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Substance Abuse

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

Outcomes

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 the 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.

Objectives

Upon completion of this educational activity, the learner will be able to:

  • Define substance abuse.
  • Describe three signs/symptoms that would indicate a need to consider substance use disorder in a client.
  • Describe the brain response system associated with substances of abuse.
  • List three common substance use disorder groups
  • Discuss withdrawal symptom unique to the three common substances.

Introduction

Pop stars, Hollywood screen personalities, the tipsy inebriated spectrum of celebrities that create a spectacle while 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 lives 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 darker twisted stories. 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 of preventable death.1 Unhealthy use or purposeful abuse of chemicals, medications, plant products, or other substances not meant to be used in such manners or quantities creates problems frequently encountered by health professionals.

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 2015 NSDUH places 24.6 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.2 This is 9.4 percent of the population, up from an already high 8.3 percent in the 2002 survey.

Overutilization of any substance can lead to undesirable effects. Tendencies to overuse some manner of chemicals in our lives may be unduly influenced by innate 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 Disorders3

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."

When the use of a specific substance harms us, common sense dictates we stop using 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 affecting us adversely. 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.3 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

IIn 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 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.

Physical versus Psychiatric Dependence3,4

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.

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 Include3:
  • Intoxication
  • Withdrawal
  • Substance induced mental disorders (i.e. substance induced psychosis, substance induced depressive disorder, substance induced delirium, etc.)

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. The severity of substance use can be isolated by the number of negative criteria affecting each person.

Substance Use Disorder Criteria3:
  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.

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), Sugar5,6,7

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.

Illegal substances are those whose possession or use is deemed by federal or state statute 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 is frequently referred to as “substances of abuse.”

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 children’s 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 OTC’s 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, Temp 99.1. 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.”

Gemina’s medications, both prescription and OTC, are 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. Our brains closely regulate 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 brain’s 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.8 Dopamine produced in this manner consequently affects an array of neurochemical and neurohormone messenger’s 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 person’s 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.

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 person’s 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 gathered into major groupings by the American Psychiatric Association.

The DSM-5 Recognizes the Following
Substance Abuse Disorder Subcategories3:
  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.

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.8

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 seek more energy, greater creativity, or perhaps enhanced pleasure. Still, others may be looking for emotional relief, 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 don't know why I became hooked, it just happened!").

Please be aware that one of the strong underlying primary motivations related to substance abuse is that of dissociation or escape. The shifting of how 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 happens!

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 for 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 Criteria3,9
  • 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
  • Pharmacologic 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

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.10 Health professionals are obligated to view all new clients as having the potential for a substance use disorder.

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

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 in 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.

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
  • A productive cough, as there is a high rate of tuberculosis and community-acquired pneumonia
  • Respiratory problems, from smoking or snorting substances
  • Needle marks, recent or 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 goldmine 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.
  • 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?

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, genes inherited 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 of 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 criteria in the DSM-5 substance use curriculum is the effect of substance use on one’s 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 considered when applying the DSM-5 diagnostic criteria to your clients.

Diagnostic Criteria for Specific Substance Use Disorders

Substance Use Disorder: Alcohol Related Disorders

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% of adults in the United States, as of the 2015 National Survey on Drug Use and Health (NSDUH).12

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 a 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.

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, lorazepam, 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 mother’s 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.

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. High levels of liver cirrhosis and pancreatitis are also 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 the 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 Tool3,12:

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 two of the eleven DSM-5 criteria during the same 12-month period receives a diagnosis of AUD.

The severity of an AUD—mild, moderate, or severe—is 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 couldn’t?
  • 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?

Any of these symptoms is a cause for concern. The more symptoms present, the more urgent the need for change.

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 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 Use13

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?

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 Consumption12,14

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 men—in 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 liquors -- the fancy term for gin, rum, vodka, whiskey etc.

The adage “once a drunk – always a drunk” does not hold up to scientific scrutiny. Alcohol use tends to be variable across an individual’s 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 person’s detriment.

Alcohol Intoxication, Diagnostic Criteria3
  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

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 Characteristics15

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

Substance Use Disorder: Caffeine Related Disorders

Caffeine is the most commonly used drug in the world.16 Excessive consumption of caffeine combined with negative physical and psychological symptoms, particularly during withdrawal, according to researchers, demonstrates a clear caffeine use disorder.

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.16 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 Criteria3
  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

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. 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 Criteria3
  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)

Caffeine dependence is very common amongst individuals who report experiencing frequent 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 is not simply marijuana anymore. It grows from three separate species of flowering plants of 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.

Like in opiates where opioid chemicals are derived from the opium poppy, cannabinoids are the unique psychoactive substances found in cannabis. Over sixty cannabinoids have been identified in cannabis, with the research focus to date being on Tetrahydrocannabinol (THC), considered the most psycho-actively potent of the cannabinoids.17 Especially with hybrid cannabis, other psychoactive cannabinoids play active roles as well. Cannabidiol (CBD) for instance, has shown antianxiety potential and is thought to have an active role in buffering the stimulant and anxiety-producing qualities possessed by straight THC.

Approximately half (49%) of Americans have used cannabis, with 12% using in the last year.18 Cannabis is the most frequently cultivated, trafficked and used illegal/ illicit plant substance worldwide. Patterns of intoxication, tolerance, and withdrawal with cannabis use are consistent and recognizable diagnostically.

Inherited metabolic traits contribute to the development of cannabis use disorder, as do environmental and social factors. Research has demonstrated that some individuals are able to tolerate cannabis use without significant consequence, while others follow a slippery slope to significant troubles. Between 9% and 30% of all users will become addicted to cannabis. Among those who start young, this percentage increases by four to seven times more than in adults.19

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.19 Sadly, the lost cognitive abilities were not fully restored even when cannabis use was discontinued.

Cannabis Intoxication, Diagnostic Criteria3
  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

Cannabis withdrawal symptoms may cause levels of distress that push the person toward resuming intake. While hospitalization due to the withdrawal of cannabis is rarely medically needed, 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 Criteria3
  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

Unusual levels of fatigue, yawning, or difficulty concentrating 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: Opioid Related Disorders

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

The term opioid use disorder (OUD) is the new diagnostic standard. It combines opioid dependence and opioid abuse, also pulling in the wide range of related opioid 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 (Leo alpha acetylmethadol), or others.

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 nor withdrawal makes an addict. The DSM-5 repeatedly emphasizes that use of a substance does not make a person an addict.

The 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 rise 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.

Individuals with opioid use disorder may show no acute symptoms that would trigger an inquiry into that person’s 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 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.

Opioids may be ingested in 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

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.22

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 a 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 delirium.

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

  • 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.22

Opioid Intoxication, Diagnostic Criteria3,22
  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

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 person’s 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.23

Opioid Withdrawal, Diagnostic Criteria3,23
  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

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. The 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 11.8% of the adult population use prescribed anxiolytics in the course of a year, while over 2% have misused tranquilizers in the past year.24,25 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.

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 is the “go to” medication for a great number of common quality-of-life impairing ailments. To have the treatment for one condition become the cause of negative consequences 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.

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 Intoxication, Diagnostic Criteria3,25
  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

Careful monitoring of intoxicated individuals is needed as episodes of generally brief yet severe depression may be associated with a 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 Criteria3, 24, 25
  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

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 by the American Psychiatric Association into one diagnosis, that of Stimulant Use Disorder.3 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 the 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 cocaine. Legitimate uses for stimulants abound, including treatments for ADHD, obesity, sleep disorders, etc.

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, and 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 one’s 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), have been processed with ammonia or baking soda and require 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. Crack’s 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 0.7% of adult Americans or 1.9 million people have used cocaine within the past thirty days. Some 867,000 U.S. adults or 0.3% of the population meet the criteria for cocaine abuse disorder. Most healthcare providers are familiar with cocaine as it is the illegal drug most often associated with hospital emergency room visits.26 In the year 2011, the Drug Abuse Awareness Network (DAWN), estimated 40.3% of all illicit drug-related emergency visits involved cocaine.26

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.26 Sleep disturbances, weight loss, tremors, and stereotyped behaviors such as picking at the skin also accompany cocaine use.27

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.

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 for 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.

Acute stimulant intoxication may present with grandiose statements or actions and proceed to restlessness, sudden jerky 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 Criteria3, 27
  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

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. 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 Criteria3, 27
  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

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 with more than 41,000 of those deaths resulting from secondhand smoke.28 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.

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.

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 of 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 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 are 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 as well as the 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 Criteria3, 28
  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

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. Increased appetite with weight gain and sluggishness hangs on for extended periods 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 category where uncommon, unusual and just plain 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, that are somewhat location specific, or that negatively affect relatively limited numbers of the general population. Some of these other 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 new designer drugs cropping up.
Other (or Unknown) Substance Use Disorder, Diagnostic Criteria3
  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.

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 one’s 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 consider 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 Criteria3
  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. 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. 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.

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 Criteria3
  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.

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 adjust and become dependent on the presence of the drug, chemical, or plant with negative symptoms occurring on a sudden drastic lowering of intake of the substance. Symptoms and severity of withdrawal vary according to the substance in question and the individual’s 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 not specifically highlighted within the DSM-5. As soon as the substance is identified, it should be reflected in the diagnostic label, e.g., Substance Use Disorder (Other) Laxatives.

References

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  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th ed. Arlington, VA: American Psychiatric Publishing. 2013.
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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, Rhode Island Substance Abuse Requirement


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