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Introduction

This article addresses terminology, prevalence, screening, approach to treatment of substance use disorders in general. It does not address psychopathology and specific treatments of individual substance use disorders; please refer to dedicated articles for that information.

Substance use disorders (SUDs) include two major categories: substance abuse (SA) and substance dependence (SD). In addition, there are intoxication and withdrawal states related to specific substances.

The term dependence has two meanings:

  • it may refer to physiological dependence on a substance (e.g. increased tolerance and symptoms of withdrawal),
  • and also to a maladaptive/harmful syndrome defined by DSM as follows: "The essential feature of dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues substance use despite significant substance-related problems."
    • since physiological dependence (tolerance, withdrawal) is expected/normal with many prescribed medications when taken appropriately (e.g. SSRIs, beta-blockers), DSM-5 will use term addiction to describe the maladaptive syndrome of dependence. (VERIFY ME!)

Generally, the term illicit substances does not include alcohol, and tobacco, but does include prescription medications used inappropriately. Alcohol, tobacco, and caffeine are "licit" substances in this sense.

While increased tolerance and s/sx of withdrawal are frequently used to screen for SD, they are neither necessary nor sufficient (need 3 of 7 criteria) to make the diagnosis.

DSM-IV to DSM-5 changes in diagnosis of substance use

DSM-5

DSM-5 got rid of the confusing and inadequate distinction between substance abuse and substance dependence. Criteria were combined into the diagnosis of Substance Use Disorder, cravings was added, legal problems was removed.

  • 2 out 11 criteria over 12-month period are required to make the diagnosis.
  • 11 criteria are grouped into 4 categories, to make them easier to remember (see figure)
  • Current or past history of withdrawal is one of the criteria for Substance Use Disorder (just like it was in the DSM-IV, under the Substance Dependence), but active withdrawal is also on of the Substnace-induced Disorders.

Epidemiology

Adult prevalence and comorbidity

It is estimated (2006) that 10% of the population >12yo meet criteria for a substance use disorder (SUD) (tobacco excluded)

  • Men have prevalence of ~12%, and women 6-7%;
  • The 2:1 ratio persists when alcohol and illicit drugs are considered separately.

20/20 comorbidity rule:

  • 20% of patients with SUD will have a separate mood disorder; 20% of patients with a mood disoder will have SUD. (K&S)
  • the relationship is closer to 15/15 for SUD and anxiety disorders.

Pediatric prevalence

Prevalence of substance use and substance-related disorder increases linearly from early to late adolescence. Approximately one in four older adolescents meets criteria for abuse for at least one substance, and one in five meets criteria for SD.

  • 40% of high school seniors reported active drug use.
  • 3% of male seniors reported using anabolic steroids.
  • 1.2% of adolescents report that they used 3,4-methylenedioxymethamphetamine (MDMA) or Ecstasy within the past year.
  • Approximately 2% of U.S. high school seniors reported using gamma hydroxy butyrate, GHB, a CNS depressant, within the past year. (1)
  • "Spice," a synthetic form of THC, is sold as incense in smoke shops and novelty stores. Varying the formula slightly allows manufacturers to continue producing and selling it despite some states' legislation banning the substance.

This table was adopted from a large survey of drug use in adolescents (12-17) in the last year, n=72561 (2):

Substance Population prevalence Prevalence in Native Americans Population fraction developing use disorder Use disorder Prevalence
Alcohol 35% 37% 16% 5.4%
Any drug use* 19% 31% 23.8% 4.6%
Marijuana 14% 23.5% 26% 3.4%
Opioid analgesics 7.5% 9.7% 15% 1.2%
Inhalants 4.5% 5.3% 10% <1%
Stimulants 2.2% 2.4% 17% 0.6%
Cocaine 1.8% 3.7% 23% 0.4%

* excludes alcohol and nicotine.

Few points are notable:

  • Native-American adolescents have startling rates of drug use (not necessarily alcohol); overall, Native-Americans have highest prevalence of substance-related use (47.5%).
  • Opioid analgesics have replaced inhalants as the second most used illicit drug.
  • A quarter of adolescents who use marijuana go on to develop marijuana use disorder; this fraction is higher than for adolescents using alcohol and similar to rates of cocaine and heroin users developing cocaine/heroin use disorder.

Screening

CAGE screen is widely taught and used, however, in adolescents CRAFFT screen is valid and reliable.

C - Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or 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/drugs while you are by yourself, 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?

If the CRAFFT score is positive (>=2 "yes" answers), then further assessment is warranted. If an adolescent screens positive for substance use, then the next step is to determine their stage of use and readiness for change, in preparation for doing a brief intervention (BI) using the principles of motivational interviewing (MI).

Treatment Approaches

Prevention

Prevention is integral to addressing the substance use problem.

  • school-based prevention programs for middle-school kids that seek to improve life skills are effective (problem solving, goal setting, resisting media and interpersonal influences, and managing anxiety and stress) (K&S)
  • drug-specific education: (e.g. DARE - Drug Abuse Resistance Education) was not particularly effective in controlled studies (K&S)
  • decreasing access and availability of substances is also effective (higher taxes on tobacco and alcohol, drinking age)

Treatment

  • For experimentation or regular but not problematic use, providers may offer brief advice about associated risks and introduce the "Contract for Life" that was designed by Students Against Destructive Decisions "to facilitate communication between young people and their parents about potentially destructive decisions related to alcohol, drugs, peer pressure, and behavior" (available at: SADD website).
  • If screening reveals problem use or abuse, then the goal is to provide intervention and counseling.
  • For substance dependence, referral for intensive treatment program is warranted. (4)
    • a treatment program involves multiple techniques, procedures, and modalities (e.g. CBT + AA self-help group + pharmacological management)
    • treatment is tailored to specific substance(s), pattern, and quantity of use; see dedicated articles for treatment of individual SUDs.

Opioid dependence

  • Continuing treatment with buprenorphine-naloxone (BUP/NAL) for 12 weeks improved outcome compared with short-term detoxification with BUP/NAL according to a recent RCT (5). BUP/NAL should be tapered before discontinuation.

High-Yield Facts

Black belt DSM-IV facts

  • DSM-IV does not recognize cannabis withdrawal as a distinct diagnosis, despite extensive data that such syndrome exists (3). DSM-5 will include this diagnosis.
  • DSM-IV does not recognize steroids as its own category of abused substances; it's coded as "other substance use disorder."
  • When 3 or more groups of drugs are involved, the condition is coded as polysubstance dependence in DSM-IV. While the term "polysubstance abuse" is used frequently, there is no such diagnostic category in DSM-IV.

Black belt Toxicology facts

  • Codeine is a naturally occurring opioid; eating two poppy seed bagels can cause a positive codeine and morphine result (codeine is metabolized to morphine).
  • Positive heroin or oxycodone result will not happen from a poppy seed baggels.
  • Opioid toxicology screen is highly dependent on which opioids are actually tested for, and thus may be false negative.
  • Cocaine toxicology is usually accurate.
  • Stimulants toxicology is frequently false positive for actual illicit drugs, due to stimulants' wide use in over-the-counter cold medicines.
  • Second-hand cannabis exposure will not produce a positive urine tox, only 1st hand intoxication will.

Further Reading

(1) Lewis's Child and Adolescent Psychiatry. 2008
(2) Wu et.al. Racial/Ethnic Variations in Substance-Related Disorders Among Adolescents in the United States. Arch Gen Psychiatry. 2011;68(11):1176-1185
(3) Budney AJ, Hughes JR, Moore BA, Vandrey R: Review of the validity and significance of cannabis withdrawal syndrome. Am J Psychiatry 161:1967–77, 2004.
(4) Burke, et. al. Adolescent Substance Use: Brief Interventions by Emergency Care Providers. Pediatric Emergency Care. 21(11):770-776
(5) Woody GE Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial. JAMA 2008
(K&S) Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Chapter 11

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