Substance use disorders are defined by the recurrent use of alcohol and/or drugs in a manner that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. The recent opioid crisis has resulted in high morbidity and mortality rates, highlighting its importance as a public health problem. The issue has been magnified by recent abuse of the highly potent synthetic opioid fentanyl and other agents.

Drug abuse

Addiction

Substance abuse

Genetic factors have a major influence on progression of substance use to dependence, whereas environmental factors unique to the individual play an important role in exposure and initial use of substances.

• History often reveals recurring behavioral and psychosocial problems, such as relationship, work, financial, housing, or legal problems; violence and traumatic injuries; and anxiety, depression, insomnia, and cognitive and memory dysfunction.
• Repeated requests for early refills of controlled substances and obtaining prescriptions from multiple providers should raise concern for prescription drug use disorder.
• Physical and behavioral symptoms are helpful to determine drug use. Bloodshot or glazed eyes, dilated (mydriasis) or constricted (miosis) pupils (7 or 8 mm pupil size may suggest the influence of cocaine, methamphetamine, hallucinogens, or other stimulants; 1 or 2 mm pupil size may indicate the influence of opioids, or other depressants), abrupt weight changes, bruises, infections, and track marks are common physical signs. Behavioral changes occur as individual becomes more dependent on the drug. Increased aggression or irritability, sudden changes in social network, dramatic changes in habits and/or priorities, involvement in criminal activity, and financial problems are commonly observed. Substances commonly abused by adolescents are summarized in Table E1.

Theories are categorized into three main subgroups: Social, psychologic, and biologic. There has been an emphasis on the role of personality, age of starting drug abuse, and hereditary and genetic factors. Some studies identified family attributes (intrauterine alcohol exposure, maternal depression in early childhood, cumulative adverse experiences in early childhood, low family income at birth, lack of a safe and warm environment at home, insecure attachment between children and the parents, and role modeling of the parents) as the most important and crucial risk factor for drug abuse in youth. Peer pressure is also a strong risk factor.

Depending on presenting symptoms, the differential diagnosis can include attention-deficit/hyperactivity disorder (e.g., if decreased attentiveness or performance in school), primary mood or psychotic disorders (e.g., if hallucinations or disorganized behaviors, changes in sleep or appetite, and/or anhedonia), metabolic disturbances, and neurologic conditions.

Use a motivational interviewing style and evidence-based interventions; identify and treat co-occurring medical and psychiatric conditions.

Screening and assessment tools are available. CAGE (Cutdown, Annoyed, Guilty, Eyeopener) and AUDIT (Alcohol Use Disorders Identification Test) are commonly used for alcohol use disorder, and DAST (Drug Abuse Screening Test) is for drugs, CRAFFT (Table E2) (Screening tool for Adolescent Substance Abuse), CIWA-Ar (revised Clinical Institute Withdrawal Assessment for Alcohol scale assessment), and COWS (Clinical Opiate Withdrawal Scale) are used to assess the severity of alcohol and opioid withdrawal symptoms consequently.

• Blood alcohol levels, breathalyzer test results, urine drug screens, and, less commonly, hair and saliva analysis can be used to assess patients for possible alcohol and other drug use.
• Chemicals and their metabolites can be detected in the samples for limited times. Therefore, tests should be chosen and timed carefully.
• Biologic markers such as elevated mean corpuscular volume (MCV), γ-glutamyltransferase (GGT), liver function tests (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]; AST:ALT ratio of 2:1 or greater is suggestive of alcoholic liver disease), and carbohydrate-deficient transferrin (CDT) may also be used to diagnose and monitor.

Imaging techniques such as PET, functional MRI (fMRI), and electroencephalography (EEG) have been used to investigate behaviors in drug-addicted human populations. However, there is no current therapeutic use for or monitoring of the outcome of these studies. One such study used MRI and fMRI data to examine the impact of substance use disorders (SUDs) on brain alterations to see if gray matter loss (which has previously been found to be associated with SUD) is substance specific or shared across different substances.² The study found that among those with alcohol use disorder (AUD) and opioid use disorder (OUD), cortical brain thinning was observed in the right anterior brain regions, and those with AUD especially showed significantly smaller cerebellum and subcortical structures when compared to controls, OUD, and polysubstance use disorder groups.

• Motivational interviewing (MI) is an evidence-based approach that preserves patient autonomy in defining treatment goals and working toward change. For patients who express lack of readiness/commitment to change, it can be helpful to discuss the functions of their use and advantages/disadvantages the patient has personally experienced. Use an Elicit-Provide-Elicit format to counsel about risks of use and benefits of abstinence; in other words, elicit a patient’s consent and feedback before and after providing information.
• Nonpharmacologic strategies have the greatest documented efficacy: Education, feedback, goal setting, problem solving, and additional contacts for further assistance.
• Opiate contracts, prohibiting a patient from getting early refills, or obtaining opiates from multiple prescribers should be considered for all patients with chronic pain receiving opioid painkillers, especially for patients with a history of substance misuse or misuse of prescribed medication.
• Behavioral relapse prevention approaches teach patients how to avoid trigger stimuli or uncouple trigger stimuli from substance ingestion.
• Self-help and 12-step support groups such as Alcoholics Anonymous and Narcotics Anonymous are helpful in achieving and maintaining sobriety. Alternative self-help and peer groups include SMART Recovery, Dharma Recovery, Refuge Recovery, and Recovery Coach services.
• Consider psychotherapy/psychiatry referrals to address co-occurring psychiatric conditions, as well as case management referrals to address common barriers to recovery (e.g., safe housing).
• Residential or inpatient treatment programs should be a consideration for any individual with continued or escalating use despite outpatient treatment.

• Detoxification is an important first step. Seizure risk is greatest within the first 48 h of alcohol abstinence. Detoxification goals are to facilitate withdrawal and initiate abstinence safely, prevent withdrawal seizures and reduce symptoms, and refer the patient to ongoing treatment.
• Benzodiazepines are effective in acute alcohol withdrawal for the management of symptoms as well as the prevention of seizures. One strategy is to give the patient a loading dose of a long-acting benzodiazepine (e.g., 20 mg of diazepam) and then continue the benzodiazepine as scheduled while tapering down the dose gradually. An example would be chlordiazepoxide 25 to 50 mg every 6 h on day 1, 25 to 50 mg every 8 h on day 2, 25 to 50 mg every 12 h on day 3, and 25 to 50 mg at hour of sleep on day 4 and day 5 and then discontinue.
• CIWA-Ar is a symptom-triggered approach to treatment of alcohol withdrawal with benzodiazepines. Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are the most frequently used benzodiazepines.
• Studies have shown that phenobarbital is also effective and safe in the treatment of alcohol withdrawal, especially in cases of severe alcohol withdrawal nonresponsive to benzodiazepines or in complicated withdrawal (i.e., withdrawal and presence of hallucinations, seizures, or delirium tremens).³ One of the advantages of phenobarbital is its long half-life (80 to 120 h) when compared with benzodiazepines such as lorazepam (14 to 20 h). The longer half-life allows for phenobarbital to be administered less frequently than benzodiazepines.
• The prophylactic administration of thiamine and folic acid (first intravenously or intramuscularly followed by supplemental oral doses) in alcohol withdrawal is recommended before starting any carbohydrate-containing fluids or food to prevent Wernicke-Korsakoff syndrome (alcoholic encephalopathy and psychosis). Magnesium appears to be effective in the treatment of alcohol withdrawal-related cardiac arrhythmias, but not other symptoms of alcohol withdrawal.
• Beta-blockers and clonidine generally should be avoided in alcohol withdrawal; they may mask markers of the severity of the withdrawal (blood pressure and pulse rate).
• Unlike withdrawal from alcohol or benzodiazepines, opioid withdrawal is not life threatening.
• Clonidine alleviates the discomfort of opiate withdrawal. Clonidine tablets, 0.1 mg q4-6h as needed, can be used while monitoring the patient’s blood pressure. Clonidine transdermal patch, 0.1 mg/24 h, can be used to treat autonomic hyperactivity symptoms; however, it has a very slow onset and may take 2 to 3 days to achieve therapeutic levels. Antidiarrheals, ibuprofen, and dicyclomine can be used as adjuncts to treat opiate withdrawal symptoms.
• Methadone taper is an effective approach for detoxification in opioid dependence.

Buprenorphine is a partial μ-opioid receptor agonist that may be used for detoxification and maintenance in treatment of opioid dependence (see dosing in next section). The combination product Suboxone contains buprenorphine and naloxone, a mu receptor antagonist, which is included to prevent dissolving of the buprenorphine for injectable use. Naloxone is not absorbed significantly when sublingually dissolved, while buprenorphine is. However, naloxone is potent when injected, causing acute withdrawal and thus serving as a deterrent to buprenorphine abuse. Before starting buprenorphine, patients must be tapered off their opioids to avoid the acute withdrawal that comes with use of buprenorphine, which is strongly bound to the mu receptor. When buprenorphine is used for medically supervised opioid withdrawal, patients are required to go through mild to moderate withdrawal (COWS of >12) before the first dose of buprenorphine is given. Antipsychotics (i.e., haloperidol) may be considered for agitation, hallucinations, and other behavioral disturbances.

• Naltrexone helps reduce craving for alcohol. Naltrexone 50 mg once daily for 12 wk can be a useful adjunct to substance abuse counseling or rehabilitation programs. Randomized treatment studies are equivocal for long-term outcomes. Naltrexone reduces relapse and the intensity or frequency of any drinking that does occur. It can be hepatotoxic and is contraindicated in opiate users. Intramuscular naltrexone (380 mg mo) may be considered if adherence is an issue.
• Acamprosate also helps reduce craving for alcohol. Acamprosate 666 mg three times daily may be an effective adjunct to counseling. A recent meta-analysis showed overall benefit with increase in the number of abstinent days.
• Disulfiram provokes acetaldehyde accumulation after alcohol ingestion, producing a toxic state manifested by nausea, headache, flushing, and respiratory distress. Studies have shown limited efficacy mostly due to noncompliance.
• Topiramate may be an alternative treatment for alcoholism. In a 12-wk randomized trial, topiramate up to 300 mg daily significantly reduced the number of heavy drinking days.
• Methadone maintenance for opiate addiction is effective and involves once-daily dosing of methadone in a controlled setting via methadone clinics.
• Buprenorphine is as effective as low-dose methadone and may be prescribed by physicians who have completed approved training. For induction, initiate 12 to 24 h after short-acting opioid use and 24 to 48 h after long-acting opioid use. Use buprenorphine/naloxone (Suboxone) tablets in most patients, because buprenorphine-only tablets have risk of abuse. Maximum first-day dosage is 4 to 8 mg of buprenorphine. Titrate buprenorphine dose up to 12 mg on day 2 for signs of withdrawal. Then adjust dosage in frequent outpatient visits (weekly) to minimum needed for maintenance (up to 32 mg daily).
• Sublocade is an injectable, long-term buprenorphine that provides sufficient mediation maintenance up to 4 wk. Sublocade has been found to be effective at reducing opioid use. A 24-wk clinical study on 504 individuals with opioid use disorder showed the mean percentage abstinence was about 40% in subjects who took Sublocade with counseling, compared to placebo (5%).⁴
• Naltrexone (oral or injectable) may also be used for maintenance in opioid dependence treatment, though evidence of effectiveness is limited.
• Always combine pharmacotherapy with counseling. There is good evidence that this combination improves outcome.
• Treatment of comorbid psychiatric disorders improves outcomes.
• Most pharmacotherapies have been ineffective for treating cocaine use disorder. Bupropion, psychostimulants, and topiramate may improve abstinence. While no government-approved medicines are currently available to treat cocaine addiction, researchers are testing some treatments that have been used to treat other disorders, including:
  1. Disulfiram (used to treat alcoholism)
  2. Modafinil (used to treat narcolepsy-a disorder characterized by uncontrollable episodes of deep sleep)
  3. Lorcaserin (used to treat obesity)
  4. Buprenorphine (used to treat opioid addiction)

Because of the nature of this chronic/relapsing condition, individuals should be referred to and monitored at outpatient drug and/or alcohol treatment centers. Other health conditions and co-occurring psychiatric disorder treatment can be provided at general mental health clinics. Drug rehabilitation may require a controlled environment, such as those in sober houses and long-term recovery clinics. Alcoholics Anonymous (AA) programs are also effective in providing peer support.

The top three therapies-religious/spiritual healing, relaxation techniques, and meditation-are commonly used adjunctive approaches. Neurofeedback and acupuncture are also reported as supportive.

https://findtreatment.samhsa.gov/

In 2017, the federal government declared the opioid epidemic a national public health emergency within the United States. Since then, attention (in treatment and funding) has focused mainly on White suburban and rural communities. Between 2015 and 2016 the rate of increase of drug overdose deaths was 40% in Black/African Americans compared with 21% in the overall population.⁵ Systems of stigma, negative societal representations, health care inequity, and historical injustices (e.g., the “War on Drugs”) have led to discrimination and harsh (often criminal) punishment for Black/African Americans with substance use disorder instead of compassionate medical treatment and recovery services. Even for those seeking recovery, unequal access exists (e.g., Black/African Americans and Latino low-income individuals are more likely to be in treatment with methadone compared with high-income patients who are more likely to be in treatment with Suboxone). Using community-informed and culturally appropriate strategies in addition to expanding access to Suboxone will be key to addressing opioid (and other substance) use disorder within the Black/African American and Latino low-income populations.

Another group in which there exist disparities in substance use care is among sexual minorities (SMs). Data show that there are higher rates of substance use and substance use disorders among SM than in heterosexual individuals.⁶ There are high levels of unmet mental health needs among this group, particularly among SM women. There exist different patterns of substance use within the various sexual identity groups (e.g., abuse of cocaine and OxyContin is more common among lesbian and bisexual individuals); thus, understanding this heterogeneity and applying treatment models that address the unique challenges of the various SM groups will be key to delivering equitable substance use care to this population.⁷

Goals of substance use disorder treatment:

• Stop the harmful use of addictive substances.
• Improve health and wellness.
• Live a self-directed life.
• Strive to reach full potential.
• Improve quality of life.

Efforts typically focus on children and teens. Besides national recognition of substance use prevention, family-based, school-based, and community prevention programs focus on changing community conditions or policies so that the availability of substances is reduced.

Individuals are provided information to understand the many aspects of what substance use disorders are, warning signs of addiction, information about how alcohol and specific drugs affect the mind and body, and the consequences of substance use disorders. Family therapy and education play important roles in the change process. It remains to be seen how legalization of cannabis will affect the rate of early-onset psychotic illness, since cannabis is a known risk factor.

Substance use disorders are prevalent among homeless and unstably housed individuals. This is a population that has high rates of premorbid mortality for many reasons, including higher rates of substance use. Policy makers, health care advocates, and the general population at large have debated the benefits and risks of harm reduction measures ranging from supervised consumption facilities and managed alcohol programs. Studies have shown that such measures are associated with a decrease in mortality rates in individuals with OUD and stabilized consumption and reduced hospitalizations in those with AUD.⁸

Alcohol Use Disorder (Related Key Topic)

Drug Use Disorder (Related Key Topic)

Hallucinogenic Overdose (Related Key Topic)

Opioid Overdose (Related Key Topic)

Opioid Use Disorder (Related Key Topic)

Synthetic Cannabinoids (Related Key Topic)