Definition
1.Recurrent substance use with failure to fulfill major role obligations.
2.Recurrent use in physically hazardous situations.
3.Recurrent substance-related legal problems.
4.Continued use despite persistent or recurrent social or interpersonal problems.
B.Dependence: Maladaptive pattern of use as evidenced by three or more of the following occurring at any time within the same 12-month period.
1.Tolerance.
2.Withdrawal.
3.Substance taken in larger amounts over a longer period of time.
4.Persistent desire/effort to cut down or control use.
5.Increasing time spent obtaining, using, and recovering from use.
6.Important social, occupational, or recreational activities given up.
7.Continued use despite knowledge of adverse effects.
8.With physiological dependence: Evidence of tolerance or withdrawal.
9.Without physiological dependence: No evidence of tolerance or withdrawal.
C.Substances of addiction: Alcohol; caffeine; cannabis; hallucinogens; inhalants: opioids; sedatives/hypnotics/anxiolytics; stimulants; tobacco; other/unknown substances.
Incidence
A.Alcohol abuse 9.4% versus dependence 14%.
B.Cannabis 8.5%.
C.Opioids 1.4%.
D.Sedatives 1%.
E.Amphetamines 2%.
F.Cocaine 2.8%.
G.Hallucinogens 1.7%.
Pathogenesis
A.Has both a genetic and environmental risk with complex neurobiology.
Predisposing Factors
A.Age of first use matters: Odds of alcoholism as an adult go down by 14% for each year a youth does not drink after age 14.
B.Access.
C.Peer groups.
Subjective Data
A.Common complaints/symptoms.
1.Craving, irrepressible urge to seek and consume drug substance.
B.Common/typical scenario.
1.Patients commonly present for either another medical condition or a complication associated with use of the substance.
C.Family and social history.
1.Behaviors may be learned or there may be a genetic predisposition to addictive substances.
D.Review of systems.
1.Psychological—irritable, anxious, restless.
2.Cardiac—racing heart rate, feeling of palpitations.
Mental State Examination
A.General.
1.Agitated.
2.Anxious.
3.Irritable.
B.Attitude.
1.Describe if patient is friendly, cooperative, hostile, or defensive.
C.Mood.
1.General mood of patient.
D.Affect.
1.Can be described as expansive, euthymic, constricted, or blunted.
E.Speech.
1.Quantity.
2.Rate.
3.Volume.
F.Thought process and content.
1.How is the patient thinking?
Diagnostic Tests
A.Comprehensive metabolic panel (CMP).
B.Liver function tests.
C.Blood alcohol level.
D.Serum drug screen.
E.Pregnancy test.
F.HIV.
G.EKG.
H.Screening.
1.Screening, brief intervention, and referral to treatment (SBIRT).
a.Screening: A healthcare professional assesses for risky substance use behaviors using standardized screening tools such as CAGE.
b.Brief intervention: A healthcare professional engages a patient showing risky substance use behaviors in a short conversation.
2.A standard drink.
a.2 oz of beer/ale/malt liquor.
b.1.5 oz of spirits such as vodka, tequila, gin, whiskey, or rum.
c.5 oz of wine.
3.Positive screen for at-risk drinking.
a.Men: Greater than 14 drinks a week or greater than 4 on occasion.
b.Women: Greater than 7 drinks a week or greater than 3 drinks on occasion.
c.Elders: Greater than 7 drinks a week or greater than 1 drink on occasion.
4.CAGE assessment: One yes is a positive screen and needs further assessment.
a.Have you ever felt the need to CUT down on your substance use?
b.Have people ANNOYED you by criticizing your substance use?
c.Have you ever felt GUILTY about your substance use?
d.Have you ever felt the need to drink/use first thing in the morning as an EYE opener?
Differential Diagnosis
A.Attention deficit hyperactivity disorder (ADHD).
B.Bipolar disorder.
C.Trauma-related disorders.
D.Major depression.
E.Anxiety disorders.
F.Other substance use disorders.
Evaluation and Management Plan
A.Motivational interviewing to assess readiness and increase ambivalence.
B.Treatment is based on severity, individual motivation taking into account abstinence, or harm reduction.
C.Withdrawal.
D.Hierarchy of detoxification: Sedative/hypnotics, alcohol, then opioids.
E.Assessment of alcohol withdrawal and providing intervention: Risk of seizures after 48 hours of last drink and risk of DTs after 72 hours of last drink.
F.Alcohol withdrawal assessment: Clinical Institute for Withdrawal Assessment for Alcohol (CIWA-AR) and detox is most commonly attempted with a benzodiazepine.
G.Opioid withdrawal assessment: Clinical Opiate Withdrawal Scale (COWS) and detox commonly with opiates such as buprenorphine or phenobarbital.
H.Alcohol cravings: Naltrexone/Vivitrol, acamprosate, ondansetron, or disulfiram (Antabuse)—need to provide education about products to avoid adverse reactions.
I.Opioid replacement: Methadone, buprenorphine (can be prescribed by nurse practitioners [NPs] with additional training), Suboxone.
J.Nicotine replacement: NRT options (patch, gum, inhaler), bupropion (Zyban) same as Wellbutrin, varenicline (Chantix)
Follow-Up
A.Follow-up with a substance use disorder specialist for medications and therapy.
Consultation/Referral
A.Consultation for medical comorbidities.
B.Referral to outpatient support groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), Opioids Anonymous (OA).
C.Referral to treatment: A healthcare professional provides a referral to brief therapy or for additional services.
Special/Geriatric Considerations
A.Substance abuse in the elderly is a rapidly growing problem and may be triggered by retirement; death of a close family member, friend, or even pet; financial strains; or mental or physical decline.
B.Elderly patients may have a decreased ability to metabolize drugs or alcohol.
Bibliography
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: Guilford Press.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Substance Abuse and Mental Health Services Administration. (2019). Recovery and recovery support. Retrieved from https://www.samhsa.gov/find-help/recovery