Substance Abuse (FL INITIAL Autonomous Practice - Pharmacology)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Alcohol is regarded by many to be the most widely overused substance of abuse. Most people who indulge, drink in moderation. Those who overuse or use to problem levels are approximately 7% of adults in the United States, as of the 2015 National Survey on Drug Use and Health (NSDUH).¹²

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

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

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

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

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

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

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

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

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

Caffeine is contained in many of the products we consume. For a healthy adult, no more than 400mg of caffeine per day should be consumed, about two or three 8oz cups.¹⁶ Most adults consume far in excess, however, putting caffeine into the lists of recognized substances of abuse.

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

The crystalline xanthine alkaloid that is caffeine is present in tea, coffee, caffeinated sodas, the so-called “energy” drinks, weight-loss preparations, certain over the counter analgesics and cold remedies, vitamins, chocolate, and as an additive to a diverse ensemble of food products. It is no wonder that many find themselves experiencing both tolerance and withdrawal symptoms, without even realizing what behavioral choices have led them to this point.

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

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

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

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

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

Cannabis users report impaired judgment and lack of coordination while using, as well as altered perception and mood. Difficulty thinking, concentrating and problem-solving appear consistent among users and in a large long-term study of New Zealand youth ages 13 through 38, those who began smoking cannabis as teenagers showed a reduction of 8 points IQ on average.¹⁹ Sadly, the lost cognitive abilities were not fully restored even when cannabis use was discontinued.

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

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

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

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

Please remember substance use and abuse basics. Not everyone taking a particular medication or street substance is an addict. With opioids especially, the current trend in health care is to label anyone on prescription analgesics either an addict or an addict in the making. Opioids are an acceptable means of managing pain, both for short periods and long. It is an expectation that an individual utilizing them for legitimate reasons will, over time, begin to develop a physical tolerance for the medication, and upon abrupt discontinuation, experience withdrawal type symptoms as their metabolism adjusts to the absence of the opioid. Neither tolerance nor withdrawal makes an addict. The DSM-5 repeatedly emphasizes that use of a substance does not make a person an addict.

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

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

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

Opioids may be ingested in many ways:

• Orally – either in solution or as tablets or powders
• Intranasal – “sniffing” or “snorting”
• Subcutaneous injection – “skin-popping”
• Intramuscular – “muscling”
• Intravenous – “mainlining” or “shooting up”
• Smoked – smoking opioids is the fastest way to the brain and is generally a mix of opioid with cannabis or tobacco

Opioids purchased illegally run the risk of contamination by improper handling or purposeful “cutting” or dilution of the substance by other compounds. Injection users run a high risk of infection, both localized and systemic. HIV, hepatitis B, and hepatitis C are all associated with opioid and other injectable substance use. Hepatitis C infection is also associated with intranasal inhalation of opioids and other substances, particularly in group settings where users pass around a shared beverage straw for snorting.²²

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

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

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

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

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

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

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

Please be aware 80 - 90% of injection opioid users screen positive for hepatitis A, B or C. HIV is prevalent especially amongst injection Heroin users.²²

Opioid intoxication diagnosis focuses on the presence of significant negative impact, psychological and behavioral changes accompanying or following substance use. The presence of alcohol or sedatives in the person’s system can muddy diagnosis, and therefore a naloxone challenge may be administered. Naloxone is a short-acting opioid antagonist that temporarily counters the respiratory depressant and to a small degree, the sedative effects of opioids. Use of naloxone may put an opioid user suddenly into physical withdrawal, so caution should be used when administering.²³

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

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

Sedative, hypnotic, and anxiolytic medications are the most commonly prescribed drugs in the United States. Around 11.8% of the adult population use prescribed anxiolytics in the course of a year, while over 2% have misused tranquilizers in the past year.24,25 In Western Europe and parts of Asia, the usage rates for hypnotics runs approximately 25-30%, with females consuming more than males 3-to-1.

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

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

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

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

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

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

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

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

Stimulants speed up communication between the brain and the central nervous system. They are a “feel good” staple for the club and party scene. The past diagnoses of Stimulant Abuse and Stimulant Dependence have been merged by the American Psychiatric Association into one diagnosis, that of Stimulant Use Disorder.³ The severity of Stimulant Use Disorder can range from mild, to moderate, or severe and encompasses all of the areas previously utilized when attempting a clear diagnostic portrait of the individual with the unhealthy use of stimulant-related substances.

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

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

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

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

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

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

Cocaine has a legitimate legal use as a Schedule II local or topical anesthetic; although in recent years synthetic topicals have made heavy inroads into its medicinal use. Around 0.7% of adult Americans or 1.9 million people have used cocaine within the past thirty days. Some 867,000 U.S. adults or 0.3% of the population meet the criteria for cocaine abuse disorder. Most healthcare providers are familiar with cocaine as it is the illegal drug most often associated with hospital emergency room visits.²⁶ In the year 2011, the Drug Abuse Awareness Network (DAWN), estimated 40.3% of all illicit drug-related emergency visits involved cocaine.²⁶

Cocaine effects come from enhancement of monoamine neurotransmitters such as dopamine, norepinephrine, and serotonin. The positive effects are attributed to dopamine enhancement of the brain reward system and include alertness, energy, elation, and euphoria. Users describe the feeling of cocaine peaking as a “total body orgasm.” Unwanted negative effects of cocaine use include irritability, anxiety, suspiciousness, paranoia, panic attacks, impaired judgment, grandiosity, delusions, and hallucinations.²⁶ Sleep disturbances, weight loss, tremors, and stereotyped behaviors such as picking at the skin also accompany cocaine use.²⁷

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

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

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

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

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

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

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

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

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

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

Tobacco is a serious business. Cigarette smoking has been hailed as the number one leading cause of preventable death, with an annual toll of six million deaths worldwide and some 480,000 in the United States with more than 41,000 of those deaths resulting from secondhand smoke.²⁸ Studies estimate that up to one-half of all tobacco users can expect to die from a tobacco-related disease. Costs directly from tobacco use are estimated to be as high as $332.5 billion each year, around half of which comes from direct healthcare costs and half from productivity losses.

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

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

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

Basically, all tobacco products contain nicotine:

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

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

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

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

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

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

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

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

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

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

Intoxication frequently runs hand in hand with the following comorbidities:

• Other known substance use disorders
• History of previous substance intoxication episodes
• Adolescent conduct disorder
• Adult antisocial personality disorder

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