Substance Use Disorders

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

- Alcohol withdrawal: See "Alcohol Abuse and Dependence " and "Alcohol Withdrawal. " - Benzodiazepine or barbiturate withdrawal - Gradual taper preferable to abrupt discontinuation - Substitution of long-acting benzodiazepine or phenobarbital

- Stimulant withdrawal - No agent with clear benefit for cocaine - Anti-cocaine vaccine in development - Naltrexone: 50 mg PO twice weekly reduces amphetamine use in dependent patients (5)[B]. - Methylphenidate ER: titrated up to 54 mg/day PO might enhance abstinence in amphetamine-dependent patients

- Contraindications - Buprenorphine in lactation - Naltrexone in pregnancy, liver disease

- Indications for inpatient detoxification - History of withdrawal symptoms (e.g., seizures) - Disorientation - Hallucinations or psychotic features - Threat of harm to self or others - Obstacles to close monitoring (follow-up) - Comorbid medical illness - Pregnancy

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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.

EPIDEMIOLOGY

Incidence

Predominant age: 16 to 25 years
Predominant sex: male > female

Prevalence

24.6 million (9.4%) Americans reported current illicit drug use in 2013.
8.8% for age 12 to 17 years; 21.5% for age 18 to 25 years
Nearly one in five young adult men use marijuana.

ETIOLOGY AND PATHOPHYSIOLOGY

Multifactorial, including genetic, environmental

Genetics

Substances of abuse affect dopamine, acetylcholine, ³-aminobutyric acid, norepinephrine, opioid, and serotonin receptors. Variant alleles may account for susceptibility to disorders.

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

GENERAL PREVENTION

Early identification and aggressive early intervention improve outcomes.
Universal school-based interventions are modestly effective for preventing drug use among adolescents.

COMMONLY ASSOCIATED CONDITIONS

Depression
Personality disorders
Bipolar affective disorder

ALERT

Prescription narcotic overdose is the leading cause of accidental death between the ages of 25 and 45 years in the United States; this correlates with increased prescribing of long-acting oxycodone (see www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2013-a.pdf).

DIAGNOSIS

Substance use disorder (DSM-5 criteria): ≥2 of the following in past year, with severity based on number of criteria present:

Missed work or school
Use in hazardous situations
Continued use despite social or personal problems
Craving
Tolerance (decreased response to effects of drug due to constant exposure)
Withdrawal upon discontinuation
Using more than intended
Failed attempts to quit
Increased time spent obtaining, using, or recovering from the substance
Interference with important activities
Continued use despite health problems

HISTORY

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

PHYSICAL EXAM

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

DIFFERENTIAL DIAGNOSIS

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

DIAGNOSTIC TESTS & INTERPRETATION

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]

CRAFFT questionnaire is superior to cut down, annoyed by criticism, guilty about drinking, eye-opener drinks (CAGE) for identifying alcohol use disorders in adolescents and young adults; sensitivity is 94% with ≥2 "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?
Blood alcohol concentration
Urine drug screen (UDS) (order qualitative UDS, and if specific drug is in question, a quantitative analysis for specific drug; order confirmatory serum tests if you suspect false positive)
Approximate detection limitsAlcohol: 6 to 10 hoursAmphetamines and variants: 2 to 3 daysBarbiturates: 2 to 10 daysBenzodiazepines: 1 to 6 weeksCocaine: 2 to 3 daysHeroin: 1 to 1.5 daysLSD, psilocybin: 8 hoursMarijuana: 1 day to 4 weeksMethadone: 1 day to 1 weekOpioids: 1 to 3 daysPCP: 7 to 14 daysAnabolic steroids: oral, 3 weeks; injectable, 3 months; nandrolone, 9 months
Liver transaminases
HIV, hepatitis B and C screens
Echocardiogram for endocarditis
Head CT scan for seizure, delirium, trauma

TREATMENT

Determine substances abused early (may influence disposition).

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)

MEDICATION

Alcohol withdrawal: See "Alcohol Abuse and Dependence " and "Alcohol Withdrawal. "
Benzodiazepine or barbiturate withdrawalGradual taper preferable to abrupt discontinuationSubstitution of long-acting benzodiazepine or phenobarbital
Nicotine withdrawal: See "Tobacco Use and Smoking Cessation. "
Opioid withdrawalMethadone: 20 mg/day PO; use restricted to inpatient settings and specially licensed clinics (2)[A]Clonidine: 0.1 to 0.2 mg PO TID for autonomic hyperactivity (3)[A]Buprenorphine: 8 to 16 mg/day sublingually; may precipitate a more severe withdrawal if initiated too soon; use restricted to licensed clinics and certified physicians (4)[A]
Stimulant withdrawalNo agent with clear benefit for cocaineAnti-cocaine vaccine in developmentNaltrexone: 50 mg PO twice weekly reduces amphetamine use in dependent patients (5)[B].Methylphenidate ER: titrated up to 54 mg/day PO might enhance abstinence in amphetamine-dependent patients
Adjuncts to therapyUse all medications in conjunction with psychosocial behavioral interventions.Antiemetics, nonaddictive analgesics for opioid withdrawalNonhabituating antidepressants, mood stabilizers, anxiolytics, and hypnotics for comorbid mood and anxiety disorders and insomnia that persist after detoxification
ContraindicationsBuprenorphine in lactationNaltrexone in pregnancy, liver disease
Precautions: Clonidine can cause hypotension.
Significant possible interactionsBuprenorphine and ketoconazole, erythromycin, or HIV protease inhibitorsNaltrexone and opioid medications (may precipitate or exacerbate withdrawal)

ISSUES FOR REFERRAL

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

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Indications for inpatient detoxificationHistory of withdrawal symptoms (e.g., seizures)DisorientationHallucinations or psychotic featuresThreat of harm to self or othersObstacles to close monitoring (follow-up)Comorbid medical illnessPregnancy
For narcotic addiction and withdrawal
Look for signs of severe infection (e.g., bacterial endocarditis).

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
Rehabilitation plan in place

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Initially frequent visits to monitor for medical stability and adherence, then progressive follow-up intervals

Patient Monitoring

Verify patient 's compliance with the substance abuse treatment program.

DIET

Patients often are malnourished.

PATIENT EDUCATION

Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/ or 800-662-HELP for information, treatment facility locator
National Institute on Drug Abuse: http://www.drugabuse.gov/patients-families and http://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/patient-materials
Alcoholics Anonymous: http://www.aa.org/
Narcotics Anonymous: http://www.na.org.za/

PROGNOSIS

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

COMPLICATIONS

Serious harm to self and others: accidents, violence
Overdoses resulting in seizures, arrhythmias, cardiac and respiratory arrest, coma, death
Hepatitis, HIV, tuberculosis, syphilis
Subacute bacterial endocarditis
Malnutrition
Social problems, including arrest
Poor marital adjustment and violence
Depression, schizophrenia
Sexual assault (alcohol, flunitrazepam, GHB)

REFERENCES

11 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(13):1155 " 1160.22 Amato L, Davoli M, Minozzi S, et al. Methadone at tapered doses for the management of opioid withdrawal. Cochrane Database Syst Rev. 2013;(2):CD003409.33 Gowing L, Farrell MF, Ali R, et al. Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2014;(3):CD002024.44 Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207.55 Jayaram-Lindstr ¶m 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 " 1448.

ADDITIONAL READING

Patterson DA, Morris GWJr, Houghton A. Uncommon adverse effects of commonly abused illicit drugs. Am Fam Physician. 2013;88(1):10 " 16.
Shapiro B, Coffa D, McCance-Katz EF. A primary care approach to substance misuse. Am Fam Physician. 2013;88(2):113 " 121.
Standridge JB, Adams SM, Zotos AP. Urine drug screening: a valuable office procedure. Am Fam Physician. 2010;81(5):635 " 640.
Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. http://store.samhsa.gov/home.

CODES

ICD10

F19.10 Other psychoactive substance abuse, uncomplicated
F10.10 Alcohol abuse, uncomplicated
F12.10 Cannabis 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
F14.10 Cocaine abuse, uncomplicated
F18.10 Inhalant abuse, uncomplicated
F11.10 Opioid abuse, uncomplicated

ICD9

305.90 Other, mixed, or unspecified drug abuse, unspecified
305.00 Alcohol abuse, unspecified
305.20 Cannabis abuse, unspecified
305.1 Tobacco use disorder
304.90 Unspecified drug dependence, unspecified
305.50 Opioid abuse, unspecified
305.30 Hallucinogen abuse, unspecified
305.70 Amphetamine or related acting sympathomimetic abuse, unspecified
303.0 Acute alcoholic intoxication
305.80 Antidepressant type abuse, unspecified
305.40 Sedative, hypnotic or anxiolytic abuse, unspecified
305.60 Cocaine abuse, unspecified

SNOMED

66214007 Substance abuse (disorder)
15167005 Alcohol abuse (disorder)
37344009 Cannabis abuse
89765005 Tobacco dependence syndrome (disorder)
191928000 Abuse of antidepressant drug
78267003 cocaine abuse (disorder)
84758004 amphetamine abuse (disorder)
74851005 Hallucinogen abuse
5602001 Opioid abuse (disorder)
231462006 Barbiturate abuse
91388009 Psychoactive substance abuse (disorder)

CLINICAL PEARLS

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.
Motivational interviewing, brief interventions, and a nonjudgmental attitude can help to promote a willingness to change behavior. Research shows the benefit of referring patients with alcohol dependence to an addiction specialist or treatment program.