Substance Use Disorders: Diagnosis

Substance Use Disorders

• Encompasses alcohol-related disorders, caffeine-related disorders, cannabis-related disorders, hallucinogen-related disorders, inhalant-related disorders, opioid-related disorders, sedative-, hypnotic-, or anxiolytic-related disorders, stimulant-related disorders and tobacco-related disorders.
• Includes diagnoses relating to the use, intoxication from, and withdrawal from substances.
• Also includes other substance-related disorders and gambling disorder.

Diagnosis of Substance Use Disorders

• Involves identifying inappropriate substance use.
• Includes considering the context of abuse or dependence and comparing to DSM-5 criteria for use disorders because abuse is difficult to distinguish from dependence.
• Intoxication and withdrawal are considered separate disorders.
• Intoxication is a reversible syndrome linked to recent substance use.
• Withdrawal refers to a cluster of symptoms following cessation or dose reduction of a substance.

Diagnostic Criteria for Substance Use Disorders

• Requires 2 or more of 11 criteria within a 12-month period.
• Clinically significant impairment must be established.
• The 11 symptoms can be grouped into impaired control, social impairment, risky use, and pharmacological criteria (tolerance or withdrawal).
• Severity is classified as mild (2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms).
• Early remission is defined as having no symptom criteria for at least 3 months.
• Sustained remission is defined as having no symptom criteria for the past 12 months.

Assessment of Substance Use Disorders

• Perform a thorough history, including collateral information from relatives, friends, and other physicians.
• Perform a physical exam, looking for signs of intoxication or withdrawal.
• Lab testing is indicated for routine workup, intoxication/overdose, and mood or behavior alterations.
• Blood or urine sampling may be necessary.
• Mental status examination is necessary.

Etiology of Substance Use Disorders

• Combination of genetics and individual biology contributing 40-60% of addiction risk.
• Protective alcohol metabolizing enzymes like ADH2*2.
• Dopamine pathways function as part of the reward system in the ventral tegmental region and nucleus accumbens.
• Person's environment includes societal and family values, peer influence, and parental role models.
• The substance itself provides rapid relief, energy, increased alertness, and temporary escape from reality.
• Drugs with rapid action, such as those that are sniffed, smoked, or injected intravenously are preferred.
• Co-occurring medical and psychiatric disorders like anxiety, chronic pain, and depression.
• Personality traits such as hostility, low frustration tolerance, inflexibility, and difficulty delaying gratification can contribute to substance use.

Alcohol-Related Disorders

• Alcohol is the most commonly abused substance.
• More prevalent among hospital patients.
• The male to female ratio is 2-3:1.
• Onset typically occurs between ages 16-30, but earlier in men.
• Groups prone to alcohol use disorder include bartenders, construction workers, writers, tobacco users, and those with mood disorders, anxiety, antisocial personality, and gambling disorders.

Diagnostic Criteria for Alcohol-Related Disorders

• Includes drinking alcohol in larger amounts or for longer periods than intended.
• A persistent desire to cut down or control alcohol use, or unsuccessful attempts to do so.
• Spending a great deal of time obtaining, using, or recovering from alcohol's effects.
• Craving or a strong urge to use alcohol.
• Recurrent alcohol use resulting in a failure to fulfill major obligations at work school, or home.
• Alcohol use continues despite persistent or recurrent social or interpersonal problems.
• Important activities are given up or reduced because of alcohol use.
• Recurrent alcohol use in physically hazardous situations.
• Continued alcohol use despite knowledge of having a related physical or psychological problem.
• Tolerance, meaning either a need for more alcohol to achieve the desired effect or a diminished effect with continued use of the same amount.
• Withdrawal symptoms, or taking alcohol/related substances like benzodiazepines to relieve or avoid withdrawal.

Assessment of Alcohol-Related Disorders

• Includes the CAGE questionnaire, a four-question screening test.
• Blood alcohol concentration, where 150-250 mg/dl correlates to slurred speech and ataxia, and >350 mg/dl can lead to coma and death.
• Abnormal lab findings include increased HDL, LDH, uric acid, MCV, AST, ALT, and GGT and decreased LDL, BUN, and red blood cell volume.

Clinical Findings of Alcohol-Related Disorders

• Family members/coworkers can identify early symptoms.
• Symptoms include poor work productivity, unexplained absences, lateness, irritability, and moodiness.
• Physical changes include acne rosacea, palmar erythema, painless liver enlargement, infections, bruises, amnesia, minor accidents, and DWI arrests/accidents.
• Later progression can include jaundice, ascites, testicular atrophy, gynecomastia, Dupuytren’s contractures, job loss, loss of friendships, and marital/family problems.

Medical Complications of Alcohol-Related Disorders

• Affects almost all organ systems.
• Gastrointestinal complications include benign fatty infiltration of the liver, gastritis, diarrhea, peptic ulcers, cirrhosis (in 10% of heavy drinkers), and pancreatitis.
• Hematologic complications include anemia and thrombocytopenia.
• Cardiovascular complications include cardiomyopathy.
• Peripheral neuropathy presents with stocking-and-glove distribution and is related to Vitamin B deficiency.
• Cerebellar damage can cause dysarthria and ataxia.
• Wernicke's encephalopathy presents with nystagmus, ataxia, mental confusion, and thiamine deficiency. Wernicke's encephalopathy is potentially reversible.
• Wernicke-Korsakoff syndrome results in enduring cognitive and memory impairment, reversible in 1/3 of patients.
• Anterograde amnesia occurs with confabulations.
• Necrotic lesions form in the mamillary bodies, thalamus, and brain stem regions.

Additional Complications

• Major neurocognitive disorder with etiology stemming from vitamin deficiency or the direct effects of alcohol.
• Neuroimaging shows enlarged cerebral ventricles and widened cortical sulci.
• Neuropsychological testing reveals mild to moderate cognitive deficits which are partially reversible with sobriety.
• Fetal alcohol syndrome (FAS) is related to maternal alcohol consumption during pregnancy, particularly binge drinking.
• FAS occurs in 1-2 infants per 100,000 live births.
• Findings of FAS include facial anomalies (small head circumference, epicanthic folds, indistinct philtrum and small midface), low IQ, and behavior problems.

Other Medical Complications cont.

• Trauma, including 50% of all motor vehicle deaths.
• Subdural hematomas from falls.
• Cancer of the mouth, tongue, larynx, esophagus, stomach, liver, and pancreas.
• Endocrine complications, including lower serum testosterone (impotence and infertility) and increased estrogen levels (gynecomastia and female pubic hair pattern in men).

Psychiatric Complications

• Intoxication and withdrawal.
• Amnestic syndromes.
• Alcohol-related neurocognitive disorders.
• Major depressive disorder.
• High suicide rates.

Course of Alcohol-Related Disorders

• Onset often occurs in early teen years.
• Women start drinking later in life than men.
• Most individuals have periods of sobriety.
• Some return to nonhazardous drinking.
• Some achieve sustained abstinence without treatment.
• Remission is often associated with important life changes.
• Individuals typically have a shortened lifespan.

Clinical Management of Alcohol Withdrawal

• Uncomplicated alcohol withdrawal ("shakes") begins 12-18 hours after drinking cessation.
• Symptoms peak at 24-48 hours and subside within 5-7 days.
• Minor symptoms include anxiety, tremors, nausea, vomiting, elevated blood pressure, and elevated heart rate.
• Alcoholic withdrawal seizures ("rum fits") begin 7-38 hours after cessation of drinking, peak at 24-48 hours, and present as a single burst of 1-6 generalized seizures.
• Alcoholic hallucinosis begins within 48 hours of drinking cessation with clear sensorium.
• Presents with vivid and unpleasant auditory, visual, or tactile hallucinations, and typically lasts about one week but can become chronic.
• Alcohol withdrawal delirium (delirium tremens) begins 2-3 days after drinking cessation or significant reduction of intake.
• Symptoms peak at 4-5 days and include confusion, agitation, perceptual disturbances, mild fever, and autonomic hyperarousal and can be fatal.

Management of Alcohol Withdrawal cont.

• General support includes food, hydration, medical monitoring, nutritional supplementation, and benzodiazepine use.
• Uncomplicated withdrawal can be managed as an outpatient.
• Longer-acting benzodiazepines such as chlordiazepoxide, clonazepam, or diazepam are preferred.
• Hospitalization is recommended in those with a history of severe withdrawal symptoms, comorbid medical disorders, depression, suicidal ideation, or poor social support.
• Nutritional supplementation includes an adequate diet, oral thiamine 100 mg daily, folic acid 1 mg daily, and thiamine given before loading glucose.

Benzodiazepine Dosing

• With symptom triggered management, medication is given based on signs and symptoms of withdrawal.
• Clinical Institute Withdrawal Assessment for Alcohol Scale Revised (CIWA-Ar) used for patient assessment.
• With fixed dosing, medication is given on a predetermined schedule.
• Fixed dosing is better for those with severe withdrawal symptoms.
• Additional doses are given for breakthrough signs or symptoms.
• CIWA can be used to monitor withdrawal state.
• Includes anti-nausea agents, non-steroidal anti-inflammatory drugs, loperamide, and antipsychotics for hallucinations.

Rehabilitation

• The goal is for the patient to remain sober and for coexisting disorders to be identified and treated.
• Treatment should include providing a proper diagnosis.
• There should be individual therapy for triggers and learning coping strategies.
• Motivational interviewing can be used.
• Group therapy can be used to see problems mirrored in others.
• Patients should be encouraged to attend Alcoholics Anonymous (12-step program).
• Includes family therapy.
• Includes programs taking place in residential or outpatient settings.
• Better prognosis is associated with stable marriage, employment, fewer co-occurring psychiatric disorders, and no family history of alcoholism.

FDA Approved Medications

• Disulfiram inhibits aldehyde dehydrogenase, causing accumulation of acetaldehyde, nausea, vomiting, palpitations, and hypotension to deter alcohol use.
• Individuals must be motivated to avoid alcohol.
• Naltrexone acts as a µ-opioid antagonist, which reduces the pleasurable effects of and craving for alcohol.
• Naltrexone can cause nausea, headache, and anxiety/sedation.
• Black-box warning to not administer to individuals with severe liver disease as periodic monitoring of liver enzymes must be performed.
• Available in a long-acting injectable formulation.
• Acamprosate is a glutamate receptor modulator that decreases cravings, though side effects include headache, diarrhea, flatulence and nausea.
• Taken in three divided doses, which may reduce compliance.