12: Substance Use Disorders

Question 1

What fall under DSM-5’s Substance-Related and Addictive Disorders?

Answer 1

• 10 separate classes of drugs plus gambling
• Substance use disorders
• Suststance-induced disorders
  
  • Intoxication
  • Withdrawal
  • Substance/medication-induced mental disorders

Question 2

How is substance use disorder definited in DSM-5?

Answer 2

• Maladaptive pattern of substance use leading to clinically significant impairment or distress
• Mild (2-3 symptoms), moderate (4-5 symptoms) or severe (6+ symptoms) occuring within a 12-month period
  
  • Substance taken in larger amounts than intended
  • Persistent desire or unsuccessful effort to cut down or control
  • Great deal of time obtaining, using, recovering from substance use
  • Craving or strong desire or urge to use the substance
  • Recurrent failure to fulfill major obligation at work, school or home
  • Continued use despite recurrent social/interpersonal problems
  • Important social, occupational or recreational activites given up
  • Recurrent use in situations which are hazardous
  • Continued use despite physical or psychological problems
  • Tolerance
  • Withdrawal

Question 3

What psychiatric disorders do substance use disorders (SUDs) commonly occur with?

Answer 3

• Major depression (20.1%)
• Mania (5.0%)
• Social phobia (4.7%)

Question 4

Review the initial evaluation in the context of an SUD.

Answer 4

• Identifying data
  
  • Assessment of resources: social and financial (to determine Tx resources)
• Chief complaint
  
  • Self-seeking vs. directed by others to seek treatment?
• History of the present illness
  
  • What substances and how often?
  • How much being spent?
  • Desirable and undesirable effects?
  • How is functioning and/or psychiatric symptomatology affected by substance use?
  • Is there a crisis present?
• Past substance use history
  
  • How much and for how long?
  • Overdoses and other serious sequellae?
  • Past Tx and/or periods of abstinence?
• Present and past psychiatric history
  
  • Relationship between psychiatric symptoms and substance use
• Past medical history
  
  • Seizures, chest pain, hepatitis, HIV, endocarditis, abscesses
• Medications
  
  • Focus on prescribed controlled substances
• Family history
  
  • Discuss role of genetic predisposition with patient
• Social history
  
  • Home and work environments supportive of abstinence?
  • Criminal justice problems?
• MSE
  
  • Can current Sx be explained entirely by substance use, or is a substance-independent disorder present?
• Laboratory exam
  
  • Urine toxicology and/or alcohol breath testing
  • Chemistry and hemogram

Question 5

Describe the formulation and diagnosis of SUD.

Answer 5

• Formulation
  
  • Is there a substance use disorder present and does it require specialized treatment now?
    
    • Inpatient rehab center, intensive outpatient program, individual/group options
  • Will the patient agree to treatment recommendations?
• Differential diagnosis
  
  • Distinguish substance-induced vs. substance-independent disorders?
    
    • Which appeared first?
    • During periods of abstinence, were psychiatric symptoms present?

Question 6

For cocaine & meth, name:

1. Psychiatric symptoms (intoxication or withdrawal)
2. Similar psychiatric disorders

Answer 6

1. Mania, psychosis, inattention
2. Bipolar disorder, SZ, SZA, ADHD

Question 7

For alcohol, name:

1. Psychiatric symptoms (intoxication or withdrawal)
2. Similar psychiatric disorders

Answer 7

1. Low mood, neurovegetative withdrawal delirium
2. MDD, cognitive and memory disorders

Question 8

For marijuana, name:

1. Psychiatric symptoms (intoxication or withdrawal)
2. Similar psychiatric disorders

Answer 8

1. Inattention, anxiety
2. ADHD, GAD, panic disorder

Question 9

For sedative-hypnotics, name:

1. Psychiatric symptoms (intoxication or withdrawal)
2. Similar psychiatric disorders

Answer 9

1. Anxiety
2. GAD, panic disorder

Question 10

For opioids, name:

1. Psychiatric symptoms (intoxication or withdrawal)
2. Similar psychiatric disorders

Answer 10

1. Low mood, anxiety
2. MDD, GAD, panic disorder

Question 11

What are the various treatment settings for SUDs?

Answer 11

• Inpatient detoxification unit: specialized care for opioid, alcohol and sedative-hypnotic withdrawal
• Intensive outpatient program: daily treatment, mostly group-based, drug testing (provides support and structure)
• Residential treatment facilities, i.e., rehab: safe environment, no access to substances, but expensive and inconvenient
• Mutual support meetings, e.g., AA & NA: free, available nearly everywhere, provide social support, but not professionally facilitated, and emphasis on spirituality