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Chapter 9. Substance-Related Disorders

Martin H. Leamon, M.D.; Tara M. Wright, M.D.; Hugh Myrick, M.D.
DOI: 10.1176/appi.books.9781585623402.327735

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Excerpt

Psychoactive substance use has been part of people's lives for millennia (Austin 1978). About half of the world population uses at least one psychoactive substance, and although most do so without difficulties, for others problems arise that are related to the substance use (United Nations Office on Drugs and Crime 2005). Worldwide, drug and alcohol use disorders (excluding tobacco) are the sixth leading cause of disease burden in adults, whereas tobacco use and exposure to tobacco smoke are the leading preventable causes of death (World Health Organization 2003). Nationally (again excluding tobacco), 63% of American adults report that alcohol or drug addiction in themselves, family, or close friends has had an impact on their lives (Peter D. Hart Research Associates 2004). This chapter presents an overview of substance-related disorders, primarily focusing on those substances that are abused for their psychoactive effects, with additional material contained in the "Suggested Readings" listed at the end of the chapter.

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FIGURE 9–1. Neural circuitry implicated in the process of addiction.GABA = -aminobutyric acid.Source. Reprinted from Kalivas PW, Volkow ND: "The Neural Basis of Addiction: A Pathology of Motivation and Choice." American Journal of Psychiatry 162:1403–1413, 2005. Used with permission.

FIGURE 9–2. Alcohol Use Disorders Identification Test (AUDIT).Source. Reprinted from Babor TF, Higgins-Biddle JC, Saunders J, et al.: AUDIT, the Alcohol Use Disorders Identification Test, 2nd Edition. Geneva, Switzerland, World Health Organization, 2001. Available at: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf Accessed July 30, 2006. May be reproduced without permission for noncommercial purposes.

FIGURE 9–3. Clinical Institute Withdrawal Assessment for Alcohol—Revised (CIWA-Ar).Note. CNS = central nervous system.Source. Adapted from Sullivan et al. 1989.

FIGURE 9–4. Fagerström Test for Nicotine Dependence.Source. Adapted from Heatherton et al. 1991.
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TABLE 9–1. DSM-IV-TR classification of substance-related disorders
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TABLE 9–2. DSM-IV-TR diagnostic criteria for substance intoxication
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TABLE 9–3. DSM-IV-TR diagnostic criteria for substance withdrawal
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TABLE 9–4. DSM-IV-TR diagnostic criteria for substance abuse
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TABLE 9–5. DSM-IV-TR diagnostic criteria for substance dependence
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TABLE 9–6. DSM-IV-TR diagnoses associated with class of substances
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TABLE 9–7. ICD-10 classification of substance use disorders
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TABLE 9–8. Maximum alcohol consumption for low-risk drinking
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TABLE 9–9. Percentage of past-year substance users with abuse or dependence, by substance: 2004
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TABLE 9–10. The CAGE questions, adapted to include drugs
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TABLE 9–11. Basic components of substance use disorder evaluation
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TABLE 9–12. Stages of change
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TABLE 9–13. American Society of Addiction Medicine Patient Placement Criteria levels and dimensions
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TABLE 9–14. The Twelve Steps
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TABLE 9–15. Twelve-Step group Web sites
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TABLE 9–16. Empirically based psychosocial interventions
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TABLE 9–17. Blood alcohol level and corresponding symptoms of intoxication in the nontolerant patient
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TABLE 9–18. DSM-IV-TR diagnostic criteria for alcohol withdrawal
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TABLE 9–19. Laboratory abnormalities associated with harmful levels of drinking
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TABLE 9–20. Comparison of U.S. Food and Drug Administration–approved medications for the treatment of alcohol dependence
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TABLE 9–21. Symptoms of cannabis intoxication
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TABLE 9–22. Cannabis withdrawal symptoms
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TABLE 9–23. DSM-IV-TR diagnostic criteria for cocaine or amphetamine intoxication
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TABLE 9–24. DSM-IV-TR diagnostic criteria for cocaine or amphetamine withdrawal
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TABLE 9–25. DSM-IV-TR diagnostic criteria for opioid intoxication
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TABLE 9–26. Management of acute opioid overdose
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TABLE 9–27. Signs and symptoms of opioid withdrawal
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TABLE 9–28. Opioid detoxification medication protocols
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TABLE 9–29. DSM-IV-TR diagnostic criteria for nicotine withdrawal
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TABLE 9–30. Smoking cessation information Web sites
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TABLE 9–31. Principles of treatment for nicotine dependence
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TABLE 9–32. First-line pharmacotherapies approved for use for smoking cessation by the U.S. Food and Drug Administration*
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TABLE 9–33. DSM-IV-TR diagnostic criteria for sedative-hypnotic withdrawal
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TABLE 9–34. Sedative-hypnotics and their phenobarbital withdrawal equivalents
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TABLE 9–35. DSM-IV-TR diagnostic criteria for polysubstance dependence
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TABLE 9–36. CRAFFT questionnaire to identify problem drinking in adolescents
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Worldwide drug and alcohol use disorders, excluding tobacco, are the sixth leading cause of disease burden in adults, whereas tobacco use and exposure to tobacco smoke are the leading preventable causes of death.

Looking at lifetime risk, the NCS, conducted in the early 1990s, found that around one-third of the subjects who had smoked cigarettes at least once developed nicotine dependence, 15% of subjects who had ever drank alcohol developed alcohol dependence, and about 15% of subjects who had ever tried other drugs developed drug dependence.

Physicians should inquire about all classes of substances (e.g., alcohol, opioids, sedative-hypnotics, stimulants, cannabis, nicotine), including prescription medications, as well as legal and illegal substances, because a patient may not regard abuse of some substances to be as significant as that of others.

Although psychosocial and behavioral approaches are the cornerstones of treatment for substance dependence, medications are increasingly used to augment the treatment of alcohol, opioid, and nicotine dependence. Developing medications for the treatment of stimulant dependence is a federal research priority.

There are currently four medications with FDA approval for the maintenance treatment of alcohol dependence: disulfiram, naltrexone, a long-acting intramuscular formulation of naltrexone, and acamprosate.

The use of buprenorphine for detoxification or maintenance treatment in opioid dependence is increasingly common, in part because buprenorphine can be prescribed in a physician's office with up to 1 month's prescription at a time.

Although it may take several tries, the overall success rate in helping patients quit smoking is relatively good. The long-term (e.g., 12 months) quit rates for a single attempt are less than 10%, whereas the lifetime long-term quit rate is approximately 50%.

Polysubstance abuse is common; 56% of patients admitted to publicly funded treatment programs in 2002 reported abuse of more than one substance, and more than 70% smoked cigarettes. If undetected, polysubstance abuse can complicate the treatment of substance intoxication, withdrawal, abuse, or dependence.

Substance use disorders and other psychiatric disorders commonly co-occur, and the relationship is complex and bidirectional.

The recent increase in the rates of nonmedical use of prescription pain killers (specifically opioids) in adolescents is notable and concerning.

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For which of the following classes of substances does DSM-IV-TR (American Psychiatric Association 2000) recognize only the diagnoses of dependence and withdrawal?
2.
In the 2004 National Survey on Drug Use and Health, which of the following substances was associated with the highest percentage of past-year users meeting criteria for abuse or dependence?
3.
The Stages of Change model (Prochaska and DiClemente 1992) is useful for conceptualizing a patient's motivation to address substance use problems. The model divides the recovery process into sequential stages, requiring achievement of stage-specific goals before progression. Which stage has as its task determination of the best course of action?
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