Substance-related and addictive disorders

Last updated: November 29, 2022

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Substance-related disorders are a class of psychiatric disorders characterized by a craving for, the development of tolerance to, and difficulties in controlling the use of a particular substance or set of substances. There are two groups of substance-related disorders: substance-induced disorders and substance use disorders (SUDs). Substance-induced disorders include intoxication, withdrawal, and substance-induced mental disorders. SUDs (e.g., opioid use disorder and alcohol use disorder) have unique features but are all characterized by cognitive and behavioral changes and physical symptoms related to the continued use of one or more substances despite negative consequences. The addictive potential of these substances results from how they act on the brain's reward system and affect emotion, mood, and perception, often inducing a euphoric state colloquially referred to as a “high.” Individuals with SUD may participate in high-risk or illegal behaviors (e.g., exchanging sex for drugs, unsafe needle practice, erratic or aggressive behavior, theft), either as a result of substance use or in pursuit of substances, which can lead to social isolation, housing instability, and worsening of mental illness (e.g., comorbid bipolar disorder, major depressive disorder, or anxiety disorder). Treatment for SUD involves counseling (e.g., motivational interviewing), psychotherapy, and/or pharmacotherapy.

Substance use disorder [1][2][3]

  • Description: a chronic condition in which an uncontrolled pattern of substance use leads to significant physical, psychological, and social impairment or distress, with continued use despite substance-related problems.
  • Epidemiology
  • Characteristics: features that are typical for all substance use disorders (≥ 2 features must occur within 1 year to fulfill the DSM-V criteria)
    • Impaired control
      • Using a substance in larger amounts and/or for a longer time than originally intended
      • Repeated failed attempts to cut down on use
      • A great deal of time spent on substance-related activities (e.g., seeking out, buying, using, recovering from use)
      • Intense desire to obtain and use substance (craving)
    • Social impairment
      • Problems fulfilling work, school, family, or social obligations (e.g., not attending work or school, neglecting children or partner)
      • Problems with interpersonal relationships directly related to substance use (withdrawal from relationships, marital issues)
      • Reduced social, occupational, and recreational activities (e.g., less time socializing with friends, neglecting hobbies)
    • Risky use
      • Use in physically hazardous situations; (e.g., driving a car under the influence, unprotected sex, operating heavy machinery)
      • Continued use despite awareness of problems related to or exacerbated by substance use (e.g., continued alcohol use despite having cirrhosis)
    • Pharmacologic indicators
      • Drug tolerance: the need to continuously increase the dose of a substance to achieve the same desired effect
      • Drug withdrawal: a substance-dependent collection of symptoms that appear after cessation of prolonged heavy drug use accompanied by a strong urge to readminister the substance
  • Exception: patients undergoing supervised treatment with certain psychoactive substances (e.g., stimulants, cocaine, opioids, nitrous oxide, sedative-hypnotic drugs, anxiolytic drugs, cannabis) [4]
    • Tolerance and withdrawal can be normal physiological adaptations.
    • In the absence of other DSM-V criteria, tolerance and withdrawal do not necessarily indicate substance use disorder.

Withdrawal from some substances, such as alcohol, benzodiazepines, and barbiturates, can be fatal!

Substance-induced disorders

  • Intoxication: a temporary condition caused by recent ingestion of a substance that alters a person's consciousness, cognition, perception, judgment, affect, and/or behavior; commonly occurs in substance use disorders but also in one-off use
  • Withdrawal: a condition characterized by behavioral, physiological, and cognitive changes caused by a sudden reduction or cessation of substance intake after a prolonged period of heavy intake; usually occurs in association with substance use disorders
  • Substance/medication-induced mental disorders: a psychiatric disorder that develops within 1 month of intoxication or withdrawal of a substance and is not attributable to an independent mental disorder (e.g., substance/medication-induced anxiety disorder)

Related definitions

  • Abuse
    • In the context of substance use, the term “abuse” should generally be avoided due to its impreciseness and the historical burden of stigma.
    • “Substance use” is generally the preferred term in this context, with “substance misuse” being appropriate in the context of prescription drugs.
  • Drug-seeking behavior
    • A maladaptive behavioral response to substance addiction that involves manipulative and/or demanding behaviors to obtain the desired substance
    • Often indicative of an underlying substance use disorder
    • Examples of drug-seeking behavior
      • Faking/aggravating symptoms
      • Bribes, threats, theft (e.g., prescription pads)
      • Forging prescriptions or using those of others (e.g., under the names of family members)
      • Pretending to lose prescriptions and asking for new ones
      • Insisting that a treatment that does not involve one or more certain (addictive) drugs is ineffective or not tolerated (e.g., due to an alleged allergy)
      • Demanding a stronger medication or higher dose due to an allegedly high drug tolerance
      • Claiming that another, an ostensibly more experienced or more caring, physician would prescribe the desired drug or threatening to see another physician if the desired drug is not prescribed.
  • Medication-assisted treatment (MAT): treatment for substance use disorder that combines counseling with pharmacological and behavioral therapy, tailored to each patient's needs. [5]
Overview of substance intoxication and withdrawal [6]
Intoxication Withdrawal
Substance Pupils Cardiovascular system Concomitant symptoms
Depressants
Alcohol
Opioids
Barbiturates

Benzodiazepines

  • Normal (mild intoxication)
  • Mydriasis (severe intoxication)
  • Autonomic symptoms (e.g., sweating, hypertension)
  • Gastrointestinal symptoms (e.g., nausea, vomiting)
  • Neurological symptoms (e.g., seizures, tremors)
  • Psychiatric symptoms (e.g., depressive moods, insomnia)
Inhalants
Stimulants
Amphetamines
  • ↓ Appetite, weight loss
  • ↑ Libido
Cocaine

Synthetic cathinones

  • Aggression, confusion
  • Muscle spasms
Caffeine
Nicotine
  • Euphoria
  • Restlessness, anxiety, insomnia
  • ↑ Gastrointestinal motility, weight loss
Hallucinogens
Cannabinoids
  • Conjunctival injection (red eyes)
  • ↑ Appetite, dry mouth
  • Impaired reaction time, concentration, and motor coordination
  • Social detachment
  • Irritability, anxiety, depression
  • ↓ Appetite, anorexia
  • Restlessness, sleep disturbances

Lysergic acid diethylamide (LSD)

  • Flashbacks (rarely unsettling)
  • None
MDMA
  • Changes in sleep and appetite
  • Difficulty concentrating
  • Fatigue, depression, anxiety
Phencyclidine (PCP)
Gamma-hydroxybutyric acid (GHB) Low dose
  • Intensification of sensory experience
  • Enhanced empathy and libido
  • Disinhibition
High dose
Overdose

SUD screening [8]

Indications

Validated screening tools

The harms of screening for unhealthy drug use outweigh the benefits when treatment cannot be provided or when findings may result in punitive actions (e.g., some US state laws penalize pregnant individuals who use substances or seek addiction treatment). [11]

SUD assessment [5]

The screening, brief intervention, and referral to treatment (SBIRT) model may be used to identify and assess SUD in any care setting. [5]

Drug testing [12][13]

  • Definition: the testing of biological samples for the presence of drugs and drug metabolites

Urine drug test

Urine drug test immunoassays can generate false-positive and false-negative results because of cross-reactivity with other medications (e.g., rifampin with opioid assays, sertraline with benzodiazepines, metformin with amphetamines). [12]

Blood/serum drug test

Laboratory methods

  • Immunoassays
  • Mass spectrometry
    • Often obtained based on a presumptive positive result
    • Definitive results
    • Can provide quantitative drug levels

Always confirm qualitative point-of-care drug test results (i.e., with mass spectrometry) when the results might have legal, financial, or employment implications.

Management

Disposition [16][17]

The most appropriate treatment setting may change over time and is influenced by: [18]

Withdrawal management settings [16][17]

Overview
Setting Indications Description
Hospital
  • Inpatient treatment program
  • Daily physician evaluations
  • Addiction services
Residential
  • Severe withdrawal
  • Need for 24-hour support
  • Outpatient withdrawal treatment is neither safe nor feasible.
  • Inpatient treatment program
  • Access to a physician
  • Addiction services
Intensive outpatient
  • Patients with:
    • Need for daily support
    • Reliable means to access care (e.g., transportation)
    • A supportive living environment
  • Outpatient programs in specialized centers
  • High patient oversight
  • Direct administration of medications (e.g., methadone)
Outpatient
  • Stable patients with:
    • Less than daily support needs
    • A secure living environment
    • High general functioning
  • Home or clinic setting
  • Lower patient oversight than intensive outpatient WM
  • Physicians prescribe medications for outpatient use.

Forced treatment is not recommended as it is often followed by relapse and a loss of trust in treatment services and providers.

See the article on alcohol-related disorders.

  • Substance: cannabis
  • Street names: weed, grass, pot, ganja, skunk, spliff
  • Forms of preparation (most commonly smoked; vaporized; ingested orally via pill, capsules, oil, food)
  • Mechanism of action: tetrahydrocannabinol (THC; main active component) interacts with cannabinoid receptors CB1 and CB2 inhibition of adenylate cyclase
  • Clinical features of intoxication:
    • DSM-V requires the following features to be present: [1]
      • Any of the following behavioral/mental disturbances must occur during or shortly after cannabis consumption
        • Euphoria
        • Perceptual disturbances (e.g., distorted sense of time)
        • Impaired reaction time, concentration, and motor coordination
        • Social detachment
        • Impaired judgment
        • Joviality, anxiety, panic
      • At least two of the following symptoms must be present within two hours after cannabis consumption:
    • Additionally, the following features may be present [1][23]
  • Clinical features of cannabis withdrawal: DSM-V requires ≥ 3 of the following features to occur within one week following cessation of prolonged cannabis use [1]
    • Irritability, aggression
    • Anxiety
    • Depression
    • ↓ Appetite and/or weight loss
    • Restlessness
    • Sleep disturbances
    • Anorexia
    • At least one of the following physical symptoms must also be present: headaches, tremors, abdominal pain, fever, chills, sweating.
  • Treatment:
    • Intoxication: symptomatic treatment [24]
    • Withdrawal: psychosocial support and interventions [25]
  • Complications [26]
    • Cannabis; -induced psychosis with paranoia, delusional thoughts, and/or hallucinations
    • Cannabis-induced anxiety disorder
    • Cannabis-induced sleep disorder
    • Higher lifetime probability of other substance use disorders
    • Cannabinoid hyperemesis syndrome [27]
      • Side effect of long-term cannabis use
      • Pathophysiology: remains incompletely understood
      • Clinical features
        • Episodic abdominal pain, nausea, and vomiting.
        • Relief with exposure to hot water (e.g., a bath) [28]
      • Treatment: complete cessation of cannabis use
    • Cannabis use disorder: DSM-V requires ≥ 2 of the following features to occur within a 1-year period of cannabis use, accompanied by agitation and severe impairment of functioning
      • Using cannabis in larger amounts or over a longer period than intended
      • Persistent desire to cut down the amount of cannabis used or repeated unsuccessful efforts to stop using it
      • A large amount of time is spent using cannabis, trying to acquire it, or recovering from its effects
      • Strong craving to consume cannabis
      • Cannabis use has a negative impact on social and professional function (e.g., at work, school, or home)
      • Continued cannabis use despite social or interpersonal problems that are directly caused or exacerbated by its use
      • Loss of interest in activities that were important to user prior to regular cannabis use
      • Recurrent use of cannabis in situations in which its use is associated with the risk of physical harm (e.g., driving a car)
      • Continued cannabis use despite persistent or recurrent psychological or physical problems that can most likely be attributed directly to the use of cannabis
      • Tolerance, which can manifest as:
        • The need to markedly increase the amount of cannabis to achieve the desired effect/intoxication
          and/or
        • A reduced effect over time when the same amount of cannabis is used
      • Withdrawal, which can manifest in the form of:
    • Long-term effects include pulmonary problems (e.g., wheezing, shortness of breath), immunosuppression, and sex hormone imbalance.

DroNABINOl is an example of medical canNABINOids.

  • Because hallucinogens are not typically associated with symptoms of withdrawal, the information about the clinical features provided below pertains specifically to the issues associated with intoxication with the corresponding substances.

General considerations

Tryptamine derivatives [6]

Phenethylamine derivatives

Overdose with opioid analgesics is the most common cause of death in adults < 50 years of age.

References:[40][43]

β-blockers can cause unopposed α-agonism, which worsens vasospasm!

Suspect cocaine use in individuals with weight loss, behavioral changes, and erythema of the turbinates and nasal septum.

References:[48]

References:[36][49][50]

  • Substance: nicotine from the tobacco plant (consumed in cigarettes, cigars, pipes, e-cigarettes)
  • Mechanism of action: stimulates nicotinic receptors in autonomic gangliasympathetic and parasympathetic stimulation [53]
  • Epidemiology [54]
    • Approx. 13% of adults in the US smoke cigarettes
    • Most prevalent cause of preventable morbidity and mortality in the US
  • Clinical features
  • Assessment: Smoking history is measured in pack years, which is used to quantify a person's lifetime exposure to tobacco.
    • The number of cigarette packs (20 cigarettes) that a person smokes per day multiplied by the number of years of cigarette consumption, e.g., (1 pack/day) x (10 years smoking history) = 10 pack years.
  • Treatment [53][55]
    • Counseling and support
    • Varenicline (alpha-4-beta-2 nACHR partial agonist): reduces positive symptoms and prevents withdrawal
    • Bupropion: reduces craving and withdrawal symptoms
    • Nicotine replacement therapy; (inhaler, lozenges; , transdermal patch; , nasal spray, gum)
  • Complications [53][55]

GHB is sometimes used as an acquaintance rape drug because it is hard to detect and has amnestic effects and a rapid onset of action.

Definition: toxicity and potential overdose from large amounts of substance entering the bloodstream after swallowed/inserted drug packets open inside the body (depends on the specific substance)

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