Substance Abuse

Substance Use Disorders

• Characterized by a problematic pattern of substance use leading to functional impairment or distress.
• Frequent use does not automatically indicate a disorder unless it causes problems.
• Diagnosis requires at least two of the following criteria within a 12-month period:
  • Using substance more than initially intended.
  • Persistent desire or unsuccessful efforts to cut down on use.
  • Significant time spent obtaining, using, or recovering from substance.
  • Craving to use substance.
  • Failure to fulfill obligations at work, school, or home.
  • Continued use despite social or interpersonal problems due to substance.
  • Limiting social, occupational, or recreational activities because of substance use.
  • Use in dangerous situations (e.g., driving a car).
  • Continued use despite subsequent physical or psychological problems (e.g., worsening liver problems).
  • Tolerance (needing higher amounts for desired effect or diminished effects with same dose).
  • Withdrawal (specific syndrome occurring when substance use stops or reduces).
• Severity of disorder depends on number of criteria met (mild, moderate, or severe).
• One-year prevalence of substance use disorder in the US is approximately 8%.
• More common in men than in women.
• Alcohol and nicotine are most commonly used substances.

Epidemiology

• One-year prevalence of any substance use disorder in the US is approximately 8%.
• More common in men than women.
• Alcohol and nicotine are the most commonly used substances.

Psychiatric Symptoms

• Mood symptoms are common in substance use disorders.
• Psychotic symptoms can occur with some substances.
• Personality disorders and psychiatric comorbidities (e.g., major depression, anxiety) are common.
• It's often difficult to determine if psychiatric symptoms are primary or secondary to substance use (self-medication).

Acute Intoxication and Withdrawal

• Diagnosis and treatment can be difficult due to simultaneous substance use.
• Clinical presentation may be atypical.
• Look for multiple substances.

Treatment of Substance Use Disorders

• Behavioral counseling is essential.
• Psychosocial treatments include motivational intervention (MI), CBT, contingency management, and individual/group therapy.
• Residential ("rehab") programs (usually 28-day) are common for severe cases, with some choosing partial hospitalization or intensive outpatient programs.

Direct Testing for Substances

• Table includes the substances and time they stay in the system. (e.g. Alcohol, Cocaine, Amphetamines, PCP, Sedative-hypnotics, Opioids, Marijuana)

Stages of Change

• Stages to understand and manage any substance use disorder.
• Includes precontemplation, contemplation, preparation, action, maintenance, and relapse.

Alcohol (EtOH)

• Activates GABA, dopamine, and serotonin receptors, inhibiting glutamate receptors.
• A potent CNS depressant
• Metabolized to acetaldehyde then acetic acid (by alcohol dehydrogenase and aldehyde dehydrogenase respectively).
• These enzymes are upregulated in heavy drinkers. Some populations may have less aldehyde dehydrogenase. This leads to flushing and nausea with alcohol consumption.
• Important consideration for tolerance and withdrawal.
• Common co-ingestant in overdose scenarios.

Alcohol Intoxication

• Symptoms depend on blood alcohol level (BAL).
• Higher BALs associated with more severe symptoms.
• Includes impaired fine motor control, judgment, coordination, memory, lethargy, coma, respiratory depression, death.
• Early monitoring key. Crucial to monitor airway, breathing, circulation, glucose, electrolytes, acid-base status.
• Thiamine (vitamin B1) and folate necessary; thiamine must be given first, followed by glucose.

Alcohol Withdrawal

• Dangerous condition after chronic use cessation.
• Possible symptoms: autonomic instability, hallucinations (visual and tactile), seizures, delirium tremens (DTs), delirium.
• Can be fatal if untreated.
• Treatment focuses on stabilization and symptomatic relief with benzodiazepines (common choice: chlordiazepoxide [Librium] or lorazepam [Ativan]).

Wernicke's Encephalopathy

• Caused by thiamine (vitamin B1) deficiency, often linked to poor nutrition.
• Symptoms: ataxia, confusion, oculomotor symptoms (e.g., nystagmus, gaze palsies).
• Note emergency condition requiring immediate treatment with high dose IV/IM thiamine, even before any glucose administration.

Cocaine

• Blocks dopamine, noradrenaline, and serotonin reuptake; produces a stimulant effect.
• Leads to increased dopamine in the brain reward pathways.
• Can cause dangerous symptoms like hyperthermia, seizures, and cardiac arrhythmias.

Amphetamines

• Block reuptake and release dopamine and norepinephrine, producing a stimulant effect.
• Examples: various drugs (e.g. Dexedrine, Ritalin, methamphetamine).
• Potential for high toxicity and adverse effects. Includes use in home labs and potential for severe overdose.

Phencyclidine (PCP)

• Dissociative, hallucinogenic drug.
• Antagonizes NMDA glutamate receptors and often causes stimulant or CNS depressive effects.
• Risk of violence and dangerous behavior in intoxication.

Sedative-Hypnotics

• Include benzodiazepines, barbiturates, zolpidem, zaleplon, and others, affecting GABA receptors and increasing chloride channel opening duration.
• Risk of overdose and strong respiratory depression.
• Risk of severe withdrawal in cases of prolonged ingestion or rapid cessation.

Opioids

• Stimulates mu, kappa, and delta receptors, involved in analgesia, and dependence.
• Examples: heroin, oxycodone, codeine, morphine etc.
• High potential for overdose and severe respiratory depression.
• Risk of high tolerance and significant withdrawal in cases of cessation.
• Naloxone (an opioid antagonist) for overdose is crucial.

Marijuana

• Primary active compound is THC (tetrahydrocannabinol).
• Associated with cannabinoid receptors, influencing appetite increase, nausea and vomiting treatment, and chronic pain management.
• Potential for respiratory issues and psychological effects.

Inhalants

• A broad range of drugs inhaled and absorbed through the lungs, primarily by adolescents.
• Includes solvents, glue, paint thinners, etc.
• Toxic effects on various organ systems, leading to acute and chronic illnesses.

Caffeine

• Adenosine antagonist, causing cAMP increase and excitatory neurotransmitter release.
• Causes mild-moderate anxiety, insomnia, muscle twitching, etc. in cases of overdose.
• Supportive care and symptomatic relief are crucial for withdrawal management.

Nicotine

• Stimulates nicotinic receptors in the autonomic nervous system, leading to tolerance, dependence, and withdrawal effects.
• Associated with significant health risks like COPD, cardiovascular diseases, and certain cancers.
• Very addictive substance, and abrupt withdrawal can cause cravings and physical/psychological discomfort.

Gambling Disorder

• Characterized by problematic gambling behavior.
• Persistent, recurrent gambling causing significant impairment or distress (four or more criteria needed within a 12 month period).
• Includes factors like preoccupation with gambling, increasing money amounts, unsuccessful attempts to quit/reduce, irritability/restlessness without gambling, gambling to relieve distress, lying, jeopardizing relations/job, relying on others.

Hallucinogens (LSD, PCP, Mushrooms)

• Produce altered perceptions and hallucinations; can cause dangerous behaviors.