A substance use disorder manifests as any pattern of substance use causing significant physical, mental, or social dysfunction:

• Substances of abuse include:
  • Alcohol
  • Amphetamines
  • Anabolic steroids
  • Barbiturates
  • Benzodiazepines
  • Cannabinoids (hashish, marijuana)
  • Club and designer drugs (mostly methamphetamine derivatives)
  • Cocaine
  • Flunitrazepam
  • Gamma-hydroxybutyrate
  • Heroin (diacetylmorphine)
  • Inhalants (gasoline, glue, paint thinners, nitrous oxide)
  • Ketamine
  • Lysergic acid diethylamide (LSD)
  • Mescaline, psilocybin (mushrooms, peyote)
  • Methadone
  • Methamphetamines
  • Methaqualone
  • Methylphenidate
  • Nicotine
  • Opium
  • Opioids (codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, propoxyphene, others)
  • Phencyclidine
• For current listing of street terms, see drug charts at http://www.nida.nih.gov/drugpages/.
• System(s) affected: Cardiovascular; Endocrine/Metabolic; CNS
• Synonym(s): Drug abuse; Drug dependence; Substance abuse

ALERT
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.

Incidence

• Predominant age: 16–25 years
• Predominant sex: Male > Female

Prevalence

• 21.8 million, or 8.7%, of Americans reported use of illicit substance in last month in 2009.
• Rates: 10% for ages 12–17 years; 21.2% for ages 18–25 years
• 1 in 6 males aged 18–25 years uses marijuana.

• 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

Genetics Substances of abuse affect dopamine, acetylcholine, gamma-aminobutyric acid, norepinephrine, opioid, and serotonin receptors. Variant alleles may account for susceptibility to disorders.

Early identification and aggressive early intervention improve outcomes.
ALERT
Screening: A single question: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”: In primary care setting, resulted in sensitivity of 100% and specificity of ~75% (1)[B].

Multifactorial, including genetic, environmental
ALERT
Prescription narcotic overdose is the leading cause of accidental death between the ages of 35 and 55 in the US; this correlates with the increase in prescription of long-acting oxycodone ( http://www.cdc.gov/injury/wisqars/pdf/Unintentional_2007_BW-a.pdf).

• Depression
• Personality disorders
• Bipolar affective disorder

• Substance abuse: A maladaptive pattern of substance use manifested by 1 or more of the following:
  • Failure to fulfill major obligations at work, school, or home
  • Recurrent use in hazardous situations
  • Recurrent substance-related legal problems
  • Continued substance use despite substance-related social or interpersonal problems
• Substance dependence: A maladaptive pattern of substance use manifested by 3 or more of the following:
  • Tolerance (decreased response to effects of drug due to constant exposure)
  • Withdrawal (physical or psychological response following the abrupt drug discontinuation)
  • Using the substance more than intended
  • Persistent desire or attempts to cut down or stop
  • Much time spent obtaining, using, or recovering from the substance
  • Social, occupational, or recreational activities sacrificed for substance use
  • Continued use despite substance-related physical or psychological problems

• History of infections (e.g., endocarditis, hepatitis B or C, TB, STI, or recurrent pneumonia)
• Social or behavioral problems, including chaotic relationships and/or employment
• Frequent visits to emergency department
• Criminal incarceration
• History of blackouts, insomnia, mood swings, chronic pain, repetitive trauma
• Anxiety, fatigue, depression, psychosis
• Sexual assault related to use of GBH or Rohypnol

• Abnormally dilated or constricted pupils
• Needle marks on skin
• Nasal septum perforation (with cocaine use)
• Cardiac dysrhythmias, pathologic murmurs
• Malnutrition with severe dependence

• CRAFFT questionnaire is superior to CAGE for identifying alcohol use disorders in adolescents and young adults; sensitivity is 94% with 2 or more “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?
• TICS (2-item conjoint screen): ≥1 positive response is 79% sensitive, 78% specific for current substance use disorder:
  • In the past year, have you ever drunk or used drugs more than you meant to?
  • Have you felt you wanted to cut down on your drinking or drug use in the past year?

Lab

• Blood alcohol concentration
• Urine drug screen (Order qualitative UDS and, if specific drug is in question, a quantitative analysis for specific drug; confirmatory serum tests if you suspect false positive.)
• Approximate detection limits:
  • Alcohol: 6–10 hours
  • Amphetamines and variants: 2–3 days
  • Barbiturates: 2–10 days
  • Benzodiazepines: 1–6 weeks
  • Cocaine: 2–3 days
  • Heroin: 1–1.5 days
  • LSD, psilocybin: 8 hours
  • Marijuana: 1 day–4 weeks
  • Methadone: 1 day–1 week
  • Opioids: 1–3 days
  • PCP: 7–14 days
  • Anabolic steroids: Oral, 3 weeks; injectable, 3 months; nandrolone, 9 months
• Liver transaminases
• HIV, hepatitis B and C screens

Imaging

• Echocardiogram for endocarditis
• Head CT scan for seizure, delirium, trauma

• Depression, anxiety, or other mental states
• Metabolic delirium (hypoxia, hypoglycemia, infection, thiamine deficiency, hypothyroidism, thyrotoxicosis)
• ADHD
• Medication toxicity

Determine substances abused early (may influence disposition).

• Alcohol withdrawal: See “Alcohol Abuse and Dependence” and “Alcohol Withdrawal.”
• Benzodiazepine or barbiturate withdrawal:
  • Gradual taper preferable to abrupt discontinuation
  • Substitution of longer-acting benzodiazepine or phenobarbital
• Nicotine withdrawal: See “Tobacco Use and Smoking Cessation.”
• Opioid withdrawal:
  • Buprenorphine: 2–16 mg/d sublingually; use restricted to licensed clinics and certified physicians (2)[A]
  • Methadone: 20–35 mg/d PO; use restricted to inpatient settings and specially licensed clinics (3)[A]
  • Clonidine: 0.1–0.2 mg PO t.i.d. for autonomic hyperactivity (4)[A]
• Stimulant withdrawal:
  • No agent with clear benefit for cocaine
  • Naltrexone: 50 mg PO twice weekly reduces amphetamine use in dependent patients (5)[B].
  • Methylphenidate ER: 54 mg/d PO might enhance abstinence in amphetamine-dependent 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)

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)

Issue for Referral

• Consider addiction specialist, especially for opioid and polysubstance abuse.
• Maintenance therapy for opioid dependence (e.g., methadone) only in licensed clinics
• Psychiatry for comorbid psychiatric disorders
• Social services

Initial Stabilization Look for signs of severe infection (e.g., bacterial endocarditis).

Admission Criteria

• Indications for inpatient detoxification:
  • History of withdrawal symptoms (e.g., seizures)
  • Disorientation
  • Threat of harm to self or others
  • Obstacles to close monitoring (follow-up)
  • Comorbid medical illness
  • Pregnancy
• For narcotic addiction and withdrawal

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

Restricted if dangerous, psychotic, or disoriented

Patient Monitoring Verify patient’s compliance with the substance abuse treatment program.

Patients often are malnourished.

• Center for Substance Abuse Treatment: (800) 662-HELP or http://findtreatment.samhsa.gov (facility locator)
• Substance Abuse and Mental Health Services Administration: http://ncadi.samhsa.gov
• Alcoholics Anonymous: Contact local chapter or http://www.aa.org
• Narcotics Anonymous: http://www.na.org

• Patients in treatment for longer periods of time (≥1 year) have higher success rates.
• Behavioral therapy and pharmacotherapy are most successful when used in combination.

• Hepatitis, HIV, tuberculosis, syphilis
• Subacute bacterial endocarditis
• Malnutrition
• Social problems, including arrest
• Poor marital adjustment and violence
• Depression, schizophrenia
• Serious harm to self and others: Accidents, violence
• Sexual assault related to use of GHB, Rohypnol
• Overdoses resulting in seizures, arrhythmias, cardiac and respiratory arrest, coma, death

• Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results from the 2009 national survey on drug use and health. Accessed July 4, 2011, at http://oas.samhsa.gov.
• Griswold KS, Aronoff H, Kernan JB, et al. Adolescent substance use and abuse: Recognition and management. Am Fam Physician. 2008;77:331–6.

Alcohol Abuse and Dependence; Alcohol Withdrawal; Tobacco Use and Smoking Cessation

• 305.1 Tobacco use disorder
• 305.20 Nondependent cannabis abuse, unspecified use
• 305.90 Other, mixed, or unspecified drug abuse, unspecified
• 305.30 Nondependent hallucinogen abuse, unspecified use
• 305.40 Nondependent barbiturate and similarly acting sedative or hypnotic abuse, unspecified use
• 305.50 Nondependent opioid abuse, unspecified use
• 305.60 Nondependent cocaine abuse, unspecified use
• 305.70 Nondependent amphetamine or related acting sympathomimetic abuse, unspecified use
• 305.80 Nondependent antidepressant type abuse, unspecified use
• 305.00 Alcohol abuse, unspecified

• F19.10 Other psychoactive substance abuse, uncomplicated
• F10.10 Alcohol abuse, uncomplicated
• F12.10 Cannabis abuse, uncomplicated
• F16.10 Hallucinogen abuse, uncomplicated
• F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
• F11.10 Opioid abuse, uncomplicated
• F14.10 Cocaine abuse, uncomplicated
• F15.10 Other stimulant abuse, uncomplicated
• F18.10 Inhalant abuse, uncomplicated

• 66214007 substance abuse (disorder)
• 15167005 alcohol abuse (disorder)
• 89765005 tobacco dependence syndrome (disorder)
• 37344009 Cannabis abuse (disorder)
• 74851005 hallucinogen abuse (disorder)
• 231462006 barbiturate abuse (disorder)
• 5602001 opioid abuse (disorder)
• 78267003 cocaine abuse (disorder)
• 84758004 amphetamine abuse (disorder)
• 191928000 abuse of antidepressant drug (disorder)

• 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.
• The CRAFFT questionnaire is preferred for identifying alcohol and substance use disorders in adolescents and young adults.
• Motivational interviewing, brief interventions, and a nonjudgmental attitude can help to promote a willingness to change behavior.

S. Lindsey Clarke, MD, FAAFP

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;170:1155–60.  [PMID:20625025]
2. Gowing L, Ali R, White JM, et al. Buprenorphine for the management of opioid withdrawal. Cochrane Database Syst Rev. 2009;CD002025.  [PMID:19588330]
3. Mattick RP, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009;CD002209.  [PMID:19588333]
4. Gowing L, Farrell M, Ali R, et al. Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2009;CD002024.  [PMID:19370574]
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):1442–8.  [PMID:18765480]

© Wolters Kluwer Health Lippincott Williams & Wilkins