Substance use disorder

A substance use disorder (SUD), also known as a drug use disorder, is a medical condition in which the use of one or more substances leads to a clinically significant impairment or distress.[1] Substance use disorders are characterized by an array of mental, physical, and behavioral symptoms that may cause problems related to loss of control, strain to one's interpersonal life, hazardous use, tolerance, and withdrawal.[2] Drug classes that are involved in SUD include: alcohol; caffeine; cannabis; hallucinogens (such as arylcyclohexylamines); other hallucinogens (such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants; tobacco; and other or unknown substances.[3]

Substance use disorder
Other namesDrug use disorder
SpecialtyPsychiatry

In the DSM-5, substance abuse and substance dependence have been merged into the category of substance use disorders.[4] The severity of substance use disorders can vary widely; in the diagnosis of a SUD, the severity of an individual's SUD is qualified as mild, moderate, or severe on the basis of how many of the 11 diagnostic criteria are met. In the DSM-5, the term drug addiction is synonymous with severe substance use disorder.[5][6]

Worldwide 271 million people (5.5% of adults) were estimated to have used an illicit drug in 2017.[7] Of these 35 million have substance use disorder.[7] In 2017 substance use disorders resulted in 585,000 deaths,[7] up from 165,000 deaths in 1990.[8][9] Of these, the highest numbers are from alcohol use disorders at 137,500, opioid use disorders at 122,100 deaths, amphetamine use disorders at 12,200 deaths, and cocaine use disorders at 11,100.[8] The number of deaths directly caused by drug use has increased over 60 percent from 2000 to 2015.[10]

Definitions
Addiction and dependence glossary[11][12][13][5]
  • addiction – a brain disorder characterized by compulsive engagement in rewarding stimuli despite adverse consequences
  • addictive behavior – a behavior that is both rewarding and reinforcing
  • addictive drug – a drug that is both rewarding and reinforcing
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Substance use may lead to drug addiction, drug dependence, or both, depending on the substance.[14] Both substance abuse and substance dependence are distinct from addiction which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency .[15] Dependence often implies abuse, but abuse can occur without dependence, particularly when an individual first begins to abuse a substance. Physical dependence requires the development of tolerance leading to withdrawal symptoms; it involves physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society.[16]

Substance abuse is sometimes used as a synonym for drug abuse, drug addiction, and chemical dependency, but actually refers to the use of substances in a manner outside sociocultural conventions. All use of controlled drugs and all use of other drugs in a manner not dictated by convention (e.g. according to physician's orders or societal norms) is abuse according to this definition; however there is no universally accepted definition of substance abuse.[17]

Substance use may be better understood as occurring on a spectrum from beneficial to problematic use. This conceptualization moves away from the ill-defined binary antonyms of "use" vs. "abuse" towards a more nuanced, public health-based understanding of substance use.

Signs and symptoms

Addiction is a brain disorder characterized by compulsive drug use (i.e., the use of drugs due to irresistible urges or "cravings") despite negative consequences.[15] The medical community makes a distinction between physical dependence and psychological dependence upon drugs.[18] Physical dependence refers to the process by which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific symptoms upon cessation (characterized by symptoms of physical withdrawal symptoms, like tremors and sweating).[16] Conversely, psychological dependence occurs when a drug becomes central to a person's thoughts, emotions and activities.[14] They may have strong desire to use the drug, despite being aware of its harmful effects. A drug can cause physical dependence and not psychological dependence (for example, a person who is physically dependent on prescribed opioid medications may not experience a loss of control, strong cravings, etc.) and some can cause psychological dependence without physical dependence (the withdrawal symptoms associated with cocaine are all psychological, there is no associated vomiting or diarrhea as there is with opiate withdrawal).[19][20]

Causes

There are many known risk factors associated with an increased chance of developing a substance use disorder. Children born to parents with SUDs have roughly a two-fold increased risk in developing a SUD compared to children born to parents without any SUDs.[21] Taking highly addictive drugs, and those who develop SUDs in their teens are more likely to have continued symptoms into adulthood.[21] Other common risk factors are being male, being under 25, having other mental health problems, and lack of familial support and supervision.[21] Psychological risk factors include high impulsivity, sensation seeking, neuroticism and openness to experience in combination with low conscientiousness.[22][23]

Diagnosis

Individuals whose drug or alcohol use cause significant impairment or distress may have a substance use disorder (SUD).[2] Diagnosis usually involves an in-depth examination, typically by psychiatrist, psychologist, or drug and alcohol counselor.[24] The most commonly used guidelines are published in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).[24] There are 11 diagnostic criteria which can be broadly categorized into issues arising from substance use related to loss of control, strain to one's interpersonal life, hazardous use, and pharmacologic effects.[2]

DSM-5 guidelines for the diagnosis of a substance use disorder requires that the individual have significant impairment or distress from their pattern of drug use, and at least two of the symptoms listed below in a given year.[2]

  1. Using more of a substance than planned, or using a substance for a longer interval than desired
  2. Inability to cut down despite desire to do so
  3. Spending substantial amount of the day obtaining, using, or recovering from substance use
  4. Cravings or intense urges to use
  5. Repeated usage causes or contributes to an inability to meet important social, or professional obligations
  6. Persistent usage despite user's knowledge that it is causing frequent problems at work, school, or home
  7. Giving up or cutting back on important social, professional, or leisure activities because of use
  8. Using in physically hazardous situations, or usage causing physical or mental harm
  9. Persistent use despite the user's awareness that the substance is causing or at least worsening a physical or mental problem
  10. Tolerance: needing to use increasing amounts of a substance to obtain its desired effects
  11. Withdrawal: characteristic group of physical effects or symptoms that emerge as amount of substance in the body decreases

There are additional qualifiers and exceptions outlined in the DSM. For instance, if an individual is taking opiates as prescribed, they may experience physiologic effects of tolerance and withdrawal, but this would not cause an individual to meet criteria for a SUD without additional symptoms also being present.[2] A medical professional trained to evaluate and treat substance use disorders will take these nuances into account during a diagnostic evaluation.

Severity

Substance use disorders range can range widely in severity, and there are numerous methods to monitor and qualify the severity of an individual's SUD. The DSM-5 includes specifiers for severity of a SUD.[2] Individuals who meet only 2 or 3 criteria are often deemed to have mild SUD.[2] Substance users who meet 4 or 5 criteria may have their SUD described as moderate, and persons meeting 6 or more criteria as severe.[2] In the DSM-5, the term drug addiction is synonymous with severe substance use disorder.[5][6] The quantity of criteria met offer a rough gauge on the severity of illness, but licensed professionals will also take into account a more holistic view when assessing severity which includes specific consequences and behavioral patterns related to an individual's substance use.[2] They will also typically follow frequency of use over time, and assess for substance-specific consequences, such as the occurrence of blackouts, or arrests for driving under the influence of alcohol, when evaluating someone for an alcohol use disorder.[2] There are additional qualifiers for stages of remission that are based on the amount of time an individual with a diagnosis of a SUD has not met any of the 11 criteria except craving.[2] Some medical systems refer to an Addiction Severity Index to assess the severity of problems related to substance use.[25] The index assesses potential problems in seven categories: medical, employment/support, alcohol, other drug use, legal, family/social, and psychiatric.[26]

Screening tools

There are several different screening tools that have been validated for use with adolescents, such as the CRAFFT, and with adults, such as CAGE. Laboratory tests to detect alcohol and other drugs in urine and blood may be useful during the assessment process to confirm a diagnosis, to establish a baseline, and later, to monitor progress.[27] However, since these tests measure recent substance use rather than chronic use or dependence, they are not recommended as screening tools.[27]

Mechanisms
Main articles: Addiction § Mechanisms, and Substance dependence § Biomolecular mechanisms

Management

Detoxification

Depending on the severity of use, and the given substance, early treatment of acute withdrawal may include medical detoxification. Of note, acute withdrawal from heavy alcohol use should be done under medical supervision to prevent a potentially deadly withdrawal syndrome known as delirium tremens. See also Alcohol detoxification.

Therapy
Main article: Drug rehabilitation

Therapists often classify people with chemical dependencies as either interested or not interested in changing. About 11% of Americans with substance use disorder seek treatment, and 40–60% of those people relapse within a year.[28] Treatments usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention approaches to specific influences that affect addictive behavior, using therapeutic interviews in an effort to discover factors that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain.

Treatments
Behavioral pattern Intervention Goals
Low self-esteem, anxiety, verbal hostility Relationship therapy, client centered approach Increase self-esteem, reduce hostility and anxiety
Defective personal constructs, ignorance of interpersonal means Cognitive restructuring including directive and group therapies Insight
Focal anxiety such as fear of crowds Desensitization Change response to same cue
Undesirable behaviors, lacking appropriate behaviors Aversive conditioning, operant conditioning, counter conditioning Eliminate or replace behavior
Lack of information Provide information Have client act on information
Difficult social circumstances Organizational intervention, environmental manipulation, family counseling Remove cause of social difficulty
Poor social performance, rigid interpersonal behavior Sensitivity training, communication training, group therapy Increase interpersonal repertoire, desensitization to group functioning
Grossly bizarre behavior Medical referral Protect from society, prepare for further treatment
Adapted from: Essentials of Clinical Dependency Counseling, Aspen Publishers

From the applied behavior analysis literature and the behavioral psychology literature, several evidence-based intervention programs have emerged, such as behavioral marital therapy, community reinforcement approach, cue exposure therapy, and contingency management strategies.[29][30] In addition, the same author suggests that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious.

Medication

Medication-assisted treatment (MAT) refers to the combination of behavioral interventions and medications to treat substance use disorders.[31] Certain medications can be useful in treating severe substance use disorders. In the United States five medications are approved to treat alcohol and opioid use disorders.[32] There are no approved medications for cocaine, methamphetamine, or other substance use disorders as of 2002.[32]

Medications, such as methadone and disulfiram, can be used as part of broader treatment plans to help a patient function comfortably without illicit opioids or alcohol.[33] Medications can be used in treatment to lessen withdrawal symptoms. Evidence has demonstrated the efficacy of MAT at reducing illicit drug use and overdose deaths, improving retention in treatment, and reducing HIV transmission.[34][35][36]

Epidemiology
The disability-adjusted life year, a measure of overall disease burden (number of years lost due to ill-health, disability or early death), from drug use disorders per 100,000 inhabitants in 2004
  no data
  <40
  40-80
  80-120
  120-160
  160-200
  200-240
  240-280
  280-320
  320-360
  360-400
  400–440
  >440

Rates of substance use disorders vary by nation and by substance, but the overall prevalence is high.[37] On a global level, men are affected at a much higher rate than women.[37] Younger individuals are also more likely to be affected than older adults.[37]

United States

In 2017, roughly 7% of Americans aged 12 or older had a SUD in the past year.[38] Rates of alcohol use disorder in the past year was just over 5%. Approximately 3% of people aged 12 or older had an illicit drug use disorder.[38] The highest rates of illicit drug use disorder was among those aged 18 to 25 years old, at roughly 7%.[38][37]

There were over 72,000 deaths from drug overdose in the United States in 2017.[39] This represents a 3-fold increase in mortality from overdose from 2002 to 2017.[39] Overdose fatalities from synthetic opioids, which typically involve fentanyl, have risen sharply in the past several years to contribute to nearly 30,000 deaths per year.[39] Death rates from synthetic opioids like fentanyl have increased 22-fold in the period from 2002 to 2017.[39] Heroin and other natural and semi-synthetic opioids combined to contribute to roughly 31,000 overdose fatalities.[39] Cocaine contributed to roughly 15,000 overdose deaths, while methamphetamine and benzodiazepines each contributed to roughly 11,000 deaths.[39] Of note, the mortality from each individual drug listed above cannot be summed because many of these deaths involved combinations of drugs, such as overdosing on a combination of cocaine and an opioid.[39]

Deaths from alcohol consumption account for the loss of over 88,000 lives per year.[40] Tobacco remains the leading cause of preventable death, responsible for greater than 480,000 deaths in the United States each year.[41] These harms are signifiant financially with total costs of more than $420 billion annually and more than $120 billion in healthcare.[42]

Canada

According to Statistics Canada (2018), approximately one in five Canadians aged 15 years and older experience a substance use disorder in their lifetime.[43] In Ontario specifically, the disease burden of mental illness and addiction is 1.5 times higher than all cancers together and over 7 times that of all infectious diseases.[44] Across the country, the ethnic group that is statistically the most impacted by substance use disorders compared to the general population are the Indigenous peoples of Canada. In a 2019 Canadian study, it was found that Indigenous participants experienced greater substance-related problems than non-Indigenous participants.[45]

Statistics Canada's Canadian Community Health Survey (2012) shows that alcohol was the most common substance for which Canadians met the criteria for abuse or dependence.[43] Surveys on Indigenous people in British Columbia show that around 75% of residents on reserve feel alcohol use is a problem in their community and 25% report they have a problem with alcohol use themselves. However, only 66% of First Nations adults living on reserve drink alcohol compared to 76% of the general population.[46] Further, in an Ontario study on mental health and substance use among Indigenous people, 19% reported the use of cocaine and opiates, higher than the 13% of Canadians in the general population that reported using opioids.[47][48]

Australia

Historical and ongoing colonial practices continue to impact the health of Indigenous Australians, with Indigenous populations being more susceptible to substance use and related harms.[49] For example, alcohol and tobacco are the predominant substances used in Australia.[50] Although tobacco smoking is declining in Australia, it remains disproportionately high in Indigenous Australians with 45% aged 18 and over being smokers, compared to 16% among non-Indigenous Australians in 2014-2015.[51] As for alcohol, while proportionately more Indigenous people refrain from drinking than non-Indigenous people, Indigenous people who do consume alcohol are more likely to do so at high-risk levels.[52] About 19% of Indigenous Australians qualified for risky alcohol consumption (defined as 11 or more standard drinks at least once a month), which is 2.8 times the rate that their non-Indigenous counterparts consumed the same level of alcohol.[51]

However, while alcohol and tobacco usage are declining, use of other substances, such as cannabis and opiates, is increasing in Australia.[49] Cannabis is the most widely used illicit drug in Australia, with cannabis usage being 1.9 times higher than non-Indigenous Australians.[51] Prescription opioids have seen the greatest increase in usage in Australia, although use is still lower that in the US.[53] In 2016, Indigenous persons were 2.3 times more likely to misuse pharmaceutical drugs than non-Indigenous people.[51]

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