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Substance Abuse

8.00 Contact Hours:
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A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Authors:    David Tilton (RN, BSN) , Susan Tilton (BSB BSMT)

Purpose/Goals

Substance abuse is at an all-time high. As health professionals we provide care to clients and families who find their bodies, minds, and quality of life shattered by direct and indirect consequences of ingesting substances of abuse at levels harmful to body and mind. We need to be alert for the best information concerning which substances have the potential for abuse, at what levels of consumption. We need the most current tools to assist our charges to decrease or eliminate harmful items from their day-to-day lives, while recovering quality of life to the best level possible.

Objectives

On completion of this educational activity, you will be able to:

  •   Discuss a basic definition of substance abuse.   
  •   Describe three signs/symptoms that would indicate a need to consider substance use disorder in a client.   
  •   Provide an overview of the brain response system associated with substances of abuse.   
  •   Name three common substance use disorder groups and a withdrawal symptom unique to each.   
  •   Outline one method of brief intervention used in dealing with substance use disorders.

Introduction

Pop stars, Hollywood screen personalities, the tipsy inebriated spectrum of celebrities that create a spectacle, surfing waves of psychoactive chemicals, make glamorous exciting news stories as we watch them stagger and carouse their way through glittery, drama-filled lives. Abuse of substances does not really lead to happy affairs or overflowing bags of money from product endorsements, despite the efforts of popular media to portray it that way. Studies, observation, and the rarest ability of all, common sense, tell a darker twisted story. The much too common tale of horrendous, yet potentially reversible, injuries to mind and body. What is needed is for health professionals to share what we know amongst ourselves, without being enmeshed in media half-truths or spins on facts. Whether we personally fall into the sweet trap of substances of abuse or not, each of us are affected by substance abuse as individuals, and as a society.

Scope of Problem

The voluntary, harmful use of substances remains amongst the foremost causes for preventable death. Unhealthy use or purposeful abuse of chemicals, medications, plant products, or other substances not meant to be used in such manners or such quantities creates problems frequently encountered by health professionals. (Saitz, R., 2013).

The unhealthy use of substances afflicts the old and the young, all economic levels, all cultural divisions. The annual National Survey on Drug Use and Health (NSDUH) reveals that despite concerted efforts, substance abuse continues to rise. The 2012 NSDUH places 23.9 million Americans aged 12 and older in the category of abusing psychotherapeutic medications (stimulants, pain relievers, tranquilizers, or other illicit substances) in the month prior to the survey. This is 9.2 percent of the population, up from an already high 8.3 percent in the 2002 survey. (DrugFacts: Nationwide Trends, January 2014).

Overutilization of any substance can lead to undesirable effects. Tendencies to overuse some manner of chemicals in our lives may be unduly influenced by inborn molecular genetic predispositions. Of concurrent importance is the presence of individualized behavioral rewards for using a given substance in the unhealthy manners we do. In order to shape what we know about substances we use, and at times become dependent on, a good global definition of substance abuse is warranted.

DSM-5 Substance Use Disorders

According to the newly revised fifth edition of the Diagnostic and Statistical Manual from the American Psychiatric Association, the essence of a substance use problem may be summed up by the phrase:

"cognitive, behavioral, and physiological symptoms indicating the individual continues using the substance despite significant substance-related problems."

(American Psychiatric Association DSM-5, 2013)

When the use of a specific substance harms us, common sense dictates we stop it. Unfortunately, substance abuse is not an area where the decrees of common sense apply. This may be in part due to the human ability to deceive ourselves when what we are doing or feeling is effecting us adversely, or perhaps we are simply too good at ignoring indications that personal disaster is approaching. Whichever it may be, abusive use of a chemical or substance, according to the Diagnostic and Statistical Manual of the American Psychiatric Association (APA DSM-5) may be recognized by groupings of physiologic, cognitive, or behavioral symptoms that demonstrate that an individual is using on a continuing basis a substance that is causing significant problems. The problem item can be a prescription medication, a recognized drug of abuse, or other substances that can be taken into the body.

Recognizing a Substance Use Disorder

In 2013 the American Psychiatric Association took a bold step and eliminated the confusing, often conflicting, diagnostic divide between chemical dependence and substance abuse. Formerly physical dependence with any signs of withdrawal from a substance meant addiction, a false and often dangerous treatment conclusion. Dependence on a medication or substance manifests with time in the natural metabolic process of tolerance, and when the substance is discontinued, progression into a withdrawal process due to central nervous system and metabolic shifts that occur from lack of the consistent presence of the substance. Unfortunately, the presence of normal withdrawal symptoms when ceasing use of a substance automatically flagged many non-addicts with the life-long label of substance abusers. For, while physical withdrawal does not automatically mean addiction, the widespread misunderstanding of normal dependence created a dangerous diagnostic trap. (WHO, 2014).

Physical versus Psychiatric Dependence

Physical dependence can occur during the use of many medications or substances, even when taken appropriately.

Physical dependence is NOT addiction.

With time the body adjusts to the presence of substances, adapting to maintain balanced function (a.k.a., homeostasis). With frequent use the body learns to tolerate the presence of a substance and anticipate its presence metabolically. This is reflected in the bodys enhanced ability to break down, utilize the chemical components of, and speedily excrete substances that are familiar.

When the presence of the substance ceases, metabolic balance again shifts, or withdraws from active preparations to utilize a familiar, anticipated substance. During this period of readjustment observable signs or symptoms of metabolic shifting will commonly be present.

Addiction IS a psychiatric illness.

Psychiatric dependence, compulsions and cravings, for a substance despite harmful consequences of continuing use, is the result of a shift in a persons normal hierarchy of needs and desires, placing the need to procure and use a specific substance above other normal needs or desires. This change in brain function, in thinking, planning, responding in a normal manner, separates the psychiatric dependence of addiction from physical dependence.

(National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide, 3rd ed., 2012)

With the release of the DSM-5 both of the diagnostic categories Substance Abuse and Chemical Dependence are eliminated and replaced with the more comprehensive category, Substance Use Disorders that regards the presence of unwanted effects of a substance on a continuum ranging from mild to severe. The presence of Substance Use Disorder is diagnosed with specific criteria, which then allows a more targeted focus according to the specific substance involved such as alcohol, caffeine, heroin, etc.

Not all people are automatically or equally vulnerable to substances associated with a risk for abuse. Some individuals have higher tolerances, or a faster metabolism for processing problematic chemicals. Others may have lower self-control or genetic predispositions allowing them to be more prone toward developing problems when exposed to specific drugs. The DSM-5 recognizes two general groups of substance related disorders: Substance Induced Disorders, and Substance Use Disorders.

Substance Induced Disorders are characterized by specific symptoms directly caused by a particular substance during or immediately after an individual episode of use.

Substance Induced Disorders Symptoms Include:
  • Intoxication
  • Withdrawal
  • Substance induced mental disorders (i.e. substance induced psychosis, substance induced depressive disorder, substance induced delirium, etc.)
(American Psychiatric Association DSM-5, 2013)

Substance Use Disorders are patterns of symptoms resulting from the use of a substance that the person continues to consume, despite experiencing problems as a result. Eleven different negative outcomes of substance use serve as the general substance use disorder diagnostic criteria. Severity of substance use can be isolated by the number of negative criteria affecting each person.

Substance Use Disorder Criteria:
  1. Taking the substance in larger amounts or for longer than you meant to.
  2. Wanting to cut down or stop using the substance but not managing to.
  3. Spending a lot of time getting, using, or recovering from use of the substance.
  4. Cravings and urges to use the substance.
  5. Not managing to do what you should at work, home or school, because of substance use.
  6. Continuing to use, even when it causes problems in relationships.
  7. Giving up important social, occupational or recreational activities because of substance use.
  8. Using substances repeatedly, even when it puts you in danger.
  9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
  10. Needing more of the substance to get the effect you want (tolerance).
  11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Severity of Substance Use Disorder - Indicated by number of symptom categories present:
  • MILD: Two or three symptoms indicate a mild substance use disorder,
  • MODERATE: four or five symptoms indicate a moderate substance use disorder, and   
  • SEVERE: six or more symptoms indicate a severe substance use disorder.
(American Psychiatric Association DSM-5, 2013)

Substances of abuse are not always illegal. Any substance can be the focus of a use disorder. Certain chemicals, prescription medications, or plant preparations tend to be found more frequently than others in conjunction with use disorders, however abuse patterns can be associated with the most innocent of items.

Substance Use Disorder (Other), Sugar

In February 2012 the science magazine Nature created a firestorm of opinions with the article "The Toxic Truth About Sugar". In it University of California researchers detail specific evidence concluding that;

"Sugar also has clear potential for abuse. Like tobacco and alcohol, it acts on the brain to encourage subsequent intake. There are now numerous studies examining the dependence-producing properties of sugar in humans."

Global sugar intake has tripled over the last 50 years and sugar consumption relates directly to disease processes resulting in 75% of all health care costs.

(Lustig, "The Toxic Truth About Sugar", 2012)
(Kearney, "Sugar Attacking Health Globally", 2012)

Illegal substances are those whose possession or use is deemed by federal or state statue to violate a judicial regulation or decision. Illicit substances are those whose use may or may not violate a specific law yet are considered wrong or unacceptable by prevailing social customs or standards. Illegal or illicit substances can, and frequently are, the subjects of substance abuse, and tend to be the items tracked by law enforcement and health advocacy groups whenever usage statistics are cited.

Use disorders can be present with legitimate and legal substances of use (i.e. alcohol, prescription pharmaceuticals, over the counter medications, tobacco, etc.). It is important as a health professional to be constantly aware that dependency is not limited to what are frequently referred to as "substances of abuse". Aunt Millies special cough elixir with its high composition alcohol base, sugar sweetening and other special ingredients can be the source of negative use consequences, which require identification and treatment.

Case Study: Gemina
Gemina is a 70 y/o type 2 diabetic female one day post ankle surgery. Her surgery was done using a regional anesthetic in order to decrease the possibility of complications. Other than oral hypoglycemics she is on no routine prescription medication, and indicates that the only over the counter items she regularly takes are a daily childrens aspirin and a mail order cough remedy she takes four times a day and whenever she feels it is needed. The client reports that she uses no recreational substances and is an adamant non-drinker.
In the admission notes, it indicates that the client brought both OTCs with her to presurgery admission despite being instructed that hospital policy prevent their use during her stay, and that she became upset and argumentative with the admissions staff when they were sent home with family.
Late in the post-op evening Gemina begins complaining of anxiety and uncontrollable "shivering". On examination, she is diaphoretic and tachycardic. Her BP is 164/90, P112, R22, Temp99.1. Her Blood Sugar, which was checked immediately by the attending nurse, is 71.
Resolution:
Review of admission paperwork and questioning of Gemina along with a phone call to her family reveal that the OTC adult liquid remedy that the client compulsively imbibes has high alcohol and high fructose corn syrup contents not listed on the label as "active" ingredients. The complex she takes four or more times daily is meant for once daily, and she keeps a bottle at her home bedside in case she has "difficulty sleeping" during the night as it seems to soothe her "nerves".
Geminas hypoglycemic medication is discontinued pending evaluation and she is diagnosed with acute alcohol withdrawal.

Brain Reward in Substance Use Disorders

Substance use disorder occurs in the brain. Brain reward is a term used to describe the recognition of, desire for, and drive to continue the use of a substance even after we consciously realize detrimental effect accompanies its use. Each of our brains closely regulates the interplay of chemicals we ingest during the ongoing balancing act of daily life. A key player in this ongoing and at times frantic, juggle of biochemistry is the brains reward system, the mesolimbic dopamine system. Research into brain chemistry is showing that brain reward can be triggered when a substance stimulates dopamine production in the mesolimbic system. Dopamine produced in this manner consequently affects an array of neurochemical and neurohormone messengers dependent on individual factors such as prevalent demands and functional imbalances. This helps explain why certain ingested chemicals are problematic to one person while not desired by another (e.g. one persons cravings for amphetamines rather than heroin even after being exposed to both). The uniqueness of the needs for balancing each of our individual brain chemistries plays a role in what triggers the brain reward response in each of us. (National Institute on Drug Abuse, Drugs Brains and Behavior, 2014).

Closely allied to the neurochemical brain reward response are the cognitive behavioral effects of substances. The correct chemical trigger at the proper time for the right person can nudge brain chemistry and make our thoughts and feelings regarding unpleasant life circumstances better, at least for a time. So closely linked are the behavioral rewards of substances consumed to the biochemical brain reward system, that no clear differentiation can be made. Even after negative consequences of substance use become evident in a dependent persons life and health, we cling to our chemicals of choice, hoping perhaps for better future results and fearing what life would be without the support of our ingested helpers.

Substances with a greater chance of leading to misuse have been grouped into major groupings by the American Psychiatric Association.

The DSM-5 Recognizes the Following
Substance Abuse Disorder Subcategories:
  1. Alcohol,
  2. Caffeine,
  3. Cannabis,
  4. Hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, other hallucinogens such as LSD),
  5. Inhalants,
  6. Opioids,
  7. Sedatives, Hypnotics, Anxiolytics,
  8. Stimulants (amphetamine-type substances, cocaine, and other stimulants),
  9. Tobacco,
  10. Other (or Unknown) substances.
(American Psychiatric Association DSM-5, 2013)

Substances in these high abuse risk groupings provoke the release of dopamine (either directly or indirectly) from the brain resulting in the brain reward response. Differences in what triggers the brain reward response and how sensitive each person is to that reward once triggered, contributes toward the level of risk for a substance use disorder, what is sometimes referred to as the abuse potential of the substance. (National Institute of Drug Abuse, Understanding Drug Abuse and Addiction, 2012).

Discussion Point: Seeking Dissociation

Those caught in the web of substance use disorder have an expansive range of motivations. Some become enmeshed while seeking relief from physical pain, depression, stress, anxiety, while others may be seeking more energy, greater creativity, or perhaps enhanced pleasure. Still others may be looking for emotional relief brought by a sense of numbness or a change of sensations. Often, awareness of any primary motivation for continued use past the point of negative life consequences will be absent;

(e.g., "I dont know why I became hooked, it just happened!").

Please be aware that one of the strong underlying primary motivations related to situations that develop into substance abuse is that of dissociation or escape. The shifting of the way which that individual feels about themselves, their life, or their frustrations - both related to specific or general situations.

Homework Assignment: When working with a substance use disorder client, set aside a brief interval to contemplate the following key principle;

"What is the primary benefit this person achieves from their substance of choice?"

Many people are able to control their use of substances with the potential for abuse without experiencing sustained or serious consequences from occasional responsible use. The experience of those who become burdened with unwanted dependence can be thought of as an abnormal level of response (brain reward) which leads to a desire for more of the substance inevitably followed by continuing increases in both the frequency of use and the amount of the item needed for effect. In conjunction with the substance ingestion, or resulting from consequences of the substance use, negative consequences arise giving the health professional diagnostic clues on which to home in.

Diagnostic Evidences

The best situation is the client who approaches their care provider with concerns about a substance they are taking and the negative consequences they are experiencing.

Yes, this does happen!

Substance misuse scenarios are not confined to what is portrayed on TV dramas. Frequently people find themselves in uncomfortable situations regarding prescription pain medications, social drinking, recreational substances, and so on. Often they voice concerns to health care providers that they have never voiced to anyone else, even their families, about adverse circumstances they are facing or unusual cravings that concern them.

Families and friends may also be the ones to bring a substance use concern up to the affected individual or to a trusted health care provider. The perceptions and concerns voiced by someone who knows the individual well should always be considered as a potential, needing follow up.

Both acute symptoms and chronic health consequences of substance use may bring the matter to the awareness of the health care system. Presenting symptoms can vary greatly depending on the individual and the substance involved, although some key diagnostic criteria are shared by each of the substance use disorders.

Shared Diagnostic Criteria
  • Impaired Control
    • Using for longer periods of time than intended
    • Using larger amounts than intended
    • Wanting to reduce use yet having no success doing so
    • Spending excessive time getting-using-recovering from substance use
    • Cravings
  • Social Impairment
    • Use leads to work-school-family-social problems
    • Use continues despite interpersonal problems, such as arguments about use
    • Use requires giving up important or meaningful activities
  • Risky Use
    • Uses substance during physically dangerous pursuits, such as when operating machinery, driving, or substance specific acts, e.g. smoking in bed
    • Use continues despite physical problems, illness, or mental health issues occurring from use
  • Pharmalogical Indicators
    • Tolerance occurs, leading to increasing amounts or shorter intervals needed to maintain the desired effects of use
    • Withdrawal symptoms occur when the substance is abruptly stopped
(Horvath, A., et al., 2013, August 26)

Substance Use Evaluation

All patients should be evaluated for substance use disorders. Studies demonstrate that eight of every 100 adults in the United States will have had at least one substance use disorder within the prior 12 months. Urine and blood tests on individuals admitted to hospital care units reveal 14% of medical admissions and 26% of mental health admissions have alcohol or other high risk for abuse substances in their systems at the time of admission. Health professionals are obligated to view all new clients as having the potential for a substance used disorder. (Weaver, M. and Jarvis, A., 2013).

Locating clues, signs and symptoms of a substance use disorder, depends on a combination of good screening, history taking, physical findings, psychiatric findings, and laboratory testing.

Laboratory Testing

For alcohol and other substances of abuse, laboratory testing has limited value during initial diagnosis as no specific laboratory test can establish an unequivocal diagnosis of substance use disorder. Testing for substances is however an essential component of every treatment regimen. It is extremely important to discuss with the laboratory toxicologist the substances they may be looking for, if known.

The presence of blood alcohol levels or detection of another drug may confirm the origin of confusion or other visible symptoms. Blood levels, urine drug screens, breathalyzer test results are all useful tools to assess for the presence of a suspected substance, for evaluation after an automobile or industrial accident, or in domestic abuse and other legal situations. Performing a drug screen in some situations (e.g., workplace, school, legal setting) may be controversial. It is therefore advisable to obtain the clients (or parents/guardians) permission before initiating drug screens.

Blood, urine, and saliva studies are crucial to the effectiveness of substance treatment programs. Unambiguous testing adds structure to programs that aids individuals regain self-control and self-respect.

One of the main concerns is that while blood or urine testing has the ability to indicate what is present at the time the specimen was obtained; it is much harder to determine either usage patterns or the effect the substance has on that individuals ability to function in life.

Testing for commonly abused substances can be performed on several types of specimens, such as urine, blood, hair, saliva, sweat, and even breath. Urine testing is the most common as it is noninvasive, easy to obtain, and has good reliability at indicating the consumption of a substance within the past several days. Blood levels provide the most information when correlated with impairment, however are invasive to obtain and have a shortened detection time as substances in the bloodstream continue to be subject to metabolic breakdown even after being drawn. When looking for evidence of long-term substance use, the best combination is often a good history with a confirmatory urine toxicology screen.

When reliability and validity of urine drug test samples are a concern, please be aware of the following tampering practices:

  •   Substitution with another sample   
  •   Direct dilution of sample (e.g., watering down)   
  •   Additives to sample that interfere with assay   
  •   Sample source ingesting large amounts of fluids to dilute concentration levels   
  •   Use of secondary substance to prompt false positives and invalidate useful data from sample (e.g., using a Vicks inhaler to create false amphetamine positives, NSAIDS for false barbiturates or cannabinoids, poppy seeds or fluoroquinolones for false opiate)

Strict observation during sample collection, along with a written chain of custody document for the specimen should be the standard of practice. Strict observation during sample collection, along with a written chain of custody document for the specimen should be the standard of practice.

Physical Findings

Always be alert for findings during physical examination that might provide clues to substance use:

  •   Infection, particularly among individuals administering to self by injection   
  •   Poor hygiene   
  •   Liver abnormalities, up to 90% of injection drug users will get hepatitis C   
  •   Oral thrush, which may indicate HIV infection, an offshoot of sharing needles   
  •   Productive cough, as there is a high rate of tuberculosis and community acquired pneumonia   
  •   Respiratory problems, from smoking or snorting substances   
  •   Needle marks, from recent injections even scarred injection "tracks" over venous sites   
  •   Unusual physical illness, burns or traumatic injuries   
  •   Sudden exacerbation of a previously well controlled disease state, such as hypertension or diabetes   
  •   Unexplained weight loss   
  •   Sleep disturbances   
  •   Evidence of intoxication or withdrawal processes

Mental Health / Psychiatric Findings

Individuals with a substance use disorder often present with sudden changes in mental health, frequently manifesting in social, occupational, work, or school issues. Other findings that can assist health professionals toward an accurate evaluation include:

  •   Depression, including lack of energy, loss of interest in eating, weight loss   
  •   Anxiety, agitation, sleep difficulties, behavioral changes   
  •   Psychosis, hearing, seeing or smelling things that are not there, often with a feeling of being followed

History from Patient

Whether truth or confabulation, a good patient history can be a gold mine for diagnostic work. When suspecting substance use disorder, please consider:

  • Ask first about socially acceptable substances such as caffeine or tobacco products. This helps to establish a level of comfort for the rest of the interview. Always ask "how many" and "how often" e.g.,"You mentioned you drink the occasional latte, how many of those during the course of a week?" "So you have three, 4 shot, Grande lattes, six days a week, is that correct?"
  • Next, inquire about alcohol use. Be sure to ask specifically about beer, wine, and spirits as many cultures do not consider beer to be alcohol.
  • Next, inquire about over the counter substances, including diet aids, cough and cold preparations, herbal supplements.
  • Ask about misuse of prescription items such as sleep medications, pain preparations, medications for attention deficit disorder or weight loss.
  • Next ask about marijuana, which is legal for use in some states or settings. Be sure to quantify how much, how often.
  • Next ask about illicit drugs. Be sure to be consistently non-judgmental and focus on the information needed for accurate health assistance. Street drugs such as heroin, cocaine, hallucinogens, methamphetamine and inhalants should be asked about here.
  • Remember to ask how much, how often, length of use pattern, and the last time each substance was used. Route of administration is also important, and be sure to ask whether the person has shared substances, especially injected drugs and needles.
  • If prior substance use disorders are mentioned ask about participation in Alcoholics Anonymous (AA), Narcotics Anonymous (NA), other twelve step programs, addiction treatments, detoxifications or periods of abstinence from the substance. Of special interest is the length of the longest period without the substance without using other illicit substances or alcohol to help maintain.
  • Ask the person what benefits they obtain from their substance of choice. This will be very helpful information when treatment for their substance use disorder begins.
  • And finally, ask what negative consequences have arisen from their substance use. Should they need coaching look for items in each of these three key areas;
    • Physical risks or illnesses sickness, accidents, fractures, burns, car wrecks
    • Psychiatric problems focusing problems, anxiety, depression, suicidal thoughts, psychosis
    • Relationship problems work, social relationships, legal difficulties, financial worries

Diagnostic procedures in the acute setting rely heavily on clinician experience, histories, and interviews. Laboratory drug screening is a good confirmation of suspicion for some of the more common substances of abuse. However, it will not replace the depth of information that comes from a thorough diagnostic workup and interview. One interview tool that has been shown to be useful is the RAFFT questionnaire for substance abuse.

RAFFT Questionnaire
  • R (relax) Does the client drink or take drugs to Relax, improve a self-image, or to fit in?
  • A (alone) Does the client ever drink or take drugs while Alone?
  • F (friends) Do any close Friends drink or use drugs?
  • F (family) Does a close Family member have a problem with alcohol or drugs?
  • T (trouble) Has the client ever gotten into Trouble for drinking or taking drugs?
(Brown University, 2014)

Family History

Think of this as a family medical history with a focus on how substance use is tolerated. Whenever a health professional hears that a blood relative has struggled with moderate to severe substance use disorder, a warning flag should go up. Children of alcoholics, for example, have a three to four fold heightened risk for developing alcohol use disorder themselves. Other common substances of abuse share similar genetic tendencies.

Remember, the genes they inherit do not make your client a bad person. It is simply knowledge they will need so that extra diligence can be practiced to avoid substances that their metabolism has difficulty dealing with properly. Clients with a positive family history for substance dependence deserve added assistance whenever possible to avoid relapse once they are clean and clear from a substance use disorder.

Social History

One of the key diagnostic criterion in the DSM-5 substance use curriculum is the effect of substance use on ones social world. A brief social history can reveal important information, such as:

  •   Relationship stresses with spouse, partners, or children   
  •   New problems at work or at school   
  •   Recent incidents involving violence   
  •   Accidents   
  •   Legal problems such as driving tickets, arrests for possession, public intoxication, etc.   
  •   Risky sexual behaviors   
  •   Issues with money

Please be aware that clues arising from unwanted changes in social areas are frequently the first visible signs of a growing substance use problem. Increasing family tensions, sudden poor performance at work or school, financial and legal troubles looming up, are all concerns that should be taken into account when applying the DSM-5 diagnostic criteria to your clients.

Diagnostic Criteria for Specific Substance Use Disorders

Substance Use Disorder: Alcohol Related Disorders

Alcohol has long been associated with negative consequences of use.

Alcohol is regarded by many to be the most widely overused substance of abuse. Most people who indulge, drink in moderation. Those who overuse or use to problem levels are approximately 7.2% or 17 million adults in the United States of those 18 and older as of 2012. (NIAAA, Alcohol Use Disorder, 2014).

Alcohol withdrawal symptoms tend to develop from 4-12 hours after reduction or ceasing intake following prolonged heavy ingestion. Withdrawal symptoms can be intense and therefore lead to a drive for continued consumption despite unwanted or unpleasant consequences simply to avoid the feelings of withdrawal. Certain withdrawal symptoms such as sleep disturbances can last for several months after discontinuing alcohol use, leading to a heightened tendency toward relapse into abusive drinking patterns.

Alcohol cravings can make job or social situations untenable as the desire to consume distracts from important life activities. Cravings lead to a high probability that individuals will consume during times when their full attention is needed to safely complete dangerous tasks, such as driving or operating machinery.

Alcohol consumption affects every organ system, especially the cardiovascular, gastrointestinal, peripheral and central nervous systems. Gastritis and ulcerations occur in around 15% of heavy drinkers, with high levels of liver cirrhosis and pancreatitis present. An increased gastrointestinal cancer rate has been identified among alcohol users and hypertension is commonly associated with alcohol use. Peripheral neuropathies and alcohol induced dementia accompany persistent use of this substance, while alcohol use disorder is a known contributor to suicide risk as well as depressive and bipolar disorders.

NIAAA, the National Institute on Alcohol Abuse and Alcoholism, a division of the National Institute of Health (NIH) gives recommendations on how to adapt the DSM-5 diagnostic criteria to form a substance specific questionnaire. This aid to diagnosis is a wonderful example of health professionals working together toward better problem identification.

NIAAA Alcohol Use Disorder Screening Tool:

To be diagnosed with an Alcohol Use Disorder (AUD), individuals must meet certain criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Anyone meeting any 2 of the 11 DSM-5 criteria during the same 12-month period receives a diagnosis of AUD.

The severity of an AUDmild, moderate, or severeis based on the number of criteria met.

To assess whether you or a loved one may have an AUD, here are some questions to ask. In the past year, have you:

  • Had times when you ended up drinking more, or longer than you intended?
  • More than once wanted to cut down or stop drinking, or tried to, but couldnt?
  • Spent a lot of time drinking? Or being sick or getting over the aftereffects?
  • Experienced craving a strong need, or urge, to drink?
  • Found that drinking or being sick from drinking often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
  • Continued to drink even though it was causing trouble with your family or friends?
  • Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
  • More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?   
  • Continued to drink even though it was making you feel depressed or anxious or adding to another health problem?
  • Had to drink much more than you once did to get the effect you want, or have found that your usual number of drinks had much less effect than before?
  • Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating? Or sensed things that were not there?
If you have any of these symptoms, your drinking may already be a cause for concern. The more symptoms you have, the more urgent the need for change. A health professional can conduct a formal assessment of your symptoms to see if an alcohol use disorder is present.
(NIAAA, Alcohol Use Disorder, 2014)

Even when being fully cooperative, clients frequently underestimate their own substance use. Tools such as the CAGE-AID conjoint alcohol and drug screening questionnaire can help the health provider gain the clearest understanding possible. A single positive response for any of the CAGE-AID questions is considered as suggestive of an alcohol or other substance use problem. Two or more positive responses increase specificity for a substance use problem to around 85-percent. Please remember when using the CAGE-AID tool that it is best utilized when not preceded by questions concerning types or numbers of drinks or other substances consumed.

CAGE-AID Questionnaire for Alcohol and Drug Use
C Have you ever felt you ought to Cut down on your drinking or drug use?

A Have people Annoyed you by criticizing your drinking or drug use?

G Have you ever felt bad or Guilty about your drinking or drug use?

E Have you ever had a drink or used drugs first thing in the morning

(Eye-opener) to steady your nerves or get rid of a hangover?
(SAMHSA-HRSA, 2014)

Alcohol Use Disorder is less about blood levels and more about adverse consequences of use. As health practitioners, we may not actually need to quantify consumption amounts to great detail. However, learning the typical amount of intake during both "normal" and "binge" episodes can be helpful in both risk assessment for chronic health concerns and later in counseling for dependency.

Alcohol Consumption
Moderate alcohol consumption;
  • Dietary Guidelines for Americans list up to 1 drink per day for women, up to 2 drinks per day for men
    Binge drinking;
  • NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. This typically occurs after 4 drinks for women and 5 drinks for menin about 2 hours.
  • The Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual National Survey on Drug Use and Health (NSDUH), defines binge drinking as drinking 5 or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days.
Heavy drinking;
  • SAMHSA defines heavy drinking as drinking 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days.
Those who should avoid alcohol completely include;
  • Those planning to drive a vehicle or operate machinery
  • Take medications that interact with alcohol
  • Have a medical condition that alcohol can aggravate
  • Are pregnant or trying to become pregnant
NOTE: The CDC regards one drink as 12 ounces of beer (5% alcohol content), 8 ounces of malt liquor (7% alcohol content), 5 ounces of wine (12% alcohol content), or 1.5 ounces of 80-proof (40% alcohol content) distilled spirits or liquor -- the fancy term for gin, rum, vodka, whiskey etc.
(NIAAA, Drinking Levels Defined, 2014)
(Christensen, J., 2014, June 27)

The old adage "once a drunk always a drunk" does not hold up to scientific scrutiny. Alcohol use tends to be variable across an individuals lifespan, characterized by periods of remission and relapse with co-morbid conditions often playing a significant role in usage patterns. The presence of a conduct disorder, such as childhood conduct disorder or adult antisocial personality disorder, as well as other mood or perceptual conditions increases the tendency to use alcohol in access to that persons detriment.

Alcohol Intoxication, Diagnostic Criteria
  1. Recent ingestion of alcohol
  2. Problematic behavioral or psychological changes (e.g., aggressive, inappropriate sexual behavior, impaired judgment, mood labiality) developing during or shortly after alcohol ingestion.
  3. One or more of the following developing during or shortly after alcohol use;
    1. Slurred speech
    2. Incoordination
    3. Unsteady gait
    4. Nystagmus
    5. Impairment in memory or attention
    6. Stupor or coma
  4. Notable signs and symptoms are not attributable to another medical or mental condition nor explained by another substance.
(American Psychiatric Association DSM-5, 2013)

Withdrawal symptoms are associated with substances of abuse. For alcohol, the trials associated with the return of metabolic functions to a pre-alcohol state are sufficiently unpleasant that many drinkers are unable to quit without support, preferring to endure the negative impact of continued use rather than face the unpleasant facts of withdrawal. Symptoms of alcohol withdrawal tend to occur within 8 hours of the last drink and usually peak around 24-72 hours. Symptoms may persist for weeks, and in the case of sleep disturbances, months.

Alcohol Withdrawal Characteristics
Common symptoms include;
  • Nervousness or anxiety
  • Depression
  • Fatigue
  • Irritability
  • Shakiness or jumpiness
  • Mood swings
  • Nightmares 
  • Inability to think clearly
 Other symptoms may include;
  • Dilated (enlarged) pupils
  • Clammy skin
  • Headache
  • Insomnia
  • Loss of appetite
  • Nausea and/or vomiting
  • Pallor
  • Rapid heart rate
  • Sweating
  • Tremors of hands or other parts of the body
 Delirium tremens is a severe form of alcohol withdrawal and may include;
  • Agitation
  • Fever
  • Hallucinations
  • Seizures
  • Extreme confusion
(Dugdale III, David., 2013)

Substance Use Disorder: Caffeine Related Disorders

Caffeine is the most commonly used drug in the world according to a 2013 study. Excessive consumption of caffeine combined with negative physical and psychological symptoms, particularly during withdrawal, demonstrates according to researchers, a clear caffeine use disorder. (CBS DC, 2014) (Meredith, S. et al., 2013).

Caffeine is contained in many of the products we consume. For a healthy adult no more than 400mg of caffeine per day should be consumed, about two or three 8oz cups. Most adults consume far in excess however, putting caffeine into the lists of recognized substances of abuse.

Caffeine has long been recognized as a stimulant. Its CNS effects work to temporarily ward off sleepiness and restore alertness along with a mild energy boost. It is no wonder caffeine is the top consumed psychoactive drug in the world. In low to moderate doses caffeine can aid in lowering depression in many people. However, high amounts can lead to agitation, psychosis and mania. Sleep disturbances related to caffeine consumption are frequently reported. Even moderate regular doses of around 300mg have been observed to induce or trigger preexisting anxiety disorders.

Caffeine Intoxication, Diagnostic Criteria
  1. Recent consumption of caffeine (dose in excess of 250mg)
  2. Five or more of the following developed during or shortly after caffeine use
    1. Restlessness
    2. Nervousness
    3. Excitement
    4. Flushed face
    5. Diuresis
    6. Gastrointestinal disturbance
    7. Muscle twitching
    8. Rambling though or speech
    9. Tachycardia or other cardiac arrhythmia
    10. Periods of inexhaustibility
    11. Psychomotor agitation
  3. These signs or symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  4. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

It is not just the triple shot slurping designer coffee consumer that faces overuse issues with caffeine. The crystalline xanthine alkaloid that is caffeine is present in tea, coffee, caffeinated sodas, the so-called "energy" drinks, weight-loss preparations, certain over the counter analgesics and cold remedies, vitamins, chocolate, and as an additive to a diverse ensemble of food products. More than 85% of children and adults consume caffeine regularly. It is no wonder that many find themselves experiencing both tolerance and withdrawal symptoms, without even realizing what behavioral choices have led them to this point.

Caffeine Withdrawal, Diagnostic Criteria
  1. Prolonged daily use of caffeine
  2. Abrupt cessation of or reduction in caffeine consumption, followed within 24 hours by three or more of the following;
    1. Headache
    2. Marked fatigue or drowsiness
    3. Dysphoric mood, depressed, mood, or irritability
    4. Difficulty concentration
    5. Flu like symptoms (nausea, vomiting, muscular pain/stiffness)
  3. These signs or symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  4. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Caffeine dependence is very common amongst individuals who report experiencing common severe headaches. Some have made the association that should they miss their morning tea, coffee, or other form of energy drink a severe headache will follow. Ironically the stimulation or energy they once sought from caffeine fades as tolerance sets in, requiring ever increasing amounts of caffeine in ever shorter intervals simply to maintain an equilibrium of perceived benefit. Symptoms from caffeine withdrawal tend to appear within 12 to 14 hours of last consumption and are at their worst roughly 48 hours after last dose. Headache, malaise and associated feelings tend to linger up to 21 days before fading.

Substance Use Disorder: Cannabis Related Disorders

Cannabis has been a part of civilization for at least 5000 years, according to archeological evidences. No doubt its use, beyond having a marvelous fiber content, has been the subject of debate just as long.

Cannabis is not simply marijuana anymore. It grows from three separate species of flowering plants with the genus "Cannabis", Cannabis sativa, Cannabis indica, and Cannabis ruderalis, as well as literally thousands of domestic hybrid variations. Cannabis can be smoked, baked, made into candy, oils, ointments, crystals, and miscellaneous inhalants such as preparations compatible with electronic cigarettes.

Cannabis possesses more than a single psychoactive component. Cannabinoids is the term for those natural components that are unique to the Cannabis plant. Like in opiates where opioid chemicals are derived from the opium poppy, cannabinoids are the unique psychoactive substances found in cannabis. Some sixty-six cannabinoids have been identified in cannabis, with the research focus to date being on Tetrahydrocannabinol (THC), considered the most potent of the cannabinoids. Especially with hybrid cannabis, other psychoactive cannabinoids play active roles as well. Cannabidiol (CBD) for instance, has shown in small scale studies interesting antianxiety potential and is thought to have an active role in buffering the stimulant and anxiety producing qualities possessed by straight THC. (NCPIC, 2013).
Approximately 4% of the worlds population between the ages of 15 and 64 years old, or around 160 million people, have used cannabis in the last year, making this the most commonly cultivated and used illegal substance worldwide. Patterns of intoxication, tolerance, and withdrawal with cannabis use are consistent and recognizable diagnostically. (DuPont, R., et al., 2014).

Cannabis Use Disorder, Diagnostic Criteria
  1. A problematic pattern of cannabis use leading to clinically significant impairment or distress, manifested by at least two of the following, within a 12-month period.
    1. Cannabis often taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of it.
    4. There is a craving or strong desire to use.
    5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Continued use occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of use.
    7. Use of occurs in situations in which it is physically hazardous.
    8. Use continues despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by the substance.
    9. Tolerance has occurred, as defined by either of the following;
      1. A need for markedly increased amounts of cannabis to achieve intoxication or desire effect.
      2. Markedly diminished effect with continued use of the same amount of cannabis.
    10. Withdrawal as indicated by characteristic cannabis withdrawal symptoms or the use of a closely related substance to cannabis is taken to relieve or avoid withdrawal symptoms.
(American Psychiatric Association DSM-5, 2013)

Cannabis use disorder onset can occur at any age, though adolescence or young adulthood tends to be the most common. The negative results to health and social behaviors that indicate the use disorder tend to become evident after prolonged cannabis use, although the progression is more rapid among adolescents. Most of those who develop problems with cannabis feel that they are not having severe enough difficulties to warrant concern, after all, the reasoning goes, cannabis is visibly less harmful than either alcohol or tobacco use. Unfortunately, this perception tends to lead to increased use.

Inherited metabolic traits contribute to the development of cannabis use disorders, as do environmental and social factors. Research has demonstrated that some individuals are able to tolerate cannabis use without significant consequence, while others follow an inevitable slippery slope to significant troubles. Approximately 9% of all users will become addicted to cannabis. Among those who start young, this percentage increases to around 17%, and among those who use daily, addiction jumps to between 25-50%. (National Institute of Drug Abuse, Drug Facts Marijuana, 2014).

Cannabis users report impaired judgment and lack of coordination while using, as well as altered perception and mood. Difficulty thinking, concentrating and problem solving appear consistent among users and in a large long-term study of New Zealand youth ages 13 through 38, those who began smoking cannabis as teenagers showed a reduction of 8 points IQ on average. Sadly, the lost cognitive abilities were not fully restored even when cannabis use was discontinued.

Cannabis Intoxication, Diagnostic Criteria
  1. Recent use of cannabis.
  2. Clinically significant problematic behavioral or psychological changes (e.g., euphoria, impaired motor coordination, anxiety, sensation of slowed time, social withdrawal, impaired judgment) developed during or shortly after cannabis use.
  3. Two or more of the following developing within 2 hours of cannabis use
    1. Conjunctival injection (redness in the white sclera of the eye)
    2. Increased appetite
    3. Dry mouth
    4. Tachycardia
  4. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Cannabis withdrawal symptoms may cause levels of distress that push the person toward resuming intake rather than face them. While hospitalization due to withdrawal symptoms of cannabis is rarely medically needed due to threat to life, symptoms are sufficiently unpleasant as to warrant support from friends or others who have faced similar situations. Withdrawal will significantly impact work and social situations with the major part of the symptoms lasting approximately two weeks.

Cannabis Withdrawal, Diagnostic Criteria
  1. Cessation of cannabis use that has been heavy and prolonged, e.g. daily or almost daily use over a period of at least a few months.
  2. Three or more of the following developing within approximately 1 week from time of cannabis cessation;
    1. Irritability, anger, or aggression
    2. Nervousness or anxiety
    3. Sleep difficulty (e.g., insomnia, disturbing dreams)
    4. Decreased appetite or weight loss
    5. Restlessness
    6. Depressed mood
    7. At least one of the following causing significant discomfort: abdominal pain, shakiness/tremors, sweating, chills. fever, headache
  3. These signs or symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  4. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Unusual levels of fatigue, yawning, or difficulty concentrating, also accompany cannabis withdrawal. Most symptoms appear within 24-72 hours of cessation, peak within a week, and persist for around two weeks. Sleep difficulties linger however and may last for the next 30 days or so.

Substance Use Disorder: Hallucinogen Related Disorders

Hallucinogens and other dissociative chemicals comprise a diverse group. They disrupt an individuals ability to think, communicate rationally, and recognize reality. Needless to say, this can lead at times to bizarre or dangerous behaviors.

Hallucinogens all produce alterations to perception, mood, and cognition. Phencyclidine and closely related phencyclidine-like chemicals form the larger of the two subgroups under hallucinogen use disorders in the DSM-5. Phencyclidine in its most common form will be readily recognized by the street names PCP or angel dust. Ironically, phencyclidine and its various close cousins were originally developed to aid people as adjuncts to anesthesia during surgery and invasive procedures. Instances where the trademark dissociative effects without full unconsciousness would be desirable. Unfortunately, the effects of phencyclidine, ketamine, cyclohexamine, dizocilpine, and the handful of other related chemicals have found a much too eager audience in the recreational drug and date rape crowd.

Phencyclidine related chemicals commonly cause dissociative effects including numbness, hallucinations, psychosis, agitation, and violent behaviors. Seizures, hypoglycemia, and potentially life threatening hyperthermia can occur.

It is not uncommon for those affected by the phencyclidine related substances to be unaware they are consuming them. PCP is a frequent additive to street cannabis products, while ketamine and other related phencyclidines are a favorite for slipping into anothers drink as a joke or for more sinister purposes.

Phencyclidine Use Disorder, Diagnostic Criteria
  1. A problematic pattern of Phencyclidine or pharmacologically similar substance use leading to clinically significant impairment or distress, manifested by at least two of the following, within a 12-month period.
    1. Taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of.
    4. There is a craving or strong desire to use.
    5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Continued use occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of use.
    7. Use of occurs in situations in which it is physically hazardous.
    8. Use continues despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by the substance.
    9. Tolerance has occurred, as defined by either of the following;
      1. A need for markedly increased amounts to achieve intoxication or desire effect.
      2. Markedly diminished effect with continued use of the same amount.

NOTE: Withdrawal signs or symptoms have not yet been established for phencyclidines, so this criterion for diagnosis does not exist.

(American Psychiatric Association DSM-5, 2013)

The "Other" grouping of hallucinogen use disorders comprises everything except the phencyclidines that have the primary characteristics of alterations to perception, mood, and cognition. Hallucinogens tend to be used for what is often referred to as their "psychedelic effects". These effects include the distortion or heightening of sensory stimuli, the enhancement of feelings, and the sensation of introspection. Most hallucinogens produce sympathomimetic effects such as hyperthermia, hypertension, tachycardia, diaphoresis, nausea and vomiting. Interestingly vomiting often occurs immediately prior to the onset of hallucinogenic effects, and can be a sought after signal to users that the "best" is yet to come.

LSD, lysergic acid diethylamide, is regarded as the prototypical hallucinogen and has been extensively studied. Recently it has been passed over in amount of use by a group of hallucinogens often referred to as the "club drugs" (e.g., the synthetic cannabinoids K2, spice, etc.), along with ecstasy and a variety of mass cultivated natural growing hallucinogens such as psilocybin and Salvia divinorum. During 2012, approximately 1.1 million people in the United States used hallucinogens. (Delgado, J., 2014).

Many and chemically varied are the substances in this subgrouping under hallucinogen use disorders.

Examples of Other Hallucinogen Use Disorder substances;

  •   Lysergic acid derivatives (LSD) LSD and closely related designer drugs   
  •   Dextromethorphan (DXM) Levorphanol, a chemical analogue of codeine   
  •   Phenylethlamines Mescaline from the peyote cactus, amphetamines, methamphetamines, MDMA ecstasy, many designer drugs   
  •   Tryptamines psilocybin found in some mushrooms, AMT a synthetic developed in the 1960s as a possible antidepressant, Foxy a South American drink known there as Ayahuasca   
  •   Ethnobotanicals - Salvia divinorum a perennial herb in the mint family, jimsonweed a nightshade family plant with strong toxic effects

Users of MDMA ecstasy, as well as other hallucinogens, have a higher prevalence of other substance use disorders, than do substance users that do not use hallucinogens. (American Psychiatric Association DSM-5, 2013).

Other Hallucinogen Use Disorder, Diagnostic Criteria
  1. A problematic pattern of Phencyclidine or pharmacologically similar substance use leading to clinically significant impairment or distress, manifested by at least two of the following, within a 12-month period.
    1. Taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of.
    4. There is a craving or strong desire to use.
    5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Continued use occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of use.
    7. Use of occurs in situations in which it is physically hazardous.
    8. Use continues despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by the substance.
    9. Tolerance has occurred, as defined by either of the following;
      1. A need for markedly increased amounts to achieve intoxication or desire effect.
      2. Markedly diminished effect with continued use of the same amount.

NOTE: Withdrawal signs or symptoms have not yet been established for phencyclidines, so this criterion for diagnosis does not exist.

(American Psychiatric Association DSM-5, 2013)

Phencyclidine intoxication effects occur quickly after taking the substance in. Typically the user experiences early confusion without hallucinations, disorientation, with later hallucinations and delusions, followed by a catatonic like state and possibly coma of varying degrees. Intoxication generally lasts several hours, however, depending on factors such as, amount of substance used, other substances used, may last several days or even longer.

Bizarre, violent behaviors coupled with neuromuscular effects such as nystagmus tend to distinguish phencyclidine intoxication from other hallucinogen intoxication. Phencyclidine is also detectable in urine for up to 8 days. Unfortunately, detected amounts associate only weakly with the persons clinical condition.

Phencyclidine Intoxication, Diagnostic Criteria
  1. Recent use of phencyclidine or a closely related substance.
  2. Clinically significant problematic behavioral or psychological changes (e.g., belligerence, assaultive, impulsiveness, unpredictability, psychomotor agitation, impaired judgment) developed during or shortly after use.
  3. Within 1 hour, two or more of the following occur: (NOTE - When phencyclidine is smoked, snorted, or used intravenously symptom onset may be very rapid.)
    1. Vertical or horizontal nystagmus
    2. Numbness or diminished responsiveness to pain
    3. Hypertension or tachycardia
    4. Ataxia
    5. Dysarthria
    6. Muscle rigidity
    7. Seizures or coma
    8. Hyperacusis (often painful oversensitivity to sound or particular sounds)
    9. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Other hallucinogen intoxications may look different than phencyclidine intoxication. Most hallucinogens are ingested orally, and depending on the substance, the time of onset and duration may vary widely. Salvia divinorum for instance is typically ingested by extensive chewing of the leaves, taking a long onset for an intoxication duration of mere minutes. LSD or ecstasy on the other hand may have rapid onset with a duration lasting many hours or longer.

Impaired judgment and muddled perceptions associated with other hallucinogens can lead to heightened injury from accidents or self-injuries, although suicide is reported to be rare among other hallucinogen users. Continued use of hallucinations can have significant health consequences, MDMA in particular has been associated with neurotoxic effects.

Other Hallucinogen Intoxication, Diagnostic Criteria
  1. Recent use of a hallucinogen (other than phencyclidine).
  2. Clinically significant problematic behavioral or psychological changes (e.g., marked anxiety, depression, ideas of reference, fear of losing ones mind, paranoid ideation, impaired judgment) developed during or shortly after use.
  3. Perceptual changes in state of wakefulness and alertness (e.g., subjective intensification of perceptions, depersonalization, derealization, illusions, hallucinations, synesthesia) that develop during or shortly after use.
  4. Two or more of the following signs or symptoms that develop during or shortly after use.
    1. Pupillary dilation
    2. Tachycardia
    3. Sweating
    4. Palpitations
    5. Blurring of vision
    6. Tremors
    7. Incoordination
  5. E. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Unlike other substance use disorders, hallucinogens can be a recording experienced over and over, despite ceased ingestion of the active substance. Hallucinogen persisting perception disorder (HPPD) is re-experiencing the perceptual symptoms, even while sober, that were experienced during active intoxication with the substance. Often referred to as LSD flashbacks, any hallucinogen has the capability to produce lingering reoccurring perceptual effects.

HPPD occurs infrequently in hallucinogen users, however can occur on the very first use of a hallucinogen substance, and again after any further usage thereafter. HPPD can affect any of the perceptions however most commonly seems to effect the visual perceptions, often blurring, warping, adding colors, patterns, or other effects to what that individual perceives. The duration of effect onset of can vary from a momentary perception flicker, to individuals who suffer 24-hour-a-day perceptual shifting. In those with persistent HPPD the visual effect is often experienced as an all-inclusive geometric pattern, such as checkerboard squares or diamonds superimposed on everything seen. These pattern-like perceptions are reported to be most vivid when looking at blank surfaces such as walls. Others report flashes of light or lightening trails that follow moving images. HPPD may fade away within months of ceasing hallucinogen use, or might linger much longer.

Many hallucinogen persisting perception disorder sufferers insist there is a decrease in symptoms when wearing sunglasses. Keep in mind that clients wearing sunglasses inside, or at nighttime generally have a reason, so be sure to inquire why they are wearing sunglasses.

Hallucinogen Perception Disorder, Diagnostic Criteria
  1. Following cessation of use of a hallucinogen, the re-experiencing of one or more of the perceptual symptoms that were experienced while intoxicated with the hallucinogen (e.g., geometric hallucinations, false perceptions of movement in the peripheral visual fields, flashes of color, intensified colors, trails of images of moving objects, positive afterimages, halos around objects, macropsia and micropsia).
  2. Symptoms cause clinically significant distress or impairment to social, occupational, or other important areas of functioning.
  3. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Substance Use Disorder: Inhalant Related Disorders

Inhalant use disorders include aerosolized substances with significant acute and chronic toxicity that are used for intoxicating properties. The majority of inhalants abused are volatile hydrocarbons (e.g., the gases from paints, glues, fuels, etc.). Due to the variety of volatile inhalants available, the particular substance being used should be named in the diagnosis whenever it is known (e.g. "toluene use disorder"). Unfortunately it is rarely that simple as volatile hydrocarbons are usually used in compounds consisting of several chemicals, each of which will have psychoactive properties. Lacking clear evidence that a single, unmixed substance was used the general term "inhalant" should be used in the diagnosis (e.g., "inhalant use disorder").

Inhalant use is particularly attractive to children and adolescents due to the common availability of volatile chemicals in the average household, the low cost of inhalants, ease of purchase, and the perception that any health risk involved with inhalant use is negligible.

Sadly, the truth of the matter is that research has firmly associated inhalant use with liver toxicity, cardiac problems, acute renal failure, permanent brain injury, and death. (Perry, H., 2014).

Inhalant Use Disorder, Diagnostic Criteria
  1. A problematic pattern of a hydrocarbon based inhalant substance leading to clinically significant impairment or distress, manifested by at least two of the following, within a 12-month period.
    1. Taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of.
    4. There is a craving or strong desire to use.
    5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Use continues despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated.
    7. Tolerance has occurred, as defined by either of the following;
      1. A need for markedly increased amounts to achieve intoxication or desire effect.
      2. Markedly diminished effect with continued use of the same amount.
(American Psychiatric Association DSM-5, 2013)

Tolerance and mild withdrawal symptoms occur in only 10% of those chronically using inhalants making these aspects of use difficult to interpret as a diagnostic indicator.

Inhalants rapidly cross the pulmonary bed into the bloodstream, achieving fast distribution throughout the body. Neurons are particularly susceptible due to their high lipid content that succumbs easily to volatile hydrocarbon absorption. Inhalants produce effects within seconds that typically last from 15 to 45 minutes. Euphoria is followed by lethargy, with impairment of coordination and judgment. Stacking doses, taking one hit after another, helps to maintain the effects by boosting blood levels with repeated use. Bagging, sniffing and huffing are all terms for inhaling methods, with the dosage inhaled increasing from sniffing to huffing to bagging. (Perry, H., 2014).

  • Sniffing refers to inhaling directly from an open container or spraying the source item onto a heated surface and inhaling the vapors released.
  • Huffing entails saturating a cloth or sponge with a volatile liquid and holding that under the nose or near the mouth.
  • Bagging places the open source or saturated cloth into a plastic or paper bag that is then placed over the nose, mouth, or head. The risk of asphyxia with bagging is high due to hydrocarbons displacing oxygen in the lung alveoli. Be alert that a high association with suicide accompanies individuals who bag using the over-the-head method.

It is easy to miss inhalant use and it frequently goes undetected. Clues must often be found from odd chemical odors on the breath or rising from skin or clothes. The presence of discarded glue tubes or spray cans in the individuals living area or trash is a useful indicator. A facial pruritus often referred to as glue sniffers rash occurring around nose and mouth from the drying effects of volatile hydrocarbons can be a helpful indicator.

Inhalant Intoxication, Diagnostic Criteria
  1. Recent intended or unintended short-term high-dose exposure to inhalant substances including volatile hydrocarbons such as toluene or gasoline.
  2. Clinically significant problematic behavioral or psychological changes (e.g., apathy, impaired judgment, belligerence, assaultiveness) developed during or shortly after use.
  3. Two or more of the following signs or symptoms that develop during or shortly after use;
    1. Dizziness
    2. Nystagmus
    3. Incoordination
    4. Slurring of speech
    5. Unsteady gait
    6. Lethargy
    7. Depressed reflexes
    8. Tremor
    9. Psychomotor retardation
    10. Generalized muscle weakness
    11. Blurred vision or diplopia
    12. Stupor or coma
    13. Euphoria
  4. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Inhalant use disorders with nitrous oxide, amylbutyl, or isobutylnitrite are regarded as inhalant use (other) disorders. Just as the other inhalants they are highly volatile substances possessing lipid solubility that easily move across the lung pulmonary bed into the bloodstream.

Whippets is the most common technique for nitrous oxide inhalation. A whippet is a small cylindrical metal bulb containing compressed nitrous oxide for use as a propellant for whipped cream makers. The end of the metal bulb is designed to be easily pierced and substance users catch escaping nitrous oxide in a balloon from which it can easily be inhaled. Nitrous oxide can also be sniffed directly from whipped cream canisters. The desired effects from nitrous oxide include lightheadedness, euphoria, and the general feeling of intoxication produced by cannabis or alcohol. Effects tend to last from 15 to 30 minutes from a single dose. Undesired effects from repeated use include neurologic problems such as polyneuropathy, ataxia and psychosis.

Alkyl nitrites (e.g., amyl, butyl, and isobutyl nitrates found in deodorizer and incense products) produce intense vasodilation leading to a pleasurable sensation of warmth. Hypotension and tachycardia accompany the brief effects, lasting around five minutes. Sexual pleasure seekers inhale nitrites in an effort to promote penile erection and anal sphincter relaxation. Undesired results of repeated use include headache, nausea, dizziness, wheezing, and even methemoglobinemia a condition where the iron in red blood cells can no longer bind to oxygen. (Perry, H., 2014).

Substance Use Disorder: Opioid Related Disorders

Opioids are old friends to the health care professional. So much relief from pain and suffering can be attributed to proper use of the opioid family that it saddens us that there is the flipside of misuse and abuse that also occurs.

The term opioid use disorder (OUD) is the new diagnostic standard. It combines the previous opioid dependence and opioid abuse, also pulling in the wide range of opioid related prescriptions and illicit chemicals. Though it may seem generic, opioid use disorder guidelines by the American Psychiatric Association express the expectation that the specific agent will be added to the diagnosis once identified e.g., Opioid Use Disorder; Heroin, or, Opioid Use Disorder; Oxycontin, LAAM, or others.

Quick Fact:
This is the age of synthetic and designer drugs.
  • LAAM, or levo-alpha-acetyl-methadol is a synthetic opioid approved by the FDA in 1993 for the treatment of opioid dependence. Used much like methadone, LAAM can be taken 2-3 times a week instead of daily as in methadone treatment regimens.   
  • LAAM is no longer legally manufactured due to concerns about cardiac arrhythmia; however, authorized clinics continue to provide LAAM amongst their withdrawal options and other, not so legal enterprises make LAAM and other opioid synthetics available for recreational users.   
  • LAAM and other synthetic drugs are edging in on the recreational substance use market. Be aware that other players are out there that may not fit a cookie cutter diagnostic workup.
(Strain, E., 2014)

Please remember substance use and abuse basics. Not everyone taking a particular medication or street substance is an addict. With opioids especially, the current trend in health care is to label anyone on prescription analgesics either an addict or an addict in the making. Opioids are an acceptable means of managing pain, both for short periods and long. It is an expectation that an individual utilizing them for legitimate reasons will, over time, begin to develop a physical tolerance for the medication, and upon abrupt discontinuation, experience withdrawal type symptoms as their metabolism adjusts to the absence of the opioid. Neither tolerance or withdrawal make an addict. The DSM-5 emphasizes repeatedly that use of a substance does not make a person an addict.

Motivation for use has an important role for opioids. During assessment, ask your client whether they gain benefit from their opioid beyond the relief of pain. Feelings of well-being, euphoria, a feeling of relaxation, or a raise in mood beyond what may be attributed to pain relief. Frequently those who utilize opioids for the purpose of mood elevation or dissociation with current troubles will tell you outright, if asked. Client survey tools such as the Current Opioid Misuse Measure (COMM) or Screener and Opioid Assessment for Patients with Pain (SOAPP) are available for use when client motivation for opioid use is uncertain.

Opioid use disorder focuses on the detrimental consequences of repeated opioid use along with an observable pattern of compulsion or cravings to use. OUD is only diagnosed when opioid use becomes persistent and causes significant educational, occupational or social impairment. Commonly abused opioids include heroin, codeine, fentanyl, morphine, opium, methadone, oxycodone, and hydrocodone.

Opioid Use Disorder, Diagnostic Criteria
  1. A problematic pattern of opioid use leading to clinically significant impairment or distress, manifested by at least two of the following, within a 12-month period:
    1. Taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of.
    4. There is a craving or strong desire to use.
    5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Continued use occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of use.
    7. Use of occurs in situations in which it is physically hazardous.
    8. Use continues despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by the substance.
    9. Tolerance has occurred, as defined by either of the following;
      1. A need for markedly increased amounts to achieve intoxication or desire effect.
      2. Markedly diminished effect with continued use of the same amount.
    10. Withdrawal as manifested by either of the following:
      1. Characteristic opioid withdrawal syndrome detailed in the opioid withdrawal table.
      2. The use of opioids or closely related substances to relieve or avoid withdrawal symptoms.
(American Psychiatric Association DSM-5, 2013)

Individuals with opioid use disorder may show no acute symptoms that would trigger an inquiry into that persons health history. Opioid users may also appear intoxicated, or show signs of substance withdrawal. Opioid intoxication may appear as slurred speech, the appearance of being sedated, and the presence of pinpoint pupils. Those who have developed a tolerance may show few or no acute signs of opioid intoxication. Ongoing use of opioids tends to lead to a look of general poor health and debilitation, though mild or moderate ongoing users may not have progressed to an appearance of reduced health despite chronic use.

Opioids may be ingested many ways:

  • Orally either in solution or as tablets or powders
  • Intranasal "sniffing" or "snorting"
  • Subcutaneous injection "skin-popping"
  • Intramuscular "muscling"
  • Intravenous "mainlining" or "shooting up"
  • Smoked smoking opioids is the fastest way to the brain and is generally a mix of opioid with cannabis or tobacco, however, while common in Asian communities, smoked opioids have yet to make inroads over injections in the general population

Opioids purchased illegally run the risk of contamination by improper handling or purposeful "cutting" or dilution of the substance by other compounds. Injection users run a high risk of infection, both localized and systemic. HIV, hepatitis B, and hepatitis C are all associated with opioid and other injectable substance use. Hepatitis C infection is also associated with intranasal inhalation of opioids and other substances, particularly in group settings where users pass around a shared beverage straw for snorting. (Strain, E., 2014).

Physical examination for suspected opioid intoxication or opioid poisoning should include a search for the classic signs of opioid overdose:

  • Depressed mental status
  • Decreased respiratory rate
  • Decreased lung tidal volume
  • Decreased bowel sounds
  • Decreased (miotic constricted) pupils

Drowsiness tends to follow the euphoria sought after by users of opioids and the sedation effect may progress to coma for some. Inattention resulting from perceptual changes and ability to concentrate may progress to ignoring potentially harmful events. In rare instances, intoxication may cause hallucinations with intact reality testing or auditory, visual or tactile illusions occurring in the absence of a delirium.

For suspected acute opioid intoxication, laboratory studies should be included in the workup:

  • An immediate blood glucose for hypoglycemia, a condition often mistaken for opioid intoxication.
  • Serum acetaminophen concentration due to marketing prescription opioids in combination with acetaminophen leading to a heightened risk of acetaminophen hepatotoxicity.
  • Serum creatine phosphokinase and electrolytes to exclude rhabdomyolysis (muscle breakdown) secondary to prolonged immobility, always a concern due to the intense sedative effects of opioids.
  • Urine toxicology screens for opioids.

Some, but not all, individuals with opioid use disorder show positive for opioid drugs for 12-36 hours on routine urine toxicology tests. Opioids not detected by routine urine toxicology and must be specifically tested for are:

  • Methadone, buprenorphine, and LAAM (which can be detected for several days to more than a week).
  • Fentanyl (which can be detected for several days).

Please be aware 80 - 90% of injection opioid users screen positive for hepatitis A, B or C. HIV is prevalent especially amongst injection Heroin users.

Opioid Intoxication, Diagnostic Criteria
  1. Recent use of an opioid.
  2. Clinically significant problematic behavioral or psychological changes (e.g., euphoria followed by apathy, impaired judgment, dysphoria, psychomotor agitation or retardation) developed during or shortly after use.
  3. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs or symptoms developing during, or shortly after, opioid use.
    1. Drowsiness or coma
    2. Slurred speech
    3. Impairment in attention or memory
  4. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Opioid intoxication diagnosis focuses on the presence of significant negative impact, psychological and behavioral changes accompanying or following substance use. The presence of alcohol or sedatives in the persons system can muddy diagnosis and therefore a naloxone challenge may be administered. Naloxone is a short acting opioid antagonist that temporarily counters the respiratory depressant and to a small degree, the sedative effects of opioids. Use of naloxone may put an opioid user suddenly into physical withdrawal, so caution should be used when administering. (Stolbach, A. and Hoffman, R., 2014).

Opioid Withdrawal, Diagnostic Criteria
  1. Presence of either of the following:
    1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e., several weeks or longer).
    2. Administration of an opioid antagonist after a period of opioid use
  2. Three (or more) of the following developing within minutes to several days after Criterion A:
    1. Dysphoric mood
    2. Nausea or vomiting
    3. Muscle aches
    4. Lacrimation or rhinorrhea
    5. Pupillary dilation, sweating, or piloerection (raised or bristled hair on back of neck or skin)
    6. Diarrhea
    7. Yawning
    8. Fever
    9. Insomnia
  3. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
  4. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance
(American Psychiatric Association DSM-5, 2013)

Opioid withdrawal can be a brutal affair, and contrary to conventional shared wisdom amongst health providers, opioid withdrawal can indeed be life threatening. Withdrawal symptoms may begin immediately after the administration of an opioid antagonist (e.g., naloxone or naltrexone) or a partial opioid antagonist (e.g., buprenorphine). Stopping opioids after a prolonged period of use results in withdrawal symptoms around 6 hours after the last dose of a short acting opioid, and up to 48 hours after stopping the longest acting opioid, methadone. Peak of withdrawal tends to be with 24-48 hours yet persists several days for the short acting agents and up to 2 weeks for methadone, with sleep and mood disturbances often persisting for months. Many who have undergone opioid withdrawal compare it with the "worst case of flu imaginable" and with some justification as symptoms of withdrawal parallel those of food poisoning or the gastrointestinal effects of influenza. Muscle and abdominal cramping, nausea, diarrhea, runny nose, tearing eyes, dizziness and restlessness to name a few of the more common opioid withdrawal symptoms.

Opioid withdrawal is known to cause brief, but severe, episodes of depression that can lead to suicide attempts and completed suicide. Accidental opioid overdose, particularly among those desperate to avoid withdrawal, is common and should not be mistaken for a suicide attempt.

Substance Use Disorder: Sedative, Hypnotic, or Anxiolytic Related Disorders

Sedative, hypnotic, and anxiolytic medications are the most commonly prescribed drugs in the United States. Around 12.5% of the adult population use prescribed anxiolytics in the course of a year, while over 2% takes at least one on any given day. In Western Europe and parts of Asia, the usage rates for hypnotics runs approximately 25-30%, with females consuming more than males 3-to-1. (Scher, L, 2014).

Sedative, hypnotic, and anxiolytics (SHA) are all brain depressants. They produce similar therapeutic and substance use disorder profiles and therefore despite chemical dissimilarities are best regarded as a closely-knit group. Included in this group are the benzodiazepines and benzodiazepine-like drugs, the carbamates, barbiturates and barbiturate-like hypnotics, as well as all prescription sleep medications and nearly all prescription antianxiety agents.

There is great irony in the fact that the misuse of sedatives, hypnotics, and anxiolytics is common and problematic. This category of therapeutic agents are the "go to" medications for a great number of common quality-of-life impairing ailments. To have the treatment for one condition become the cause of negative consequences in its own right just does not seem right. Nevertheless, health professionals need to be on the lookout for the indications of misuse both in those prescribed these medications and others taking them without a prescription.

Sedative, Hypnotic, Anxiolytic Use Examples:
  • ADHD
  • Anxiety
  • Depression
  • Extrapyramidal movements
  • Fibromyalgia
  • Insomnia
  • Irritable bowel
  • Jet lag
  • Motion sickness
  • Narcolepsy
  • Pain
  • Panic disorder
  • PMS
  • Sedation
  • Smoking cessation
  • Uticaria
  • Many, many more

Individuals having use difficulties with sedative, hypnotic, anxiolytics should never automatically be labeled drug abusers. They are not bad people, they are not evil; they tend to simply be folk having a difficult time regulating what can be a challenging balance of brain chemistry versus pharmaceutical chemistry. Do be aware that those who have prescriptions and medical indications for using this category of agents will have a risk for developing dependence, a detail that needs to be factored in at the time of initial prescription. Dependence risk is heightened if a family history of alcohol use disorder is present, as a genetic predisposition toward developing dependence to the depressant effects of sedative hypnotics seems to occur in those vulnerable to alcoholism. The viewpoint of practitioners needs to be that unless dose escalation is apparent, or there is evidence of dangerous states of intoxication, there is no reason to assume that chronic SHA users are substance abusers. (Scher, L, 2014).

Use of sedative, hypnotic, anxiolytics without medical need or for the purpose of self-medicating also occurs. Those attempting to manage insomnia or chronic anxiety seek after benzodiazepines. Sedative-hypnotics have found a place in recreational use as an enhancer of opioid euphoria, and as an essential tool in the poly-substance user toolkit for lessening the withdrawal symptoms associated with other street drugs.

The positive actions of sedatives, hypnotics, and anxiolytics include reducing stress or anxiety, relaxing muscle tension, slowing racing thoughts, and reigning in CNS processes gone wild. This is accomplished by intruding on the actions of brain chemistry, most frequently gamma-aminobutyric acid (GABA).

Negative life effects from use of sedatives, hypnotics, or anxiolytics also arise from the relaxing or depressant effects. Undesired effects include harmful sedation, impaired memory, lack of coordination, impaired judgment, mood swings, loss of inhibitions, and even aggression.

Sedative, Hypnotic, or Anxiolytic Use Disorder, Diagnostic Criteria
  1. A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress, manifested by at least two of the following, within a 12-month period:
    1. Taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects.
    4. There is a craving or strong desire to use.
    5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Continued use occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of use.
    7. Important social, occupational, or recreational activities are given up or reduced because of use.
    8. Use of occurs in situations in which it is physically hazardous.
    9. Use continues despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by the substance.
    10. Tolerance has occurred, as defined by either of the following;
      1. A need for markedly increased amounts to achieve intoxication or desire effect.
      2. Markedly diminished effect with continued use of the same amount.

        NOTE: This criterion is not considered to be met for those taking sedatives, hypnotics, or anxiolytics under medical supervision.
    11. Withdrawal as manifested by either of the following:
      1. Characteristic withdrawal syndrome detailed in the sedatives, hypnotics, or anxiolytics withdrawal table.
      2. The use of sedatives, hypnotics, or anxiolytics to relieve or avoid withdrawal symptoms.
(American Psychiatric Association DSM-5, 2013)

Use of sedatives, hypnotics, or anxiolytics often occurs in the presence of other substance use disorders (e.g. stimulants, cannabis, opioid, etc.). It is not uncommon for medical providers to prescribe sedative, hypnotic, or anxiolytics as a means of alleviating unwanted effects of these other categories and aid during periods of intoxication or withdrawal symptoms from them. Likewise, the use of non-prescribed sedatives, hypnotics, and anxiolytics is a common practice among substance users faced with withdrawal symptoms due to lack of their preferred self-medication. Either way, SHA users may find themselves using, abusing, or in the grips of intoxication from sedatives, hypnotics, or anxiolytics even when this type of chemical is not their preferred cup of tea. The fact that tolerance of SHA often builds more slowly than many of the common substance use disorder categories leads to a self-deceptive condition where users feel that they can handle SHA without the unwanted progression towards tolerance, dosage increase, and the inevitable crash of withdrawal.

Sedative, Hypnotic, or Anxiolytic Intoxication, Diagnostic Criteria
  1. Recent use of sedatives, hypnotics, or anxiolytics.
  2. Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behaviors, impaired judgment, mood liability) developed during or shortly after use.
  3. One (or more) of the following signs or symptoms developing during, or shortly after use.
    1. Incoordination
    2. Slurred speech
    3. Unsteady gait
    4. Nystagmus
    5. Impairment in cognition (e.g., memory, attention)
    6. Stupor or coma
  4. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Intoxication with brain depressants such as sedatives, hypnotics, or anxiolytics may be difficult to distinguish from intoxication from other brain depressing chemicals, particularly alcohol. The presenting symptoms of behavioral and cognitive impairments such as uncharacteristic sexual and aggressive actions, along with loss of coordination and ability to function are similar bringing into focus the need for good history and supportive diagnostic studies to rule out alcohol intoxication. The smell of alcohol on the breath is a clue, however individuals with high levels of sedative, hypnotic, or anxiolytic use often imbibe in alcohol. Therefore, be aware that the odor of alcohol does not rule out substance use disorder sedative, hypnotic, or anxiolytic intoxication.

Careful monitoring of intoxicated individuals is needed as episodes of generally brief yet severe depression may be associated with severe sedative, hypnotic, or anxiolytic intoxication. Suicide or attempted suicide may be present during SHA intoxication as may be purposeful or accidental self-injury.

Almost all sedative-like drugs can be detected on standard toxicology drug urine or blood tests. Blood toxicology tests can quantify the amounts of these drugs in the body. Urine screens can remain positive for up to 1 week after the use of these agents.

Sedative, Hypnotic, or Anxiolytic Withdrawal, Diagnostic Criteria
  1. Cessation of (or reduction in) use that has been heavy and prolonged.
  2. Two (or more) of the following developing within several hours to a few days after cessation:
    1. Autonomic hyperactivity (e.g., sweating, racing pulse greater than 100 bpm)
    2. Hand tremor
    3. Nausea or vomiting
    4. Insomnia
    5. Anxiety
    6. Psychomotor agitation
    7. Transient visual, tactile, or auditory hallucinations or illusions
    8. Grand mal seizures
  3. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance
(American Psychiatric Association DSM-5, 2013)

Substance Use Disorder: Stimulant Related Disorders

Stimulants speed up communication between the brain and the central nervous system. They are a "feel good" staple for the club and party scene. The past diagnoses of Stimulant Abuse and Stimulant Dependence have been merged in 2013 by the American Psychiatric Association into one diagnosis, that of Stimulant Use Disorder. The severity of Stimulant Use Disorder can range from mild, to moderate, or severe and encompasses all of the areas previously utilized when attempting a clear diagnostic portrait of the individual with unhealthy use of stimulant related substances.

The use of stimulants is often an exercise in polysubstance use. While the stimulant using person will often have their favorite substance, many imbibe whatever is at hand that can be utilized to achieve the goal of renewed energy, a mood boost, or simply to help them maintain a feeling of control. Stimulants range from licit items such as over-the-counter (OTC) decongestants, to illicit and illegal substances such as cocaine or methamphetamines.

Stimulants can be either synthetic as most of the amphetamine-like substances are, or naturally occurring plant derived compounds such as khat or cocaine. Legitimate uses for stimulants abound, including treatments for ADHD, obesity, sleep disorders, etc.

Amphetamine and amphetamine-type substances are psychostimulants with a specific shared molecular structure, such as amphetamine, methamphetamine, and dextroamphetamine. Methylphenidate is an example of a stimulant with similar effects to the amphetamines, even though it possesses a different chemical structure. Their mode of action is to interfere with the normal release and reuptake of monoamine neurotransmitters such as dopamine, norepinephrine, and serotonin. Most serious amphetamine-type users prefer to smoke or snort the refined powders rather than to inject or ingest orally, although those routes of ingestion are used as well.

Amphetamine-type stimulants go by some of the most recognized names in the street slang pharmacopeia; Speed, Ice, Ecstasy, Base, Meth, and Chrystal just to name a few. They possess a longer active duration than cocaine, and thus need fewer uses each day to maintain the desired effects. Clinical manifestations of amphetamine-type drugs tend to revolve around sympathetic activation, e.g. increased energy, alertness, euphoria, decreased need for sleep, weight loss. With the typical downside being mood and cognitive changes, rapid tooth decay due to chronic dry mouth, problems with executive functioning and decision making.

Users who prefer the amphetamine-types tend to go on binges with periods of non-use between, often due to the lack of available substance. During binges users tend to stack doses in a sometimes purposeful, though often unplanned, manner achieving dangerously high levels of psychoactive substance in their systems. Paranoia, delusions, anxiety attacks, hallucinations, panic disorders are all possible outcomes of the high quantities of stimulants in ones circulation.

Cocaine is a tropane ester alkaloid extracted from the leaves of the South American Erythroxylum coca plant, and each stop in its processing from the leaves of this hardy plant to the final street market form has found a fan base amongst users; coca leaves, coca paste, powdered cocaine hydrochloride, and rock crystal cocaine alkaloids. The two most common street available cocaine forms are the more processed, and therefore more concentrated, forms:

  • Hydrochloride salt (a white crystalline powdered form of cocaine) dissolves in water and can be taken intravenously, snorted up the nose, smoked, or rubbed onto the gums. The peak duration may last from 15 to 30 minutes depending on the purity of the substance. Other street names are Blow, Coke, Flake, Snow.   
  • Cocaine alkaloids aka Freebase or Crack (a rock crystal form of cocaine) has been processed with ammonia or baking soda and requires heating to remove the active hydrochloride. Because it is difficult to dissolve in water Crack is smoked, and when taken has a peak duration of less than 5 to 10 minutes. The term Crack comes from a crackling sound that occurs when the rock crystal is heated. Cracks chief appeal is the low cost to make and purchase.

Cocaine has a legitimate legal use as a Schedule II local or topical anesthetic; although in recent years synthetic topicals have made heavy inroads into its medicinal use. Around 0.3 of the global population or 14 million people worldwide regularly use cocaine. Some 1.6 million U.S. adults utilize cocaine each year to the extent that they meet the criteria for abuse or dependence. Most healthcare providers are familiar with cocaine as it is the illegal drug most often associated with hospital emergency room visits. In the year 2011, an estimated 40.3% of all illicit drug related emergency visits involved cocaine, with over 6% of emergency room visits for suicide attempts having cocaine as a factor. (Gorelick, D., 2013).

Cocaine effects come from enhancement of monoamine neurotransmitters such as dopamine, norepinephrine, and serotonin. The positive effects are attributed to dopamine enhancement of the brain reward system and include alertness, energy, elation, and euphoria. Users describe the feeling of cocaine peaking as a "total body orgasm". Unwanted negative effects of cocaine use include irritability, anxiety, suspiciousness, paranoia, panic attacks, impaired judgment, grandiosity, delusions, and hallucinations. Sleep disturbances, weight loss, tremors, and stereotyped behaviors such as picking at the skin also accompany cocaine use. (Gorelick, D., 2013).

Cocaine is unique amongst the other stimulants in that it has a second strong effect, that of producing an anesthetic result due to blockage of sodium ion channels. This numbing ability is both beneficial and dangerous as it may be a major component leading to cardiac issues associated with cocaine use.

Similar to the amphetamine-type substances, cocaine users frequently binge, displaying short periods of heavy use separated by longer periods of drug abstinence until the next binge. Often these times without their substance of choice are dictated by external factors such as lack of finances or unavailability of cocaine. Be aware that the majority of cocaine users do not use frequently and tend to fly under the radar without notice by legal or health professionals. It tends to be heavy or impulse use that gains enough attention to be noticed and included in research demographics.

Substance Note: Khat

Khat (pronounced "cot") is a stimulant derived from the shrub Catha edulis that is native to East Africa and southern Arabia. The khat plant itself is not scheduled under the Controlled Substances Act; however, because one of the mind-altering chemicals found in it, cathinone, is a Schedule I drug (a controlled substance with no recognized therapeutic use). The Federal Government considers khat use illegal.

The main psychoactive ingredients in khat are cathinone and cathine. These chemicals are structurally similar to amphetamine and result in similar stimulant effects in the brain and body. Like other stimulants, cathinone and cathine stimulate the release of the stress hormone and neurotransmitter norepinephrine and raise the level of the neurotransmitter dopamine in brain circuits regulating pleasure and movement.

Chewing khat leaves is reported to induce a state of euphoria and elation as well as feelings of increased alertness and arousal. The effects begin to subside after about 90 minutes to 3 hours, but can last 24 hours. At the end of a khat session, the user may experience a depressed mood, irritability, loss of appetite, and difficulty sleeping.

A number of adverse physical effects that have been associated with heavy or long-term use of khat, including tooth decay and periodontal disease; gastrointestinal disorders such as constipation, ulcers, inflammation of the stomach, and increased risk of upper gastrointestinal tumors; and cardiovascular disorders such as irregular heart-beat, decreased blood flow, and heart attack.

It is estimated that as many as 10 million people worldwide chew khat. Its current use among some migrant communities in the United States has caused concern among policymakers and health care professionals. No reliable estimates of prevalence in the United States exist.

(DrugFacts: Khat, 2013 April)

Feelings of alertness and energy make stimulants a substance of choice among young people in dance clubs or festivals. Euphoric feelings add to the energy boost given by these drugs and become a feeling that users fight to maintain, often at the cost of cognitive functioning and their physical health. Stimulants are one of the quickest substances to form a chemical dependence in our bodies.

Stimulants dilate pupils, constrict blood vessels, increase heart rate, body temperature and blood pressure. Use can cause nausea, abdominal pain, headaches, and because stimulants decrease appetite at the same time as increasing metabolism can cause serious malnutrition effects.

Heart attack and stroke are familiar company to stimulant use. Cocaine in particular is well known for sudden cardiac arrest followed by respiratory collapse.

Laboratory testing for suspected stimulant use disorder should include; finger stick glucose, salicylate and acetaminophen levels, electrocardiogram (ECG), and pregnancy testing due to the high risk of potential effects of stimulant use to the unborn. While urine toxicology screens may be useful for documentation purposes, they have little clinical use when dealing with acute intoxication.

Stimulant Use Disorder, Diagnostic Criteria
  1. A problematic pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress, manifested by at least two of the following, within a 12-month period:
    1. Taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects.
    4. There is a craving or strong desire to use.
    5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Continued use occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of use.
    7. Important social, occupational, or recreational activities are given up or reduced because of use.
    8. Use of occurs in situations in which it is physically hazardous.
    9. Use continues despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by the substance.
    10. Tolerance has occurred, as defined by either of the following;
      1. A need for markedly increased amounts to achieve intoxication or desire effect.
      2.  Markedly diminished effect with continued use of the same amount.

        NOTE: This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy.
    11. Withdrawal as manifested by either of the following:
      1. Characteristic withdrawal syndrome detailed in the stimulant withdrawal table.
      2. The use of stimulants to relieve or avoid withdrawal symptoms.
(American Psychiatric Association DSM-5, 2013)

Acute stimulant intoxication may present with grandiose statements or actions and proceed to restlessness, jerky sudden movements, rambling speech, headache, ringing in the ears. The person may exhibit ideas of reference, paranoid thinking, auditory hallucinations, and even report the sensation of being touched or other tactile hallucinations. Sexual acting out, threats or actions of aggression, depression, suicidal feelings, and mood fluctuations may also be present.

Stimulant Intoxication, Diagnostic Criteria
  1. Recent use of an amphetamine-type substance, cocaine, or other stimulant.
  2. Clinically significant problematic behavioral or psychological changes (e.g., euphoria or affective blunting, changes in sociability, hypervigilance, interpersonal sensitivity with anxiety/tension/anger, stereotypical behaviors, impaired judgment) developed during or shortly after use.
  3. One (or more) of the following signs or symptoms developing during, or shortly after use.
    1. Tachycardia or bradycardia
    2. Pupil dilation
    3. Elevated or lowered blood pressure
    4. Perspiration or chills
    5. Nausea or vomiting
    6. Evidence of weight loss
    7. Psychomotor agitation or retardation
    8. Muscular weakness, respiratory depression, chest pain, cardiac arrhythmias
    9. Confusion, seizures, dyskinesia, dystonia, or coma
  4. The signs or symptoms are not attributable to another medical or mental condition, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

The cycle of intoxication and withdrawal tends to be very familiar to users of any form of stimulant. Binge usage means that withdrawal is only a few "hits" away, and leads to desperation that the desired feelings never end. Legal consequences of actions provoked by user desperation to maintain the positive effects of stimulant use while avoiding the inevitable crash into withdrawal can be shattering to social or work relationships.

Withdrawal from amphetamine-type substances can occur within hours of stopping use. Withdrawal symptoms tend to peak within one or two days and diminish around two weeks after substance use ceases. The acute withdrawal or "crash" includes anhedonia (the inability to experience pleasure from activities usually found enjoyable), dysphoria, fatigue, insomnia, increased need for sleep, vivid dreams, anxiety, agitation, increased appetite, and drug cravings. Following acute withdrawal, many users face a month long phase of continued insomnia/hypersomnia, appetite fluctuations, depression and tendency toward suicidal thinking.

Cocaine cessation on the other hand while having profound psychological symptoms is rarely medically life threatening. Common findings are anxiety, depression, fatigue, increased sleep, increased dreaming, difficulty concentrating, anhedonia, increased appetite and cocaine cravings. While some cocaine users experience an intensity of these feelings in the hours after ceasing cocaine use that may include severe depression and suicidal thinking most have milder symptoms that resolve within one to two weeks without medical intervention. Physical aspects of cocaine withdrawal while minor tend to include generalized musculoskeletal pain, tremors, chills, and involuntary motor movements. Myocardial ischemia has been noted during the first week of cocaine withdrawal, possibly due to coronary vasospasms.

Stimulant Withdrawal, Diagnostic Criteria
  1. Cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use.
  2. Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A:
    1. Fatigue
    2. Vivid, unpleasant dreams
    3. Insomnia or hypersomnia
    4. Increase in appetite
    5. Agitation or psychomotor retardation
  3. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.
(American Psychiatric Association DSM-5, 2013)

Long term effects of stimulant use include an increased risk of several disorders in the brain and various organ systems throughout the body. Cognitive and psychiatric disorders such as schizophrenia, major depression, stimulant induced bipolar, sleep disorder, sexual dysfunction, or anxiety disorder all have a heightened frequency in long term stimulant users.

Substance Use Disorder: Tobacco Related Disorders

Tobacco is a serious business. Cigarette smoking has been hailed as the number one leading cause of preventable death, with an annual toll of six million deaths worldwide and some 480,000 in the United States. Studies estimate that up to one-half of all tobacco users can expect to die from a tobacco related disease. Costs directly from tobacco use are estimated to be as high as $332.5 billion each year, around half of which comes from direct healthcare costs and half from productivity losses. (Rigotti, N., and Daughton, D., 2014).

Tobacco is a legal and readily available product made from the leaves of plants in the Nicotiana branch of the Solanaceae or nightshade family. The shredded dried leaves of the tobacco we recognize today are most often from the N. tabacum plant that originates from North and South America. Tobacco has many components with nicotine the primary psychoactive ingredient. Nicotine is an addictive alkaloid stimulant that can be ingested from tobacco by smoking or chewing dried leaves, being inhaled as a vaporized extract, or consumed as an additive to food or other ingestible products.

Daily use of tobacco in any form is a common factor found in those with tobacco use disorder. Likewise, it is easy to identify those users who have already developed tolerance levels for tobacco, simply by asking if they still experience nausea or dizziness after use. Cessation of tobacco produces well-documented withdrawal patterns.

Tobacco Use Disorder, Diagnostic Criteria
  1. A problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
    1. Taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects.
    4. There is a craving or strong desire to use.
    5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work).
    6. Continued use occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use).
    7. Important social, occupational, or recreational activities are given up or reduced because of use.
    8. Use of occurs in situations in which it is physically hazardous (e.g., smoking in bed).
    9. Use continues despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by the substance.
    10. Tolerance has occurred, as defined by either of the following;
      1. A need for markedly increased amounts to achieve intoxication or desire effect.
      2. Markedly diminished effect with continued use of the same amount.
    11. Withdrawal as manifested by either of the following:
      1. Characteristic withdrawal syndrome detailed in the tobacco withdrawal table.
      2. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.
(American Psychiatric Association DSM-5, 2013)

Diagnostic criteria for tobacco use disorder can be confused if the person is on medication such as nicotine replacements, bupropion, varenicline, or others designed to curb cravings. Sources of nicotine or tobacco are many and the person may not realize they are imbibing in more than one source, so careful questioning may be needed to make sure they are aware if the products they are consuming are tobacco related.
Basically, all tobacco products contain nicotine:

  • Dip dissolvable tobacco
  • Compressed tobacco strips, sticks, orbs, or lozenges of finely ground dissoluble tobacco held together by food grade binders allowing the user to suck and swallow without smoke or spit evidence of imbibing
  • Snuff coarsely ground tobacco snorted or placed between lip and gums
  • Chewing tobacco plugs, loose leaf, or twists of tobacco chewed in the manner of chewing gum
  • Bidis - flavored thin rolled tendu or temburni leaf packets for smoking containing tobacco imported from southeast Asia becoming popular due to rising first world tobacco taxes
  • Hookah referred to by the name of the device pulling mixes of charcoal heated smoldering tobacco, fruit, and vegetables through a water filter (hookah smoking is no safer than other forms of tobacco use according to a 2005 WHO study on waterpipe tobacco smoking health effects)
  • Kreteks often referred to as clove cigarettes which mix cloves, tobacco and other exotic flavorings
  • Cigarettes paper wrapped cylinders with a combination of cured finely cut tobacco, reconstituted tobacco, and many other additives such as sugar and flavorings, more than 4000 different chemicals have been found in tobacco and tobacco smoke, among these more than 60 known to cause cancer
  • Cigars typically a single type of fermented dried tobacco leaf with a higher nicotine content than cigarettes
  • Cigarillos known as "little cigars" tend to look more like cigarettes yet contain more flavorful pipe tobacco and additives
  • Pipe tobacco aged flavored shredded tobacco for smoking in pipes or "roll your own" cigarettes
  • Vape extracts from tobacco used in electronic vaporizers or e-cigarette cartridges

Tobacco cessation aids also contain nicotine; nicotine gum, nicotine patches, nicotine lozenges, and nicotine nasal sprays. Electronic or "smokeless" cigarettes typically contain nicotine although it is possible to purchase or hand mix e-cigarette cartridges with alternative active ingredients. The typical e-cigarette contents include; nicotine extract, propylene glycol, and flavoring.

Tobacco cravings begin typically within the hours of the last use. Needing that first smoke of the morning is a daily lifestyle for tobacco users. Cravings can vary in a spectrum from a mild awareness of need to crushing anxiety depending on individual genetic and psychological differences. It is common for tobacco users to give up jobs, social opportunities, and personal relationships when the situation or location limits their use of tobacco. Life stresses can magnify the desire for and intake of tobacco products creating situations where casual users slide into the role of chain smoking or never feeling safe without imbibing in their snuff, chew or other product of choice.

Tobacco Withdrawal, Diagnostic Criteria
  1. Daily use of tobacco for at least several weeks.
  2. Abrupt cessation of (or reduction in) the amount of tobacco used, followed within 24 hours by four (or more) of the following signs or symptoms:
    1. Irritability, frustration, or anger
    2. Anxiety
    3. Difficulty concentrating
    4. Increased appetite
    5. Restlessness
    6. Depressed mood
    7. Insomnia
  3. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.
(American Psychiatric Association DSM-5, 2013)

Symptoms of tobacco withdrawal are largely due to nicotine deprivation. It is generally assumed that withdrawal symptoms will be lessened in those using nicotine replacement medications than in those withdrawing directly from smoked or smokeless tobacco products, possibly due to the higher levels of nicotine present when taking in the nicotine directly from a tobacco product. Observable health changes occur during withdrawal, including an average decrease in heart rate by 5 to 12 beats per minute in the first few days without tobacco, and an average weight gain of 4 to 7 pounds during the first year without tobacco.

Tobacco withdrawal begins within 24 hours of lowering or stopping tobacco intake. Symptoms peak around 2 to 3 days after cessation and last roughly 2 to 3 weeks. An increasing desire for tobacco is generally followed by feelings of anxiety and depression. Restless tension and frustration lead to headaches and difficulty concentrating. Drowsiness with difficulty falling asleep and bad dreams with nightmares once asleep are commonly reported. An increased appetite with weight gain and sluggishness hangs on for many days during tobacco withdrawal.

Substance Use Disorder Other (or Unknown)

The American Psychiatric Association formally acknowledges in the current Diagnostic Statistic Manual what health professionals have known for a long, long time. That there is a lot of variation in this world. By formally introducing a substance use disorder category where uncommon, unusual and just plan quirkiness of substance addictions and dependencies can be discussed, with a guide for applying proper diagnostic and billing codes, a big step forward has been taken.

The "fill in the blank" format allows practitioners to follow a set diagnostic standard for substance use findings that are less common then those earlier specified, that are somewhat location specific, or that negatively affect relatively limited numbers of the general population. Some of these less common substances of abuse include, but are in no way limited to, the following:

  • Anabolic steroids,
  • Cortisol,
  • Antiparkinsonian medications,
  • Betel nuts,
  • Laxatives,
  • Kava,
  • Nonsteroidal anti-inflammatory drugs (NSAIDS),
  • Nitrous oxide,
  • Antihistamines,
  • well, the list can go on and on, particularly with the new designer drugs cropping up every week.

Other (or unknown) substance use disorder focuses on repeated use of a substance that creates serious problems for the individual. The type of problem is reflected in the diagnostic criteria, and as soon as the offending substance has been identified, the name should be reflected in the disorder name, e.g. Substance Use Disorder Sugar, from the example earlier.

Other (or Unknown) Substance Use Disorder, Diagnostic Criteria
  1. A problematic pattern of an intoxicating substance not able to be classified within the alcohol; caffeine; cannabis; hallucinogen (phencyclidine and others); inhalant; opioid; sedative, hypnotic, or anxiolytic; stimulant; or tobacco categories and leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
    1. The substance is often taken in larger amounts or over a longer period than was intended.
    2. There is a persistent desire or unsuccessful efforts to cut down or control use of the substance.
    3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of the substance.
    4. There is a craving or strong desire to use the substance.
    5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
    6. Continued use of the substance occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of use.
    7. Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
    8. Recurrent use of the substance in situations in which it is physically hazardous.
    9. Use of the substance is continued despite knowledge of having persistent or recurrent physical or psychological problems likely to have been caused or exacerbated by the substance.
    10. Tolerance, as defined by either of the following;
      1. A need for markedly increased amounts of the substance to achieve intoxication or desire effect.
      2. Markedly diminished effect with continued use of the same amount of the substance.
    11. Withdrawal as manifested by either of the following:
      1. Characteristic withdrawal syndrome detailed in the other (or unknown) withdrawal table.
      2. The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
(American Psychiatric Association DSM-5, 2013)

The unwanted, disruptive physical and mental state that occurs when a given substance is used, or immediately following the use of a specific substance is referred to as substance intoxication. When the drug or chemical causing the effect is unusual or unknown, it falls under the substance use category of other (or unknown) substance intoxication.

Diagnostic criteria or an unknown substance intoxication is tricky, as it requires identifying the presence of a reversible substance specific syndrome. The formulators of the DSM-5 acknowledge in that reference work the challenges of recognizing a substance specific syndrome without knowing what substance is triggering it. Unfortunately, that is the reality of clinical practice. Often information obtained from friends, family, or patient history can provide a working hypothesis for comparison to the observable signs and symptoms. Change in the ability to concentrate or process information, to control ones body or behaviors, and especially the inability to control emotions are all clues that a known or unknown substance intoxication may be present. Never forget to take into account regional patterns of visits. Newly available recreational chemicals or other substances often present to physician offices or emergency/urgent cares in clusters or waves. Knowing what is happening around your area gives an important knowledge base for individuals presenting with harmful symptoms related to unknown substances.

Other (or Unknown) Substance Intoxication, Diagnostic Criteria
  1. The development of a reversible substance-specific syndrome attributable to recent ingestion of (or exposure to) a substance that is not listed elsewhere or is unknown.
  2. B. Clinically significant problematic behavioral or psychological changes that are attributable to the effect of the substance on the central nervous system (e.g., impaired motor coordination, psychomotor agitation or retardation, euphoria, anxiety, belligerence, mood lability, cognitive impairment, impaired judgment, social withdrawal) and develop during, or shortly after, use of the substance.
  3. C. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.
(American Psychiatric Association DSM-5, 2013)

Depending on the substance involved, the process of intoxication tends to occur within minutes to only a few hours after use though time of onset will vary depending on additional factors such as individual metabolic response to the substance or agent, route of administration, dosage, purity, etc. Typically, chemicals, plants, or drugs ingested by mouth take longer to peak. Gaining insight into substance ingestion practices with history, interviews, and physical examination can be very beneficial.

Intoxication frequently runs hand in hand with the following comorbidities:

  • Other known substance use disorders
  • History of previous substance intoxication episodes
  • Adolescent conduct disorder
  • Adult antisocial personality disorder
Other (or Unknown) Substance Withdrawal, Diagnostic Criteria
  1. Cessation of (or reduction in) use of a substance that has been heavy and prolonged.
  2. The development of a substance-specific syndrome shortly after the cessation of (or reduction in) substance use.
  3. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including withdrawal from another substance.
  5. The substance involved cannot be classified under any of the other substance categories (alcohol; caffeine; cannabis; opioids; sedatives, hypnotics, or anxiolytics; stimulants; or tobacco) or is unknown.
(American Psychiatric Association DSM-5, 2013)

Substance withdrawal is the life disrupting state that occurs when an individual has utilized a substance at a high enough dosage for a sufficient length of time for their metabolism to make adjustments and become dependent on the presence of a specific drug, chemical, or plant and then suddenly drastically lowers intake of or ceases use of, the substance. Symptoms and severity of withdrawal vary according to the substance in question and the individuals metabolic susceptibility to its effects. In order to meet diagnostic levels, the effects of withdrawal must be sufficiently negative to mental, physical, and functional well-being to come to clinical attention. Some levels of withdrawal can be life shattering and life threatening, while the other end of the spectrum lies more on par with inconvenience and general malaise. Other (or unknown) substance withdrawal comes into play when observable withdrawal symptoms arise from the cessation of a mystery substance, or a substance not specifically highlighted within the DSM-5. As soon as the substance is identified, it should be reflected in the disorder name, e.g. Substance Use Disorder (Other) Laxatives.

Therapeutic Tools for Substance Use Disorders

Brief Intervention in Substance Abuse

Substance use troubles, when suspected, form an issue that must be addressed. It is important to inform the client of concerns in a clear and caring way. Options for treatment can be offered and while some clients will adamantly deny that there is a problem, a surprising number show relief when it is brought out into the open and is no longer a hidden burden they must bear in secret.

Acute treatment, follow-up, and ongoing maintenance therapies are all essential in the treatment of substance abuse. Acute medical interventions are focused on the specific medical needs of the individual existing at the time of diagnosis. The consensus of the medical and mental health community however is that acute treatment alone is rarely enough. Virtually every client with a substance use disorder diagnosis will benefit from consistent follow-up treatment and lasting support to maintain a substance abuse free life.

Several treatment modalities exist for follow-up treatment of substance problems. Individual factors such as time, expense, personality and available support must all be factored into the decision-making process. The therapeutic regimen known as Brief Intervention has gathered a growing following amongst practitioners due to its well-documented efficacy among the substance dependent, especially in the subset of problem alcohol behaviors.

Brief intervention is a strategy that utilizes short-duration sessions, which can begin at the time of admission. Brief intervention can be woven into treatment planning and be used at the bedside through the course of medical recovery, while also forming an integrated strategy throughout follow-up office visits or referrals. The techniques involved often take around five minutes or less, which make it a prized therapeutic method useful to even the busiest health professional. The ability to hold a meaningful session during a routine office visit, for example, makes for a happy client and clinician.

Brief intervention sessions focus on finding and emphasizing the specific motivation that will work for that particular client. These short yet structured sessions continue over a regular schedule until the client is motivated to take positive actions to change behaviors that supports their substance use problem. While brief intervention has shown good success, it must be followed up with a structured support system that focuses on maintenance of the person vulnerable to substance use issues.

FRAMES is an acronym that has been used for the separate elements incorporated in Brief Intervention sessions.

The FRAMES of Brief Intervention
  • Feedback Give Feedback on the risks and negative consequences of substance use based on thorough assessment
  • Responsibility Help the client take Responsibility for changing
  • Advice Give clear Advice on what behavior(s) must change
  • Menu Offer a Menu of options for making the change with focus on the clients involvement in decision making
  • Empathy Express Empathy for the ambivalence and difficulty that is present when making changes
  • Self-efficacy Evoke Self-efficacy to foster commitment and confidence (Self-Efficacy is ones personal ability to produce a desired result or effect)
(Miller, W., 2013)

Feedback

Promoting awareness of the negative consequences arising from use of the problem substance is the purpose of feedback in brief intervention. Utilize laboratory results such as abnormal liver function tests or connect substance use to encounters with law enforcement, job loss, and family problems. Pull from your clients life to find the correct feedback that captivates their attention to the dependency problem and solidify the link that it is their substance use behaviors that are putting their happiness at risk. The use of a daily journal or self-monitoring diary can be of assistance in this phase.

Responsibility

This is about the client. This is about the clients life, the clients behaviors. Personal responsibility is the core concept to their control of their life and happiness. Work to clarify goals that are important to your client. Goals should be reasonable and achievable. Anticipate the client will need assistance to form realistic, incremental goals.

Advice

Offer clear suggestions on reaching personal goals that are important to your client. Support here consists of suggestions and encouragement as well as providing the opportunity for the client to voice their concerns and frustrations in a climate free of condemnation and filled with encouragement toward a life free from the substance use monkey on the back.

Menu

Offer options on how to reach newly set goals. Be aware that some helps, methods or means to obtain those goals will be unknown to your client. Allow the opportunity for your client to discuss and consider what strategies appeal to them and their circumstances. Reinforce the concept of personal choice and personal responsibility in their personal treatment. Should there be concerns that too many options may overwhelm the client, carefully consider which two or three to promote, and offer information focused on those.

Empathy

The pivotal component to success in brief intervention therapy revolves around empathy. Utilize skillful listening to offer suggestions or responses that validate the clients feelings while supporting their efforts toward success. Be ever vigilant not to smother a clients progress by imposing your own life experiences or values onto them.

Self-efficacy

Success in any given venture centers on the belief that it can be achieved. Self-efficacy is about building up your clients sense of ability to succeed in this task. Promote optimism, celebrate incremental success, and assist your client to maintain a clear vision of the positive gains that will be achieved once their substance use is under control. Specific helps consist of strategies such as assisting the setting of early, easily accomplished goals and eliciting or reinforcing self-motivating statements.

Case Study: Margaret

Margaret is a 26 y/o female, married, with two children ages 3 and 5.

She was admitted for trauma workup after driving through the front window of a convenience store in an SUV. To first responders she presented with slowed responses and slurred speech though no odor of alcohol was present. Of immediate concern was the possibility of head trauma, which was later ruled out. Blood alcohol was negative. Present on toxicology screening was benzodiazepines for which she has a valid prescription treating generalized anxiety disorder.

In the back seat of the SUV at the time of the accident were both children, safely secured in car seats, frightened and uninjured.

During the admission interview with the emergency room nurse Margaret reveals that she has come to depend on her prescription medication, Ativan, to help her feel "normal". Recently her medication has ceased to be effective and her general practitioner was unwilling to increase her dosage. She has been "borrowing" from her mothers Valium, which she indicates her mother rarely uses. The interview also indicates that Margaret values the health and safety of her children very highly and would never willingly put them at risk for danger.

Assignment: Initiating the FRAMES Component - Feedback

Using the Feedback component of Brief Intervention, what awareness could you offer to Margaret concerning a behavior that is putting her happiness at risk?

Motivational Interviewing in Substance Abuse

One of the prized brief intervention tools when dealing with clients is that of motivational interviewing. Motivational Interviewing (MI) is a system based on an empathetic, respectful view of the clients life struggles, with a set of simple techniques used for prompting behavioral change. Originally, MI was developed for dealing with problem drinkers yet has proven effective across the board for substance use issues. MI focuses on enhancing the clients self-motivation for change, addressing ambivalence to change, making an emphasis on personal responsibility and the ability to make meaningful choices.

Principles of Motivational Interviewing
  • Empathy, reflective listening
  • Respect and acceptance
  • Nonjudgmental, collaborative relationship
  • Supportive, knowledgeable consulting
  • Positive focus
  • Listening, not telling
  • Change is up to the client
  • Support
  • Helping the client recognize discrepancies between goals and behavior
  • Avoiding confrontation or argumentation
  • Adjusting to client resistance, e.g., "roll with resistance"
  • Supporting the clients self-efficacy and optimism
Key Skills of Motivational Interviewing
  • Open-ended questions
  • Reflective listening
  • Affirmations
  • Summarizing
  • Eliciting self-motivational statements
(SAMHSA-NREPP, 2014)

Using Open-ended Questions

The use of open-ended questions is helpful due to the need of the client to provide informative responses, rather than yes/no answers. Use of questions such as "What does it feel like when you smoke crack cocaine?" imparts that you want to understand the person and their experience rather than just hurry them into agreement with you. Information gained from responses about the negative and positive aspects of substance use for that unique person will be very helpful.

Using Reflective Listening

Words and silences are mirrors that help clarify the picture and progression of dealing with the challenge of a substance use disorder. Using reflective listening indicates you hear the client. Without judgment, without denying the importance or watering down what has been said. All the while asking for more. An example of reflective listening might go like this:

Clients statement: "My husband gets so pissed when I come home high after a night out."

Reflective listening: "So, he gets really angry when you have been out and return home high".

The statement from the clinician simply restates and confirms accurate understanding of what the client has said without judgment, and thereby encourages further conversation.

Using Affirmations

Affirmations are tools that convey understanding and respect. They are gentle encouragements towards progress. When a client feels respected, they become more open and likely to reveal less positive details about themselves.

Example: "You are very brave to be so open about how this is affecting you."

Using Summarizing Statements

Summarizing is the art of returning to the client the essence of what you, the professional, has heard over a period of time. Summarization is a good way to cleanly move from one topic to the next.

An example of summarization: "What you said is very important to me, and here is what I heard. Did I hear you correctly?" (Client response). "That covers this area thoroughly, lets move on and discuss".

Eliciting Self-Motivational Statements

Prompting and encouraging self-motivational statements is important, especially for those clients not yet committed to making changes. Four question types can help pull concerns out into the open and allow the client to focus on self-motivation:

  • Problem Recognition Questions: "How do you think you have been hurt by your alcohol use?", "How has your caffeine use created problems for you?"
  • Apprehensions Questions: "What are you afraid of if you continue to use meth?", "What worries do you have about shooting up with heroin?"
  • Intent to Change Questions: "How important is it to you, on a scale of 1 to 10 with 10 being the highest, for you to stop using ecstasy?" Note: If the client answers "4", for example, ask them why they did not select "3" or "5". This prompts for reasons blocking or encouraging change.
  • Optimism Questions: "What difficult goals have you reached in the past?" Responses uncover strengths and confidence they can leverage into their attempts to overcome substance use problems.

Summary

Substance use disorders are the use or overuse to the point of abuse of one or more substances that can be licit, illicit or illegal. Use disorders can be identified by the presence of two or more diagnostic criteria detailed in the DSM-5. These criteria include; 1) being taken in larger amounts over longer periods than intended, 2) presence of a persistent desire or unsuccessful efforts to cut down or control use, 3) a great amount of time Is spent obtaining, using, or recovering from its effects, a craving or strong desire to use exists, 5) use results in failure to fulfill role obligations, 6) use continues despite social or interpersonal problems it causes or worsens, 7) social, work, or recreational activities are reduced or ended due to use, 8) it is used in situations that are physically hazardous, 9) use continues despite knowledge physical or psychological problems are likely, 10) tolerance develops, 11) withdrawal occurs on lowering or ceasing use. A key concept to the presence of a substance problem is the presence of negative consequences in the life of the user in the realms of social, occupational, physical, or psychological functioning.

Brain reward is a system of neurochemical feedback governed by the mesolimbic dopamine response. Triggering of the brain reward prompts each of us to respond favorably to the presence of preferred substances that may be unique to each of us. Behavioral rewards are also a huge factor in the overuse of recreational, prescription or street drugs so it is important to consider what primary benefit is being achieved by your clients substance use.

Individuals enmeshed in the web of substance use problems may find themselves drawn to different groups of substances depending on behavioral rewards and how their brain reward system responds. General groupings of chemicals that have a greater risk for negative life consequences are; Alcohol, Caffeine, Cannabis, Hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, other hallucinogens such as LSD), Inhalants, Opioids, Sedatives/Hypnotics/Anxiolytics, Stimulants (including amphetamine-type substances, cocaine, and other stimulants), Tobacco, and Other or unknown substances.

When clients present with aspects of tolerance, avoidance of withdrawal, high levels of consumption in a particular substance group, or negative life consequences not readily associated to another known event then substance use disorder should be considered.

Acute medical treatment followed by structured follow-up using a system such as Brief Intervention or Motivational Interviewing are important steps in helping the client to regain a life free of the bonds of substance abuse.

We are all affected by substance use problems. Be it in a family member, a client, or in ourselves. The burden placed on society as a whole by the impact of substance abuse is horrific. By sharing what we know and have observed we can, as health professionals be more alert and provide earlier therapeutic interventions with better outcomes for those snared in the web of substance abuse.

References

American Psychiatric Association DSM-5. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Brown University. (2014). "RAFFT: Relax, Alone, Friends, Family, Trouble". Brown University Project ADEPT. Retrieved October 25, 2014 from (Visit Source).

CBS DC. (2014, January 29). "Experts Warn of Caffeine Use Disorder". CBS Washington. Retrieved September 27, 2014 from (Visit Source).

Christensen, J. (2014, June 27). "Are You A Heavy Drinker? Youd Be Surprised". CNN. Retrieved September 27, 2014 from (Visit Source).

Delgado, J., (2014). Intoxication from LSD and Other Common Hallucinogens. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.

DrugFacts. (2013 April). "Khat". National Institute on Drug Abuse. Retrieved September 13, 2014, from (Visit Source).

DrugFacts. (2014 January). "Nationwide Trends". National Institute on Drug Abuse. Retrieved September 13, 2014, from (Visit Source).

Dugdale III, David., (2013). "Alcohol Withdrawal". Medline Plus. Retrieved September 27, 2014 from (Visit Source).

DuPont, R., et al., (2014). Cannabis Use Disorder Clinical Features and Diagnosis. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.

Gorelick, D., (2013). Cocaine Use Disorder in Adults: Epidemiology, Pharmacology, Clinical Manifestations, Medical Consequences, and Diagnosis. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.

Horvath, A., et al., (2013, August 26). "The Diagnostic Criteria for Substance Use Disorders". MentalHelp.net. Retrieved September 26, 2014 from (Visit Source).

Kearney, C., (2012, February 1). "Sugar - Attacking Health Globally." Medical News Today. Retrieved September 24, 2014 from (Visit Source).

Lustig, R. D. (2012). "The toxic truth about sugar." Nature, 482(7383), 27-29.

Meredith, S. et al., (2013). "Caffeine Use Disorder: A Comprehensive Review and Research Agenda". Journal of Caffeine Research. 114 DOI: 10.1089/jcr.2013.0016.

Miller, W., (2013). "What Is Brief Intervention for Addiction, Alcoholism?". Psych Central. Retrieved on October 26, 2014, from (Visit Source).

National Institute on Drug Abuse., (2012). Principles of Drug Addiction Treatment: A Research-Based Guide, 3rd edition. National Institute of Health. Bethesda, MD.

National Institute of Drug Abuse., (2012). "Understanding Drug Abuse and Addiction". Retrieved September 26, 2014 from (Visit Source).

National Institute on Drug Abuse., (2014). "Drugs, Brains, and Behavior: The Science of Addiction". Retrieved September 26, 2014 from (Visit Source).

National Institute of Drug Abuse., (2014). "Drug Facts Marijuana". Retrieved September 28, 2014 from (Visit Source).

NCPIC. (2013). "Cannabinoids." National Cannabis Prevention and Information Center. Retrieved October 28, 2014 from: (Visit Source).

NIAAA National Institute on Alcohol Abuse and Alcoholism. (2014). "Drinking Levels Defined". Retrieved September 27, 2014 from (Visit Source).

NIAAA National Institute on Alcohol Abuse and Alcoholism. (2014). "Alcohol Use Disorder". Retrieved September 25, 2014 from (Visit Source).

Perry, H., (2014). Inhalant Abuse in Children and Adolescents. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.

Rigotti, N., and Daughton, D., (2014). Patterns of Tobacco Use. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.

Saitz, R., (2013). Screening for Unhealthy Use of Alcohol and Other Drugs. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.

SAMHSA-HRSA, (2014). "Screening Tools". Center for Integrated Health Solutions. Retrieved September 27, 2014 from (Visit Source).

SAMHSA-NREPP. (2014). "Motivational Interviewing." National Registry of Evidence Based Programs and Practices. Retrieved October 26, 2014 from (Visit Source).

Scher, L, (2014 February 18). "Sedative Hypnotic Anxiolytic Use Disorders." Medscape eMedicine. Retrieved October 5, 2014 from (Visit Source).

Stolbach, A. and Hoffman, R., (2014). Acute Opioid Intoxication in Adults. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.

Strain, E., (2014). Opioid Use Disorder: Epidemiology, Pharmacology, Clinical Manifestations, Course, Screening, Assessment, and Diagnosis. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.

World Health Organization. (2005). "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators". WHO Tobacco Control Papers. UC San Francisco: Center for Tobacco Control Research and Education. Retrieved October 24, 2014, from (Visit Source).

World Health Organization. (2014). "Lexicon of Alcohol and Drug Terms Published by the World Health Organization". Retrieved September 21, 2014, from (Visit Source).

Weaver, M., and Jarvis, A., (2013). Substance Use Disorder: Principles for Recognition and Assessment in General Medical Care. In: Hirsch MS (Ed.) UpToDate 22.8. Waltham, MA.


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)

Topics:

Advance Practice Nurse Pharmacology Credit, Conneticut ARNP, CPD: Practice Effectively, Delaware Requirements, Psychiatric


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