoking pot:
Narcotics
Morphine:
Heroin:
H, Big H, Big Harry, GOM (God's own medicine), crap, junk, dynamite (high-grade
heroin), lemonade (low-grade heroin)
Injection of dissolved powder: mainlining, blast, smack
Inhalation of powder: sniffing
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
8/12
12/15/11
Cocaine:
coke, snow, lady of the streets, nose candy, toot, snort, crack
H & C:
speed balls
Mi cellaneo
Barbiturates:
Social
Alienation from family, loss of employment, loss of assets, criminal activity (theft, burglary, prostitution, drug
trafficking).
Managemen
Management is complex because it includes the medical management not only of physical dependence and
withdrawal but also of the individual complex social and emotional factors. The issue of HIV prevention also
has to be addressed. Patients should be referred to a treatment clinic and then a shared care approach can
be used. The treatments include cold turkey with pharmacological support, acupuncture, megadoses of
vitamin C, methadone substitution and drug-free community education programs.
Methadone maintenance programs that include counselling techniques are widely used for heroin
dependence. Acute toxicity requires injections of naloxone.
The natural history of the opiate dependence indicates that many patients do grow through their period of
dependence and, irrespective of treatments provided, a high percentage become rehabilitated by their midthirties.
Long- e m
The influence of 'pot' has a severe effect on the personality and drive of the users. They lose their energy,
initiative and enterprise. They become bored, inert, apathetic and careless. A serious effect of smoking pot is
loss of memory. Some serious problems include:
crime
lack of morality
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
9/12
12/15/11
respiratory disease (more potent than nicotine for lung disease): causes COAD, laryngitis and rhinitis
often prelude to taking hard drugs
becoming psychotic (resembling schizophrenia): the drug appears to unmask an underlying psychosis
Withdra al
Sudden withdrawal produces insomnia, night sweats, nausea, depression, myalgia, irritability and maybe
anger and aggression.
Management
The best treatment is prevention. People should either not use it or limit it to experimentation. If it is used,
people should be prepared to 'sleep it off' and not drive.
Anabolic steroids
The apparent positive effects of anabolic steroids include gains in muscular strength (in conjunction with diet
and exercise) and quicker healing of muscle injuries. However the adverse effects, which are dependent on
the dose and duration, are numerous.
Adverse effects in women are:
masculinationmale pattern beard growth
suppression of ovarian function
changes in mood and libido
hair loss
In adult men, adverse effects are:
feminisation: enlarged breasts, high-pitched voice
acne
testicular atrophy and azoospermia
libido changes
hair loss
Severe effects with prolonged use include:
liver function abnormalities including hepatoma
tumours of kidneys, prostate
heart disease
In prepubescent children there can be premature epiphyseal closure with short stature.
Drugs in sport
It is important for general practitioners to have a basic understanding of drugs that are banned and those that
are permissible for elite sporting use. The guidelines formulated by the International Olympic Committee (IOC)
Medical Commission are generally adopted by most major sporting organisations. 7 Tables 18.4 and 18.5
provide useful guidelines. The IOC's list of prohibited drugs is regularly revised. Banned classes of drugs
include stimulants, narcotics, anabolic agents, diuretics and various hormones. Banned methods include
blood doping (the administration of blood, red blood cells and related blood products) and pharmaceutical,
chemical and physical manipulation (substances or methods that alter the integrity and validity of the urine
testing).
Restricted drugs include alcohol, marijuana, local anaesthetics, corticosteroids and betablockers.
Practitioners can check the guidelines and provide written notification to the relevant authority.
Table 18.4 Prohibited classes of substances ith e amples International Ol mpic Committee
Medical Commission 1998
Classes
A. Stimulants
E amples
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
10/12
12/15/11
ephed ine, me oca b, e b aline,* alme e ol,* alb amol,* p e doephed ine,
phen lp opanolamine
B. Na co ic **
C. Anabolic agen
D. Di e ic
h opoie in
Re
ic ed in ce ain po
( efe o eg la ion )
B. Ma ij ana
Re
ic ed in ce ain po
( efe o eg la ion )
C. Local anae he ic
Mo agen
injec ion
D. Co ico e oid
Ro e of admini
injec ion
E. Be a-blocke
Re
a ion e
ic ed o local o in a-a ic la
ic ed in ce ain po
* pe mi ed b inhale onl b
** codeine, de
pe mi ed
pe mi
i h pe mi
ome ho phan, de
op opo
ion
phene, dih d ocodeine, dipheno
la e and pholcodeine a e
Table 18.5 Guidelines for treatment of specific conditions International Ol mpic Committee Medical
Code 1996
A hma
Co gh
emic
ol e
Pain
la e, lope amide, p od c
Allo ed A pi in, codeine, dih d ocodeine, ib p ofen, pa ace amol, all NSAID
Banned P od c
References
1. K me PJ, Cla k ML. Clinical medicine (2nd edn). London: Baillie e Tindall, 1990, 733-740.
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
11/12
12/15/11
2. Holman CDJ. The quantification of drugcaused morbidit and mortalit in Australia. Canberra:
Commonwealth Department of Communit Services and Health, 1988.
3. Mashford ML (chairman). Cardiovascular drug guidelines (2nd edn). VMPF Therapeutics Committee,
1995/6, 53-58.
4. Murtagh JE. Alcohol abuse in an Australian communit . Aust Fam Ph sician, 1987; 16:20-25.
5. Jagoda J. Drug dependence and narcotic abuse: Clinical consequences. Course Handbook:
Melbourne: Monash Universit of Communit Medicine, 1987, 66-71.
6. Goldman L. Handbook on alcohol and other drug problems for medical practitioners. Canberra:
Australian Government Publishing Service, 1991, 35.
7. International Ol mpic Committee. List of prohibited classes of substances and prohibited methods.
Lausanne; IOC, 1996.
file:///E:/Do nloads/murtagh/GP_Murtagh/html/GP-C18.htm
12/12