Basics
Description
- Dependence: Repeated substance use, with or without physical dependence
- Abuse: Substance use that deviates from accepted medical or social norms
- Intoxication: Substance use that causes a reversible syndrome affecting physiologic, cognitive, emotional, and behavioral functioning
- Withdrawal: A syndrome that occurs after stopping or reducing the amount of a substance previously used
- Tolerance: Original dose of a substance produces a decreased effect or larger doses must be taken to obtain same effect observed with original dose
- Types of substances:
- CNS depressants: Alcohol, barbiturates, benzodiazepines, inhalants, and opioids
- CNS stimulants: Amphetamines, caffeine, cocaine, and nicotine
- Hallucinogens: Cannabis, LSD, mescaline, psilocybin, and ecstasy (MDMA)
Epidemiology
- Among women, lifetime prevalence of:
- Alcohol abuse = 11.5% (see "Alcohol Use Disorders " chapter)
- Alcohol dependence = 8%
- Drug abuse = 5.2%
- Drug dependence = 2%
- The lifetime prevalence of alcohol and drug use disorders is lower for women than men.
- Women develop substance abuse and dependence patterns more rapidly than men.
- Women may have the same severity of symptoms of problematic substance use as men yet seek treatment sooner.
Risk Factors
- Family history of substance use
- Personality disorders
- Depression
- Involvement with an alcohol/drug-dependent partner
Genetics
- Genetic influence for drug abuse or dependence is greater for men than for women (33% vs. 11%).
- Ongoing research into genes associated with specific substance use disorders
- Dopamine and GABA receptor genes associated with alcohol use
General Prevention
- Education about the:
- Effects and consequences of substance use
- Use of addictive prescription medications
- Modeling abstinence for youth
Pathophysiology
- Substances stimulate limbic system: Nucleus accumbens and ventral tegmentum most affected
- Dopamine, an important neurotransmitter involved in reward circuitry, reinforces substance use.
Associated Conditions
- Women with substance use disorders are more likely than men to have comorbid psychiatric diagnoses:
- Mood disorders
- Anxiety disorders
- Eating disorders
- Pathological gambling
- Women who smoke cannabis report panic attacks more frequently than men.
(See "Pregnancy, Substance Abuse " chapter)
- Cocaine use:
- Associated with meconium staining
- Premature rupture of membranes
- Prematurity, reduced birth weight and height
- Abruptio placentae
- Attention deficits, impulsivity, and hyperactivity in offspring
- Opioid use:
- During pregnancy, stabilize with the lowest effective dose of methadone or buprenorphine rather than detoxify
- Methadone metabolism is increased in the third trimester of pregnancy, and doses may need to be increased to prevent symptoms of withdrawal and/or relapse.
- Buprenorphine is associated with reduced neonatal withdrawal because of low placental transference of this medication.
- Opioid withdrawal syndrome in newborns includes seizures, sleep abnormalities, feeding difficulties, weight loss. Treatment includes opioids, sedatives, and clonidine.
- Alcohol use:
- Associated with fetal alcohol spectrum disorder, characterized by shortened palpebral fissures, flat midface, low nasal bridge, micrognathia, mild-to-moderate mental retardation, reduced growth and hypotonia
- No known safe limit of alcohol use in pregnancy
- Tobacco use:
- Increased risk of premature delivery is related to its stimulating effects on oxytocin.
- Increases the risk of fetal growth retardation, sudden infant death syndrome, low birth weight and height, and hypertension
Diagnosis
History
Obtain information about past and present use:
- Type of substances used
- Quantity and frequency of use
- Age when substance use began
- Amount of time and money spent obtaining substances " screen for illegal activity such as prostitution, assault, and theft to pay for substances
- History of prior substance use treatment or psychiatric treatment
- Withdrawal: Presence of delirium tremens or withdrawal seizures
Because detecting and evaluating substance use disorders is difficult,
- Brief alcohol screening evaluations (i.e., CAGE, AUDIT) may be less sensitive among women than men and may need lower cut-off points.
- Obtain information from other sources (i.e., family members, coworkers)
- Remember that patients often underestimate the amount of substances used
- Health care providers are less likely to recognize and address alcohol-related problems in women than men.
- Men typically prefer to seek specialized mental health treatment whereas women are more likely to seek help from their primary care physician.
Physical Exam
Perform an extensive medical and psychiatric assessment:
- Opioids: Miosis
- Stimulants: Mydriasis, pressured speech
- Depressants: Slurred speech, slowed motor response, gait disturbance
- Subcutaneous or IV drug users: Scars, abscesses, heart murmur (bacterial endocarditis), right upper quadrant tenderness (hepatitis), thrombophlebitis, signs of tetanus
- Intranasal use (cocaine, heroin): Deviated or perforated septum, nasal bleeding, tetanus
- Smokers of crack, marijuana, or other drugs and inhalant abusers: Bronchitis, asthma, chronic respiratory conditions
Tests
Lab
- Toxicology: Urine/blood tests; usually positive for up to 2 days after use of most substances, and up to 30 days for cannabis
- Pregnancy test: Informs treatment options
- Prolactin level:
- Cocaine can induce hyperprolactinemia that may cause changes in the menstrual cycle.
- Cannabis can produce significant, transient decreases in plasma level of prolactin and luteinizing hormone during the luteal phase.
- Nicotine can inhibit the release of prolactin and luteinizing hormone.
Differential Diagnosis
- Hyperthyroidism
- Psychosis
- Delirium
- Anxiety
- Depression
Treatment
Medication
- Pharmacological treatment for opioid dependence:
- Methadone: Opioid agonist
- Buprenorphine: Partial opioid agonist
- Pharmacological treatment for alcohol dependence:
- Disulfiram: Counsel about risk of serious morbidity and mortality with concomitant alcohol use (1)[C]
- Naltrexone: Counsel about decreased effects of opioids while using this medication given mechanism of action as an opioid antagonist (1)[C]
- Acamprosate: Utility limited by frequency of dosing. Primarily excreted by the kidneys and therefore may be better option for patients with compromised liver function.
- Pharmacological treatment for nicotine dependence (see "Tobacco Use " chapter):
- Nicotine replacement: Nasal spray, transdermal patch, tablet/lozenge, gum or inhaler
- Bupropion: Also first-line agent for treatment of depression
- Varenicline: Some data suggest varenicline may be more effective than other pharmacotherapies for smoking cessation. It -carries a black box warning for serious neuropsychiatric side effects, including depression and suicidality. However, recent data suggest that in patients without a psychiatric disorder there is no significant increase in neuropsychiatric side effects other than sleep disturbances (2)[A].
Additional Treatment
General Measures
- Treat comorbid psychiatric disorders
- Involve family members/social supports
- Encourage treatment for patient 's partner if he or she also abuses substances
- Treat comorbid physical conditions
- Be mindful of a woman 's menstrual cycle when counseling about smoking cessation as quitting during premenstrual symptoms may be more difficult.
Complementary and Alternative Medicine
- Yoga
- Deep relaxation
- Exercise
- Acupuncture
In-Patient Considerations
Initial-Stabilization
- Observe for possible overdose and polysubstance intoxication
- Evaluate for medical conditions
- Discontinue the use of substances as quickly as possible through detoxification:
- Opioids: Use methadone, buprenorphine, or clonidine and benzodiazepines
- Alcohol/sedatives: Use barbiturates (phenobarbital) or benzodiazepines (lorazepam or chlordiazepoxide)
- Providing psychosocial treatment (i.e., psychotherapy) during opioid detoxification in addition to pharmacological treatment improves outcome (3)[C]
Ongoing Care
Follow-Up Recommendations
- Referrals to mutual help groups
- Individual, group, and family psychotherapy
- Continued involvement of the family
- Medication maintenance, if indicated (see "Medication " )
- Continue to screen for comorbid psychiatric disorders
Patient Monitoring
Provide frequent motivation checks
Patient Education
- Mutual help groups:
- Alcoholics anonymous (AA)
- Narcotics anonymous (NA)
- Women-only groups
- Mutual help groups for family members/supports:
Prognosis
- Relapse is common.
- Educate patient that long-term sobriety may require multiple attempts
- Persistent physical pain is associated with greater addiction severity.
Complications
- Substance use disorders:
- Involved in most cases of domestic violence
- Major cause of motor vehicle injuries and fatalities
- IV drug use:
- Risk of infection: HIV, hepatitis B, hepatitis C, and syphilis
- Tobacco use:
- Increased risk for impaired immune response, cardiovascular disease, and cancer of the lung and bladder
- Increased rates of breast, ovarian, and cervical cancers
- Lung cancer mortality rates surpass breast cancer as the most frequent cause of death.
References
1Snyder JL, Bowers TG. The efficacy of acamprosate and naltrexone in the treatment of alcohol dependence: A relative benefits analysis of randomized controlled trials. Am J Drug Alcohol Abuse. 2008;34:449 " 461. [View Abstract]2Tonstad S, Davies S, Flammer M. Psychiatric adverse events in randomized, double-blind placebo-controlled clinical trials of varenicline: A pooled analysis. Drug Safety. 2010;33(4):289 " 301. [View Abstract]3Amato L, Minozzi S, Davoli M. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev. 2008;4:CD005031. [View Abstract]
Additional Reading
1 Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association, 2000.2Burt BK, Hendrick VC. Clinical manual of women 's mental health. Washington, DC: American Psychiatric Publishing, Inc, 2005.3Sadock B, Sadock V. Kaplan & Sadock 's pocket handbook of clinical psychiatry, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005.4Zilberman M, Blume S. Substance abuse and abuse in women. In: Romans S, Seeman M Women 's mental health: a life cycle approach. Philadelphia, PA: Lippincott Williams & Wilkins, 2006:179 " 190.
Codes
ICD9
- 303.90 Other and unspecified alcohol dependence, unspecified
- 305.00 Alcohol abuse, unspecified
- 305.90 Other, mixed, or unspecified drug abuse, unspecified
- 305.1 Tobacco use disorder
- 305.40 Sedative, hypnotic or anxiolytic abuse, unspecified
- 305.30 Hallucinogen abuse, unspecified
- 305.70 Amphetamine or related acting sympathomimetic abuse, unspecified
- 305.20 Cannabis abuse, unspecified
- 305.60 Cocaine abuse, unspecified
ICD10
- F10.10 Alcohol abuse, uncomplicated
- F10.20 Alcohol dependence, uncomplicated
- F19.10 Other psychoactive substance abuse, uncomplicated
- Z72.0 Tobacco use
- F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
- F16.10 Hallucinogen abuse, uncomplicated
- F15.10 Other stimulant abuse, uncomplicated
- F12.10 Cannabis abuse, uncomplicated
- F14.10 Cocaine abuse, uncomplicated
SNOMED
- 66214007 substance abuse (disorder)
- 15167005 alcohol abuse (disorder)
- 26416006 drug abuse (disorder)
- 110483000 tobacco user (finding)
- 64386003 sedative abuse (disorder)
- 74851005 hallucinogen abuse (disorder)
- 441527004 stimulant abuse (disorder)
- 37344009 Cannabis abuse (disorder)
- 78267003 cocaine abuse (disorder)
Clinical Pearls
- Substance use disorders (both abuse and dependence) develop more rapidly in women than men.
- Substance use disorders complicate pregnancy and increase the risk of abnormalities in the newborn.
- Treatment should include treating comorbid conditions and involve family members.
- Substance use disorders are chronic conditions. Relapse is part of recovery.