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Substance Use Disorders
Substance use disorders are a type of substance-related disorder that involves a pathological pattern of behavior in which patients continue to use a substance despite experiencing significant problems related to its use. There may also be physiological manifestations, including changes in brain circuits.
The substances involved are typically members of the 10 drug classes that typically cause substance-related disorders . These substances all directly activate the brain’s reward system and produce feelings of pleasure. The activation can be so intense that patients crave the substance intensely and neglect normal activities to obtain and use it.
The common terms “drug addiction”, “abuse” and “addiction” are often used to refer to substance use, but these terms are defined too loosely and variably to be useful in systematic diagnosis. Substance use disorder is more complete and has fewer negative connotations.
Use of recreational and illicit substances
Illegal drug use, while problematic because it is illegal, does not always lead to a substance use disorder. Conversely, legal substances, such as alcohol and prescription drugs (and cannabis in a growing number of US states), can be involved in a substance use disorder. The problem caused by the abuse of prescription drugs and illegal substances is transversal to all socio-economic groups.
Recreational drug use, while not generally sanctioned by society, is not a new phenomenon, and has existed in one form or another for centuries. People have used substances for a variety of reasons:
To change or improve mood
As part of religious ceremonies
To get spiritual enlightenment
To improve performance
Some consumers are apparently free; they tend to use drugs episodically in relatively small doses, avoiding the onset of clinical toxicity and the development of tolerance and physical dependence. Various recreational drugs (eg, raw opium, alcohol, marijuana, caffeine, hallucinogenic mushrooms, coca leaves) are “natural” (ie, plant-based extracts); they contain a mixture of psychoactive compounds in relatively low concentrations and are not synthetic psychoactive substances.
Etiology of substance use disorders
People with a substance use disorder usually move from experimentation to casual use to eventually intense use and sometimes substance use disorder. This progression is complex and only partially understood. The process depends on the interaction between the substance, the consumer and the context.
Drug
Drugs in the 10 classes vary in how likely they are to cause a substance use disorder. The likelihood is termed drug addiction liability. The liability for drug addiction depends on a combination of factors, including
Route of administration
The rate at which the drug crosses the blood brain barrier and stimulates the reward circuit
Time of onset of effect
Ability to induce tolerance and / or withdrawal symptoms
Additionally, substances that are legally and / or readily available (eg, alcohol, tobacco) are more likely to be used initially and thereby increase the risk of progression to problematic use. Furthermore, if the perception of risk in using a particular substance decreases, there may be subsequent experimentation and / or recreational uses of the substance, increasing exposure to substances of abuse. Fluctuations in risk perception are influenced by multiple factors, including outcomes regarding medical and psychiatric sequelae of use and social outcomes.
During the treatment of medical illness or following surgery or dental procedures, patients are regularly prescribed opioids . A substantial portion of these drugs are neglected, as they represent an important source for children, adolescents and adults who wish to use them for non-medical purposes. In response, more emphasis was placed on the need for
Prescribe opioid medications in lower amounts more appropriate to the duration and severity of pain
Promote the safe storage of unused drugs
Expand prescription withdrawal programs
Consumer
Consumer predisposing factors include:
Physical characteristics
Personal characteristics
Circumstances and disturbances
Physical characteristics likely include genetic factors. However, while researchers have long sought to identify specific factors, they have found few biochemical or metabolic differences between people who take drugs and those who do not develop a substance use disorder.
Personal characteristics are clearly not a strong factor, although people with low levels of self-control (impulsivity) or high levels of risk-taking and novelty seeking may have an increased risk of developing substance use disorder. However, the hypothesis of an addictive personality that has been variously described by some behavioral scholars has little scientific evidence to support it.
A number of coexisting conditions and disorders appear to increase the risk. For example, people who are sad, emotionally upset, or socially alienated may find these feelings temporarily relieved by a drug; this can lead to increased use and sometimes a substance use disorder. Patients with other, unrelated psychiatric disorders are at increased risk of developing a substance use disorder. Patients with chronic pain(eg, back pain, pain due to sickle cell disease, neuropathic pain, fibromyalgia) often take opioid drugs for relief; many subsequently develop a substance use disorder. However, in many of these patients, non-opioid drugs and other treatments can adequately relieve pain and suffering.
Tips and mistakes to avoid
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Context
Cultural and social factors are very important for initiation and maintenance (or relapsing a) of substance use. Observing family members (eg, parents, older siblings) and peers who use substances increases the risk of people starting to use substances. Peers are a particularly strong influence among adolescents (see Drug and Narcotic Abuse in Adolescents ). People who are trying to stop using a substance find it much more difficult when they are surrounded by other users who are also using that substance.
Doctors may inadvertently contribute to the harmful use of psychoactive drugs by over-zealously prescribing them for stress relief. Many social factors including mass media contribute to the patient’s expectation that drugs should be used to relieve any discomfort.
Diagnosis of substance use disorders
Specific criteria
The diagnosis of substance use disorder is based on the identification of a pathological pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) provides 11 criteria divided into 4 categories.
Reduced usage control
A person who takes the substance in larger quantities or for a longer time than originally intended
Person who wants to stop or reduce the use of the substance
Person who spends significant time obtaining, using, or recovering from the effects of the substance
Person who has an intense desire (craving) to use the substance
Social impairment
Person who does not respect the main duties of the role in the workplace, at school, or at home
Person who continues to use the substance, even if it causes (or worsens) social or interpersonal problems
Person who reduces or gives up significant social, work or leisure activity due to substance use
Risky use
Person using the substance in physically hazardous situations (eg, while driving or in hazardous social circumstances)
Person who continues to use the substance knowing that a medical or psychological problem is worsening
Pharmacological symptoms *
Tolerance: the subject needs to progressively increase the dose of the substance to produce intoxication or the desired effect, or the effect of a administered dose decreases over time
Withdrawal: unpleasant physical effects that occur when the substance is withdrawn or when it is blocked by a specific antagonist
* Note that some medications, particularly opioids , sedatives / hypnotics and stimulants , can cause tolerance and / or withdrawal symptoms, even when taken as prescribed for legitimate medical reasons and for relatively short periods ( < 1 week for opioids) . Withdrawal symptoms that develop following appropriate medical uses do not count as criteria for diagnosing a substance use disorder.
People who have ≥ 2 of these criteria within a 12-month period are considered to have a substance use disorder. The severity of the substance use disorder is determined by the number of symptoms:
Mild: 2 to 3 criteria
Moderate: 4 to 5 criteria
Severe: ≥ 6 criteria
Treatment of substance use disorders
It varies according to the substance and the circumstances
Treatment of substance use disorder is challenging and includes one or more of the following:
Acute detoxification
Withdrawal prevention and management
Termination (or rarely, reduction) of use
Maintaining abstinence
Different stages of treatment can be managed with medication and / or counseling and support. Specific measures and problems are discussed within each specific subject elsewhere in the Handbook, including Alcohol Use Disorders and Opioid Use Disorders .
With growing evidence and a greater understanding of the biological processes underlying compulsive substance-taking, substance use disorders have become much more firmly established as medical illnesses. As such, these diseases are amenable to various forms of treatment, including support groups (Alcoholics Anonymous and other programs such as the Twelve Steps); psychotherapy (eg, motivational enhancement therapy, cognitive-behavioral therapy, relapse prevention); and drugs, ranging from agonist therapy (eg, nicotine replacement therapy for tobacco use disorder, methadone, and buprenorphine for opioid use disorder) to new approaches currently under investigation. Focus on
Key points on substance use disorders
Substance use disorder involves a pathological pattern of behavior in which patients continue to use a substance despite experiencing significant problems related to its use.
Manifestations are divided into reduced control over use, social impairment, risky use, and drug symptoms.
The terms “drug addiction”, “abuse” and “addiction” are vague and loaded with value; It is preferable to talk about substance use disorder and focus on specific manifestations and their severity.
The consequences and treatment of substance use disorder vary greatly depending on the substance.
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