Post on 29-May-2018
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Slide show includes
Topic Headings
Tables and Figures
Key Points
Substance-Related DisordersMartin H. Leamon, M.D., Tara M. Wright, M.D.,
Hugh Myrick, M.D.
The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRYFifth EditionEdited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.
2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 9
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CHAPTER 9 Tables and Figures
Table 91. DSM-IV-TR classification of substance-related disorders
Table 92. DSM-IV-TR diagnostic criteria for substance intoxication
Table 93. DSM-IV-TR diagnostic criteria for substance withdrawal
Table 94. DSM-IV-TR diagnostic criteria for substance abuse
Table 95. DSM-IV-TR diagnostic criteria for substance dependence
Table 96. DSM-IV-TR diagnoses associated with class of substances
Table 97. ICD-10 classification of substance use disorders
Table 98. Maximum alcohol consumption for low-risk drinking
Figure 91. Neural circuitry implicated in the process of addiction.
Table 99. Percentage of past-year substance users with abuse or dependence, by substance: 2004
Table 910. The CAGE questions, adapted to include drugs
Table 911. Basic components of substance use disorder evaluation
Table 912. Stages of change
Table 913. American Society of Addiction Medicine Patient Placement Criteria levels and dimensions
Table 914. The Twelve Steps
Table 915. Twelve-Step group Web sitesTable 916. Empirically based psychosocial interventions
Table 917. Blood alcohol level and corresponding symptoms of intoxication in the nontolerant patient
Table 918. DSM-IV-TR diagnostic criteria for alcohol withdrawal
Table 919. Laboratory abnormalities associated with harmful levels of drinking
Figure 92. Alcohol Use Disorders Identification Test (AUDIT).(continued)
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CHAPTER 9 Tables and Figures (continued)
Figure 93. Clinical Institute Withdrawal Assessment for AlcoholRevised (CIWA-Ar).
Table 920. Comparison of U.S. Food and Drug Administrationapproved medications for the treatment
of alcohol dependence
Table 921. Symptoms of cannabis intoxication
Table 922. Cannabis withdrawal symptoms
Table 923. DSM-IV-TR diagnostic criteria for cocaine or amphetamine intoxication
Table 924. DSM-IV-TR diagnostic criteria for cocaine or amphetamine withdrawal
Table 925. DSM-IV-TR diagnostic criteria for opioid intoxication
Table 926. Management of acute opioid overdose
Table 927. Signs and symptoms of opioid withdrawal
Table 928. Opioid detoxification medication protocols
Table 929. DSM-IV-TR diagnostic criteria for nicotine withdrawal
Table 930. Smoking cessation information Web sites
Table 931. Principles of treatment for nicotine dependence
Figure 94. Fagerstrm Test for Nicotine Dependence.
Table 932. First-line pharmacotherapies approved for use for smoking cessation by the U.S. Food and
Drug Administration
Table 933. DSM-IV-TR diagnostic criteria for sedative-hypnotic withdrawal
Table 934. Sedative-hypnotics and their phenobarbital withdrawal equivalents
Table 935. DSM-IV-TR diagnostic criteria for polysubstance dependence
Table 936. CRAFFT questionnaire to identify problem drinking in adolescents
Summary Key Points
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TABLE 91. DSM-IV-TR classification of substance-related disorders
DSM-IV-TR defines a substance as a drug of abuse, a medication, or a toxin (American Psychiatric
Association 2000) and classifies disorders attributable to substance use according to the schema in
Table 91. Eleven classes of substances that include the commonly recognized abusable drugs are
described, and other medications or toxins that could cause disorders are grouped into the class of
other or unknown.
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TABLE 92. DSM-IV-TR diagnostic criteria for substance intoxication
Included in the DSM-IV-TR classification of substance-related disorders are the substance-induced
disorders of intoxication and withdrawal (Tables 92 and 93) and the substance use disorders of
abuse and dependence (Tables 94 and 95).
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TABLE 93. DSM-IV-TR diagnostic criteria for substance withdrawal
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TABLE 94. DSM-IV-TR diagnostic criteria for substance abuse
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TABLE 96. DSM-IV-TR diagnoses associated with class of substances
Other substance-induced disorders are classified with their phenomenologically similar disorders; for
example, substance-induced mood disorder is included in the DSM-IV-TR mood disorders section. Not all
types of disorders are recognized for all classes of substances (Table 96).
Source. Adapted from American Psychiatric Association 2000, p. 193.
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TABLE 97. ICD-10
classification of
substance use disorders
The World Health Organizations (2006) International Statistical Classification of Diseases and
Related Health Problems, 10th Revision (ICD-10) is similar to DSM-IV-TR in its recognition of
intoxication, withdrawal, and dependence syndromes. Instead of the disorder of substance abuse,
however, ICD-10 includes the disorder of harmful use, which has somewhat broader diagnostic
criteria (Table 97).
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TABLE 98. Maximum alcohol
consumption for low-risk
drinking
Another classification system, used only for alcohol, is that of high-risk and low-risk drinking (Table
98) (National Institute on Alcohol Abuse and Alcoholism 2005). Unlike the DSM-IV-TR system, which
focuses on the behavioral consequences of dysfunctional use, the high-/low-risk system focuses
exclusively on volumetric and frequency criteria, based on the association of these parameters with
risks of general medical sequelae to alcohol use (Rehm et al. 2003).
Source. Adapted from National Institute on Alcohol
Abuse and Alcoholism 2005. Public domain.
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FIGURE 91. Neural
circuitry implicated in
the process of
addiction.
A number of different neuronal
circuits and neurotransmitters
have been implicated in the
process of addiction. In addition to
dopamine, the neurotransmitters
glutamate, K-aminobutyric acid(GABA), and opioid neuropeptides
are important in this circuitry
(Figure 91).
GABA = K-aminobutyric acid.
Source. Reprinted from Kalivas PW, Volkow ND:
The Neural Basis of Addiction: A Pathology of
Motivation and Choice. American Journal of
Psychiatry162:14031413, 2005. Used with
permission.
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TABLE 99.
Percentage of
past-year
substance users
with abuse or
dependence, by
substance: 2004
There is ample epidemiological and experimental evidence that susceptibility to addiction is
influenced by genetics and that the genetic contribution is determined by multiple genes and is
modulated by environmental influences. One of the environmental factors does seem to be the type of
drug used. The 2004 National Survey on Drug Use and Health revealed large differences between
substances in the percentage of past-year users meeting criteria for abuse or dependence (Table 99).
Source. Substance Abuse and
Mental Health Services
Administration 2005.
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TABLE 910. The CAGEquestions, adapted to
include drugs
Because patients with a substance use disorder may present in a number of different ways, all patients
should be routinely and consistently screened for substance use disorders. One useful screening
instrument is the CAGE-D (Table 910).
Source. Reprinted from Brown RL, Rounds LA:
Conjoint Screening Questionnaires for Alcohol
and Drug Abuse. Wisconsin Medical Journal
94:135140, 1995. Used with permission.
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TABLE 911. Basic components
of substance use disorder
evaluation
There is a large societal stigma
against people with substance use
disorders, and patients may be quite
averse to acknowledging substance-
related problems. Questions must be
asked with nonjudgmental empathyand caring professional interest.
Confrontational challenging is not
always useful and may disrupt
therapeutic rapport. The basic areas
of inquiry are listed in Table 911.
Source. Adapted from Workgroup on Substance Use
Disorders 2006. Used with permission.
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TABLE 912. Stages of change
The Stages of Change model (Prochaska and DiClemente 1992) is useful for conceptualizing a patients
motivation to address substance use problems. The model, derived from research on tobacco
cessation, divides the recovery process into sequential stages, with stage-specific goals to achieve
before progression (Table 912). The practitioner matches interventions to the patients stage to
enhance commitment to change and to increase the probability of successful change in substance use.
Source. Prochaska and DiClemente 1992.
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TABLE 913. American Society of
Addiction Medicine Patient Placement
Criteria levels and dimensions
A motivated patient ideally should be
enrolled in a treatment program of an
intensity commensurate with his or her
level of problems. The Patient Placement
Criteria algorithm developed by the
American Society of Addiction Medicineassigns a patient within five levels of care
(with sublevels) based on six dimensions
(Table 913). Patients matched to treatment
placements based on this algorithm have
been shown to have better outcomes than
mismatched patients, and although further
research continues, it already has been
widely implemented (Magura et al. 2003).
Source. Mee-Lee et al. 2001.
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TABLE 914. The Twelve
Steps
The most prevalent and widely used psychosocial interventions for substance disorders are the mutual
self-help groups based on the 12 Steps of Alcoholics Anonymous (AA) (Table 914). In studies of
alcohol dependence, more frequent AA attendance has been associated with better outcomes. For
individuals who find the 12 Steps emphasis on spirituality unacceptable, lay alternatives do exist, but
there is much less research supporting their effectiveness.
(continued)
Source. The Twelve Steps are reprinted with permission
of Alcoholics Anonymous W orld Services, Inc. (AAWS ).
Permission to reprint the Twelve Steps does not mean
that AAWS has reviewed or approved the contents of this
publication, or that AAWS necessarily agrees with the
views expressed herein. AA is a program of recovery from
alcoholism onlyuse of the Twelve Steps in connectionwith programs and activities which are patterned after AA,
but which address other problems, or in any other non-AA
context, does not imply otherwise.
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TABLE 914. (continued)
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TABLE 915. Twelve-Step group Web sites
Table 915 lists Web sites for other substance abuse self-help groups modeled on AA.
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TABLE 916. (continued)
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TABLE 917. Blood alcohol level and corresponding symptoms of intoxication in thenontolerant patient
The degree of clinical impairment from alcohol intoxication is dependent on the individuals tolerance,
the amount and type of alcoholic beverage ingested, and the amount absorbed. Table 917 lists blood
alcohol levels and typical corresponding clinical features of intoxication in an individual who has not
developed any tolerance.
Source. Adapted from Mack et al. 2003.
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TABLE 918. DSM-IV-TR
diagnostic criteria for alcohol
withdrawal
Alcohol withdrawal typically begins
68 hours after the last drink, peaks
2428 hours after the last drink, and
generally resolves within 7 days
(Myrick and Anton 2004). The spectrum
of alcohol withdrawal symptoms iswide, and the more common
presentations are outlined in Table
918. Only about 5% of individuals with
alcohol dependence will develop more
than mild to moderate withdrawal
symptoms.
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TABLE 919. Laboratory
abnormalities associated with
harmful levels of drinking
Laboratory data and biological markers can be clues to an alcohol use disorder in a patient. Table 919
lists possible laboratory abnormalities in the setting of alcohol abuse or dependence.
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FIGURE 92. Alcohol Use
Disorders Identification
Test (AUDIT).
Several questionnaires are available for
the detection of drinking-related
problems. A positive response to any of
the questions on the CAGE (see Table
910) should lead the clinician to
investigate problem drinking with thepatient further. The Alcohol Use
Disorders Identification Test is another
10-item questionnaire used for the
screening of alcohol use disorders
(Figure 92).
Source. Reprinted from BaborTF, Higgins-Biddle JC,Saunders J, et al.: AUDIT, the Alcohol Use Disorders
Identification Test, 2nd Edition. Geneva, Switzerland, World
Health Organization, 2001. Available at:
http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf
Accessed July 30, 2006. May be reproduced without
permission for noncommercial purposes.
(continued)
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FIGURE 92. (continued)
Source. Reprinted from BaborTF,
Higgins-Biddle JC, Saunders J, et al.:
AUDIT, the Alcohol Use Disorders
Identification Test, 2nd Edition.
Geneva, Switzerland, World HealthOrganization, 2001. Available at:
http://whqlibdoc.who.int/hq/2001/WH
O_MSD_MSB_01.6a.pdf Accessed
July 30, 2006. May be reproduced
without permission for noncommercial
purposes.
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FIGURE 93. Clinical Institute
Withdrawal Assessment for
AlcoholRevised (CIWA-Ar).
The Clinical Institute Withdrawal Assessment
Scale for AlcoholRevised is a short test
rating the severity of alcohol withdrawal as
observed by a health care professional
(Figure 93). This 10-item assessment tool
can be used to quantify the severity of alcoholwithdrawal syndrome and to monitor and
medicate patients going through withdrawal.
CNS = central nervous system.
Source. Adapted from Sullivan et al. 1989.
(continued)
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FIGURE 93. (continued)
Source. Adapted from Sullivan et al. 1989.
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TABLE 920.
Comparison
of U.S. Food
and Drug
Administration
approved
medications for
the treatment ofalcohol
dependence
As of July 2007, only four medications had U.S. Food and Drug Administration (FDA) approval for use
in the maintenance treatment of alcohol dependence: disulfiram, naltrexone, a long-acting
intramuscular formulation of naltrexone, and acamprosate. Table 920 offers a comparison of these
medications.
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TABLE 921. Symptoms of cannabis intoxication
Cannabis intoxication (Table 921) has been associated with increased risk of automobile accidents.
No specific treatment is generally indicated.
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TABLE 922. Cannabiswithdrawal symptoms
A cannabis withdrawal syndrome has recently been described (Table 922). It begins 23 days after
cessation of use and is generally mild, but the duration has been variable in studies, from 12 to 115
days. No specific treatment is generally needed.
Source. Center for Substance Abuse
Treatment 2006 and Copersino et al. 2006.
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TABLE 923. DSM-IV-TR diagnostic criteria
for cocaine or amphetamine intoxication
Cocaine and amphetamine intoxication have similar
symptoms (Table 923). The differences in clinical
presentation are due to the respective half-lives of
the drugs, which are approximately 4060 minutes
for cocaine and 612 hours for methamphetamine.
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TABLE 924. DSM-IV-TR
diagnostic criteria for cocaine
or amphetamine withdrawal
As with intoxication, the symptoms of cocaine and amphetamine withdrawal are similar, distinguished
primarily by time course (Table 924).
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TABLE 925. DSM-IV-TR
diagnostic criteria for
opioid intoxication
The pleasurable sensation derived from the ingestion of an opioid drug is referred to as a rush. The
onset, duration, and intensity of the rush are dependent on the particular drug that is used, how much is
used, and the route of administration (oral ingestion, inhalation, intravenous injection). The characteristic
symptoms of opioid intoxication are listed in Table 925.
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TABLE 926. Managementof acute opioid overdose
Overdose involving opioid drugs is a life-threatening situation. Table 926 reviews the steps necessary
in the management of an opioid overdose (Zimmerman 2003).
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TABLE 927. Signsand symptoms of
opioid withdrawal
Table 927 outlines the most common signs and symptoms of opioid withdrawal. With any opioid, after
acute withdrawal symptoms have subsided, a protracted abstinence syndrome, including disturbances
of mood and sleep, can persist for 68 months.
Source. Adapted from Collins and Kleber 2004.
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TABLE 928. Opioid
detoxification medicationprotocols
Management of acute opioid withdrawal involves a combination of general supportive measures
in conjunction with pharmacotherapy (Table 928).
(continued)
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TABLE 928. (continued)
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TABLE 929. DSM-IV-TR
diagnostic criteria for
nicotine withdrawal
Given that tobacco use is legal and its acute use causes minimal behavioral disruption, treatment of
nicotine dependence focuses on managing withdrawal and cravings (Table 929) and developing other
behaviors that promote abstinence and prevent relapse.
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TABLE 930. Smoking cessation
information Web sites
Evidence-based clinical practice
guidelines for nicotine dependence are
readily available (e.g., Fiore et al. 2000),
as are self-help Web sites and phone
lines (Table 930).
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TABLE 931. Principles of treatment for
nicotine dependence
Treatment principles for nicotine dependence are
listed in Table 931. The issue of concurrent
treatment of nicotine and other substance use
disorders continues to be debated (Ziedonis et al.
2006). In two recent review articles, one group
recommended concurrent and the other sequentialtreatments (Kalman et al. 2005; Metz et al. 2005).
Source. Adapted from U.S.Department of Health and Human Services
Public Health Service 2000. Public domain.
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FIGURE 94. (continued).
Source. Adapted from Heatherton et al. 1991.
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TABLE 933. DSM-IV-TR
diagnostic criteria for sedative-
hypnotic withdrawal
Abrupt discontinuation of sedative-
hypnotics in individuals who are
physically dependent on them can lead
to significant withdrawal symptoms, the
most serious being death. Table 933
identifies the most common signs andsymptoms seen in sedative-hypnotic
withdrawal.
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TABLE 934.Sedative-
hypnotics
and their
phenobarbital
withdrawal
equivalents
The phenobarbital substitution option has the broadest use for sedative-hypnotic withdrawal and can be
used for barbiturate, benzodiazepine, or combined alcohol/sedative-hypnotic withdrawals. Phenobarbital
is long-acting, has little variation in blood levels between doses, and has both a low abuse potential and a
high therapeutic index. The patients average daily sedative-hypnotic dosage is calculated (Table 934)
and then divided into three doses spread out over the day.
Source. Adapted from
Smith and Wesson 2004.
(continued)
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TABLE 934. (continued)
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TABLE 935. DSM-IV-TR diagnostic criteria for polysubstance dependence
Polysubstance dependence (Table 935) may be less common and may be associated with poorer
outcome and greater impairment than dependence on a single substance (Medina et al. 2006;
Schuckit et al. 2001). All substances must be addressed during treatment for dependence, and the
patient may have different levels of motivation for recovery from different substances.
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TABLE 936. CRAFFT questionnaire to identify problem drinking in adolescents
CRAFFT (Table 936) is a useful mnemonic-based questionnaire to screen for possible substance
disorders in adolescents (Knight et al. 2002). An answer of yes to two or more questions is indicative
of harmful substance use.
Source. Reprinted from Knight JR, Sherritt L, Shrier LA, et al: Validity of the CRAFF T Substance Abuse Screening Test Among Adolescent Clinic Patients. Archives of
Pediatrics and Adolescent Medicine 156:607614, 2002. Used with permission.
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CHAPTER 9 Key Points
Worldwide drug and alcohol use disorders, excluding tobacco, are the sixth
leading cause of disease burden in adults, whereas tobacco use and
exposure to tobacco smoke are the leading preventable causes of death.
Looking at lifetime risk, the National Comorbidity Survey, conducted in the
early 1990s, found that around one-third of the subjects who had smoked
cigarettes at least once developed nicotine dependence, 15% of subjects who
had ever drunk alcohol developed alcohol dependence, and about 15% of
subjects who had ever tried other drugs developed drug dependence.
Physicians should inquire about all classes of substances (e.g., alcohol,
opioids, sedative-hypnotics, stimulants, cannabis, nicotine), including
prescription medications, as well as legal and illegal substances, because
patients may not regard abuse of some substances to be as significant as
that of others.
Although psychosocial and behavioral approaches are the cornerstones of
treatment for substance dependence, medications are increasingly used toaugment the treatment of alcohol, opioid, and nicotine dependence.
Developing medications for the treatment of stimulant dependence is a
federal research priority.(continued)
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There are currently four medications with FDA approval for the maintenance
treatment of alcohol dependence: disulfiram, naltrexone, a long-acting
intramuscular formulation of naltrexone, and acamprosate.
The use of buprenorphine for detoxification or maintenance treatment in opioid
dependence is increasingly common, in part because buprenorphine can be
prescribed in a physicians office with up to 1 months prescription at a time.
Although it may take several tries, the overall success rate in helping patients
quit smoking is relatively good. The long-term (e.g., 12 months) quit rates for a
single attempt are less than 10%, whereas the lifetime long-term quit rate is
approximately 50%.
Polysubstance abuse is common; 56% of patients admitted to publicly funded
treatment programs in 2002 reported abuse of more than one substance, and
more than 70% smoked cigarettes. If undetected, polysubstance abuse can
complicate the treatment of substance intoxication, withdrawal, abuse, or
dependence. Substance use disorders and other psychiatric disorders commonly co-occur,
and the relationship is complex and bidirectional.
The recent increase in the rates of nonmedical use of prescription pain killers
(specifically opioids) in adolescents is notable and of concern.
CHAPTER 9 Key Points (continued)