09 Substance-Related Disorders

8/9/2019 09 Substance-Related Disorders

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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,

Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org1

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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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

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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 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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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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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org 36


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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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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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 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)

09 Substance-Related Disorders

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