Substance-Related and Addictive Disorders

Substance use disorders are a significant cause of morbidity and mortality, especially among adolescents and young adults. A substance-related and addictive disorder is the continued use of a substance despite harmful consequences; these include significant impairment to one’s health or relationships or failure to fulfill major responsibilities at work, school, or home because of substance use. There are several individual substance use disorders, and they are linked by their chronicity and the significant impairment they cause. Most substance use disorders have associated intoxication and withdrawal symptoms. Treatment options include pharmacotherapy and behavioral interventions; however, individuals with substance use disorders have frequent relapse/remission as well as low compliance with treatment.

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Overview

Introduction

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) Work Group revisions combined abuse and dependence criteria from previous classifications into a single substance use disorder.

  • Lack of agreement on the terms “addiction “and “dependence” among the DSM-5 Substance-Related Disorders Work Group
  • Added the title “Substance-Related and Addictive Disorders” to include the diagnosis of “gambling addiction” (moved from “Impulse-Control Disorders”); now in the same chapter as substance use disorders 
  • New section on “Conditions for further study”:
    • Internet gaming disorder 
    • Caffeine use disorder 
  • Cannabis withdrawal disorder was added as a substance-specific diagnosis. 
  • Since DSM-5 combines dependence and abuse, nicotine use disorder was examined with regard to the substance use disorders criteria for research and clinical assessment. “Tobacco use disorder” was aligned with the criteria for other substance use disorders.
  • Disorders involving sexual behaviors or eating are not listed under addictive disorders; they are included elsewhere in the DSM-5.

Definition

A substance-related and addictive disorder is the continued use of a substance despite harmful consequences, including significant impairment to one’s health or relationships or failure to fulfill major responsibilities at work, school, or home due to substance use.

Epidemiology

  • Prevalence: approximately 7.2% of individuals > age 12 in the United States: 
    • 5.3% with alcohol use disorder
    • 2.8% with illicit drug use disorder
    • Total > 7.2% because the 2 disorders may coexist.
  • Clinical assessment of substance use:
    • Unhealthy use of 1 substance ↑ likelihood of unhealthy use of other substances.
    • Start with “socially accepted” substances:
      • Caffeine
      • Tobacco/nicotine
      • Alcohol
    • Prescription medication misuse:
      • Opioids
      • Sedative/hypnotics
      • Stimulants
    • Marijuana
    • Illicit drugs:
      • Stimulants (e.g., methamphetamine, cocaine)
      • Opioids (e.g., heroin)
      • Hallucinogens
      • Inhalants

Etiology

  • Combination of multiple factors 
  • Biologic factors: 
    • Feedback cycle of drug use or dangerous behavior
    • Dependence/escalation
    • Withdrawal/relapse
    • Enhanced effect of dopamine at the nucleus accumbens 
    • Drugs of abuse replace reinforcement 
  • Genetic factors: 
    • Alcohol use disorder: correlated with biologic parents
    • No specific genes have been identified with substance use disorders. 
  • Environmental factors: 
    • Low socioeconomic status
    • Pressure from substance-using peers 
  • Personality disorders (especially cluster B):
    • Borderline 
    • Histrionic 
    • Narcissistic
    • Antisocial
Cycle of substance-related and addictive disorders

Cycle of substance-related and addictive disorders

Image by Lecturio.

Clinical Presentation and Management

Substance use disorder assessments should establish the type of substance(s) used as well as the frequency, amount, and whether other mental health disorders (mood disorders, schizophrenia, personality disorders) or past history of substance use disorder are present.

Effect of substances on pupils

Substances causing pupil dilation:

  • Opioid withdrawal
  • Amphetamine
  • Cocaine
  • Lysergic acid diethylamide (LSD)
  • Anticholinergics (atropine, tropicamide, scopolamine)
  • Medications with anticholinergic activity (tricyclic antidepressants, antihistamines)
  • Sympathomimetics

Substances causing pupil constriction:

  • Opioid intoxication
  • Heroin
  • Sympatholytics (alpha-2 adrenergic agonists, decongestants)
  • Parasympathomimetics (pilocarpine), organophosphates

Summary of intoxication findings and their management: stimulants

Table: Summary of intoxication findings and their management: stimulants
SubstanceIntoxication findingsManagement
Nicotine/tobacco
  • Restlessness, insomnia, anxiety
  • Increase GI motility
Supportive treatment
Cocaine
  • Weight loss, chills, diaphoresis
  • Euphoria, psychomotor agitation, or depression
  • Dilated pupils
  • Elevated blood pressure, tachycardia
  • Hyperthermia
  • Psychosis, paranoia, hallucinations
  • May present with MI
  • Intracranial hemorrhage or stroke (due to vasoconstrictive effect)
  • Reassurance
  • Antipsychotics and benzodiazepines for severe cases of aggression
  • Symptomatic support (control blood pressure, arrhythmias)
  • Treating hyperthermia with ice bath, cooling blanket
Amphetamines
  • Euphoria
  • Skin excoriation
  • Pupillary dilation
  • Restlessness, agitation, tachycardia, arrhythmia, hyperthermia
  • Hyperreflexia and seizures
  • Psychosis (delusions, paranoia)
  • Dry mouth (leading to tooth decay)
  • Stabilize (rehydrate, correct electrolytes).
  • Treat hyperthermia.
  • Treat sympathetic overactivity.
  • Benzodiazepines: 1st-line option to decrease agitation
Synthetic canthinones (“bath salts”): a stimulant found naturally in the khat plant
  • Severe agitation, combativeness
  • Psychosis, delirium
  • Myoclonus, seizures
  • Sympathetic overactivity (significantly increased blood pressure, tachycardia)
  • Long-duration symptoms (days to weeks)

Summary of intoxication findings and their management: depressants

Table: Summary of intoxication findings and their management: depressants
SubstanceIntoxication findingsManagement
Alcohol
  • Mood elevation
  • Sedation
  • Behavioral disinhibition, emotional lability
  • Slurred speech
  • Ataxia (positive field sobriety test)
  • Self-resolving, requires supportive treatment only
  • Ensure safety of individual: airway, breathing, circulation (ABCs)
  • Administer thiamine.
  • Correct glucose, electrolytes, acid–base disorders.
Opioids
  • Constricted pupils (not in all cases)
  • Euphoria
  • Slurred speech
  • Seizures
  • Constipation
  • Respiratory depression
  • Maintain ABCs.
  • Administer naloxone.
  • Ventilatory support if naloxone fails to improve respiration
Sedatives and hypnotics (benzodiazepines, barbiturates)
  • Drowsiness, confusion, slurred speech, impaired memory
  • Incoordination, ataxia, mood lability
  • Respiratory depression
  • Hypotension
  • Impaired judgment, nystagmus
  • Ensure safety of individual(ABCs)
  • Barbiturates → sodium bicarbonate for urine alkalinization
  • Benzodiazepines → flumazenil (use with caution, as may induce seizures)

Summary of intoxication findings and their management: hallucinogens

Table: Summary of intoxication findings and their management: hallucinogens
SubstanceIntoxication findingsManagement
Cannabis
  • Euphoria or feeling relaxed
  • Conjunctival injection
  • Psychomotor slowing
  • Increased appetite
  • Dry mouth
Supportive treatment
Hallucinogens (e.g., phencyclidine (PCP))
  • Violent behavior, impulsivity
  • Severe hyperthermia
  • Nystagmus
  • Seizures
  • Tachycardia, hypertension
  • Hallucinations
  • Put the individual in a quiet room.
  • Benzodiazepines (1st-line)
  • Antipsychotics if needed
Hallucinogens (e.g., LSD)
  • Depersonalization
  • Hemodynamic changes (tachycardia, hypertension)
  • Hallucinations
  • Quiet room
  • Benzodiazepines (1st-line)
  • Clonidine if needed
Ecstasy (methylenedioxymethamphetamine (MDMA))
  • Hallucinations
  • Psychosis
  • Sociability
  • Hyperthermia
  • Dehydration
  • Hyponatremia
  • Hypertension, tachycardia
  • Serotonin syndrome
  • Rhabdomyolysis → renal failure/acute tubular necrosis (ATN)
  • Stabilize individual (rehydrate, correct electrolytes).
  • Treat hyperthermia.
  • Treat sympathetic overactivity.
  • Benzodiazepines (1st-line) to decrease agitation
  • Consider dantrolene (postsynaptic muscle relaxant).
Inhalants
  • Euphoria
  • Impaired judgment and memory
  • Lethargy, stupor, or coma
  • Nasal crusting, rash (dermatitis)
  • Intoxicated appearance, tremor, muscle weakness, hyporeflexia, ataxia
  • Elevated liver enzymes
  • Supportive care
  • Chelation if possible
  • Preventing and treating complications
  • Hyperbaric chamber
  • Psychological counseling
  • Antipsychotics

Summary of withdrawal findings and their management: stimulants

Table: Summary of withdrawal findings and their management: stimulants
SubstanceWithdrawal findingsManagement
Nicotine/tobacco
  • Intense craving
  • Dysphoria
  • Anxiety
  • Poor concentration
  • Increased appetite, weight gain
  • Irritability, restlessness, and insomnia
  • Nicotine replacement therapy (patch, gum, inhaler)
  • Medications (varenicline, bupropion)
  • Behavioral therapy
Cocaine
  • Malaise, fatigue, hypersomnolence
  • Depression, anhedonia, hunger, constricted pupils
  • Vivid dreams, psychomotor agitation or retardation
  • Increased suicidal ideation
Supportive treatment only
Amphetamines, synthetic canthinones (“bath salts”)
  • Increased appetite
  • Severe depression
  • Fatigue
  • Sleep disturbance and vivid dreams
  • Difficulty concentrating
  • Mostly supportive treatment
  • Antidepressants if suicidal
  • Benzodiazepines or antipsychotics to decrease irritability and anxiety

Summary of withdrawal findings and their management: depressants

Table: Summary of withdrawal findings and their management: depressants
SubstanceWithdrawal findingsManagement
Alcohol
  • Anxiety, insomnia, tremors, agitation
  • Tachycardia, palpitations
  • Generalized tonic-clonic seizures
  • Hallucinations (mainly visual)
  • Delirium tremens (confusion, agitation, hallucinations, tremors)
  • Benzodiazepines (lorazepam is preferred with hepatic failure)
  • Vitamins (thiamine, folate)
  • Correct electrolytes
Opioids
  • Dysphoria (depression), insomnia
  • Lacrimation, rhinorrhea, yawning, fatigue
  • Sweating, piloerection, nausea vomiting, diarrhea
  • Fever, dilated pupils, abdominal cramps
  • Arthralgias, myalgias
  • Hypertension, tachycardia
  • Moderate symptoms: clonidine, NSAIDs
  • Severe symptoms: detoxification with buprenorphine or methadone (usually resolve within 2–3 days)
Sedatives and hypnotics (benzodiazepines, barbiturates)
  • Anxiety
  • Tremor
  • Insomnia, psychosis
  • Perceptual disturbances
  • Seizures
  • Tachycardia, palpitations
Taper using a long duration medication (diazepam, phenobarbital)

Summary of withdrawal findings and their management: hallucinogens

Table: Summary of withdrawal findings and their management: hallucinogens
SubstanceWithdrawal findingsManagement
Cannabis
  • Craving
  • Sleeping disturbances, vivid dreams
  • Restlessness
  • Hyperalgesia
  • Depression
  • Headaches, sweating, chills
  • Decreased appetite
Supportive treatment
Inhalants
  • Craving and irritability
  • Sleep disturbance
  • Increase sweating
  • Muscle aches
  • Anxiety
  • Depression
  • Hallucinations
  • Supportive care
  • Benzodiazepines and antipsychotics may be helpful.
Ecstasy
  • Depression, fatigue, change in appetite
  • Decreases concentration, anxiety
  • Supportive treatment
  • Antidepressants if suicidal

Diagnosis

The DSM-5 uses 11 criteria (including dependence criteria, abuse criteria, and craving) to classify substance abuse disorders. There are separate criteria for substance intoxication and withdrawal.

Criteria for substance use disorders (including gambling disorder)

Diagnosis is made by a problematic pattern of use leading to significant impairment or distress manifested by ≥ 2 of the following in a 12-month period:

Impaired control:

  • Overconsumption of the substance
  • Inability to cut down or control use
  • Excessive time spent obtaining, using, or recovering from effects of a substance/gambling
  • Craving 

Social impairment:

  • Failure to fulfill major role obligations due to substance use/gambling
  • Continued use despite social or interpersonal problems caused by the substance
  • Reduction/stopping social, occupational, or recreational activities due to substance use/gambling

Risky use:

  • Recurrent substance use in physically hazardous situations
  • Continued use despite physical or psychological problems caused by the substance/gambling

Pharmacologic criteria inherent to the substance:

  • Tolerance, defined as either:
    • A need for an ↑ amount of the substance to achieve the desired effect, or 
    • A diminished effect with continued use of the substance
  •  Withdrawal, manifested by either:
    • Withdrawal signs, or
    • Relief or avoidance of withdrawal symptoms by ingestion of the substance or similar substance

Other factors relevant to diagnosis:

  • Severity score = total of substance disorder criteria met:
    • Mild: 2–3 criteria
    • Moderate: 4–5 criteria
    • Severe: > 6 criteria
  • There is no longer a diagnosis of “polysubstance use disorder” or “multiple substance use disorder”; each substance must be listed. 
  • There are no agreed-upon definitions for unhealthy use of substances other than alcohol:
    • Men: 
      • > 5 drinks/day (1 drink = 12 g of ethanol (43 mL (1.5 oz) of 80 proof liquor, 142 mL (5 oz) of wine, or 341 mL (12 oz) of beer))
      • > 14 drinks per week on average
    • Women (any age) or men > age 65: 
      • > 4 drinks/day
      • > 7 drinks/week on average
    • For some other substances, any use may be considered unhealthy.

Criteria for substance intoxication and withdrawal

  • Intoxication: 
    • Recent usage history
    • Intoxication signs/physiologic correlation (varies by substance):
      • Stupor
      • Unsteady gait
      • Slurred speech 
    • Clinically significant functional impairment
    • Exclusion of other medical conditions or mental disorders
  • Withdrawal: development of a substance-specific syndrome due to the cessation (or reduction) of substance after heavy and prolonged use:
    • Physical symptoms:
      • Nausea
      • Diarrhea
      • Chills 
      • Myalgias
    • Psychological symptoms: compulsion or perceived need to use the substance
    • Clinically significant functional impairment
    • Exclusion of other medical conditions or mental disorders
  • Tolerance: need to increase the dose of the substance or intensity of the behavior to achieve the same desired effect 
  • Substance-induced psychiatric disorders: each substance may cause a range of psychiatric syndromes during intoxication or withdrawal phase.
    • Anxiety disorder 
    • Psychotic disorder 
    • Mood disorder (depression and bipolar disorder) 

Assessment

  • History: 
    • Starts with a nonjudgmental interview; individuals are often unwilling to disclose substance use habits to a healthcare provider.
    • Include social issues related to substance use (e.g., lack of housing)
    • Inquire: use the SBIRT (Screening, Brief Intervention, and Referral to Treatment) tool
      • Screen individuals for substance use and addictive disorders.
      • Assess the severity of substance use.
      • Identify the appropriate level of treatment. 
      • Brief intervention (discussion about risks of unhealthy habits)
      • Assess motivation toward behavioral change.
      • Refer to specialty care if needed.
      • Follow up regularly.
  • Physical exam:
    • Identify medical diagnoses.
    • Concomitant psychiatric conditions
  • Lab studies to evaluate possible comorbidities:
    • Chemistry panel: electrolytes, renal, hepatic function 
    • HIV and hepatitis serologies if IV substance use
  • Urine drug toxicology screen:
    • Useful in offering treatment during the intoxication or withdrawal phase 
    • Basic urine drug screens include:
      • Amphetamine
      • Benzodiazepines 
      • Cannabis
      • Cocaine
      • Opioids
      • PCP 
    • Many substances can cause false positive results.

Management and Complications

Substance use disorders often coexist with other medical and psychiatric conditions.

Management

  • Information gathered in the history, exam, and substance use assessment help identify:
    • Severity of the disorder; may warrant multiple treatment methods
    • Readiness for treatment
    • Level of treatment needed (outpatient versus inpatient)
  • Behavioral interventions: 
    • Motivational interviewing: an approach for behavioral modifications 
    • CBT: 
      • Helps identify triggers for use 
      • Creates healthier coping skills
    • Group therapy or other peer support groups: 
      • Alcoholics Anonymous (AA)
      • Narcotics Anonymous (NA)
      • Gamblers Anonymous (GA)
      • Other community-based support groups
  • Pharmacotherapy: medications to decrease cravings for abuse:
    • Alcohol use disorder:
      • Naltrexone
      • Disulfiram
      • Acamprosate
    • Opioid use disorder:
      • Methadone
      • Buprenorphine
      • Naltrexone
      • Lofexidine
    • Hallucinogen use disorder:
      • Benzodiazepines 
      • Antipsychotics 
    • Tobacco use disorder (nicotine):
      • Bupropion
      • Nicotine replacement therapy
      • Varenicline

Relapse and complications

  • Substance use and addiction:
    • Complex and chronic disease
    • Associated with compromised functioning in almost every organ system 
  • Relapse:
    • Rate of relapse: 40%–60% despite treatment
    • Does not indicate treatment failure; considered a normal part of recovery
    • Need to modify or change the treatment plan
    • Nonadherence: similar levels to other chronic illnesses (e.g., hypertension, diabetes)
  • Dropout rate of in-person psychosocial substance use disorder treatment studies: variable, but approximately 30%
  • Neonatal complications of mothers with substance use disorder:
    • Fetal growth retardation
    • Prematurity
    • Neonatal abstinence syndrome
    • Compounding factor: less prenatal care
  • Breastfeeding: not contraindicated unless active use or untreated substance use disorder

References

  1. National Institute on Drug Abuse. (n.d.). Principles of effective treatment. https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment
  2. Sadock, B. J., Sadock, V. A., Ruiz, P. (2014). Substance use and addictive disorders. In Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. Philadelphia: Lippincott Williams and Wilkins, pp. 616–693.
  3. Thompson, A. (2021). Clinical management of drug use disorders. DeckerMed Medicine. Retrieved February 16, 2021, https://doi.org/10.2310/im.13042
  4. Hoffman, R. (2021). Testing for drugs of abuse (DOAs). UpToDate. Retrieved March 7, 2021, from https://www.uptodate.com/contents/testing-for-drugs-of-abuse-doa 
  5. Chang, G. (2020). Substance use during pregnancy: screening and prenatal care. UpToDate. Retrieved March 7, 2021, from https://www.uptodate.com/contents/substance-use-during-pregnancy-screening-and-prenatal-care
  6. Hasin, D.S., et al. (2013). DSM-5 criteria for substance use disorders: recommendations and rationale. American Journal of Psychiatry 170:834–851. https://doi.org/10.1176/appi.ajp.2013.12060782
  7. Dugosh, K.L., Cacciola, J.S. (2019). Clinical assessment of substance use disorders. UpToDate. Retrieved August 26, 2021, from https://www.uptodate.com/contents/clinical-assessment-of-substance-use-disorders
  8. Lappan, S.N., Brown, A.W., Hendricks, P.S. (2019). Dropout rates of in-person psychosocial substance use disorder treatments: a systematic review and meta-analysis. Addiction 115:201–217. https://doi.org/10.1111/add.14793

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