This manual is a guidebook, not a textbook. Each chapter has a different style and goal within which are couched the tools that you’ll want handy when working with the substance-using patient. In certain areas, there is no right or wrong; many chapters represent thought exercises designed to guide you toward the approach you will use with substance-dependent individuals. Much of my commentary is what you would hear from me if you were working as a member of my clinical team. That commentary is based in part on the literature and on my training, but in far larger part upon the thousands of patients with substance use disorders who have trained me as they worsened or improved. Rather than placing citations within the text, I’ve used authors’ names within sentences and will allow you to find the citation within the references at the end of the book. There are at least one dozen fine texts available that will educate you about the pharmacology of cocaine or the correct protocol to use when detoxing a patient from heroin. There, you will read about GABA receptors and alcohol, the epidemiology of cocaine use, and the medical management of acute intoxication. I have endeavored not to provide yet another source of this information. Daniel Carlat, the author of The Psychiatric Interview, the first book in the Practical Guides series, has written expertly there about interview techniques. I have provided some amendments and modifications to his approach where necessary for the substance-using patient, but refer the reader to his text for education about the basics.
Early in your professional career, you no doubt learned the truism about alcohol or other drug problems, namely that the patient has a problem when his or her use is more than your own. As time passed, you realized that this was a somewhat simplistic approach. You might not use any substances at all, making nearly everyone fodder for a substance disorder. Or perhaps you’ve made your way through training despite several charges of Driving Under the Influence or Drunk and Disorderly, and even a brief time in the local rehab, thereby making almost no one you see problematic. By now, though, you’ve hopefully realized that a patient’s illness has nothing to do with you. You’re left with little on which you can base your diagnosis. Or so it might appear.
Chapter 1: Substance Use Disorders: A Practical Guide