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Substance Abuse

2 Contact Hours including 2 Advanced Pharmacology Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Sunday, December 13, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

FPTA Approval: CE24-970698. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.

Substance use disorders (SUD) are at an all-time high. As healthcare professionals, we supply care to clients and families who find their bodies, minds, and quality of life shattered by the consequences of ingesting substances of abuse at harmful levels. We need to be alert for the best information concerning which substances have the potential for abuse and at what levels of consumption. We need the most current tools to help decrease or end the use of harmful substances in their daily lives while maintaining their quality of life.


After completion of this course, the participant will be able to:

  1. Identify the different types of abused substances.
  2. Evaluate lab tests used for identifying abused substances.
  3. List common symptoms of withdrawal for different abused substances.
  4. Summarize the guidelines of care for different abused substances.
  5. Characterize symptoms of use/intoxication of abused substances.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Substance Abuse
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    David Tilton (RN, BSN)


Personalities and celebrities often make glamorous, exciting, and drama-filled media stories concerning the misuse of substances. Misuse of substances does not lead to a happy life or overflowing bags of money from product endorsements, despite the efforts of the media to portray it that way. Studies, observation, and the rarest ability of all, common sense, tell darker, twisted stories—much too common tales of horrendous, avoidable injuries to the mind and body. Health professionals must share knowledge without being entangled in media half-truths or spins on facts. Whether we fall into the sweet trap of substance abuse or not, we are all affected by substance misuse as individuals, professionals, and a society.

Scope of Problem

The terminology associated with the acknowledgment of abuse and the labeling of addiction may be outdated (National Institute on Drug Abuse, 2021b). It is not uncommon in health care that difficult-to-address issues become redefined. The presence of new definitions and altered nomenclature speak directly to the difficulty and urgency facing the misuse of substances. The new, more gentle term for the same dismal swamp of pain and suffering is "substance use disorder" or SUD.

SUD is the unhealthy use or purposeful misuse of chemicals, medications, plant products, or other substances not meant for use in such manners or quantities. Global estimates show that the current use of illegal drugs, just one type of SUD, affects 64% of all people, over half of the world's population (Ashton, 2021). The annual National Survey on Drug Use and Health (NSDUH) reveals that substance misuse continues to rise despite concerted efforts. The 2020 NSDUH estimates that 162.5 million Americans over the age of 12 are engaged in patterns of use or misuse of substances that we know have detrimental effects. NSDUH also estimates that 50% currently misuse alcohol, 18.7% misuse tobacco products, and 13.5% use or misuse illicit substances such as marijuana, heroin, stimulants, or others (Substance Abuse and Mental Health Services Administration, 2021).

The unhealthy use of substances afflicts the old and the young at all economic levels and cultural divisions. One national survey revealed that 14.5 % of those 12 or older in the United States possessed a diagnosable SUD within the last twelve months (Dugosh & Cacciola, 2022). In 2021, the United States Centers for Disease Control (CDC) estimated 105,752 substance overdose deaths, giving a perspective on the burden placed on emergency services.

Misuse of any substance can lead to undesirable effects. Tendencies to overuse chemicals in our lives may be unduly influenced by inborn molecular genetic predispositions. Individualized behavioral rewards for misusing substances are of concurrent importance. An accurate global definition of substance misuse is necessary to shape what we know about the substances we use and become dependent on.

DSM-5-TR 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."
(Sachdev, 2022; American Psychiatric Association, 2022)

When a substance harms us, common sense dictates we stop using it. Unfortunately, substance misuse is not an area where common sense decrees are followed. The use of these substances may be partly due to the human ability to deceive ourselves when what we are doing or feeling appears to meet a need or desire. According to the 5th edition of the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association, abusive use of a chemical or other substance may be recognized by groupings of physiologic, cognitive, and/or behavioral symptoms. The problem item can be a prescription medication, a recognized drug of abuse, or other substances taken into the body.

Recognizing a Substance Use Disorder

The American Psychiatric Association started to redefine abuse into different use disorders and categories. 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. A substance-specific reaction to the cessation of intake, which can either be physical, psychological, or both, is referred to as withdrawal. Therefore, when a substance is stopped, withdrawal occurs due to the shift in the central nervous system from the sudden lack of the consistent presence of the substance. Unfortunately, the presence of withdrawal symptoms when ceasing substance use automatically flagged non-addicts with the life-long label of substance abusers. While physical withdrawal does not automatically mean addiction, the widespread misunderstanding of normal dependence has created a dangerous diagnostic trap.

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

Physical dependence is NOT addiction.
With time the body adjusts to the presence of substances, adapting to support balanced function (a.k.a. homeostasis). With frequent use, the body learns to tolerate the presence of a substance and even expect its presence metabolically. The body now has an enhanced ability to break down, use chemical components, and speedily excrete familiar substances.

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

Addiction IS a Psychiatric illness.

Despite harmful consequences of continuing use, psychiatric dependence, compulsions, and cravings for a substance result from a shift in a person's normal hierarchy of needs and desires, placing the need to obtain and use a specific substance above other normal needs or desires. The change in brain function, thinking, planning, and responding normally separates the psychiatric dependence of addiction from physical dependence.
(Dorwart, 2022)

With the release of the DSM-5, the Substance Abuse and Chemical Dependence categories were eliminated and replaced with a more comprehensive category that regards the presence of unwanted effects of a substance on a continuum ranging from mild to severe. A SUD with specific criteria allows for 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 substance abuse. Certain individuals have higher tolerances or a faster metabolism for processing problematic chemicals. Others may have lower self-control or genetic predispositions, making them more prone to developing problems when exposed to specific substances. The DSM-5 recognizes two general groups of substance-related disorders: SUDs and Substance-Induced Disorders (SIDs). SIDs are characterized by specific symptoms directly caused by a particular substance during or after an individual episode of use.

Symptoms of SIDs:
  • Intoxication - physical and mental side effects or changes from alcohol or drugs. It may include feelings of euphoria, lack of inhibitions, clouded thinking, slurred speech, impaired balance, and blurred vision.
  • Withdrawal - a condition that is a direct result of physical and mental dependence on drugs or alcohol. Withdrawal occurs when a person tries to stop taking the substance. In some instances, withdrawal can be severe or even fatal. It may manifest as nausea, vomiting, body aches, tremors, fevers, insomnia, depression, or anxiety.
  • Substance-induced mental disorders – disorders that relate directly to substance use or misuse (i.e., substance-induced psychosis, depressive disorder, delirium, anxiety, sleep disorders, obsessive-compulsive disorder, bipolar disorder, neurocognitive disorder, sexual dysfunction).
(Oro House Recovery Centers, 2022; Kahn, 2022)

SUD's pattern of symptoms results from continued substance use, despite experiencing problems. Eleven different negative outcomes of substance use serve as the general SUD diagnostic criteria. The severity of substance use can be isolated by the number of negative criteria affecting each person.

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 often than others in conjunction with use disorders; however, abuse patterns can be associated with the most innocent items, such as sugar or caffeine (Wrona, 2022; Greenberg and St Peter, 2021).

Illegal substances are those whose possession or use is considered by federal or state statutes 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 often are, the subjects of substance misuse and abuse and tend to be tracked by law enforcement and health advocacy groups whenever usage statistics are cited.

Use disorders can be present with legitimate and legal substances (i.e., alcohol, prescription pharmaceuticals, over-the-counter medications, tobacco). It is vital as a healthcare professional to be constantly aware that dependency is not limited to what is often referred to as "substances of abuse."

Case Study: Gemina
Gemina is a 78-year-old female who has diabetes and is one-day post ankle surgery. Her surgery was done using a regional anesthetic to decrease the possibility of complications. Other than oral hypoglycemics, she is on no routine prescription medication. She 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.
The admission notes show that the client brought both medications with her despite being instructed that hospital policy prevented their use during her stay. She became upset and argumentative with the staff when the medications were sent home with the family.
Late in the post-op evening, Gemina begins complaining of anxiety and uncontrollable shivering. On examination, she is diaphoretic and tachycardic. Her blood pressure is 164/90, her pulse is 112, her respiratory rate is 22, and her temperature is 99.1. Her blood sugar was checked by the attending nurse, and is 61.
A review of admission paperwork and questioning of Gemina, along with a phone call to her family, reveals that the over-the-counter adult liquid remedy that the client compulsively uses has a high alcohol and fructose corn syrup content. She takes the medication four or more times daily, though it is only meant to be taken once daily. She keeps a bottle at her bedside in case she has difficulty sleeping during the night, as it seems to soothe her nerves.
Gemina's prescription and over-the-counter medications are stopped pending evaluation, and she has been diagnosed with acute alcohol withdrawal.

Brain Reward

SUD 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 the detrimental effect that goes with its use. Our brains tightly regulate the interplay of chemicals we ingest during the ongoing balancing act of daily life. A key player in this ongoing and frantic juggle of biochemistry is the brain's reward system, the mesolimbic dopamine system. Research into brain chemistry shows that brain reward can be triggered when a substance stimulates dopamine production in the mesolimbic system (Sabater, 2021). Dopamine produced in this manner affects an array of neurochemical and neurohormone messengers dependent on individual factors such as prevalent demands and functional imbalances. These factors help explain why certain ingested chemicals are problematic to one person while not wanted by another (e.g., one person's cravings are for amphetamines rather than heroin even after being exposed to both). The uniqueness of the need for balancing our brain chemistries plays a role in what triggers the brain reward response in each of us.

The cognitive behavioral effects of substances are closely tied to the neurochemical brain reward response. The correct chemical trigger at the proper time for the right person can nudge brain chemistry and improve our thoughts and feelings about unpleasant life circumstances, at least for a short time. Even after the negative consequences of substance use become clear 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.

Substance Abuse Disorder Subcategories:
  • Alcohol Use Disorder (AUD) – is considered a toxic substance with both stimulant and depressive properties.
  • Caffeine Use Disorder – stimulant found in many commercial beverages, not just coffee.
  • Cannabis Use Disorder (CUD) - the problematic use of marijuana products, including traditional marijuana, vape pens, and edibles.
  • Hallucinogen Use Disorder - phencyclidine or similarly acting arylcyclohexylamines, as well as other hallucinogens such as LSD and ecstasy.
  • Inhalant Use Disorder - continued use of hydrocarbon-based inhalant substances having acetone, benzene, toluene, turpentine, or gasoline.
  • Opioid Use Disorder (OUD) - a class of substances originally derived from the poppy plant to treat pain. They release dopamine into the brain, activating the reward system.
  • Sedative, Hypnotic, or Anxiolytic Use Disorder – substances that slow down brain activity.
  • Stimulant Use Disorder – cocaine, amphetamine-type substances, or other unspecified stimulants.
  • Tobacco Use Disorder – is really about the nicotine in tobacco products. These include cigarettes and loose-leaf tobacco such as dip, hookah, and snuff pouches. Tobacco use is currently the most common SUD in the United States.
  • Other (or unknown) Use Disorder - substances not otherwise specified in any other categories that still cause significant distress and disruption.
(Veronika, 2022; American Psychiatric Association, 2022)

Substances in these high-risk groupings tend to provoke dopamine release (either directly or indirectly), resulting in the brain reward response. Differences in what triggers the brain reward response and how sensitive each person is to that reward contribute to the risk level for a SUD, sometimes referred to as the substance's abuse potential.


Those caught in the web of a SUD have an expansive range of motivations. Some become enmeshed while seeking relief from physical pain, depression, stress, and anxiety, while others may seek more energy, greater creativity, or perhaps enhanced pleasure. Still, others may seek emotional relief, 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!"). One of the strong underlying primary motivations related to substance abuse is dissociation or escape. 
Homework Assignment: When working with a client with SUD, set aside time to contemplate the following key principle:
"What are the primary benefits this person achieves from their substance of choice?"

Many people can control their substance use without experiencing sustained or profound consequences from occasional responsible use. The experience of those who become burdened with unwanted dependence can be thought of as having an abnormal level of response (brain reward) which leads to a desire for more of the substance. Inevitably, this is followed by continuing increases in both the frequency of use and the amount of the item needed for effect. In conjunction with substance ingestion, negative consequences arise, giving the health professional clues to the problem.

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. Substance misuse scenarios are not confined to what is portrayed in TV dramas. Frequently people find themselves in uncomfortable situations with prescription pain medications, social drinking, recreational substances, and such. Often, they voice concerns to healthcare 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 up a substance use concern to the affected individual or a trusted healthcare provider. The beliefs 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 healthcare system. Presenting symptoms can vary greatly depending on the individual and the substance involved, although each SUD shares some key diagnostic criteria.

Shared Diagnostic Criteria

Criteria Grouping "A" (Criteria 1-4) Impaired Control

  • Criteria 1 – Larger amounts.
    • Use of a substance in greater amounts for longer than originally planned.
  • Criteria 2 – Persistent desire.
    • Expressing or having a continuous desire to cut down or regulate the consumption of a substance.
  • Criteria 3 – Time spent obtaining.
    • Spending a lot of time obtaining more substances and recovering from substance effects.
  • Criteria 4 – Craving.
    • Desire, at times intense, for a substance.

Criteria Group "B" (Criteria 5-7) Social Impairment

  • Criteria 5 – Social role impairment.
    • The inability to succeed at or fulfill key role obligations at work, school, or home.
  • Criteria 6 – Social issues.
    • Continued substance use despite persistent or recurrent social or interpersonal problems caused or worsened by the effects of the substance.
  • Criteria 7 – Social withdrawal.
    • Important social, occupational, or recreational activities are given up or reduced due to substance use.
    • Withdraw from family activities and hobbies to use the substance.

Criteria Grouping "C" (Criteria 8-9) Risky Use

  • Criteria 8 – Physical danger.
    • Recurrent abuse of substances in physically hazardous situations.
  • Criteria 9 – Use despite understanding hazards.
    • Continued use of a substance despite knowledge of physical or psychological problems.

Criteria Grouping "D" (10-11) Pharmacological

  • Criteria 10 – Tolerance.
    • Requiring a markedly increased dose of substance to achieve the desired effect or having a markedly reduced effect when the usual dose is consumed.
  • Criteria 11 – Withdrawal.
    • A physiological syndrome occurring when blood and tissue levels of a substance decline.

The Severity of SUD

  • MILD SUD: Two or three criteria
  • MODERATE SUD: four or five criteria
  • SEVERE SUD: six or more criteria.
(Dugosh and Cacciola, 2022; American Psychiatric Association, 2022; Jahan and Burgess, 2022).

Substance Use Evaluation

All patients should be evaluated for SUDs. Studies show that 14 of every 100 adults in the United States will have had at least one SUD within the prior twelve months (Dugosh & Cacciola, 2022). Healthcare professionals should view all new clients as having the potential for a SUD.

Locating clues, signs, and symptoms of a SUD depends on understanding the diagnostic criteria and 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 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 showing the consumption of a substance recently. Blood levels provide the most information when correlated with observed impairment; however, they 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, obtain a thorough history with a urine toxicology screen (Jahan & Burgess, 2022).

  • Blood alcohol level and urine drug screen - aid in finding recent substance use.
  • Liver function testing with a hepatitis panel - aids in assessing accumulative damage from substance misuse. NOTE: HIV antibody testing is often performed when IV substance misuse is suspected.
  • Complete blood count (CBC) and basic metabolic panel (BMP) - aid in finding any comorbid issues, such as electrolyte imbalances, anemia, or infection. Pancreatic enzyme serum levels are often overlooked yet may be instrumental in spotting pancreas issues secondary to binge drinking and heavy nicotine misuse.

When the reliability and validity of urine drug test samples are a concern, please be aware of the following tampering practices (Davis, 2022):

  • Substitution with another sample.
  • Direct dilution of sample (e.g., watering down).
  • Additives to the sample that interfere with the assay.
  • Ingesting substantial 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 barbiturate or cannabinoid readings, poppy seeds, or fluoroquinolones for false opiate levels). 

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

Physical Findings

Always be alert for findings during a physical examination that might provide clues to substance misuse (Myhre & Sifris, 2022; American Addiction Centers, 2022b):

  • Bloodshot or glazed eyes - dilated or constricted pupils.
  • Unusual infections - particularly among individuals administering substances by injection.
  • Poor hygiene.
  • Liver abnormalities - over 69% of new hepatitis C virus (HCV) infections occur in those who use substances by injection; that same demographic composes 78% of the total HCV infections in the United States.
  • Dental issues - including oral thrush from an HIV infection, an offshoot of sharing needles.
  • Productive cough - there is a high rate of tuberculosis and community-acquired pneumonia amongst those who misuse substances.
  • 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.
Common Withdrawl Symptoms
While physical withdrawal symptoms are unique to the type of substance, many responses which occur during an abrupt stop or decrease in a substance are shared.
Physical Withdrawal Symptoms
  • Headaches
  • Sweating and/or chills
  • Stomach and digestion problems
  • Loss of appetite
  • Sleep problems/fatigue
  • Increased heart rate
Psychological Withdrawal Symptoms
  • Mood changes or swings
  • Irritability
  • Feeling unsettled/unstable
  • Intense fear and/or sadness
  • Inability to feel pleasure
  • Confusion and poor concentration
Substance Specifics
  • AUD- may show simple tremors to fully blown delirium tremens characterized by autonomic hyperactivity, tachypnea, hyperthermia, seizures, and diaphoresis. About 25% of AUD withdrawal clients develop alcohol hallucinations.
  • Sedatives Withdrawal (e.g., barbiturates, benzodiazepines) - autonomic and psychomotor dysfunction is common (shakes, tremors) and, at times, seizures and rhabdomyolysis (skeletal muscle breakdown).
  • OUD Withdrawal – typically resembles a flu-like illness characterized by yawning, sneezing, rhinorrhea, nausea, diarrhea, vomiting, and dilated pupils.
  • Stimulant Withdrawal (e.g., cocaine, amphetamines) - marked depression, excessive sleep, hunger, dysphoria, and severe psychomotor retardation.
(Kelley, 2022; Gupta et al., 2022)

Individuals with SUDs often present with sudden changes in mental health, manifesting in social, occupational, work, or school issues. Other findings that can aid healthcare professionals in a correct evaluation include (American Addiction Centers, 2022b):

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

History from Client

Whether truth or confabulation, a good client-supplied history can be a gold mine for diagnostic work. When suspecting a SUD, please consider the following:

  • First, ask about socially acceptable substances such as caffeine or tobacco products to set up 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?” Always clarify what you have been told - "So, what I am hearing is that 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 certain cultures do not consider beer to be alcohol.
  • Inquire about over-the-counter substances, including diet aids, cough and cold preparations, and herbal supplements.
  • Ask about the 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 select states or settings. Be sure to quantify how much, how often, and if possible – how potent.
  • Ask about illicit drugs. Be consistently non-judgmental and focus on the information needed for health assessment. Street drugs such as heroin, cocaine, hallucinogens, methamphetamine, and inhalants should be asked about here. Be sure to ask about fentanyl, which has become widely available.
  • Remember to ask how much, how often, the length of use pattern, and the last time each substance was used. The route of administration is also important. Be sure to ask whether the person has shared substances, especially injected drugs and needles.
  • If a prior SUD is 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 longest period without the substance while refraining from using other illicit substances or alcohol.
  • Ask the person what benefits they obtain from their substance of choice; this will be immensely helpful information when treatment for their SUD begins.
  • And finally, ask what negative consequences have arisen from their substance use. If they need coaching, look for items in these three key areas.
  • Physical risks or illnesses – sickness, accidents, fractures, burns, and car wrecks.
  • Psychiatric problems – difficulty focusing, anxiety, depression, suicidal thoughts, and psychosis.
  • Relationship problems – work, social relationships, family relations, legal difficulties, and 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 the more common substances of abuse. However, it will not replace the depth of information from a thorough diagnostic workup and interview. One useful interview tool for substance abuse is the Cut down, Annoyed, Guilty, and Eye-opener questionnaire, which has been adapted to include other drugs (CAGE-AID).

CAGE-AID Questionnaire
  • Have you ever felt you ought to cut down on your drinking or drug use?
  • Have people annoyed you by criticizing your drinking or drug use?
  • Have you felt bad or guilty about your drinking or drug use?
  • Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
Each positive response generates one point. A score of 2 or 3 means there is an elevated level of concern for substance misuse. Scoring a 4 means the person is likely to have a SUD.
(Olivine, 2022)

Family History

Think of this as a family medical history focusing on how substance misuse is tolerated. Whenever a health professional hears that a blood relative has struggled with a moderate to severe SUD, a warning flag should go up. Children of alcoholics, for example, have a three to four-fold heightened risk of developing an AUD themselves (Miller, 2022). Other common substances of misuse share similar familial or genetic tendencies.

Remember, inherited genes do not make your client a bad person. It is simply knowing what they will need so that extra diligence can be practiced in avoiding substances that their metabolism has difficulty dealing with properly. Clients with a positive family history of substance dependence deserve added help whenever possible to avoid the misuse and abuse of a substance.

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 vital information, such as:

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

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

Case Study: Margaret
Margaret is a 26 y/o female, unmarried, with two children ages 3 and 5. She was admitted for a 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 for 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 yet 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 says her mother rarely uses. The interview also shows that Margaret values the health and safety of her children very highly and would never willingly put them at risk for danger.

Specific SUDs

As with many of life's challenges, it is helpful to start with a general viewpoint and then circle down to the specific. We will now go from the shared common aspects of substance use issues to specific SUDs to better grasp the conditions we are called to work with.

Alcohol-Related Disorders

Alcohol is regarded by many to be the most widely overused and abused substance. While that is a matter of contention, we do know that alcohol directly accounts for over 5% of all deaths worldwide, or roughly 3 million deaths annually (Quilalang, 2022). AUD afflicts around 16 million adults in the United States. The rise in heavy drinking during the recent pandemic is shown in current studies; for example, a study published in Britain reveals an alcohol-related death surge of 19% for 2020 (Robb-Dover, 2022).

Many people who indulge in alcohol drink in moderation. Studies show as many as 40% of adults in the United States may overindulge in alcohol (Quilalang, 2022).

The cliché "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. A conduct disorder, such as childhood conduct disorder, adult antisocial personality disorder, and other mood or perceptual conditions, increases the tendency to use alcohol.

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

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

Even when being fully cooperative, clients often underestimate their substance use (Mayo Clinic, 2021).

Moderate alcohol use for healthy adults generally means up to one drink per day for women and up to two drinks per day for men.

  • Examples of one drink include:
    • Beer: 12 fluid ounces (355 milliliters)
    • Wine: 5 fluid ounces (148 milliliters)
    • Distilled spirits (80 proof): 1.5 fluid ounces (44 milliliters)

Heavy or high-risk alcohol use is defined as more than three drinks on any day or more than seven drinks a week for women and more than four drinks on any day or more than 14 drinks a week for men.

Binge drinking is defined as four or more drinks within two hours for women and five or more drinks within two hours for men.

Alcohol consumption affects every organ system, especially the cardiovascular, gastrointestinal, peripheral, and central nervous systems. Studies have found that those who self-identified as being steady drinkers for ten years or more have elevated levels of liver cirrhosis and pancreatitis (American Addiction Centers, 2022a). An increased gastrointestinal cancer rate has also been found among alcohol users, and hypertension is commonly associated with alcohol use. Peripheral neuropathies and alcohol-induced dementia go with the persistent use of this substance. AUD is a known contributor to suicide risk and depressive and bipolar disorders.

Caffeine-Related Disorders

Caffeine is the world's most used and overused drug (Spotlight, 2021). Excessive caffeine consumption is associated with negative physical and psychological symptoms, particularly during withdrawal which, according to researchers, show a clear caffeine use disorder.

Caffeine is contained in many of the products we consume. For a healthy adult, no more than 400 milligrams of caffeine per day should be consumed- that is about two or three 8 oz cups of coffee. Caffeine, however, is an additive in many products and most adults consume far in excess, putting caffeine on the list of common substances of abuse.

Caffeine has long been recognized as a naturally occurring central nervous system stimulant of the methylxanthine class. Its effects temporarily ward off sleepiness and restore alertness, along with a mild energy boost -no wonder caffeine is the top consumed psychoactive drug in the world. In low to moderate doses, caffeine can aid in lowering depression in certain people. However, excessive amounts can lead to agitation, psychosis, and mania. Sleep disturbances related to caffeine consumption are often reported. Even moderate regular doses of around 300 milligrams have been seen to induce or trigger preexisting anxiety disorders.

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

Caffeine Withdrawal is regarded as the abrupt cessation of or reduction in caffeine consumption, followed within 24 hours by three or more of the following:

  • Headache
  • Marked fatigue or drowsiness
  • Dysphoric mood, depressed mood, or irritability
  • Difficulty concentrating
  • Flu-like symptoms (nausea, vomiting, muscular pain/stiffness)

The adverse effects of caffeine use are substantial, including death. Mild effects include restlessness, anxiety, insomnia, twitching, increased urination, facial flushing, GI upset, and irregular or elevated heart rates.

Severe adverse effects of caffeine include confusion, disorientation, hallucinations, psychosis, seizures, arrhythmias, cardiac ischemia, and rhabdomyolysis.

Lethal effects of caffeine misuse may include heart arrhythmia, myocardial infarction, electrolyte imbalances, or aspiration (Evans et al., 2022).

Cannabis-Related Disorders

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

Like in opiates, where opioid chemicals are derived from the opium poppy, cannabinoids originate as the unique psychoactive substances found in cannabis. Over one hundred twenty cannabinoids have already been found, with the research focus on Tetrahydrocannabinol (THC), which is considered the most psycho-actively potent of the cannabinoids(Oleinik, 2022). Other psychoactive cannabinoids play active roles as well, especially with hybrid cannabis.

Around 43% of American adults admit to trying cannabis, with 16.9% having used cannabis in the past year and around 11.7% having used it in the previous month (Johnson, 2022; Yerby, 2021). Cannabis is the most often 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 abuse, as do environmental and social factors. Research has shown that certain individuals can tolerate cannabis use without significant consequences, while others follow a slippery slope to significant troubles. Around 30% of all users meet the criteria for a SUD, while roughly 10% become addicted to cannabis. Among those who start young, the rate of cannabis addiction jumps to 17% (Yerby, 2021).

Cannabis users report impaired judgment, lack of coordination while using, and altered perceptions and moods. Difficulty in thinking, concentrating, and problem-solving appear consistent among users, and a few large long-term studies showed a reduction of around 5.5 points in IQ on average (McMillan, 2022). Sadly, there is no sign that lost cognitive abilities will be fully restored even when cannabis use is stopped.

Cannabis withdrawal might be considered mild to moderate, with the greatest danger being the intense cravings and desire that drive many users back to the drug. Other common features of cannabis withdrawal include irritability, anxiety, depression, headaches, sleep problems, changes in appetite centering around stomach pain, and flu-like symptoms (Hartney, 2022).

Opioid-Related Disorders

Opioids are old friends to healthcare professionals. 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 OUD is the current diagnostic standard. It combines opioid dependence and opioid abuse, pulling in the wide range of related opioid prescriptions and illicit chemicals. Though it may seem generic, OUD guidelines by the American Psychiatric Association express the expectation that the specific agent will be added to the diagnosis once found.

Please remember substance use and misuse 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 as either an addict or an addict in the making. Labeling is poor professionalism. Opioids are an acceptable means of managing pain, both for short periods and long. It is an expectation that an individual using them for legitimate reasons will, over time, begin to develop a physical tolerance for the medication. Upon abrupt discontinuation, they 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 substance use does not make a person an addict.

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

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

Individuals with OUD may show no acute symptoms that 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 with tolerance may show few acute signs of opioid intoxication. Ongoing or extended misuse of opioids may cause a look of general poor health and debilitation. However, 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 injections – "muscling."
  • Intravenous – "mainlining" or "shooting up."
  • Smoked– smoking opioids is the fastest way to the brain and is generally a mix of opioids with cannabis or tobacco.

Opioids bought illegally run the risk of contamination by improper handling or purposeful "cutting" and dilution of the substance by other compounds. Injection users run an elevated risk of infection, both localized and systemic. HIV and hepatitis are associated with opioid and other injectable substance use. Hepatitis 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.

Physical examination for suspected opioid intoxication or opioid poisoning should include a search for the classic signs of opioid overdose, which include (Fielding, 2021):

  • Decreased mental status with difficulty waking or speaking.
  • Decreased respiratory rate with cool, clammy skin.
  • Decreased lung tidal volume with blue or purple-tinged fingernails and lips.
  • Decreased bowel sounds, the "death rattle"- gurgling/snorting/choking sounds, with or without vomiting.
  • Decreased (miotic, constricted, pinpoint) pupils.

Drowsiness tends to follow the euphoria sought after by users of opioids, and the sedation effect may progress to a coma. Inattention resulting from perceptual changes and the ability to concentrate may progress to ignoring potentially harmful events. In rare instances, intoxication may cause hallucinations or auditory, visual, or tactile illusions 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- prescription opioids combined with acetaminophen lead 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.

Not all individuals with opioid use disorder show positive for opioid drugs on routine urine toxicology tests. Be aware a routine urine drug screening panel often detects only natural opioids like heroin, morphine, and codeine. Standard urine panels may not detect synthetic and semi-synthetic opioids such as tramadol, buprenorphine, levo-alpha-acetylmethadol (LAAM), methadone, or fentanyl (Warrington, 2022).

Opioid withdrawal can be a brutal affair, and contrary to conventional shared wisdom amongst health providers, opioid withdrawal can be life-threatening. Withdrawal symptoms may begin after administering 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 within 24-48 hours yet persists for days for the short-acting agents and up to 2 weeks for methadone, with sleep and mood disturbances often persisting for months. Those 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 are 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.

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders

Sedative, hypnotic, and anxiolytic (SHA) medications are among the most prescribed drugs in the United States. The lifetime prevalence of anxiolytic and sedative use disorders in the United States is estimated to be 1.1% of the population (Simone, 2021).

SHAs are all brain depressants. They produce similar therapeutic and SUD profiles and, despite chemical dissimilarities, are best regarded as a closely-knit group. The SHA group includes benzodiazepines and benzodiazepine-like drugs, carbamates, barbiturates, and barbiturate-like hypnotics, as well as all prescription sleep medications and nearly all prescription anti-anxiety agents.

SHAs are the "go-to" medication for many common ailments that cause impaired quality of life. It does not seem fair that the treatment for one condition becomes the cause of other negative consequences. Nevertheless, health professionals must be on the lookout for the indications of misuse in those prescribed these medications and others taking them without a prescription.

Individuals having use difficulties with SHAs should never automatically be labeled drug abusers. They are not bad people. They are not evil. They tend to simply be folks having a tough time regulating a challenging balance between brain chemistry and 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 prescription. Dependence risk is heightened if a family history of AUD is present. A genetic predisposition toward developing dependence on 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 clear or there is evidence of dangerous states of intoxication, there is no reason to assume that chronic SHA users are substance abusers.

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

The positive actions of SHAs include reducing stress or anxiety, relaxing muscle tension, slowing racing thoughts, and reigning in central nervous system processes gone wild. These actions are performed by intruding on the actions of brain chemistry, most often gamma-aminobutyric acid (GABA).

Negative life effects from SHAs 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.

Careful monitoring of intoxicated individuals is needed as episodes of generally brief but severe depression may be associated with severe SHA intoxication. Suicide or attempted suicide may occur during SHA intoxication; it may be purposeful or accidental self-injury.

Almost all sedative-like drugs can be detected on standard toxicology (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.

Diagnostic criteria for the withdrawal of SHAs require two (or more) of the following within hours to days after cessation of an SHA (American Psychiatric Association, 2022):

  • Autonomic hyperactivity (e.g., sweating, racing pulse greater than 100 beats per minute)
  • Hand tremor
  • Nausea or vomiting
  • Insomnia
  • Anxiety
  • Psychomotor agitation
  • Transient visual, tactile, or auditory hallucinations or illusions
  • Grand mal seizures

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 American Psychiatric Association has merged the past diagnoses of stimulant abuse and stimulant dependence into one diagnosis: stimulant use disorder. The severity of stimulant use disorder can range from mild to moderate or severe. Some examples of stimulants include amphetamines, meth, and cocaine.

The use of stimulants is often an exercise in polysubstance use. While the stimulant-using person will often have their favorite substance, many use whatever is at hand to achieve the goal of renewed energy, a mood boost, or simply to help them keep 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 many amphetamine-like substances are, or naturally occurring plant-derived compounds, such as cocaine. Legitimate stimulant uses do exist, including treatments for ADHD, obesity, and sleep disorders.

Amphetamine-type stimulants go by the most recognized names in the street slang pharmacopeia. Speed, ice, ecstasy, base, meth, and Crystal, to name a few. They have a longer active duration than cocaine and thus need fewer uses each day to support 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. The typical downside is mood and cognitive changes, rapid tooth decay due to chronic dry mouth, and problems with executive functioning and decision-making.

Users who prefer the amphetamine types tend to go on binges with periods of non-use, 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 elevated levels of a psychoactive substance in their systems. Paranoia, delusions, anxiety attacks, hallucinations, and panic disorders are all possible outcomes of the high quantities of stimulants in one's circulation.

Cocaine is a tropane alkaloid extracted from the South American Erythoxylon coca plant leaves. Each stop in its processing, from harvesting the leaves of this hardy plant to the final street market form, has found a fan base amongst users. Processing ranges from coca leaves, coca paste, and powdered cocaine hydrochloride to rock crystal cocaine alkaloids. The two most common available cocaine forms are 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. Street names are blow, coke, flake, and snow.
  • Cocaine alkaloids, aka freebase or crack (a rock crystal form of cocaine) -the cocaine extract has been processed with ammonia or baking soda and now 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. Crack's chief appeal is the low cost to make and buy.

Cocaine has a legitimate legal use as a Schedule II local or topical anesthetic, although synthetic topicals have made heavy inroads into its medicinal use in recent years. It has a substantial following and is considered the second most-used illicit drug worldwide and ranks as the third most-used illicit substance in the United States (Foy, 2022).

Cocaine is almost exclusively smuggled into the country and tends to be expensive. A heavy user can buy a gram daily and easily spend around $50,000 a year. Around 1.3 million Americans currently struggle with cocaine use disorder. Three hundred fifty thousand hospital visits are due to cocaine annually, and 54% of those in jail and prisons due to drug-related charges are due to cocaine (Foy, 2022). Perhaps most worrisome is the 16,000 overdose deaths linked to cocaine annually.

Cocaine effects come from the enhancement of monoamine neurotransmitters such as dopamine, norepinephrine, and serotonin. The positive effects are attributed to dopamine enhancement of the brain reward system, including alertness, energy, elation, and euphoria. Users describe the feeling of cocaine peaking as a "total body orgasm." Unwanted adverse 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 like picking at the skin accompany cocaine use.

Like amphetamine-type substances, cocaine users often 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 many cocaine users do not use it often and tend to fly under the radar without notice. 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 these drugs give and become a feeling that users fight to keep, often at the cost of cognitive functioning and physical health. Stimulants are one of the quickest substances to form a chemical dependence in our bodies.

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

Heart attack and stroke are familiar accompaniments to stimulant use. Cocaine 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 substantial risk of potential effects of stimulant use on 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 continue to restlessness, sudden jerky movements, rambling speech, headache, and ringing in the ears. The person may show ideas of reference, paranoid thinking, auditory hallucinations, and the client may 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.

Diagnostic criteria for stimulant intoxication include the following (American Psychiatric Association, 2022):

A. Recent use of an amphetamine-type substance, cocaine, or other stimulant.

B. 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.

C. One (or more) of the following signs or symptoms that develop during or shortly after use:

  • Tachycardia or bradycardia
  • Pupil dilation
  • Elevated or lowered blood pressure
  • Perspiration or chills
  • Nausea or vomiting
  • Evidence of weight loss
  • Psychomotor agitation or retardation
  • Muscular weakness, respiratory depression, chest pain, cardiac arrhythmias
  • Confusion, seizures, dyskinesia, dystonia, or coma

The cycle of intoxication and withdrawal tends to be familiar to users of any stimulant. Binge usage means that withdrawal is only a few "hits" away, leading to the desperation that the desired feelings may end. Legal consequences of actions provoked by user desperation to keep the positive effects of stimulant use can shatter social or work relationships.

Withdrawal from amphetamine-type substances can occur within hours of stopping use. Withdrawal symptoms 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 a 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 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 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.

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

Tobacco-Related Disorders

Tobacco is serious business. Cigarette smoking has been hailed as the number one leading cause of preventable deaths worldwide, with an annual toll of eight million(WHO, 2022). Some 480,000 deaths annually in the United States relate to tobacco, or about 1 in 5 deaths (Centers for Disease Control and Prevention, 2022).

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 as 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 tobacco use in any form is common in those with tobacco use disorder. Likewise, it is easy to find 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. Therefore, careful questioning is needed to ensure they know that the products they consume may have tobacco in them.

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.
  • Snuff – coarsely ground tobacco snorted or placed between lip and gums.
  • Chewing tobacco – plugs, loose leaf, or twists of tobacco chewed like gum.
  • Bidis - flavored thin rolled tendu or temburni leaf packets for smoking holding tobacco imported from southeast Asia, popular due to rising 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.
  • Kreteks – often referred to as clove cigarettes which mix cloves, tobacco, and other exotic flavorings.
  • Cigarettes – paper-wrapped cylinders with cured finely cut tobacco, reconstituted tobacco, and many other additives such as sugar and flavorings. More than 4000 chemicals have been found in tobacco and tobacco smoke; more than 60 are known to cause cancer.
  • Cigars – typically a single fermented, dried tobacco leaf with a higher nicotine content than cigarettes.
  • Cigarillos – known as "little cigars," tend to look more like cigarettes yet hold 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 (nicotine gum, patches, lozenges, and nasal sprays) also have nicotine. Electronic or "smokeless" cigarettes typically have nicotine, although it is possible to buy or hand mix e-cigarette cartridges with alternative active ingredients. The typical e-cigarette contents include nicotine extract, propylene glycol, and flavoring.

Tobacco cravings typically begin within hours of the last use. Needing that first-morning smoke is a daily lifestyle for tobacco users. Cravings can vary from a mild awareness of the 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 tobacco use. Life stresses can magnify the desire for and the intake of tobacco products, creating situations where casual users slide into the role of chain- smoking.

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. 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. Feelings of anxiety and depression generally follow an increasing desire for tobacco. Restless tension and frustration lead to headaches and difficulty concentrating. Drowsiness, difficulty falling asleep, and nightmares are commonly reported. Increased appetite, weight gain, and sluggishness hang on for extended periods during tobacco withdrawal.

Other (or Unknown) SUDs

The American Psychiatric Association formally acknowledges in the current Diagnostic Statistic Manual what health professionals have known for a long time- that there are many variations of drugs in this world. A big step forward has been taken by formally introducing a category where uncommon and unusual substance addictions and dependencies can be discussed, with a guide for applying proper diagnostic and billing codes.

The "fill in the blank" format allows practitioners to follow a diagnostic standard for substance use findings that are less common, are location specific, or negatively affect relatively limited numbers of the general population. 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

The unwanted, disruptive physical and mental state when a substance is used 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 for an unknown substance intoxication is tricky, as it requires finding a reversible agent for a substance-specific syndrome. The formulators of the DSM-5 acknowledge 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 client history can supply a working hypothesis for comparison to the observable signs and symptoms. Change in the ability to concentrate or process information, 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 to healthcare services. Newly available recreational chemicals or substances often present in 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.

Substance withdrawal is a life-disrupting state. Symptoms and severity of withdrawal vary according to the substance in question and the individual's metabolic susceptibility to its effects. To meet diagnostic levels, the effects of withdrawal must be sufficiently negative for mental, physical, and functional well-being to come to clinical attention. Some withdrawal levels 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 named, it should be reflected in the diagnostic label, e.g., Substance Use Disorder (Other) Laxatives.

The Challenges of Treatment

It is difficult to successfully treat the unwilling. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2020, 95% of Americans who met the diagnosis of SUD felt they needed no treatment, even taking steps to avoid any treatment offered. Treatment options during the pandemic have become more problematic as 54% of all addiction care facilities were physically forced to close at governmental orders to curb the potential of viral spread. Home groups, support gatherings, and the like have also been the target of government-mandated closures, casting adrift many SUD victims actively seeking help (Liebhaber, 2022).

Recent data shows a dramatic increase in opioid-related overdoses, which increased by 18% compared to the previous 12 months. Much of this increase is due to fentanyl, a synthetic opioid flowing in across open borders from production facilities in Mexico and China. Fentanyl is so problematic that it has been declared by the United States Drug Enforcement Agency (DEA) as 2021's leading cause of death for adults between the ages of 18 and 45 (Conklin, 2021).

The horrific onslaught of opioid overdose cases has led some cities and states to implement extreme measures such as "Narcan Vending Machines" in public areas. Narcan (naloxone) is an opioid antagonist which can be inhaled or injected and works by temporarily blocking the effects of opiates on the brain to restore breathing. It can now be obtained without a prescription and is available at pharmacies. Narcan can be given intravenously, intramuscularly, as a subcutaneous injection, or as an intranasal inhalant (Muller, 2022; Liebhaber, 2022).

The unpromising revelation that most of those with a SUD would rather avoid treatment, even when available, is not always accurate. Family, peer, and job pressures may encourage those with a SUD to seek help. A pre-pandemic National Survey on Drug Use and Health revealed that 75% of Americans with SUDs would eventually undergo recovery treatment (Liebhaber, 2022).

Substance Misuse Treatment Guidelines

The American Society of Addiction Medicine (ASAM) provides guidelines for individualizing treatment planning and placement of individuals with substance misuse or substance use disorder. The ASAM criteria involve six dimensions and four risk categories which may be adjusted to fit different needs and settings (MacKey, 2022)

Dimension 1 – Acute intoxication and/or withdrawal

Dimension 2 – Biomedical conditions and complications

Dimension 3 – Emotional, behavioral, or cognitive conditions and complications

Dimension 4 – Readiness to change

Dimension 5 – Relapse, continued use, or continued problem potential

Dimension 6 – Recovery Environment

Each ASAM dimension may be assigned a risk rating, from severe (highest score) to low or even no risk. The rating allows healthcare professionals to get an at-a-glance feel for where the client is and what focus of care is needed.

ASAM risk rating categories (Walker, 2022):

4 – Utmost severity, the threat of imminent danger

3 – Serious issue that needs addressing

2 – Moderate difficulty in functioning efficiently

1 – Mildly difficult

0 – No issue, extremely minimal risk

It is becoming common for care to be based on ASAM risk and needs ratings.

Substance Use Care Continuum
Level 4: Medically Managed Intensive Inpatient
  • Including in-hospital general to critical care.
  • Direct care by a physician and care team in an inpatient hospital-based setting.
Level 3: Residential Treatment
  • Admission to a variety of 24-hour supported care inpatient facilities.
  • Includes recovery centers, halfway houses, and psychiatric clinics.
Level 2: Intensive Outpatient Services
  • Day treatment at a rehabilitation facility or clinic with access to a phone, chat, or distance video help 24 hours a day.
Level 1: Outpatient Services
  • Returning to clinic or recovery center for scheduled sessions and care.
  • These services tend to be 9 hours or less of face-to-face weekly treatment for adults.
Level 0: Prevention and Early Intervention
  • Counseling and medication changes are conducted during routine medical care visits.
  • Consultations and referrals made by a general practitioner or other health professional.
(O'Leary, 2022)

Dimension 1: Acute Intoxication or Withdrawal

Treatment begins with assessment. The treatment process starts with a detailed intake interview, observable symptoms, laboratory studies, and a search into each client's history. A client with visible tremors, confusion, and voiced cravings might score a 4 on the ASAM risk rating for Dimension One. In contrast, a client with a calm presentation, clear speech, and laboratory indicators of low substance presence might call for a lower risk rating.

Medical stabilization and acute care are advised when the assessing health professional feels it is called for. Intravenous fluids aid in flushing substances and offset dehydration, a frequent accompaniment in acute intoxication and withdrawal (Hardey et al., 2022).

Dimension 1 Care
(Substance Use, Acute Intoxication, Withdrawal Potential)
Severity Rating/Care LevelClient Presentation
0: None - Prevention & Early InterventionThe client is fully functioning, with no signs of intoxication or withdrawal.
1: Mild - Outpatient ServicesMild to moderate intoxication interferes with daily functioning but does not pose a danger to self/others. Minimal risk of severe withdrawal.
2: Moderate - Intensive Outpatient ServicesIntoxication may be severe, yet it responds to support, not posing a danger to self or others. Moderate risk of severe withdrawal.
3: Significant - Residential TreatmentSevere signs/symptoms of intoxication indicate imminent danger to self/others. Risk of severe but manageable withdrawal or withdrawal is worsening.
4: Severe - Inpatient HospitalizationIncapacitated, with severe signs/symptoms. Severe withdrawal presents a danger, such as seizures. Continued substance use poses an imminent threat to life (e.g., liver failure, GI bleeding, or fetal death).
(Moonshine, 2019)

Remember, encouraging self-care instead of inpatient care or as an extension of in-facility care is important for the client. Moderate, healthy exercise promotes endorphin release and a positive chemical balance. Sleep and stress reduction are also promoted by exercise. Balanced, high-nutrient meals supply the resources the body needs to restore metabolism and aid in healing. Good hydration helps to offset the tendency toward dehydration that often goes with the metabolic challenges presented during a withdrawal process.

Dimension 2: Biomedical Conditions and Complications

The second ASAM dimension concerns the interaction of "comorbid" or "co-occurring" conditions in those suffering from SUDs and other medical conditions. These may be general medical conditions (e.g., high blood pressure, asthma, diabetes, pregnancy), conditions brought on by substance misuse (Wernicke-Korsakoff Syndrome from thiamine deficiency and alcohol misuse), or ironically, the medical condition which originally led to the use of the problematic substance (misuse of opioids because of severe pain).

The need to treat both substance misuse and other ongoing medical conditions complicates matters. It is not unusual to postpone detox or substantial substance use treatment while stabilizing or resolving comorbid medical issues. Deciding the priority of treatment requires individualization of care. Close management of the SUD is crucial.

Dimension 2 Care
(Biomedical Conditions and Complications)
Severity Rating/Care LevelClient Presentation
0: None - Prevention & Early InterventionThe client is fully functioning and able to cope with any present physical discomfort or situation.
1: Mild - Outpatient ServicesAdequate ability to cope with physical issues. Mild to moderate symptoms, such as mild to moderate pain, interferes with daily functioning.
2: Moderate - Intensive Outpatient ServicesDifficulty tolerating physical problems. Acute medical symptoms (intense pain, signs of malnutrition, or electrolyte imbalance) are present. The client is neglecting serious biomedical problems.
3: Significant - Residential TreatmentThe ability to tolerate and cope with physical problems and/or general health conditions is poor. Severe medical problems (severe pain requiring medication or hard-to-control type 1 diabetes) are present.
4: Severe - Inpatient HospitalizationThe person is incapacitated with severe medical problems (extreme pain, uncontrolled diabetes, GI bleeding, or infection requiring IV antibiotics).
(Moonshine, 2019)

Medical conditions commonly present during substance misuse include (American Addiction Centers, 2022b; Crane, 2022):

  • Diminished immune system function and infection.
    • Injected substances, in particular, carry a considerable risk of creating infection (HIV, hepatitis, and bacterial infections).
    • Snorting or smoking substances leads to tissue irritation and increased infections, such as upper respiratory conditions, which may continue to bronchitis or pneumonia. Substances such as cocaine directly decrease the immune system's ability to create white blood cells, leading to an increased risk of infections.
    • Substance use increases the risk of sexually transmitted diseases.
  • Cardiovascular problems.
    • Stimulants increase the user's heart rate, while depressants slow it. Constant low blood pressure is associated with ischemic injury, blood clots, and circulatory problems.
    • Misuse of certain substances is associated with irregular heartbeats. Stimulants such as cocaine and methamphetamines are associated with an increased risk of cardiac arrest.
  • Gastrointestinal issues.
    • Opioid misuse often leads to chronic constipation, stomach upset, indigestion, nausea, or vomiting.
    • Alcohol misuse can increase reflux esophagitis (GERD), GI cancer risk, pancreatitis, Mallory-Weiss tears (ruptured lower esophagus resulting in GI bleeding), and malabsorption with nutritional deficiencies.
    • Stimulants such as cocaine and methamphetamines are associated with dangerous gastrointestinal issues, such as mesenteric arterial vasospasm, which can lead to a loss of blood supply between the heart and the gastrointestinal system. Mesenteric arterial vasospasm is a medical emergency as it can lead to ischemic colitis and, in severe cases, bowel tissue death, known as bowel necrosis.
  • Respiratory problems.
    • Alcohol misuse has been associated with a heightened risk of pneumonia, tuberculosis, and acute respiratory distress syndrome.
    • Depressants, especially opioids, can slow breathing or make breathing shallow or irregular, leading to hypoxia and death. If a person has a reduced or depressed breathing pattern for an extended period, their body could become starved of oxygen, leading to damaged organs.
  • Liver damage.
    • The liver is a primary site of detoxification for many consumed substances. Elevated levels of certain substances can overwhelm the liver, causing organ tissues to break down. Alcohol, inhalants, heroin, steroids, and acetaminophen can all damage the liver, causing cirrhosis or hepatitis.
  • Kidney damage.
    • Kidneys work to filter toxins from the bloodstream. Repeated exposure to certain substances may lead to progressive kidney damage, renal failure, and dialysis.
  • Neurological issues.
    • The good news is that as the brain and nervous system are exposed to substance misuse, it adapts and learns to make use of the substance. The sad news is that as the brain and nervous system are exposed to substance misuse, it adapts and becomes dependent on the presence of the substance.
    • Consistent substance use may lead to dependence and addiction. As addiction develops, regions of the brain involved with key functions such as reward/pleasure, decision-making, and impulse control change.
    • Alcohol, benzodiazepines, and sedatives are associated with movement problems, significant cognitive impairment, and memory loss.
    • Stimulants like cocaine, meth, ecstasy, and designer drugs lead to the imbalance of neurotransmitters like serotonin, dopamine, and norepinephrine. They are also associated with transient and permanent brain damage, such as strokes and Parkinson-type conditions.

Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications

The third ASAM dimension involves emotional, behavioral, and cognitive complications common with substance misuse. Emotional, behavioral, or cognitive problems paired with substance use have been associated with greater functional impairment and higher mortality rates than comorbid physical illnesses (National Institute on Drug Abuse, 2021a).

SUDs are themselves classified by the DSM-5 as mental, emotional, and behavioral in nature (American Psychiatric Association, 2022). Possessing diagnosable comorbid issues in this range should be expected (Bonilla, 2022).

  • Anxiety disorders, such as generalized anxiety, panic disorder, or PTSD.
  • Mood disorders, like bipolar disorder and depression.
  • Personality disorders, such as antisocial, avoidant, and borderline personality disorders.
  • ADHD.
  • Psychotic disorders, such as schizophrenia.

It is generally accepted as the best treatment practice to deal with the substance issue simultaneously with any mental, emotional, or behavioral comorbid condition (Behave Health, 2022).

Dimension 3 Care
(Emotional, Behavioral, or Cognitive Conditions or Complications)
Severity Rating/Care LevelClient Presentation
0: None - Prevention & Early InterventionThe client shows good impulse control, coping skills, and function in the subdomains (dangerousness/lethality, recovery efforts, social functioning, self-care ability, and course of illness).
1: Mild - Outpatient ServicesThere is a suspected or diagnosed condition that requires intervention, but it does not significantly interfere with treatment. Relationships are impaired but not endangered by substance use.
2: Moderate - Intensive Outpatient ServicesPersistent condition with symptoms that distract from recovery efforts but are not an immediate threat to safety and do not prevent independent functioning.
3: Significant - Residential TreatmentSevere symptomatology but sufficient enough control to avoid involuntary confinement. Impulses to harm self/others are present but not an obvious danger.
4: Severe - Inpatient HospitalizationSevere symptoms requiring involuntary confinement. Exhibits severe and acute life-threatening symptoms (e.g., dangerous, impulsive behavior and/or cognitive functioning) that pose an imminent danger to self or others.
(Moonshine, 2019)

Several treatment therapies exist for treating clients with comorbid SUDs and other mental, emotional, and behavioral conditions (National Institute on Drug Abuse, 2021a).

  • Cognitive Behavioral Therapy (CBT) is designed to change harmful beliefs and maladaptive behaviors and shows strong effectiveness for individuals with SUDs. CBT is the most successful psychotherapy for children and adolescents with anxiety and mood disorders.
  • Dialectical Behavior Therapy (DBT) is designed to reduce self-harm behaviors, including suicidal attempts, thoughts, urges, cutting, and drug use. It is one of the few treatments effective for individuals who meet the criteria for borderline personality disorder.
  • Assertive Community Treatment (ACT) programs integrate behavioral treatments for severe mental illnesses like schizophrenia and co-occurring SUDs. ACT is different from other approaches centered around case management due to factors such as a smaller caseload size, team management, outreach emphasis, and a highly individualized and assertive approach to keeping contact with clients.
  • Therapeutic Communities (TCs) are a form of long-term residential treatment for SUDs. They focus on the "resocialization" of the individual, often using broad-based community programs as active components of treatment. TCs are right for populations with a high prevalence of co-occurring disorders, such as criminal justice-involved persons, individuals with vocational deficits, vulnerable or neglected youth, and homeless individuals. In addition, evidence suggests that TCs may be helpful for adolescents who are receiving treatment for substance use and addiction.
  • Integrated Group Therapy (IGT) is a treatment developed specifically for clients with comorbid bipolar disorder and SUD. It is largely based on CBT principles and is usually an adjunct to supportive medication. The IGT approach emphasizes helping clients understand the relationship between the two disorders, the link between thoughts and behaviors, and how they contribute to recovery and relapse.
  • Seeking Safety (SS) is a present-focused therapy aimed at simultaneously treating trauma-related problems (including PTSD) and SUD. Clients learn behavioral skills for coping with trauma and SUDs.

Dimension 4: Readiness to Change

The fourth ASAM dimension may be the greatest predictor of recovery from substance misuse. Readiness to change shows where a client is in terms of successful behavioral change. The Stages of Change Model or Transtheoretical Model are usually divided out as the items below(Ho, 2018):

  • Precontemplation – when asked, the client does not plan to make any positive changes in the next six months.
  • Contemplation – the client begins to consider the pros and cons of changing.
  • NOTE: Some therapists refer to this wryly as the "procrastination" stage.
  • Preparation – the client begins to consider a plan to change their current substance misuse situation.
  • Action – the client begins the process of changing their substance use patterns. Steps may be small at first; progress should be celebrated!
  • Maintenance – change has occurred! Now the arduous work of avoiding old substances and forming new healthier habits occurs.
  • Termination or Relapse – a full commitment to a new healthy lifestyle or the backward voyage into re-using unhealthy substances.
Dimension 4 Care
(Readiness to Change)
Severity Rating/Care LevelClient Presentation
0: None - Prevention & Early InterventionEngaged in treatment as an initiative-taking, responsible participant. Committed to change.
1: Mild - Outpatient ServicesWilling to explore the need for treatment and strategies to reduce or stop substance use.
2: Moderate - Intensive Outpatient ServicesReluctant to agree to treatment. Able to articulate negative consequences (substance use and/or mental health problems) but a low commitment to change.
3: Significant - Residential TreatmentMinimal acknowledgment of the need to change. Only partially able to follow through with treatment recommendations.
4: Severe - Inpatient HospitalizationUnable to follow through, has little or no awareness of problems, sees no connection between substance use and consequences. Not willing to explore change. Unwilling/unable to follow through with treatment recommendations.
(Moonshine, 2019)

Understanding the stages of change benefits health professionals and clients, allowing them to put progress into a framework and celebrate success!

Dimension 5: Relapse, Continued Use, or Continued Problem Potential

The fifth ASAM dimension examines the client's awareness of and ability to implement recovery skills, like naming triggers for misuse, coping with cravings, and dealing with impulse control. For SUD clients, the potential for relapse is high.

Dimension 5 Care
(Relapse, Continued Use, or Continued Problem Potential)
Severity Rating/Care LevelClient Presentation
0: None - Prevention & Early InterventionLow or no potential for further substance use problems or has low relapse potential. Good coping skills in place.
1: Mild - Outpatient ServicesMinimal relapse potential. Some risk but fair coping and relapse prevention skills.
2: Moderate - Intensive Outpatient ServicesImpaired recognition and understanding of substance use relapse issues. Able to self-manage with prompting.
3: Significant - Residential TreatmentLittle recognition and understanding of relapse issues and poor skills to cope with relapse.
4: Severe - Inpatient HospitalizationRepeated treatment episodes have had little positive effect on functioning. No coping skills are present to offset relapse or addiction problems. Substance use and behavior place self/others in imminent danger.
(Moonshine, 2019)

Dimension 6: Recovery Environment

ASAM's Sixth Dimension, the Recovery or Living Environment, is about the client's current life state. The importance of this dimension concerns their life and how fulfilling it is. So, inquire about relationships, jobs, family life, financial troubles, current living status, mode of transportation, and how they are currently feeling.

Here is where all these questions are leading – is this the life they want to be living?

  • If it is, there is no real motivation to change the misuse of a substance.
  • If it is not, then consider how releasing the burden of substance misuse may help to achieve what they would prefer or truly desire.

Also, does the client have the resources they need for the recovery process? Are they able to use the resources they do have? Not everyone wanting to change and better themselves have what they need. Support, finances, childcare, and transportation are all venues that need to be explored.

As healthcare professionals, it is our responsibility to help our clients move toward the life they want—a life not shrouded in the hazy painful glitter of an unhealthy dependence on a chemical or substance.

Dimension 6 Care
(Recovery/Living Environment)
Severity Rating/Care LevelClient Presentation
0: None - Prevention & Early InterventionThe client has a supportive environment and the ability to cope in that environment.
1: Mild - Outpatient ServicesThe client has passive or disinterested social support yet is not distracted by this situation and is still able to cope.
2: Moderate - Intensive Outpatient ServicesUnsupportive environment; can cope with a clinical structure nearly all the time.
3: Significant - Residential TreatmentUnsupportive environment and difficulty coping with the lack of support, even with clinical structure helping.
4: Severe - Inpatient HospitalizationEnvironment is toxic or hostile to recovery (i.e., there are drug-using friends, or drugs are readily available in the home environment, or there are chronic lifestyle problems). The client cannot cope with the negative effects of this environment for recovery.
(Moonshine, 2019)

Recovery can be exhausting for a client, the client's family, and the health professional. The client will need support and aid for that journey, and each of us, as health professionals, will need the help of others to make it all happen.


SUDs are the use or overuse of one or more substances that can be legal or illicit. Many use disorders can be shown by the presence of two or more diagnostic criteria detailed in the DSM-5. A key concept to 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 us to respond favorably to the presence of preferred substances. 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 client's substance use.

Individuals entangled in the web of substance use may find themselves drawn to different 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 (LSD, phencyclidine, or similarly acting arylcyclohexylamines), inhalants, opioids, SHAs, stimulants (including amphetamine-type substances, cocaine, and other stimulants), tobacco, and other or unknown substances.

SUDs should be considered when clients present with aspects of tolerance, avoidance of withdrawal, elevated levels of consumption in a particular substance group, or negative life consequences not readily associated with another known event.

Acute medical treatment followed by structured follow-up using a system such as the ASAM dimensions of care is important in helping the client regain a life free of substance misuse.

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

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


  • American Addiction Centers. (2022a). Alcoholic gastritis: Causes, symptoms and treatment. American Addiction Centers. Visit Source.
  • American Addiction Centers. (2022b). Symptoms and Signs of Substance Abuse. Visit Source.
  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). In APA, DSM-5-TR (pp. 481-590). Arlington, VA, USA: APA.
  • Ashton, L. (2021). Drug Use, Abuse & Addiction Statistics, Trends & Data (2021 Update). CFAH. Visit Source.
  • Behave Health. (2022). Mastering The ASAM Criteria for Addiction Treatment is More Important Than Ever Before. Behave Health. Visit Source.
  • Bonilla, C. A. (2022). Dealing With Substance Abuse and a Co-Occurring Disorder. Stairway Resource Center Inc. Visit Source.
  • Centers for Disease Control and Prevention. (2018). CDC - fact sheet - current cigarette smoking among adults in the united states - smoking & tobacco use. Centers for Disease Control and Prevention. Visit Source.
  • Conklin, A. (2021). Fentanyl overdoses become No. 1 cause of death among US adults, ages 18-45: “A national emergency.” Fox News. Visit Source.
  • Crane, M. (2022). Common Neurological Risks of Drug Abuse [Review of Common Neurological Risks of Drug Abuse]. American Addiction Centers. Visit Source.
  • Davis, S. (2022). Popular Drug Test Chest Devises and How to Combat Them. National Drug and Alcohol Screening Association. Visit Source.
  • Dorwart, L. (2022). The Effects of Drug Addiction on the Brain and Body. Verywell Health. Visit Source.
  • Dugosh, K., & Cacciola, J. (2022). Clinical Assessment of Substance Use Disorders. UpToDate: Visit Source.
  • Evans, J., Richards, J. R., & Battisti, A. S. (2022). Caffeine. In StatPearls. StatPearls Publishing.
  • Fielding, S. (2021). 8 Opioid Overdose Symptoms, and What to Do If You Suspect That Someone Has ODed. Health. Visit Source.
  • Foy, C. (2022). Cocaine trends and statistics (2022). FHE Health – Addiction & Mental Health Care. Visit Source.
  • Greenberg, D., & St Peter, J. V. (2021). Sugars and Sweet Taste: Addictive or Rewarding?. International journal of environmental research and public health, 18(18), 9791. Visit Source.
  • Gupta, M., Gokarakonda, S. B., & Attia, F. N. (2022). Withdrawal Syndromes. In StatPearls. StatPearls Publishing.
  • Hardey, S., Thomas, S., Stein, S., Kelley, R., & Ackermann, K. (2022). 10 ways to get through your withdrawal symptoms. American Addiction Centers. Retrieved September 2, 2022. Visit Source.
  • Hartney, E. (2022). How Long Does Withdrawal From Marijuana Last? Verywell Mind. Visit Source.
  • Ho, L. (2018). How the Stages of Change Model Helps You Change Your Habits. Lifehack. Visit Source.
  • Jahan, A. R., & Burgess, D. M. (2022). Substance Use Disorder. In StatPearls. StatPearls Publishing.
  • Johnson, L. (2022). What Can We Learn About Cannabis Users From the Statistics? An In-Depth Look. CBD Oracle. Visit Source.
  • Kelley, R. (2022). Common Drug Withdrawal Symptoms. Oxford Treatment Center. Visit Source.
  • Liebhaber, L. (2022). Over 1 million Americans are seeking treatment for substance use disorder—here’s how it breaks down by state. Zinniahealth. Visit Source.
  • MacKey, B. (2022). A Guide to the 6 Dimensions of the ASAM Criteria. Rehab 4 Addiction. Visit Source.
  • Mayo Clinic. (2021). Alcohol Use: Weighing Risks and Benefits. Mayo Clinic. Visit Source.
  • McMillan, C. (2022). Does Cannabis Lower Your IQ? Cannabis | Weed | Marijuana | News. Visit Source.
  • Miller, L. (2022). Helping Children of Adults with Alcohol Use Disorder. American Addiction Centers. Visit Source.
  • Moonshine, C. (2019). The Art and Science of Treating Clients with Addictions and Dual Diagnosis Problems in Community Counseling Setting. Slideserve. Visit Source.
  • Muller, J. (2022). Narcan vending machines target opioid overdose crisis. Axios. Visit Source.
  • Myhre, J., & Sifris, D. (2022). Opioid Drugs and the Risk of Hepatitis C. VerywellHealth. Visit Source.
  • National Institute on Drug Abuse. (2021a). Why is there Comorbidity Between Substance Use Disorders and Mental Illnesses? National Institute on Drug Abuse. Visit Source.
  • National Institute on Drug Abuse. (2021b). Words Matter - Terms to Use and Avoid When Talking About Addiction. National Institute on Drug Abuse. Visit Source.
  • O’Leary, D. (2022). ASAM Levels of Care, Explained. Never Alone Recovery. Visit Source.
  • Oleinik, G. (2022). Your Complete Guide to Cannabinoids. CBDNerds. Visit Source.
  • Olivine, A. (2022). Addressing Alcohol Abuse With the CAGE Questionnaire. VerywellHealth: Visit Source.
  • Oro House Recovery Center. (2022). Substance Induced Disorders Causes and Treatment. Oro House Recovery Center. Visit Source.
  • Quilalang, C. (2022). Addiction Statistics (2022 Update). Addiction Group. Visit Source.
  • Robb-Dover, K. (2022). Alcohol Trends and Statistics (2022). FHE Health – Addiction & Mental Health Care. Visit Source.
  • Sabater, V. (2021). The Fascinating World of Your Brain’s Reward System. Exploring Your Mind. Visit Source.
  • Sachdev, P. (2022). Are Addiction and Substance Abuse Disorder the Same? MedicineNet. Visit Source.
  • Simone, C. (2021). Anxiolytics and Sedative-Hypnotics Toxicity. StatPearls. Visit Source.
  • Spotlight. (2021). Caffeine: The World’s Favorite Drug. Spotlight English. Visit Source.
  • Substance Abuse and Mental Health Services Administration. (2021). 2020 NSDUH Annual National Report. U.S. Department of Health & Human Services. Visit Source.
  • Veronika. (2022). Substance Use Disorders: DSM 5 Definitions. Addiction Group. Visit Source.
  • Walker, L. (2022). ASAM Criteria & Levels of Care in Addiction Treatment. American Addiction Centers. Visit Source.
  • Warrington, J. S. (2022). Opioid Testing. Testing. Visit Source.
  • WHO. (2022). Tobacco. World Health Organization. Visit Source.
  • Wrona, T. (2022). The Dangers of Sugar: Everything you Need to Know. Doctor Kiltz. Visit Source.
  • Yerby, N. (2021). Addiction Statistics - Facts on Drug and Alcohol Addiction. Addiction Center. Visit Source.