Substance Abuse Disease

DESCRIPTION

Any pattern of substance use causing significant physical, mental, or social dysfunction
Substances of abuse include:
- Alcohol
- Amphetamines (Dexedrine, black beauties, crosses, hearts)
- Amphetamine variants (DOB, DOM, MDA, MDMA, ecstasy, STP, XTC)
- Anabolic steroids (testosterone, T/E ratio, Stanozolol, Nandrolone)
- Barbiturates (Phenobarbital, barbs)
- Benzodiazepines (Ativan, Halcion, Librium, Rohipnol, roofies, tranks, Valium, Xanax)
- Cocaine (coke, crack, flake, rocks, snow)
- Codeine
- Hashish (hash)
- Heroin (diacetylmorphine, horse, smack)
- Inhalants (glue, paint thinners, nitrous oxide)
- Lysergic acid diethylamide (LSD, acid, microdont)
- Marijuana (blunt, grass, herb, pot, sinsemilla, smoke, reefer, weed)
- Mescaline (buttons, cactus, mesc, peyote)
- Methadone (Amidone, Dolophine, Methadose)
- Methamphetamines (crank, crystal, ice, speed)
- Methaqualone (Quaalude, ludes)
- Methylphenidate (Ritalin)
- Morphine
- Nicotine (tobacco)
- Opium (Paregoric, Dover's powder)
- Phencyclidine (PCP, angel dust, boat, hog, love boat)
- Psilocybin (magic mushroom, purple passion, shrooms)
- Others (over the counter and prescription drugs, any combination of above)
Substance abuse (adapted from the DSM-IV): A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12 month period and symptoms have not met the criteria for substance dependence for this class of substance:
- Recurrent substance use resulting in a failure to fulfill major obligations at work, at school, or home
- Recurrent substance use in situations in which it is physically hazardous
- Recurrent substance-related legal problems
- Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
Substance dependence (adapted from the DSM-IV): A maladaptive pattern of substance use leading to a significant impairment or distress, as manifested by 3 (or more) of the following occurring at any time in the same 12 month period:
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the substance to achieve intoxication or desired effect
- Markedly diminished effect with continued use of the same amount of the substance
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for the substance
- The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
- The substance is often taken in larger amounts or over a longer period than was intended
- There is a persistent desire or unsuccessful efforts to cut down or control substance use
- A great deal of the time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
- Important social, occupational or recreational activities are given up or reduced because of substance use
- The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
System(s) affected: Nervous, Endocrine/Metabolic, Cardiovascular
Genetics: The dopamine system in the ventral tegmental area of the brain is activated during the use of virtually all drugs of abuse. Substances of abuse affect dopamine, acetylcholine, GABA, norepinephrine, opioid, and serotonin receptors. Variant alleles of these receptors probably account for interpersonal differences in susceptibility to substance use disorders.
Incidence/Prevalence in USA:
- 36% have used an illicit substance at least once
- 13.9 million or 6% (11.4% for ages 12-17) have used in past month
- 1 in 6 males ages 18-25 currently use marijuana
Predominant age: 18-25
Predominant sex: Male > Female

SIGNS AND SYMPTOMS

History of infections, e.g., endocarditis, hepatitis B or C, tuberculosis, sexually transmitted diseases, or recurrent pneumonia
Social or behavioral problems, including chaotic relationships and/or employment
Frequent visits to emergency department
Criminal incarceration
History of blackouts or morning tremor, insomnia, mood swings, chronic pain, repetitive trauma
Dilated or constricted pupils, reduced pupillary response to light
Needle marks on skin
Perforation of the nasal septum (with cocaine use)

CAUSES

Multifactorial including genetic, environmental

RISK FACTORS

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

LABORATORY

Blood alcohol concentration
Urine drug screen, confirmatory tests
Approximate detection limits:
- Alcohol: 6-10 hours
- Amphetamines & variants: 1-2 days
- Barbiturates: 2-10 days
- Benzodiazepines: 1-6 weeks
- Cocaine: 1-4 days
- LSD, psilocybin: 8 hours
- Marijuana: 1 day - 5 weeks
- Methadone: 1 day - 1 week
- Opioids: 1-2 days
- PCP: 2-8 days
- Anabolic steroids: oral = 3 weeks, injectable = 3 months, Nandrolone = 9 months
For altered mental status consider CBC, glucose, chemical panel, TSH, T4, RPR, UA, Head CT scan, CXR, EKG, lumbar puncture, pulse oximetry/ABG
HIV, Hepatitis B & C screens

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

N/A

IMAGING

N/A

DIAGNOSTIC PROCEDURES

History (often unreliable) and physical; substance abuse screening tests
CAGE questionnaire (used for alcoholism):
- Have you ever felt you should cut down on your drinking?
- Have people annoyed you by criticizing your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
Rost, et al screening:
- Have you misused one of these substances (see DESCRIPTION) more than 5 times in your life?
- Have you ever found that you needed to increase your use of a substance in order to get the same effect?
- Have you ever had emotional or psychological problems from using drugs - like feeling crazy or paranoid or uninterested in things?

APPROPRIATE HEALTH CARE

Outpatient usually. Some patients may benefit from inpatient rehabilitation units while others can be treated by individual physician or by outpatient substance abuse clinics.
Severely ill patients or those with suicide ideation may require hospitalization

GENERAL MEASURES

Behavioral therapies include drug counseling, behavioral and cognitive-behavior therapies, and psychodynamic strategies
Family members should be involved in the recovery process (community reinforcement)
Self-help groups:
- Can be important adjunct to treatment plan (Alcoholic Anonymous, Narcotics Anonymous, Cocaine Anonymous). Their twelve-step programs have been helpful for many patients.
- Encourage support groups for family members (Al-Anon and Alateen)
- Other support groups include the Rational Recovery and Secular Organizations for Sobriety. These are newer organizations and their success rate is still unclear.

SURGICAL MEASURES

N/A

ACTIVITY

Unrestricted

DIET

Patients often malnourished; emphasize good nutrition

PATIENT EDUCATION

Alcoholics Anonymous: literature, crisis hot line, from local chapter or http://www.alcoholics-anonymous.org
Cocaine Anonymous
Narcotics Anonymous
National Clearinghouse for Alcohol and Drug Information (800) 729-6686 or http://www.health.org
Rational Recovery
Secular Organizations for Sobriety

PREVENTION/AVOIDANCE

Reduce risks through education
Early identification and aggressive early intervention (mild substance abuse disorders respond better to treatment intervention)

POSSIBLE COMPLICATIONS

Hepatitis, HIV, tuberculosis
Subacute bacterial endocarditis
Many other infectious diseases
Malnutrition
Social problems including arrest
Poor marital adjustment and violence
Serious harm to self and others
Overdoses resulting in seizures, arrhythmias, cardiac and respiratory arrest, coma, death

EXPECTED COURSE AND PROGNOSIS

Success rates vary widely
Patients who stay in treatment for longer periods of time (at least a year) have a higher success rate
Counseling combined with drug therapy appears to be more successful than either one alone

ASSOCIATED CONDITIONS

Depression
Personality disorders
Manic-depressive disorder

AGE-RELATED FACTORS

Pediatric: Levels of marijuana use among youth (12-17) have been steadily increasing since 1992. Between 1993 and 1994, rates of use of illicit drugs, alcohol and cigarettes has remained stable in persons age 18 and older.
Geriatric: Alcohol, prescription drugs
Others: N/A

PREGNANCY

Substance abuse may cause major problems that can lead to fetal abnormality, morbidity, and death of infant and mother

OTHER NOTES

N/A

ABBREVIATIONS

LSD = lysergic acid diethylamide
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

Clinical Investigations

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