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Substance Use Disorders
S. Lindsey Clarke, MD, FAAFP
image BASICS
DESCRIPTION
A substance use disorder manifests as any pattern of substance use causing significant physical, mental, or social dysfunction.
  • Substances of abuse include the following:
    • Alcohol
    • Tobacco
    • Cannabinoids (marijuana)
    • Synthetic cannabinoids (Spice, K2, Mojo, Cloud 9, Relax, Crown); note: Increasingly, these are sold as liquid in eyedropper bottles for use with vaporizing devices (vape/hookah pens).
    • Prescription medications
      • CNS depressants (barbiturates, benzodiazepines, hypnotics)
      • Opioids and morphine derivatives (codeine, fentanyl, hydrocodone, hydromorphone, oxymorphone [Opana], meperidine, methadone, morphine, oxycodone)
      • Stimulants (amphetamines, methylphenidate)
      • Dextromethorphan
    • Stimulants (cocaine, amphetamines, methamphetamines, Khat)
    • Club drugs (MDMA [ecstasy, Molly], PMMA [Superman], flunitrazepam, &ggr;-hydroxybutyrate [GHB])
    • Opioids (heroin, opium, desomorphine [Krokodil])
    • Dissociative drugs (ketamine, phencyclidine [PCP])
    • Hallucinogens (lysergic acid diethylamide [LSD], salvia)
    • Synthetic cathinones (bath salts, Flakka/&agr;-PVP)
    • Inhalants (glue, paint thinners, nitrous oxide)
    • Anabolic steroids
  • See also www.drugabuse.gov/drugs-abuse.
  • System(s) affected: cardiovascular, endocrine/metabolic, CNS
  • Synonym(s): drug abuse; drug dependence; substance abuse
Geriatric Considerations
  • Alcohol is the most commonly abused substance, and abuse often goes unrecognized.
  • Higher potential for drug interactions
Pregnancy Considerations
Substance abuse may cause fetal abnormalities, morbidity, and fetal or maternal death.
EPIDEMIOLOGY
Incidence
  • Predominant age: 16 to 25 years
  • Predominant sex: male > female
Prevalence
  • 24.6 million (9.4%) Americans reported current illicit drug use in 2013.
  • 8.8% for age 12 to 17 years; 21.5% for age 18 to 25 years
  • Nearly one in five young adult men use marijuana.
ETIOLOGY AND PATHOPHYSIOLOGY
Multifactorial, including genetic, environmental
Genetics
Substances of abuse affect dopamine, acetylcholine, &ggr;-aminobutyric acid, norepinephrine, opioid, and serotonin receptors. Variant alleles may account for susceptibility to disorders.
RISK FACTORS
  • Male gender, young adult
  • Depression, anxiety
  • Other substance use disorders
  • Family history
  • Peer or family use or approval
  • Low socioeconomic status
  • Unemployment
  • Accessibility of substances of abuse
  • Family dysfunction or trauma
  • Antisocial personality disorder
  • Academic problems, school dropout
  • Criminal involvement
GENERAL PREVENTION
  • Early identification and aggressive early intervention improve outcomes.
  • Universal school-based interventions are modestly effective for preventing drug use among adolescents.
COMMONLY ASSOCIATED CONDITIONS
  • Depression
  • Personality disorders
  • Bipolar affective disorder
image DIAGNOSIS
Substance use disorder (DSM-5 criteria): ≥2 of the following in past year, with severity based on number of criteria present:
  • Missed work or school
  • Use in hazardous situations
  • Continued use despite social or personal problems
  • Craving
  • Tolerance (decreased response to effects of drug due to constant exposure)
  • Withdrawal upon discontinuation
  • Using more than intended
  • Failed attempts to quit
  • Increased time spent obtaining, using, or recovering from the substance
  • Interference with important activities
  • Continued use despite health problems
PHYSICAL EXAM
  • Abnormally dilated or constricted pupils
  • Needle marks on skin
  • Nasal septum perforation (with cocaine use)
  • Cardiac dysrhythmias, pathologic murmurs
  • Malnutrition with severe dependence
DIFFERENTIAL DIAGNOSIS
  • Depression, anxiety, or other mental states
  • Metabolic delirium (hypoxia, hypoglycemia, infection, thiamine deficiency, hypothyroidism, thyrotoxicosis)
  • ADHD
  • Medication toxicity
DIAGNOSTIC TESTS & INTERPRETATION
  • CRAFFT questionnaire is superior to cut down, annoyed by criticism, guilty about drinking, eye-opener drinks (CAGE) for identifying alcohol use disorders in adolescents and young adults; sensitivity is 94% with ≥2 “yes” answers.
    • C: Have you ever ridden in a car driven by someone (including yourself) who was “high” or who had been using alcohol or drugs?
    • R: Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
    • A: Do you ever use alcohol or drugs while you are alone?
    • F: Do you ever forget things you did while using alcohol or drugs?
    • F: Do your family or friends ever tell you that you should cut down on your drinking or drug use?
    • T: Have you gotten into trouble while you were using alcohol or drugs?
  • Blood alcohol concentration
  • Urine drug screen (UDS) (order qualitative UDS, and if specific drug is in question, a quantitative analysis for specific drug; order confirmatory serum tests if you suspect false positive)
  • Approximate detection limits
    • Alcohol: 6 to 10 hours
    • Amphetamines and variants: 2 to 3 days
    • Barbiturates: 2 to 10 days
    • Benzodiazepines: 1 to 6 weeks
    • Cocaine: 2 to 3 days
    • Heroin: 1 to 1.5 days
    • LSD, psilocybin: 8 hours
    • Marijuana: 1 day to 4 weeks
    • Methadone: 1 day to 1 week
    • Opioids: 1 to 3 days
    • PCP: 7 to 14 days
    • Anabolic steroids: oral, 3 weeks; injectable, 3 months; nandrolone, 9 months
  • Liver transaminases
  • HIV, hepatitis B and C screens
  • Echocardiogram for endocarditis
  • Head CT scan for seizure, delirium, trauma
image TREATMENT
Determine substances abused early (may influence disposition).
P.999

GENERAL MEASURES
  • Nonjudgmental, medically oriented attitude
  • Motivational interviewing and brief interventions can overcome denial and promote change.
  • Behavioral and cognitive therapy
  • Community reinforcement
  • Interventional counseling
  • Self-help groups to aid recovery (Alcoholics Anonymous, other 12-step programs)
  • Support groups for family (Al-Anon and Alateen)
MEDICATION
  • Alcohol withdrawal: See “Alcohol Abuse and Dependence” and “Alcohol Withdrawal.”
  • Benzodiazepine or barbiturate withdrawal
    • Gradual taper preferable to abrupt discontinuation
    • Substitution of long-acting benzodiazepine or phenobarbital
  • Nicotine withdrawal: See “Tobacco Use and Smoking Cessation.”
  • Opioid withdrawal
    • Methadone: 20 mg/day PO; use restricted to inpatient settings and specially licensed clinics (2)[A]
    • Clonidine: 0.1 to 0.2 mg PO TID for autonomic hyperactivity (3)[A]
    • Buprenorphine: 8 to 16 mg/day sublingually; may precipitate a more severe withdrawal if initiated too soon; use restricted to licensed clinics and certified physicians (4)[A]
  • Stimulant withdrawal
    • No agent with clear benefit for cocaine
    • Anti-cocaine vaccine in development
    • Naltrexone: 50 mg PO twice weekly reduces amphetamine use in dependent patients (5)[B].
    • Methylphenidate ER: titrated up to 54 mg/day PO might enhance abstinence in amphetaminedependent patients
  • Adjuncts to therapy
    • Use all medications in conjunction with psychosocial behavioral interventions.
    • Antiemetics, nonaddictive analgesics for opioid withdrawal
    • Nonhabituating antidepressants, mood stabilizers, anxiolytics, and hypnotics for comorbid mood and anxiety disorders and insomnia that persist after detoxification
  • Contraindications
    • Buprenorphine in lactation
    • Naltrexone in pregnancy, liver disease
  • Precautions: Clonidine can cause hypotension.
  • Significant possible interactions
    • Buprenorphine and ketoconazole, erythromycin, or HIV protease inhibitors
    • Naltrexone and opioid medications (may precipitate or exacerbate withdrawal)
ISSUES FOR REFERRAL
  • Consider addiction specialist, especially for opioid and polysubstance abuse.
  • Maintenance therapy for opioid dependence (e.g., methadone) only in licensed clinics
  • Psychiatrist for comorbid psychiatric disorders
  • Social services
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Indications for inpatient detoxification
    • History of withdrawal symptoms (e.g., seizures)
    • Disorientation
    • Hallucinations or psychotic features
    • Threat of harm to self or others
    • Obstacles to close monitoring (follow-up)
    • Comorbid medical illness
    • Pregnancy
  • For narcotic addiction and withdrawal
  • Look for signs of severe infection (e.g., bacterial endocarditis).
IV Fluids
Maintenance until patient is taking fluids well by mouth
Nursing
  • Take frequent vital signs during withdrawal.
  • Monitor for signs of drug use in the hospital.
Discharge Criteria
  • Detoxification complete
  • Rehabilitation plan in place
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Initially frequent visits to monitor for medical stability and adherence, then progressive follow-up intervals
Patient Monitoring
Verify patient's compliance with the substance abuse treatment program.
DIET
Patients often are malnourished.
PATIENT EDUCATION
  • Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/ or 800-662-HELP for information, treatment facility locator
  • National Institute on Drug Abuse: http://www.drugabuse.gov/patients-families and http://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/patient-materials
  • Alcoholics Anonymous: http://www.aa.org/
  • Narcotics Anonymous: http://www.na.org.za/
PROGNOSIS
  • Patients in treatment for longer periods (≥1 year) have higher success rates.
  • Behavioral therapy and pharmacotherapy are most successful when used in combination.
REFERENCES
1. Smith PC, Schmidt SM, Allensworth-Davies D, et al. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13): 1155-1160.
2. Amato L, Davoli M, Minozzi S, et al. Methadone at tapered doses for the management of opioid withdrawal. Cochrane Database Syst Rev. 2013;(2):CD003409.
3. Gowing L, Farrell MF, Ali R, et al. Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2014;(3):CD002024.
4. Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207.
5. Jayaram-Lindström N, Hammarberg A, Beck O, et al. Naltrexone for the treatment of amphetamine dependence: a randomized, placebo-controlled trial. Am J Psychiatry. 2008;165(11):1442-1448.
Additional Reading
&NA;
  • Patterson DA, Morris GW Jr, Houghton A. Uncommon adverse effects of commonly abused illicit drugs. Am Fam Physician. 2013;88(1):10-16.
  • Shapiro B, Coffa D, McCance-Katz EF. A primary care approach to substance misuse. Am Fam Physician. 2013;88(2):113-121.
  • Standridge JB, Adams SM, Zotos AP. Urine drug screening: a valuable office procedure. Am Fam Physician. 2010;81(5):635-640.
  • Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. http://store.samhsa.gov/home.
See Also
&NA;
Alcohol Abuse and Dependence; Alcohol Withdrawal; Tobacco Use and Smoking Cessation
Codes
&NA;
ICD10
  • F19.10 Other psychoactive substance abuse, uncomplicated
  • F10.10 Alcohol abuse, uncomplicated
  • F12.10 Cannabis abuse, uncomplicated
Clinical Pearls
&NA;
  • Substance use disorders are prevalent, serious, and often unrecognized in clinical practice. Comorbid psychiatric disorders are common.
  • Substance abuse is distinguished by family, social, occupational, legal, or physical dysfunction that is caused by persistent use of the substance.
  • Dependence is characterized by tolerance, withdrawal, compulsive use, and repeated overindulgence.
  • Motivational interviewing, brief interventions, and a nonjudgmental attitude can help to promote a willingness to change behavior. Research shows the benefit of referring patients with alcohol dependence to an addiction specialist or treatment program.