Abstract
Background: Psychoactive substances have toxic effects resulting different cardiovascular and non-cardiovascular organ damage. Through a variety of mechanisms, they can trigger the onset of various forms of cardiovascular disease: acute or chronic, transient or permanent, subclinical or symptomatic. Hence, a thorough knowledge of the patient’s drug habits is essential for a more complete clinical-etiopathogenetic diagnosis and consequent therapeutic, preventive, and rehabilitative management. Summary: The prime reason for taking a psychoactive substance use history in the cardiovascular context is to identify those people who use substances (whether habitual or occasional users, symptomatic or not) and adequately assess their overall cardiovascular risk profile in terms of “user status” and type of substance(s) used. A psychoactive substance history could also alert the physician to suspect, and eventually diagnose, cardiovascular disease related to the intake of psychoactive substances, so optimizing the medical management of users. This anamnesis could finally assess the likelihood of patients persisting in the habit as a user or relapse, while maintaining high their cardiovascular risk profile. Taking such a history should be mandatory when a causal connection is suspected between intake of psychoactive substances and the observed symptoms or pathology, regardless of whether the individual is a declared user or not. Key Messages: The purpose of this article was to provide practical information on when, how, and why to perform a psychoactive substance use history.
Introduction
Psychoactive substances have toxic effects that can lead to severe organ damage, particularly in the cardiorespiratory and neurological-cognitive-sensory systems. Through variety of mechanisms, they can cause – or contribute to – the onset of various forms of cardiovascular disease (acute or chronic, transient or permanent, subclinical or symptomatic) such as ischemic heart disease, cardiomyopathy, endocarditis, myocarditis, arterial hypertension, pulmonary hypertension, arteritis, aortic dissection, arrhythmias, and sudden death [1, 2]. The risk of developing cardiovascular symptoms or damage in drug abusers depends not only on the type of substance used but on many other factors. The risk is significant also for occasional users or small doses, especially when there is a strong genetic predisposition [3] or other predisposing conditions. The pathogenetic mechanisms are multiple: some are direct (receptor-based) and specific to certain substances; others are indirect, mediated by the autonomic nervous system (sympathetic-adrenergic or parasympathetic stimulation) and common to the action of multiple substances or classes of substances [4]. Online Supplementary Table A (for all online suppl. material, see www.karger.com/doi/10.1159/000530246) outlines some of these mechanisms. Being aware if the patient has taken or is taking drugs and obtaining information on the use of these substances will provide a more accurate and complete clinical-etiopathogenetic picture for the therapeutic, preventive, and rehabilitation management.
Hence, the importance, in our opinion, of combining – in the initial phase of patient classification and only in the case of certain patients – the general medical history with a specific psychoactive substance use history. Administered in person or remotely, its aim is to assess: (i) the history of use regardless of the underlying reason (prescription drug, addiction, or for recreational purposes), (ii) the risk of toxic effects or organ damage associated with the drug, (iii) the possibility that the symptoms or disease observed are related to the use (or abuse) of legal (or illegal) substances or to the status of “user,” and (iv) the likelihood of relapse, i.e., the individual continuing to use drugs after an initial period of abstention. Applied to the field of cardiology, this anamnesis specifically aims to investigate the cardiovascular impact of psychoactive substances and their consequent cardiotoxic effects in the heterogeneous class of individuals who use them, whether addicted, taking them on prescription, or occasional users. It consists of a series of well formulated questions, which require the interpretation of a physician who understands the effects of drug abuse on the cardiovascular system and the various ways they act. The goal consists in assessing:
- 1.
the cardiovascular risk specifically related to the intake of psychoactive substances, and the additional risk of cardiovascular morbidity and mortality involved (directly or indirectly) with use and the status of “user.” The aim is to evaluate whether the patient is at risk of subclinical organ damage or clinically manifest cardiovascular disease and whether there is a risk of progression, acute complication, or relapse.
- 2.
if the reported symptoms or disease could be attributable, or associated, to substance misuse. The aim is to evaluate if one should diagnose a pathology based on substance abuse.
- 3.
the likelihood of persistence or relapse after a period of abstinence, i.e., the likelihood of maintaining high the global cardiovascular residual risk, after having diagnosed cardiovascular organ damage and/or a general medical interview on substance misuse issues.
Why take a Psychoactive Substance Use History?
The purpose of this kind of anamnesis, in the cardiovascular field, is to gather all possible information to be able to:
- 1.
Identify patients who are users, whether habitual or occasional, symptomatic or not: Identification of a user is critical for cardiovascular prevention, as the withdrawal of drug use, preferably accompanied by individualized pharmacologic or non-pharmacologic therapy is demonstrated to be useful for improving the cardiovascular risk profile, preventing the onset of associated subclinical organ damage, slowing down its progression, reducing the risk and occurrence of clinically manifest disease with its possible complications, as well as the risk of recurrence of acute events [4]. The benefit is not only in terms of prevention or stabilization of the clinical-instrumental picture but also regression or even complete healing of the organ damage. These benefits, with reduction in the incidence of related diseases and complications, concern not only the cardiovascular system, but all other systems that may be affected by the drug’s toxic effects, including the respiratory and nervous systems. The result will be reduced management costs and economic savings for the health care system.
- 2.
Adequately assess the patient’s true “comprehensive” cardiovascular risk profile: The cardiotoxic effects of psychoactive substances vary depending on the specific drug and dose taken, their concentration and purity, the mode and duration of intake, but also the type of substance with which they are cut, mixed, or combined. In addition, one must also consider synergistic interactions with other drugs, pills, or alcohol taken at the same time. Cardiotoxic effects also vary according to the individual’s age, sex, vulnerability, or genetic predisposition, as well as other objective/subjective situations contingent. In some cases, there is an increased risk (more in habitual than occasional users) of developing a real cardiopathy with an independent and added effect to that of the classic cardiovascular risk factors [1]. A further risk linked to drug use, especially in the case of classic drug addicts, is a poor “user health status,” characterized by the presence of hygienic-environmental, psycho-attitudinal, behavioral, and socio-economic factors that negatively affect the subject’s general state of health, immune defenses, adherence to treatment, but also the ease, willingness and possibility of accessing and continuing medical care. All this can increase cardiovascular morbidity and mortality. No-cardiovascular infectious and non-infectious diseases linked to substances use or to the “user status”can also have a direct or indirect negative impact on cardiovascular morbidity and mortality through drug interactions, associated therapeutic limitations, and multi-organ failure [6]. The psychoactive substance use history aims and can allow to assess all these factors as well as to estimate and quantify the real overall cardiovascular risk of a given patient, taking into account the risk component of substance abuse. This is important not only for the medical implications (i.e., the need to treat the cardiovascular risk factors more intensively, particularly if it is not possible to eliminate the use of the drug; to establish adequate screening programs for the detection of subclinical organ damage, especially in highest risk patients) but also for an insurance and legal point of view.
Suspect a Disease Associated with Drug Use: An increased cardiovascular risk profile due to psychoactive substance use and the status of user should, in the presence of specific symptoms in young and adults, prompt a suspicion of possible heart disease even in the absence of significant risk factors. In this case, the patient should be kept under observation for an extended period to exclude organ damage (which would not otherwise be considered) such as coronary artery disease due to premature and accelerated atherosclerosis, vasospasm, dissection or coronary aneurysm, cardiomyopathy, and other conditions (more frequent in substance users than in nonusers). On the other hand, a history of substance use often helps clinicians to better understand and treat otherwise unexplained symptoms. Such is the case with drug withdrawal symptoms occurring in patients who are unable to use the substance due to hospitalization for any cause (e.g., car accident) or imprisonment.
Suspect and Confirm A Psychoactive Drug Etiology in Cardiovascular Disease: Identifying a cause-and-effect link between drug use and cardiovascular disease can be difficult and has important legal, epidemiological, therapeutic, prognostic, and preventive implications. Thorough knowledge of the potential cardiovascular effects due to use of a specific drug and proving a connection or compatibility between the cardiovascular damage found and the known effects of the substance(s) are key to a correct differential diagnosis with other causes (online suppl. Table B). A correct etiopathogenetic diagnosis of substance-related cardiac damage can result in patients being directed to specific rehabilitation programs to improve their prognosis in relation to substance use. Moreover, in the acute phase, early identification of drug abuse in the etiology of cardiac disease is important for an appropriate therapeutic management. For example, in some cases, benzodiazepines and phentolamine may be more useful and safer than cardiologic drugs to counteract the effects of the substance of abuse [7]. In other cases, an antidote such as naloxone may be used to ease symptoms in cases of opioid abuse, or specific antagonists (cyproheptadine, methysergide, quetiapine) may be used in cases of ventricular arrhythmias due to serotonergic seizures related to 3,4-methylenedioxymethamphetamine (ecstasy) intake. Intravenous administration of sodium bicarbonate (PH as low as 7.0–7.5) may be useful to interrupt a wide QRS tachycardia that arises shortly after cocaine intake, probably due to a dose-dependent blockage of the sodium channel. Another possible therapeutic strategy is to reduce the absorption and/or accelerate elimination of the substance (e.g., forced acid diuresis may facilitate methamphetamine – MA – elimination). Occasionally, treatment of predisposing conditions such as hypokalemia, hypoxia, adrenergic stress, or simply monitoring the patient till the end of the effect of short half-life substances may be a valuable treatment option to prevent anti-arrhythmic drug use [8]. A differential diagnosis between pulmonary edema from opioid or MA abuse and other cardiogenic/non-cardiogenic etiologies is crucial for an appropriate therapy (e.g., use of antidotes, prudent use of diuretics, and prompt evaluation for ventilatory support). In addition, the duration of anticoagulant therapy may differ between abuse-related versus non-related peripheral thrombosis. Therapeutic management of transient brain attack in patients with patent foramen ovale (PFO) may be different in cases of overt substance abuse such as cocaine or cannabis. One should consider the possibility that PFO may simply be an occasional event within a predominant etiopathogenetic picture of cocaine- or cannabis-induced vasospasm, especially if there is a temporal connection between symptoms and substance intake. In contrast, when substance abuse pathegenesis is unlikely and unconfirmed at the anamnesis, other conditions (e.g., a congenital predisposition for a Brugada pattern recorded on ECG) should be excluded or more deeply investigated. However, the categorical confirmation or exclusion of a toxicological cause in the etiology of heart disease is difficult, as the lack of shared guidelines, and diagnostic limitations. Moreover, patients often deny abuse or do not know the exact composition of the substance taken, and laboratory tests are not always reliable in detecting the presence of all the synthetic drugs, whose effect may be hundreds of times stronger than the natural substances.
Optimize The Therapeutic Management of Drug Abusers: The “user status” affects the cardiological therapeutic management of drug users, even when the clinical/pathological event is not closely related to the drug’s effects. This is mainly due to adverse interactions between the substance and cardioactive medical treatments, which may worsen the damage, especially when the substance of abuse has just been taken and not yet converted or metabolized [9]. Being aware of the patient's state of addiction may alert physicians to be more cautious in administering drugs, especially in the acute phase of the disease, but also during the follow-up for individuals who chronically persist in recreational substance use. Physicians must also consider the cardiological effect of interactions between cardiovascular drugs and drugs used to treat psychiatric, infectious, or other diseases often present in drug addicts.
Diagnose Persistent Drug Addiction: It has been shown that giving up use of drugs for pleasure is the best primary and secondary prevention therapy for individuals with a history of drug abuse. Conversely, the risk of disease progression and major life-threatening events with relapse is elevated in persistent users of psychoactive substances. In a previous study, the risk of a repeat acute myocardial infarction due to drugs and not to other causes was much higher in patients who persisted in their abuse [10]. Moreover, as the damage progresses, more and more organs can become involved. For this reason, it is the physician’s duty to severely discourage taking drugs, especially after there has been an acute event, but also to refer patients to the management of a specialized support facility, particularly when persistent substance abuse is suspected. It is imperative to keep in mind that patients who continue to use substances risk a possible drug interaction with other medical treatments that may persist over time. Therefore, patients at high risk of relapse should be followed up more intensively to facilitate early diagnosis of organ damage progression, possible therapy adjustments, and more drastic periodic reassessment of the coexisting cardiovascular risk. For better adherence to therapy and follow-up evaluation, dedicated programs of monitoring and counselling should be planned with the appropriate facilities. Family support and involvement in rehab programs play a central role in the management of drug abusers. Finally, in young and adult patients, routinely performing the psychoactive substance use history is very important: even if it is simply limited to asking whether or not they are taking substances of abuse, explaining the reasons behind the assessment. Indeed, this can help raise awareness not only among potential users but also among all physicians to consider substances of abuse as a real risk factor for cardiovascular and other diseases.
When Is It Most Recommended To Take A Drug Abuse History?
A toxicological anamnesis assessment seeks to investigate the use of psychoactive substances, as their potential cardiotoxic effects, for whatever reason (whether medically prescribed or for recreational purposes). It should be performed not only in adolescents but also in adults and even in elderly patients. This is because, regrettably, all people – no matter what age – are potential drug users. In recent years, in fact, not only the substances but also the profile of drug users has greatly changed. Substance-related cardiovascular diseases can remain subclinical and be diagnosed accidentally or symptomatically in adults or even elderly people who use or have used substances. The risk of developing certain heart diseases increases with age of the user because the time of exposure to the cardiotoxic effects of the substances is greater, because some diseases take time to manifest, and because there may be other cardiovascular risk factors at play.
In Which Cases Should a Psychoactive Substance Use History Be Systematically Collected?
- 1.
When there is a suspected co-causal link between substance use and the symptoms/disease observed. Such is the case especially in the absence of other major cardiovascular risk factors or if there are certain indicators (clinical-instrumental features) that are likely to be associated with drug involvement. For example, a young or adult who presents a myocardial infarction associated with early aggressive coronary atherosclerosis in the absence of multiple risk factors; or a major coronary vasospasm or reduced blood flow in the presence of normal coronary arteries, where vasospasm or transient coronary thrombosis facilitated by some drugs may have played a role. Or in the presence of ectasia/coronary artery dissection [11]. The same recommendation applies to individuals with arrhythmias, cardiomyopathies (unexplained myocardial hypertrophy, alterations in global or segmental cardiac contractility, acute dilated cardiomyopathy with toxic-adrenergic etiology of the Takotsubo type) or other cardiovascular pathologies unusual for their age, not explainable by other causes, and potentially associated with drug abuse. The coexistence of different pathological pictures even at different times, the onset of symptoms at the weekend or during or immediately after parties may suggest a voluptuary origin.
- 2.
When psychoactive substance abuse is suspected. The suspicion can arise from physical examination (e.g., needle-stick marks), from patient behavior or the clinical anamnesis (previous diagnoses of drug-related non-cardiovascular disease; traffic accidents; use of drugs normally used to counteract the unpleasant effects of substances of abuse).
- 3.
In the case of overt substance abuse, the aim of the investigation is not only to verify misuse but also to gather information useful for diagnostic, prognostic, therapeutic, and preventive/rehabilitation purposes.
What to ask during a Psychoactive Substance Use History?
Our goal is to provide a list of questions that can help achieve the intended objectives and lay the foundation for this anamnesis. The questions asked obviously presuppose, on the part of the physician, an expert knowledge of the substances of abuse, their pathological mechanism, drug interactions, associated cardiovascular diseases, as well as the knowledge necessary for the best use of the information obtained. The scheme can be simplified, augmented, or modified to suit the specific needs, the expertise of the specialist, the cooperation of the patient, and the context in which the evaluation is taking place (emergency department, cardiology outpatient clinic, etc.). The basis of the “Substance Use History Anamnesis” can be structured (Table 1) with questions aimed to find out the following:
- a.
General information: For a complete assessment of the cardiovascular risk profile, it is good to collect personal data including marital status, schooling, type of occupation, parents’ work (especially in the case of minors), social status, criminal record. But also, previous hospitalization for drug abuse, other cardiovascular risk factors (known or presumed) including socioeconomic background or psychophysical stress, and lastly factors acknowledged by international guidelines as triggers predisposing to acute cardiovascular disease (recent flu, periodontitis, etc.) [12]. It is also advisable to find out any personal details that could influence quitting. Of note, previous hospitalizations for drug disorders, as mentioned above, are an indicator of susceptibility to the toxic effect of drugs. On the other hand, loss of tolerance to drugs, even if related to a short period of abstinence or reduced substance use (e.g., due to a recent hospitalization), can increase the risk of harm from previous standard doses (Reverse Tolerance Effect).
- b.
Information about generic drug habits: Smoking, alcohol intake (such as beer and/or wine), mild cannabis, energy drinks, anabolic substances, or drugs that affect mental status. Alcohol abuse can undermine overall health status, but not only: it also induces drug interactions and increases the cardiovascular risk leading to specific heart diseases. Alcohol can indeed facilitate drug taking (by fueling, e.g., a state of euphoria that prompts the person to take substances) with the risk of also enhancing and prolonging the action of sympathomimetic drugs. Alcohol allows a faster and more complete absorption of the snorted substances through vasodilation of the nasal mucosa [13] and promotes the transformation of cocaine into its most potent and long-acting metabolite: coca-ethylene [14]. The stimulating effect of caffeine and other substances in energy drinks encourages people to stay awake longer and drink more as well.
- c.
Information on the psychoactive substances (drugs) used and mode of assumption: For individuals who respond positively to the initial question if they have ever tried psychoactive substances, especially if they are habitual users or have cardiovascular disease or symptoms, the anamnesis should continue with the questions summarized in Table 2, whose importance is testified by the following practical examples.
What substances are (or were) you taking? This question is extremely important because each substance has unique characteristics [15]. Previous research has shown that the risk of developing a disease or symptoms related to drug abuse varies according to the type of drug taken and increases with simultaneous intake of other synergistic drugs. In addition, diseases can result from the effects of some substances but not others. For example, arterial hypertension, tachycardia, aortic dissection,Takostubo-like acute dilated cardiomyopathy are more frequently described in cocaine and sympathomimetic drugs users due to acute adrenergic mediated toxic damage. At the same time, myocardial damage may be caused by apoptosis which is often an effect of cocaine [16]. Similarly, a Brugada-like ECG picture can only be caused by drugs with sodium channel blocking properties (e.g., cocaine primarily, dextropropoxyphene, some synthetic opioids, and inhalants can have this effect) [17]. Such questions are helpful to prove a connection between substance intake and symtoms and understand the pathogenetic mechanism of the disease and so choose an approved therapy, selective antidotes – if available – and avoid synergistic interactions. For example, especially in the acute phase of arrhythmias due to sympathomimetic drugs, some ß-blockers (e.g., propanolol) should be used with caution to avoid the risk of triggering arrhythmias on a hypoxic-ischemic basis from vasospasm and/or bronchospasm, or hypertensive changes [18]. Drugs with a mixed effect (alpha/ß blocker) such as labetalol and carvedilol or with a short half-life such as esmolol should be preferred. In addition, class IC anti-arrhythmics such as flecainide, frequently used for the treatment of paroxysmal atrial fibrillation in young adults, should be avoided in cases of arrhythmias caused by cocaine (because of the pro-arrhythmic and negative inotropic effect additive to sodium channel blockade) [19]. Similarly, procainamide in pooled serum samples is shown to inhibit the degradation of cocaine and coca-ethylene. The use of lidocaine to treat cocaine-induced arrhythmias is controversial. Lidocaine can directly inhibit cocaine binding to sodium channels, but it increases the risk of seizure onset. It should be added that cocaine and MA abuse is a risk factor for elevated defibrillation threshold (above 10 joules). The use of implantable cardiac defibrillators (ICDs) with higher energy levels or the use of other techniques to reduce the defibrillation threshold in this category of patients should be carefully weighed up [20], as should ICD implantation itself. This is because they increase:
complications such as pocket infection, lead malfunction, or endocarditis in the case of intravenous drug abuse;
the risk of complications arising from drug abuse;
the risk of complications going unnoticed;
the risk of inappropriate shocks due to sinus or supraventricular tachycardia triggered by psychoactive substance use;
and, finally, there is a lack of prospective studies showing that ICDs reduce the risk of sudden death or all-cause mortality in stimulant users with or without cardiomyopathy.
When did you take the last dose? This question is related to the risk of drug-drug interaction, which is higher if the drug is not yet metabolized, to the risk of the substance becoming the main cause of a clinical complication (drugs “acute” effects are temporally related to the last dose taken and to the amount of the dose) and to the likelihood of spontaneous symptoms resolution based on the substance half-life. Myocardial infarction due to cocaine and/or MA abuse usually occurs within 3–4 h after intake. However, the risk persists in the first 4 days [21]. Similarly, drugs induced arrhythmias are generally related to the intake of the last dose because of a time- and dose-dependent action on Na+ and K+ ion channels [8] or strong acute autonomic nervous system stimulation. However, arrhythmias can also occur against a background of cardiomyopathy or coronary disease due to chronic drug intake. In this case, other triggers could promote the onset of arrhythmias and not only the last drug intake.
What was the amount of dose taken?Some substances can act or have different effects, especially in the acute phase, depending on the amount taken. For example, cannabis causes tachycardia at low doses, but at higher doses it produces parasympathetic stimulation and thus bradycardia and hypotension [22].However, the presence of even very low doses of high-potency synthetic drugs can play a confounding role, contaminating the alleged substance used and causing an added effect.
How often do you habitually consume? What is the regular dose consumed? Has there been an increase in quantity? These questions help properly assess cardiovascular risk, which is obviously higher in a regular than occasional user, and justify chronic organ damage requiring prolonged substance use. These questions help understand the degree of dependence, which is an indicator of the likelihood of continued drug use and helps the physician assess the person’s individual susceptibility to drug effects. For example, the onset of cardiovascular disease after a small dose taken indicates higher vulnerability, which may be fostered by unknown congenital alterations (e.g., long QT syndrome, Brugada syndrome). In these situations, the effect of the drug is to unmask a pathological condition that itself requires cardiological investigation.
What is the method of drug intake? Intravenous intake is associated with increased dependence, increased infectious risk, and increased vascular complications. In addition, this mode of intake causes a faster and more intense pharmacological effect because of its greater speed of action and onset than other modes of intake. Sometimes, the heat used to dissolve the drug can also modify its effects.
- •
In previous drug intakes, did you experience symptoms?When did you experience them? Were these symptoms by any chance like your current symptoms? And finally, how did you manage them? The purpose of these questions is self-evident.
Have you also taken alcohol or other drugs? Alcohol increases the risk of sudden death by 23% and promotes electrolyte imbalance, which can potentiate alterations due to other drugs [23]. It is important to distinguish the effects of alcohol and other drugs from those due to the specific substance of abuse. When alcohol or other drugs have been consumed, the physician should consider changing some drug therapies to others with a lower impact of potentially dangerous interactions or risk of adverse events. For example, shorter-acting drugs such as droperidol may be preferred to haloperidol, monitoring the QTc interval, if additional antipsychotic agents are needed in patients with MA-induced arrhythmias. QTc prolonging drugs may precipitate arrhythmias, and should be avoided in patients receiving methadone.
Where and how are the substances procured? Some substances are actual drugs that may even be legally prescribed; however, purchase through illegal routes may be associated with variations in the purity and concentration of the alleged substance taken, with unexpected and unpredictable effects.
- d.
Information on cardiovascular and non-cardiovascular effects (symptoms and/or disease) related to substance use. These data are important not only for a multispecialty management of the patient but also to assess the person’s susceptibility to substance effects and the associated cardiovascular risk. Of note, the presence of certain respiratory, nephrological, or even infectious (HIV, HCV) diseases, as well as the presence of behavioral-psychiatric disorders, can affect cardiovascular morbidity and mortality in multiple and different ways.
- e.
Information on the degree of dependence: diagnosis of substance use disorder according to DSM-5 (16) – see Table 3.
- f.
Information on risk factors associated with short- or long-term substance relapse. In our opinion, the anamnesis should consist of indirect or explicit questions that assess the degree of dependence and the relative likelihood of the person to permanently stop taking psychoactive substances (at least, those not taken on prescription). Substance abusers are at high risk of returning to substance use, despite knowing its harmful effects and even after suffering adverse health consequences. This important clinical finding has now, in fact, become an integral part of the definition of pathological dependence. Although several questionnaires are available to assess the risk of resuming drinking [24, 25] and/or drug use [24, 26], none of them has been validated (in Italy) or used consistently in the cardiology field. Table 4 lists the main items that can be used to assess the risk of relapse that, based on the scientific literature, reflect multiple potential psychosocial risk factors for relapse to drug abuse. In this way, it is possible to estimate the severity of the long-term risk of substance use persistence or relapse. This assessment takes place after organ damage has been found and after an initial comprehensive medical interview about the health risks associated with these substances. Future prospective studies will be able to develop a standardized score and cut-off for stratifying risk categories and establish the relative importance of each factor. Previous studies have examined individual risk factors, but only a few have evaluated the ability of these factors to predict relapse when considered together. They have shown that a multidisciplinary approach, including a rigorous psychosocial assessment, is the most effective method for identifying the risk of relapse in post-liver transplant patients who have abused alcohol [25]. Investigating multiple risk factors is also a way to mitigate any bias resulting from the patient’s resistance and minimization in responding.
General structure of the psychoactive substance use history
A. General information |
B. Information on generic toxicological-voluptuous habits |
C. Information on psychoactive substance use: which drugs are taken and how they are taken |
D. Information on the cardiovascular and other side effects caused by drug use |
E. Information on the degree of dependence (Diagnosis of Substance Use Disorder according to DSM-5) |
F. Information on risk factors and probabilities associated with relapse occurring in the short or long term after substance use |
A. General information |
B. Information on generic toxicological-voluptuous habits |
C. Information on psychoactive substance use: which drugs are taken and how they are taken |
D. Information on the cardiovascular and other side effects caused by drug use |
E. Information on the degree of dependence (Diagnosis of Substance Use Disorder according to DSM-5) |
F. Information on risk factors and probabilities associated with relapse occurring in the short or long term after substance use |
Sample questions for the psychoactive substance use history in a cardiology context
Checking for potential substance intake | |
• | Have you ever tried/taken substances/drugs capable of changing your mental state, even those legally sold? |
• | Have you ever tried/taken substances (drugs)? |
• | If so, can you tell me which ones? |
o | Cannabis (e.g., Marijuana, Hashish) |
o | Cocaine |
o | Heroin or other natural opioids |
o | Amphetamine |
o | Ecstasy or other mind-blowing substances |
o | Hallucinogenic substances (e.g., LSD, fungi) |
o | Methadone |
o | Synthetic opioids (e.g., fentanyl, tramadol) |
o | Other questions… |
Duration of intake (by individual substance) | |
• | At what age did you start using it? |
• | For how long overall did you use it? (Only years of actual use should be counted) |
• | Have there been periods when you stopped taking it completely? If yes, can you tell me for how long? |
• | When was the last time you used drugs? (if necessary, specify the exact time frame and the occurrence of any symptoms) |
Frequency of intake (per individual substance) | |
• | In the last year of use, how often did you consume it on average in a month/week or in a day? |
Checking the dose taken | |
• | What is the average single-day intake? |
• | What was the maximum amount consumed in a day? |
Method of administration | |
• | What was the predominant mode of intake? |
• | What was the last mode of taking it? |
Correlation with observed symptoms or cardiac pathology | |
• | Did you last use substances together with alcohol or other substances or drugs? |
• | Has the frequency, the average or maximum dose, the quality of the substance, or the method of intake changed in the last few days? |
• | When you used this substance have you ever experienced a heavy heartbeat/tachycardia, chest pain, shortness of breath, dizziness, vertigo, or numbness? |
• | Were these symptoms present also in the past or have they only appeared recently? |
• | How many times have you experienced this symptom/these symptoms after drug use? |
• | How long after taking substances do you experience, or did you experience, this symptom/these symptoms? |
• | How long does the acute symptom last or did it use to last? |
• | Have you ever thought that these symptoms could be related to the use of the substances? |
• | Have your consumption habits changed since the onset of these symptoms? |
• | Have you ever reported these symptoms to your local doctor? |
• | Have you ever received emergency medical/hospital care for this symptom(s)? If so, how many times? |
Checking for potential substance intake | |
• | Have you ever tried/taken substances/drugs capable of changing your mental state, even those legally sold? |
• | Have you ever tried/taken substances (drugs)? |
• | If so, can you tell me which ones? |
o | Cannabis (e.g., Marijuana, Hashish) |
o | Cocaine |
o | Heroin or other natural opioids |
o | Amphetamine |
o | Ecstasy or other mind-blowing substances |
o | Hallucinogenic substances (e.g., LSD, fungi) |
o | Methadone |
o | Synthetic opioids (e.g., fentanyl, tramadol) |
o | Other questions… |
Duration of intake (by individual substance) | |
• | At what age did you start using it? |
• | For how long overall did you use it? (Only years of actual use should be counted) |
• | Have there been periods when you stopped taking it completely? If yes, can you tell me for how long? |
• | When was the last time you used drugs? (if necessary, specify the exact time frame and the occurrence of any symptoms) |
Frequency of intake (per individual substance) | |
• | In the last year of use, how often did you consume it on average in a month/week or in a day? |
Checking the dose taken | |
• | What is the average single-day intake? |
• | What was the maximum amount consumed in a day? |
Method of administration | |
• | What was the predominant mode of intake? |
• | What was the last mode of taking it? |
Correlation with observed symptoms or cardiac pathology | |
• | Did you last use substances together with alcohol or other substances or drugs? |
• | Has the frequency, the average or maximum dose, the quality of the substance, or the method of intake changed in the last few days? |
• | When you used this substance have you ever experienced a heavy heartbeat/tachycardia, chest pain, shortness of breath, dizziness, vertigo, or numbness? |
• | Were these symptoms present also in the past or have they only appeared recently? |
• | How many times have you experienced this symptom/these symptoms after drug use? |
• | How long after taking substances do you experience, or did you experience, this symptom/these symptoms? |
• | How long does the acute symptom last or did it use to last? |
• | Have you ever thought that these symptoms could be related to the use of the substances? |
• | Have your consumption habits changed since the onset of these symptoms? |
• | Have you ever reported these symptoms to your local doctor? |
• | Have you ever received emergency medical/hospital care for this symptom(s)? If so, how many times? |
Criteria for the diagnosis of substance use disorders (DUS). Degree of addiction to substances (DSM-5)
1 | Tolerance: intensification of use behavior is necessary (dose increase and/or frequency of intake) to achieve the same effects on the organism |
2 | Withdrawal: emotional or physical symptoms that appear when the intake behavior cannot be implemented |
3 | Discontinuation or reduction of social, work, or leisure activities |
4 | Unsuccessful attempts to reduce and control the use of substances |
5 | Waste of time (how much time the patient spends researching, using, or recovering from the effects of the substance) |
6 | Loss of control over use: pathological behavior of use of the substance that tends to occur despite the negative consequences it has obviously brought and despite the person’s awareness of it (behavior of use becomes “compulsive”) |
7 | Continuous use despite the awareness that the drug is a problem |
8 | Recurrent use with inability to perform tasks |
9 | Use in risky situations |
10 | Recurrent use despite the social or interpersonal problems that it causes |
11 | Craving: an urgent and irrepressible desire for the substance |
1 | Tolerance: intensification of use behavior is necessary (dose increase and/or frequency of intake) to achieve the same effects on the organism |
2 | Withdrawal: emotional or physical symptoms that appear when the intake behavior cannot be implemented |
3 | Discontinuation or reduction of social, work, or leisure activities |
4 | Unsuccessful attempts to reduce and control the use of substances |
5 | Waste of time (how much time the patient spends researching, using, or recovering from the effects of the substance) |
6 | Loss of control over use: pathological behavior of use of the substance that tends to occur despite the negative consequences it has obviously brought and despite the person’s awareness of it (behavior of use becomes “compulsive”) |
7 | Continuous use despite the awareness that the drug is a problem |
8 | Recurrent use with inability to perform tasks |
9 | Use in risky situations |
10 | Recurrent use despite the social or interpersonal problems that it causes |
11 | Craving: an urgent and irrepressible desire for the substance |
Main items for investigating the severity of relapse risk
- | Craving (“How strong do you feel the desire to consume substances?”) |
- | Quantitative and qualitative motivations for quitting consumption (“How strongly do you feel motivated to quit?” and “What are the reasons behind this? Health, family, work, economic issues, etc.”) |
- | Personal opinion about occasional consumption/abstinence (“Do you believe you will manage not to touch substances within the next month? How confident are you about this?”) |
- | Personal opinion with respect to habitual consumption (“How confident are you about being able to quit for good?”) |
- | Active/potential professional psychosocial support (“Are you following a psychological/psychotherapeutic path to quit?”) |
- | Active/potential medical support (“Are you taking any drug therapy to help you quit?”) |
- | Active informal social support (“Do you live with any family members/friends who can help you or would help you to quit?”) |
- | Type of relapse (sudden, short-term, long-term). For instance, the patient does not know whether he/she will use drugs again; it usually happens suddenly and without planning. In addition, he/she longs to start drug abuse again. And before starting again, he/she thinks about it often and for several days |
- | Environmental risk factors such as family, friends, events (“Do you live with people who consume substances even occasionally?,” “Do you hang out with friends/acquaintances who consume substances?,” “In the places you go, do people usually take drugs?”) |
- | Depression |
- | Anxiety |
- | Stress |
- | Anger |
- | Spontaneous statement about inability to give up substance use |
- | Spontaneous admission about the desire and intent to continue substance use |
- | Craving (“How strong do you feel the desire to consume substances?”) |
- | Quantitative and qualitative motivations for quitting consumption (“How strongly do you feel motivated to quit?” and “What are the reasons behind this? Health, family, work, economic issues, etc.”) |
- | Personal opinion about occasional consumption/abstinence (“Do you believe you will manage not to touch substances within the next month? How confident are you about this?”) |
- | Personal opinion with respect to habitual consumption (“How confident are you about being able to quit for good?”) |
- | Active/potential professional psychosocial support (“Are you following a psychological/psychotherapeutic path to quit?”) |
- | Active/potential medical support (“Are you taking any drug therapy to help you quit?”) |
- | Active informal social support (“Do you live with any family members/friends who can help you or would help you to quit?”) |
- | Type of relapse (sudden, short-term, long-term). For instance, the patient does not know whether he/she will use drugs again; it usually happens suddenly and without planning. In addition, he/she longs to start drug abuse again. And before starting again, he/she thinks about it often and for several days |
- | Environmental risk factors such as family, friends, events (“Do you live with people who consume substances even occasionally?,” “Do you hang out with friends/acquaintances who consume substances?,” “In the places you go, do people usually take drugs?”) |
- | Depression |
- | Anxiety |
- | Stress |
- | Anger |
- | Spontaneous statement about inability to give up substance use |
- | Spontaneous admission about the desire and intent to continue substance use |
Toxicological Tests
Toxicological tests are useful in individuals in whom a psychoactive substance use history cannot be performed (e.g., who are unconscious or unable to cooperate due to severely altered mental status), or when it is not possible to obtain a reliable report, or in all those cases where for clinical or legal reasons the use of substances needs to be verified. The most used test, both for its low cost and noninvasiveness, is the toxicological examination of urine that can also be done in the emergency room in view of the rapidity of the response with a detection window generally of a few days, depending on the type, frequency, and amount of substance taken.
The urine test can detect the consumption of certain substances above a threshold value, but it cannot correctly determine the frequency and intensity of use, distinguish between occasional and habitual users or correlate the clinical symptoms with the substance found. In addition, with the urinary matrix screening test there can be false positives (ibuprofen can produce false positives for marijuana) and false negatives (the concentrations of substance in the particular sample examined may be below the detection threshold value). For these reasons, the urine screening test, and toxicological tests in general, cannot replace a specific anamnesis, also because they detect the presence of only some substances, not all.
In addition, they can have a confounding effect in that the clinical symptoms can be falsely attributed to the substance found in the test and not to the one actually taken (which was not detected). In carrying out a toxicological test, there may be protocols to respect that depend on local/state legislation and the reason why it is required. It is essential to know the local code of ethics and regulations designed to reconcile adequate medical assistance with respect for privacy and the willingness of the patient to undergo treatment, in order to avoid medicolegal problems. As the legislative references vary from state to state, we cannot give universally valid indications here, but limit ourselves to providing some suggestions for the physician to bear in mind. For legal purposes
Consider recording any dissent of the patient, especially if the test is mandatory, because this may result in sanctions or disciplinary action for those who refuse to undergo the test.
Comply with the requirements of reliability, transparency, uniformity, and traceability at every stage of the test process.
If the test is performed for clinical purposes
Ensure that it does not require mandatory informed consent, as is the case, at least in some countries, for HIV testing.
In the absence of such obligation, consider informing the patient and documenting in the medical record that toxicological tests are also among the examinations required for the clinical management of the patient, bearing in mind the social, work, family implications that a test positive for legal or illegal psychoactive substances may entail.
Consider the need to justify the clinical indications for performing the toxicological test.
Check whether there are local laws or procedures that allow the patient to perform medical examinations in complete anonymity, and if such anonymity can be applied.
In the case of refusal to perform the test, consider recording this dissent, in order to justify any incorrect diagnosis or treatment as a result of the lack of such information.
Check the local legislation to verify that the patient’s informed consent is not required for medical reasons (suspected intoxication by psychoactive substances) in conditions of urgency-emergency when a patient is unconscious or incapable of understanding or in a seriously altered mental state, according to the principle of necessity of medical intervention to save the patient or others.
In any case, always consider the possible intake, by the person under investigation, of drugs or food that may interfere with the results of the test in the 4–5 days prior to collection, the opportunity to collect more samples for confirmatory and/or second level tests, and the laws governing the processing of the acquired data.
Final Suggestions
However, as emerged from a study [27], in clinical practice health professionals are not likely to ask patients whether they are taking substances, even in cases where the question would be more than justified. It is common opinion that there is much reluctance to broach this subject, perhaps for fear of offending the patient, or because of an unclear concept of privacy, or simply because of lack of sensitivity or knowledge in this field. But also, for fear of not really knowing what to do, or of putting oneself in an awkward situation. Sometimes there is little time to delve into these matters, even acknowledging their relevance, and sometimes a specific investigation is not even initiated, with the excuse of being certain of a negative response or lack of cooperation from the patient. To this end, we make some suggestions that might be helpful for obtaining truthful answers and maximum cooperation from the patient (Table 5). First, every patient is different, not only in terms of history of consumption but also of work, education, and social background. It may be easy to obtain information from persons with a known history of drug addiction, if their clinical condition permits and their answers are not biased by medicolegal or judicial implications. In contrast, it is certainly more difficult to obtain reliable answers from individuals whose history of intake could have a negative impact on their social, family, and work life. A good start is to recognize the type of patient, so that one can tailor the approach accordingly. In some cases, a winning strategy is to precede the history collection (and especially the crucial question about substance abuse intake) with a rationale that empowers the patient in responding. For example, emphasizing the importance of receiving such information to avoid administering drugs that could be harmful or contraindicated, or so as to exclude a psychoactive substance etiology before starting other diagnostic and therapeutic courses that might be more challenging, costly, and risky. Starting to address this topic after building a good doctor-patient relationship can certainly help in conducting the anamnesis. Sometimes, after an initial negative or vague answer, a new attempt to return to the topic can be satisfying. Statements such as the following: “This type of question is routine because of a wide substance abuse in the general population, especially when a pathology is compatible with drug use and no other causes have been found” can also be used to justify an anamnesis, when required. Moreover, greater cooperation on the part of the patient establishes a fundamental “diagnostic-therapeutic alliance.” Finally, consider recording patient's refusal to cooperate and having countersigned his/her denial of having taken substances.
Tips and key points for effectively administering a psychoactive substance use history
• Take the medical history in a private place, without the presence of family members, caregivers, or other medical/nursing personnel, so as to put the person at ease. By doing so, the physician can demonstrate his or her willingness to want to ensure the utmost confidentiality of the information received and to give due importance to this time of medical evaluation |
• Seek permission to be allowed to ask questions about personal and sensitive issues, explaining the obligation to professional secrecy and the commitment to ensure strict confidentiality of the information received |
• Justify the purpose of the questions asked and hold the patient accountable by informing the patient that physicians cannot refrain from asking certain information that is necessary to make a correct diagnosis, choose the right treatment, and generally better manage the patient's health |
• Use professional, direct, simple, and unambiguous language, with an appropriate tone of voice that emphasizes the importance of the work being done and tends to normalize the topic at hand |
• Avoid mechanically following a set of written questions and expecting excessively precise answers unless strictly necessary |
• Demonstrate interest in the answers given by the patient but avoid probing or delving into personal details that are not relevant to the diagnostic history-making activity |
• Maintain a welcoming attitude and nonjudgmental verbal/nonverbal communication to establish a good doctor-patient relationship and facilitate patient openness and sincerity; this will certainly be appreciated by the patient. Avoid expressing astonishment or irony, lecturing or criticism while acquiring responses |
• Always respect the individual in front of you, even if he/she shows reluctance to provide the answers |
• Demonstrate awareness of drug effects and use the “street” terms by which drugs or substances are called |
• Consider taking the full substance use medical history not in one single interview but at different moments, even though, in some situations, it is essential to obtain immediately all the information needed for correct and timely case management |
• Consider informing the patient about the main harmful consequences of various substances |
• Take the medical history in a private place, without the presence of family members, caregivers, or other medical/nursing personnel, so as to put the person at ease. By doing so, the physician can demonstrate his or her willingness to want to ensure the utmost confidentiality of the information received and to give due importance to this time of medical evaluation |
• Seek permission to be allowed to ask questions about personal and sensitive issues, explaining the obligation to professional secrecy and the commitment to ensure strict confidentiality of the information received |
• Justify the purpose of the questions asked and hold the patient accountable by informing the patient that physicians cannot refrain from asking certain information that is necessary to make a correct diagnosis, choose the right treatment, and generally better manage the patient's health |
• Use professional, direct, simple, and unambiguous language, with an appropriate tone of voice that emphasizes the importance of the work being done and tends to normalize the topic at hand |
• Avoid mechanically following a set of written questions and expecting excessively precise answers unless strictly necessary |
• Demonstrate interest in the answers given by the patient but avoid probing or delving into personal details that are not relevant to the diagnostic history-making activity |
• Maintain a welcoming attitude and nonjudgmental verbal/nonverbal communication to establish a good doctor-patient relationship and facilitate patient openness and sincerity; this will certainly be appreciated by the patient. Avoid expressing astonishment or irony, lecturing or criticism while acquiring responses |
• Always respect the individual in front of you, even if he/she shows reluctance to provide the answers |
• Demonstrate awareness of drug effects and use the “street” terms by which drugs or substances are called |
• Consider taking the full substance use medical history not in one single interview but at different moments, even though, in some situations, it is essential to obtain immediately all the information needed for correct and timely case management |
• Consider informing the patient about the main harmful consequences of various substances |
Conclusion
Administering the psychoactive substance use history is a very delicate task and, in fact, interpersonal relationship skills play a major and decisive role, as do the experience and knowledge of the physician in this field. In our opinion, this type of anamnesis, with due adaptations, can find its practical usefulness not only in cardiology, but also in other disciplines such as neurology, psychiatry, respiratory diseases, infectious diseases, as well as general medicine. This is because of the help it can give in the epidemiological, diagnostic-etiologic, prognostic, and preventive-therapeutic framework of non-cardiovascular pathologies as well. A greater diffusion of the psychoactive substance use history in daily clinical practice is desirable, as well as introducing its teaching in medical schools. This would increase the awareness and knowledge among the new generations of doctors toward these issues.
Acknowledgments
We thank Rosemary Allpress and Prof. Chiara Lopriore for English language assistance in the preparation of the manuscript.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
No funding was received for the preparation of the manuscript.
Author Contributions
Ciccirillo F. and Abrignani M.G. were responsible for the conception and design of the study; Ciccirillo F., Abrignani M.G., Temporelli P.L., Binaghi G., Cappelletto C, and Lopriore V. wrote the first draft of the manuscript; Cesaro A., Maloberti A., Cozzoli D., Riccio C., Caldarola P., Oliva F., Gabrielli D., and Colivicchi F. contributed to the design of the study and made critical revision of the manuscript related to its important intellectual content; and all authors gave final approval of the version of the article to be published.