Urine drug testing has become widely used in clinical practice as a measure to monitor patient adherence to treatment plans and assess the efficacy of the treatment prescribed. In many circumstances, the clinician is challenged with an abnormal urine drug screen either for a new patient or for a patient presumed to be compliant with the medication regimen; proper interpretation of the test result and a detailed history and physical examination during the visit are necessary to identify the cause of the abnormality and properly care for the patient.

Palliative care is an interdisciplinary specialty focused on providing comfort, communication, and support for patients, families, and professional caregivers throughout the course of a life-limiting illness. This chapter discusses assessment and treatment of symptoms and disorders that commonly contribute to patient distress during these illnesses: pain, disorders of the respiratory and gastrointestinal systems, skin disorders, hot flashes, fatigue, pruritis, insomnia, and delirium. This chapter reviews care of the imminently dying patient, discusses methods for assessing patients' symptoms, and provides two examples of valid and reliable symptom measurement systems: the Edmonton Symptom Assessment Scale and the Memorial Symptom Assessment Scale. Achieving symptom control requires the physician to assess patient suffering in all dimensions: physical, psychological, social, and spiritual. The extent of the assessment may be modified, however, based on patients’ prognosis as well as their goals and the burden and benefit of the diagnostic intervention. A 10-step protocol for terminal wean is presented. Signs that patients are entering their final days and symptom management in the last hours of a patient's life are discussed. Tables list the modified Edmonton Symptom Assessment Scale; the Memorial Symptom Assessment Scale; the DOLOPLUS-2 scale (behavioral pain assessment in the elderly); relative potencies of commonly used opioids; conversions between the transdermal fentanyl patch and morphine; symptomatic treatment for dyspnea, cough, and hiccups; pharmacologic treatment of nausea and vomiting; a progressive bowel regimen for patients receiving opioid therapy; treatments for constipation; etiology-based treatment for oral problems; risk factors for pressure ulcers; and applicable medications for physical and psychological sources of distress near the end of life.

This review contains 12 tables and 120 references

Withdrawal syndromes are clusters of signs and symptoms that occur with cessation or decrease in use of a substance. All substance withdrawal syndromes are classified and diagnosed based on criteria published in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). All withdrawal syndromes range in their ability to cause significant medical and/or psychiatric consequences. Alcohol withdrawal remains a medically serious syndrome that can occur within hours to days of decreased use and result in hallucinations, delirium, seizures, and death. Despite increasing research into the type, frequency, dose, and route of administration, benzodiazepines remain the first-line treatment in preventing alcohol withdrawal complications. Although typically not medically severe, opioid withdrawal is often associated with relapse even after successful detoxification. Opioid-agonist therapy, including methadone and buprenorphine, remains the treatment of choice for both opioid withdrawal and relapse prevention. Stimulant withdrawal from cocaine or amphetamines can cause significant psychiatric symptoms within minutes to hours of cessation and may require psychiatric hospitalization for suicidal ideation or attempts. There are no current medications approved by the Food and Drug Administration (FDA) for treatment of stimulant withdrawal. Cannabis withdrawal, although not medically dangerous, has recently been adopted as a discrete syndrome in the DSM-5. Its severity correlates significantly with the amount of cannabis used, functional impairment, and ability to achieve sustained remission. There are no current medications approved by the FDA for treatment of cannabis withdrawal.

This review contains 6 figures, 13 tables, and 101 references.

Key words: alcohol, amphetamine, benzodiazepines, buprenorphine, cannabis, clonidine, cocaine, dexmedetomidine, methadone, opioid, phenobarbital, stimulant, withdrawal 

Mood disorders (major depressive disorders [MDDs] and bipolar disorders [BDs]) are common psychiatric conditions and major causes of morbidity and mortality worldwide. Their neurobiology is extensively studied, and major advances have been made in understanding the neuroanatomic, neurochemical, synaptic plasticity, and genetic correlates. In this review, we discuss the major neuroanatomic regions in the brain affected in mood disorders and brain structural and functional alterations, the main hypotheses for the neurobiology, the major neurotransmitters and neuromodulators implicated, the synaptic plasticity changes, the role of stress and the hypothalamic-pituitary-adrenal axis, the importance of circadian rhythms, and the role of genetics. We discuss differences in the neurobiology between MDDs and BDs and connect the knowledge of neurobiology to therapeutics. We discuss the main classes of medications, such as antidepressants for treatment of MDD and mood-stabilizing drugs for treatment of BD, and neuromodulation therapies such as transcranial magnetic stimulation. We point to unanswered questions and future directions, such as elucidation of the role of atypical neurotransmitters in mood disorders, the need for better understanding of the genetics and interactions between the immune and central nervous systems, and the development of biomarkers and personalized therapeutics based on the neurobiology. Notably, there are discrepancies in the current scientific knowledge and many unanswered questions in the neurobiology due to the different ages of patients, disease stage, presence of medications, and other comorbidities. It is notable, however, that mood disorders have a clearly established biological basis with alterations in the immune and central nervous systems that affect synaptic plasticity, neural circuits, and larger-scale brain networks and communicate with the autonomic nervous system.

This review contains 5 figures, 4 tables and 62 references

Key words: antidepressant, bipolar disorder, epigenetics, hypothalamic-pituitary-adrenal axis, immune system, limbic system, major depressive disorder, mood stabilizer, neurotransmitter, synaptic plasticity, transcranial magnetic stimulation 

The cough reflex is critically important in the clearance of abnormal airway secretions and protection of the lower respiratory tract from aspirated foreign matter. A weak or ineffective cough can lead to respiratory compromise from even a relatively minor bronchial infection. Persistent cough is often one of a constellation of symptoms indicative of respiratory disease—a potential clue in the differential diagnosis of the patient’s illness. Given the widespread distribution of sensory nerve endings of the cough reflex throughout the upper and lower respiratory tract, it is not surprising that myriad respiratory diseases, involving lung parenchyma and airways, can manifest with cough. Sometimes cough is the sole or predominant symptom in a patient who is otherwise well. Evaluating and treating the patient with persistent cough who has few, if any, other respiratory symptoms is a common challenge for the practicing physician. This review covers the normal cough mechanism, impaired cough, pathologic cough, cough suppressant therapy, and new developments. Figures show a flow-volume loop during cough, a posteroanterior chest x-ray in a patient presenting with chronic cough, flow-volume curves and spirograms documenting expiratory airflow obstruction, and the approach to the patient with chronic cough. The table lists selected examples of extrapulmonary physical findings of potential importance in the assessment of cough.

This review contains 4 highly rendered figures, 1 table, and 94 references.

Efforts to prevent or lessen the functional impact of psychosis can be informed by a better understanding of the neurobiological underpinnings at the earliest stages of the disorder. Understanding these processes early in the psychosis spectrum will in turn allow more targeted efforts to prevent or minimize functional limitations among patients with psychosis. Advances in technology have enabled the study of a host of biomarkers implicated in the neurobiology of psychosis offering unique avenues to investigate mechanisms of disease while at the same time shedding some light on more patient-tailored treatments and setting the foundation for personalized medicine in psychosis. Insights into the neurobiology of psychosis are reviewed, including findings from neuroimaging, neurocognitive, and electrophysiologic studies and findings related to the role of hypothalamic-pituitary axis activity and neuroinflammation in the emergence of psychosis. Biomarker-informed treatments are discussed, and potential promising biomarkers and related treatments are proposed.

This review contains 5 figures, 13 tables, and 85 references. 

Key words: attenuated risk syndrome, biomarkers, prodrome, psychosis, schizophrenia, treatment

Psychiatrists routinely encounter legal and regulatory issues in the practice of psychiatry. This review provides an overview of the psychiatrist’s duties and responsibilities in the doctor-patient relationship and common legal issues arising in clinical practice, with reference to US statutory and regulatory practices. The field of forensic psychiatry is described, and the roles of the forensic evaluator and the treatment provider are compared.

This review contains 2 figures, 5 tables, and 64 references.

Key words: civil commitment, confidentiality, duty to third parties, forensic psychiatry, guardianship, gun ownership, medical decision making, medical marijuana, risk assessment 

The term “drugs of abuse” lacks a formal medical definition. Historically, discussions of drugs of abuse focused on “street drugs”; however, the adverse effects of the nonmedical use of prescription medications, such as opiates, benzodiazepines, and therapeutic amphetamines, are increasingly seen. The purpose of this review is to aid the clinician in identifying and treating a broad representation of drugs of abuse, which may include those illicitly produced in laboratories (e.g., methamphetamine), diverted pharmaceuticals (oxycodone), and herbal products (marijuana). This review covers stimulants, hallucinogens, cannabinoids, and sedative-hypnotics. Figures show substances ranked according to weighted harm score on a normalized scale from 0 being no harm to 100 being extreme harm to self and others, a treatment algorithm for sympathomimetic toxicity, a treatment algorithm for sedative-hypnotic overdose, and a treatment algorithm for opioid overdose. Tables list commonly abused sympathomimetic agents, modern novel drugs of abuse, commonly abused sedative-hypnotic agents, commonly abused opiates, and pitfalls of the drug screen.

This review contains 4 highly rendered figures, 5 tables, and 89 references

Addiction is a disorder characterized by poorly controlled substance use despite negative health and social consequences. Additionally, the only behavioral addiction recognized in the main text of the DSM-5, gambling disorder, presents similarly to many substance addictions with respect to the underlying neurobiology and poorly controlled gambling despite negative consequences (e.g., financial, familial problems). This review first provides an overview of the diagnostic criteria for addictive disorders—both substance and nonsubstance—and subsequently reviews the extant literature examining epidemiology, including global prevalence and co-occurring disorders, as well as differences in addicted and nonaddicted groups with respect to genotype, brain function, and neurochemical systems. Last, the prognosis, quality of life, and current treatment strategies for addictions are discussed. The review also includes tables and figures to supplement the text, summarizes important points, and provides visual representations of tasks used to study cognitive aspects of addictions and addiction pathophysiology.

This review contains 5 figures, 6 tables, and 81 references.

Key words: brain function, cognitive function, epidemiology, functional magnetic resonance imaging, genetics, neurochemistry, positron emission tomography, treatment

Substance use disorders are a major source of morbidity and mortality, contributing to a significant proportion of deaths in the United States and worldwide each year. A substantial rise in deaths related to drug overdoses in recent decades has drawn increasing public attention to this issue. However, the majority of individuals struggling with substance use disorders remain untreated. The financial costs and health burden are substantial. This review provides a broad overview of substance-related and addictive disorders. The evolution of the classification system is described, and the diagnostic criteria for the various substance use disorders are reviewed. Epidemiology and etiologic considerations, including neurobiological pathways, genetics, environmental influences, and dimensional risk factors, are examined. Finally, individual substances and their related disorders are reviewed, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, stimulants, tobacco, and other or unknown substances. Intoxication and withdrawal syndromes are described where applicable, and clinical management concepts are discussed. 

This review contains 6 figures, 5 tables, and 71 references.

Key words: abuse, addiction, alcohol, caffeine, cannabis, dependence, diagnosis, DSM-5, epidemiology, hallucinogen, hypnotic, inhalant, intoxication, methamphetamine, nicotine, opioid, sedative, stimulant, substance use disorders, tobacco, tolerance, withdrawal

Despite mammoth efforts toward the treatment and prevention of substance use disorders in the United States over the past 30 years, they remain a significant public health concern and an all-too-common comorbidity among people with other forms of mental illness. Continued research into genetics, pharmacotherapies, psychotherapies, and epidemiology for substance use disorders results in huge amounts of new information for clinicians to assimilate each year. This review summarizes current diagnostic and categorical standards in substance use disorders, epidemiology, genetic and physiologic factors in addiction for each class, clinically relevant laboratory testing, evidence-based treatments, and prognostic considerations in substance use disorders. Specifically, sections cover cannabinoids, hallucinogens, opioids, sedatives, and stimulants.

This review contains 3 figures, 6 tables and 60 references

Key words: benzodiazepines, cannabis, drug dependence, hallucinogens, MDMA, substance abuse, substance dependence, synthetic cannabinoids

There is a consistent body of evidence showing that substance abuse and dependence can worsen preexisting medical conditions, can temporarily mimic medical and psychiatric disorders, and can themselves cause medical problems, including life-threatening overdose. Substance use disorders are common in young and middle-aged persons: the lifetime prevalence of these syndromes, including alcoholism, is over 20% for men and about 15% for women. This chapter discusses dependence, abuse, substance use disorder, and substance-induced disorders involving depressants, stimulants, opioids, cannabinoids, hallucinogens, N-methyl-D-aspartate (NMDA) receptor channel blockers, and inhalants. Epidemiology, etiology, pathophysiology, diagnosis (including clinical assessment and laboratory tests), and treatment are reviewed. Treatment of intoxication, overdose, withdrawal, and rehabilitation is discussed. A figure illustrates the neurocircuitry of addiction. Tables describe the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnostic criteria for abuse and dependence; frequently misused drugs; neural effects of commonly abused drugs; the natural history of drug dependence; conditions affecting the outcome of urinary drug tests; and pharmacologic options for treatment of drug overdose.

This chapter contains 1 figure , 6 tables and 112 references

Public interest in disease and injury prevention is very high, driven by a steady accumulation of high-quality evidence that preventive interventions do reduce cause-specific death rates. The purpose of these interventions is to eliminate the root causes of diseases that precede death (e.g., heart disease, cancer, and stroke). This chapter presents a review of health risks posed by substance abuse (tobacco, alcohol, and drugs), accidents (e.g., from motor vehicles, accidental poisoning, falling, fire, drowning, and firearms), and domestic violence. The physician’s role in prevention is to identify risk factors for disease and injury and counsel patients about modifying potentially harmful behaviors. Figures illustrate the life expectancy of men and women, and years of potential life lost from various causes, in the United States. Tables list recommendations of the United States Preventive Services Task Force (USPSTF), years of smoking abstinence needed to reduce the risk of disease, elements of a successful smoking cessation strategy, stages of readiness for smoking cessation, the test performance of screening questionnaires for alcohol abuse, the CAGE questionnaire, unintentional and undetermined poisoning deaths in 11 states, and risk factors for falls among the elderly. A sidebar provides links to domestic violence information on the Internet.

This review contains 3 highly rendered figures, 9 tables, and 87 references.

Tourette syndrome (TS) was originally described and conceptualized by Gilles de la Tourette in 1885. Since then, our understanding of tic disorders has grown immensely and continues to evolve at a rapid pace. Tics are abrupt, usually brief and repetitive, nonrhythmic movements (motor tics) and sounds (vocal tics). Motor tics can be further subdivided into simple and complex motor tics. Simple tics are sudden, meaningless movements most commonly involving eye blinking, facial grimacing, mouth gestures, and shoulder shrugs. Complex motor tics typically involve a series of stereotyped movements that may appear to be purposeful. Vocal (also called phonic) tics are similarly subdivided into simple and complex types. This review covers disease definition/subclassification, epidemiology, etiology/genetics, pathophysiology and pathogenesis, diagnosis, differential diagnosis, and treatment of tic disorders. Figures show a risperidone safety monitoring template for children, an aripiprazole safety monitoring template for children, and adult antipsychotic safety monitoring recommendations. The video shows how to perform the extrapyramidal symptom rating scale. Tables list classification of tic disorders, medication dosing suggestions, and TS deep brain stimulation guidelines.

This review contains 3 highly rendered figures, 1 video, 3 tables, and 115 references.

Breastfeeding is endorsed by the medical community as the optimal nutrition for infants during the first 6-12 months of life.^1,2,3  Breastfeeding rates in the US and worldwide have varied over time and still vary geographically.⁴ There is robust literature addressing the physiology of lactation, composition of breast milk, and health advantages of breastfeeding for both the mother and infant as well as strategies for clinicians to promote and support breastfeeding. This chapter reviews breastfeeding history, how milk is made, why breastfeeding matters, and the somewhat controversial the World Health Organization’s Baby Friendly Hospital Initiative (BFHI)⁵ for successful initiation of lactation as well as some special situations.   

Key words:  breastfeeding, infant nutrition, human milk composition, breastfeeding advantages, lactation, lactation support, Baby Friendly Hospital Initiative, skin to skin contact

The exacerbation of pre-existing psychiatric conditions and the development of a new-onset psychiatric disorder during pregnancy directly affects the care of pregnant women. Depression and anxiety are highly prevalent in reproductive age women and may be exacerbated in the perinatal and postpartum periods. Post-traumatic stress disorder is another common condition seen in this population and may worsen under the stress of pregnancy, delivery, and childrearing. Substance abuse is also pervasive in this population, requiring obstetricians to have a thorough understanding of how to manage and treat pregnant women with dependence disorders. Psychiatric conditions and substance abuse often co-exist. These and other disorders present significant risk to the mother and fetus. It is essential therefore for obstetric care providers to understand how to screen for, diagnose, and treat psychiatric disorders during pregnancy and in the postpartum period.

This review contains 4 tables, and 58 references.

Keywords: perinatal depression, postpartum depression, postpartum psychosis, anxiety in pregnancy, substance abuse in pregnancy, post-traumatic stress disorder in pregnancy, eating disorders in pregnancy, pregnancy screening

Chronic pain occurs in one third of the American population. Management of chronic pain is a growing area in health care; however, there is a dilemma for health care providers to treat the chronic pain of individuals who have known current or suspected drug abuse or addiction. Even if the individual is not addicted to opiates or prescription pain medications, it is possible to become addicted to a new substance. The National Institutes of Health considers drug addiction a neurophysiologic disease, and as of 2014, 24.6 million people in the United States abuse drugs. As more patients are seeking treatment for chronic pain, health care providers are seeing an increase in patients who have a history of drug abuse or addiction, and it is imperative that health care providers are aware of how best to care for these patients. This review discusses chronic pain and the drugs that are typically used to treat chronic pain, as well as drugs that have been reported to be abused in chronic pain patients. There are limited or no data available on the more recent designer drugs, such as bath salts, K2 (spice), and even common drugs of abuse, such as methylenedioxymethamphetamine (MDMA). More research should be conducted on what drugs are abused in chronic pain patients, especially nonopioid drugs such as stimulants. This information would help educate health care providers and create better pain treatment regimens for patients who abuse drugs.

Key words: chronic pain, drug abuse, marijuana, methamphetamine, opioids

Management of pain in the spinal cord–injured patient can be a stressful and difficult challenge for both the patient and the physician. In spinal cord injury (SCI), pain can occur immediately or months later, with the potential for persistent pain throughout a lifetime. Unfortunately, pain in this population is often overshadowed or minimized. This is often due to bigger concerns of physical immobility, medical comorbidities, and functional capacity. Achieving pain control leads to a higher likelihood of patients regaining independence in their activities of daily living (ADL), along with providing biopsychosocial benefits to them and their contacts. Using a classification system based on injury acuity, location, and characterized pain state to identify pain generators can help practitioners implement targeted treatment plans. A combination of interventional, physical, pharmacologic, and psychological treatment will help attack the interminable issues that develop along the life span of a patient after injury. Promptly starting treatment will improve our successful management of SCI pain with care that is preventive rather than reactionary.  

Although long an integral part of the health systems of societies all around the globe, the role of complementary and alternative medicine (CAM) in Western medicine has become better defined over the past few years, especially in multidisciplinary pain management. Many patients have expressed dissatisfaction at conventional treatments of therapy, medications, and procedures. Often they have sought adjunctive treatments to make up for deficits in efficacy and to minimize unwanted side effects. CAM has been a source to fill the void. Additionally, physical modalities that promote the mind-body connection in pain states have emerged in common practice. Of the physical modalities helpful in the concurrent management of pain, yoga has emerged as one of the most effective options. The medical literature has identified acupuncture as efficacious and safe and determined that it may have benefit as a sole therapy or in conjunction with traditional interventions. Although nutraceuticals and marijuana have received lay press exposure and interest, as pain therapeutics, the mechanism of action of these agents needs to be more precisely elucidated and regulatory bodies need to ensure quality control and dosage safety in society.  

This review contains 4 figures, 1 table and 118 references

Key Words: acupuncture, lower back pain (LBP), medical marijuana, nutraceuticals, transcutaneous electrical nerve stimulation (TENS)

Chronic pain impacts the lives of millions of people in significant medical and psychosocial ways. Pharmacologic treatments are steering away from chronic opioid therapy due to serious side effects, an epidemic of prescription opioid abuse, and a lack of clear long-term benefit.  Therefore, nonopioid medications such as nonsteroidal antiinflammatory drugs, acetaminophen, tricyclic antidepressants, lidocaine patch, and anticonvulsants are important opioid-sparing or primary treatment options. Agents such as capsaicin, cannabis, botulinum toxin, and ketamine are less frequently prescribed adjuncts that are under active investigation to determine their roles in chronic pain therapy. Understanding the research can help the clinician determine the risks and benefits of these medications for their patients. In the future, dose and delivery optimization, combination therapy, elucidating the biology of pain, and developing novel agents will improve pharmacologic approaches to treatment.          

Infertility is a complex and incompletely understood disease that impacts 10 to 15% of reproductive-aged couples seeking to conceive. The World Health Organization defines infertility as the failure to conceive a clinical pregnancy after 12 or more of regular unprotected sexual intercourse. It likely involves the interaction among many variables, including age, race, ethnicity, and geography, that are laid upon the foundation of genetics and chronic medical conditions and further modified by environmental factors. A plethora of contemporary epidemiologic studies have been published detailing the relationship between male infertility, medical diseases, and environmental exposures with the primary goal of better characterizing their association, identifying risk factors, and providing more effective patient counseling and subsequent treatments. In this chapter, we aim to critically analyze available data and integrate the understanding of epidemiology and male infertility in an effort to provide clear guidance to a larger audience of clinicians of various subspecialties that encounter men with reproductive challenges.

This review contains 1 figure, 8 tables, and 62 references.

Key Words: at-risk groups, conditions, definitions, environmental factors,epidemiology, male fertility, racial geographical, variations