Chapter 7: Substance-Related and Addictive Disorders

SUBSTANCE USE DISORDERS

Substance use disorders are characterized by a problematic pattern of substance use that leads to some form of functional impairment or distress. Keep in mind that frequent use of a substance does not necessarily indicate a substance use disorder unless it is causing problems for the patient.

Diagnosis and DSM-5 Criteria

Substance use disorders are characterized by a problematic pattern of substance use causing impairment or distress, as manifested by at least two of the following within a 12-month period:

• Using substance more than originally intended.

• Persistent desire or unsuccessful efforts to cut down on use.

• Significant time spent in obtaining, using, or recovering from substance.

• Craving to use substance.

• Failure to fulfill obligations at work, school, or home.

• Continued use despite social or interpersonal problems due to the substance use.

• Limiting social, occupational, or recreational activities because of substance use.

• Use in dangerous situations (e.g., driving a car).

• Continued use despite subsequent physical or psychological problem (e.g., drinking alcohol despite worsening liver problems).

• Tolerance (needing higher amounts of the substance to achieve the desired effect or experiencing diminished effects when repeating the same dose).

• Withdrawal (a substance-specific syndrome occurring when a patient stops or reduces heavy/prolonged substance use).

Note that these criteria remain the same regardless of what substance(s) the patient is using. The disorder may be classified as mild, moderate, or severe depending on the number of criteria met.

Epidemiology

• One-year prevalence of any substance use disorder in the United States is approximately 8%.

• More common in men than women.

• Alcohol and nicotine are the most commonly used substances.

Psychiatric Symptoms

• Mood symptoms are common among persons with substance use disorders.

• Psychotic symptoms may occur with some substances.

• Personality disorders and psychiatric comorbidities (e.g., major depression, anxiety disorders) are common among persons with substance use disorders.

• It is often challenging to decide whether psychiatric symptoms are primary or substance-induced. Many patients may use substances to self-medicate for undertreated psychiatric symptoms.

Acute Intoxication and Withdrawal

Both the intoxicated and withdrawing patient can present difficulties in diagnosis and treatment. Since it is common for persons to abuse several substances at once, the clinical presentation is often confusing, and signs/symptoms may be atypical. Always be on the lookout for use of multiple substances.

Detection of ...