Staying up-to-date with DSM-V!
For substance use, DSM-V no longer includes the terms “substance abuse” or “substance dependence”; instead “substance use disorder” is preferred terminology.
Substance Use Disorder (SUD) = A problematic pattern of use leading to clinically significant impairment or distress, which is manifested by two or more of the following within a 12-month period:
- Often taken in larger amounts or over a longer period than was intended.
- A persistent desire or unsuccessful efforts to cut down or control use.
- A great deal of time is spent in activities necessary to obtain, use, or recover from the substance’s effects.
- Craving or a strong desire or urge to use the substance.
- Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by its effects.
- Important social, occupational, or recreational activities are given up or reduced because of use.
- Recurrent use in situations in which it is physically hazardous.
- Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
- Tolerance.
- Withdrawal.
The above criteria can be used to determine severity:
- Mild = 1-2
- Moderate = 4-5
- Severe = ≥6
SUD is PREVALENT
Per 2019 data from the Substance Abuse & Mental Health Services Administration (SAMHSA):
- 7.2% individuals ≥12 yo had diagnosable SUD
- 5.3% had alcohol use disorder
- 2.8% had illicit drug use disorder
A substantial proportion of ED visits in the US are associated with illicit drug use and non-medical use of medications, either alone or in combination with alcohol
Risk factors for substance use include:
- A romantic partner with a SUD
- Friends who have SUDs
- Living in a community characterized by poverty, violence, and/or high alcohol and other drug availability
Asking about substance use in clinic
Many substances to consider:
- Alcohol
- Caffeine
- Illicit drugs: stimulants (e.g., cocaine), opioids (e.g., heroin), hallucinogens, inhalants, etc.
- Marijuana
- Prescription medication misuse
- Tobacco/nicotine
- Vaping
Many routes of administration to consider:
- Oral (e.g., drinking, swallowing pills)
- Smoking
- Intranasal inhalation (aka snorting, sniffing)
- Subcutaneous injection (aka skin popping)
- Intramuscular injection (aka muscling)
- Intravenous injection (aka shooting up)
substance slang
Amphetamines: Addys, Uppers, Beans, Black Beauties, Pep Pills, Speed, Dexies, Zing, Study Buddies, Smart Pills
Cocaine: Coke, Blow, Rock, Crack, Yayo, Snow, Sniff, Sneeze, White, Nose Candy, Bernice, Toot, Line, Dust, Flake
Codeine: Captain Cody, Cody, Lean, Schoolboy, Sizzurp, Purple Drank. (With glutethimide: Doors & Fours, Loads, Pancakes and Syrup)
Fentanyl: Apache, China Girl, China White, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, Tango and Cash, TNT
Heroin: H, Smack, Dope, China White, Horse, Skag, Junk, Black Tar, Big H, Brown Sugar, Mud, Dragon, Boy, Mexican Brown, Thunder, Skunk
Marijuana: Weed, Pot, Hashish, Hash, Green, Bud, Grass, Trees, Reefer, Herb, Mary Jane, Ganja, Hemp, Dope, Chronic, Kush, Sinsemilla, Purple Haze, Skunk
Oxycodone: O.C., Oxycet, Oxycotton, Oxy, Hillbilly Heroin, Percs, O, Ox, Blue, 512s, Kickers, Killers
PCP: Angel Dust, Ozone, Rocket Fuel, Love Boat, Embalming Fluid, Hog, Superweed, Wack, Wet (a marijuana joint dipped in PCP)
Synthetic Marijuana: Spice, K2, K2 Drug, K3 Drug, Bliss, Black Mamba, Yucatan Fire, Skunk, Genie, Bombay Blue, Solar Flare, Zohai, Joker, Kush, Kronic
Unhealthy Alcohol Use…
Prevalence of unhealthy alcohol use:
- 28% of US adults
- 25% of people ≥12yo report “binge” alcohol use in the past month (5+
standard drinks for males, 4+ for females on one occasion) - A population survey in 2012-2013 found that 13% of adults in the US had alcohol use disorder in the last 12 months
- >85,000 deaths a year in the US are directly attributed to alcohol use; the annual economic cost of alcohol use is estimated to be over $250 billion
- ~1 in 10 deaths among working age adults results from excessive drinking
Risk factors:
- Male gender
- Age 18-29yo
- Significant disability
- Other substance use disorder
- Mood disorder (e.g., major depression, bipolar disorder)
- Personality disorder (e.g., borderline or antisocial personality disorder)
MANY negative health consequences:
- Trauma or injury
- Anxiety, depression, suicidality
- Comorbid SUDs
- HTN
- GI symptoms
- Cardiac symptoms
- Central/peripheral neurologic symptoms
- Electrolyte disturbance
- Sleep disturbance
- Increased liver enzymes, including GGT
- Bone marrow suppression
- Macrocytosis
- Malignancies of various organ systems (e.g., oropharynx, GI, breast)
- Social or legal problems
Why do general practitioners struggle to ask about alcohol use?
“General screening is not viewed by GPs as a suitable strategy regarding alcohol problems, yet they often feel responsible and intervene when encountering alcohol-related conditions”
Lid TG, Malterud K. General practitioners’ strategies to identify alcohol problems: a focus group study. Scand J Prim Health Care. 2012 Jun;30(2):64-9.
This study identified 7 main categories that either prevent or promote discussion about alcohol consumption:
- the sensitive nature of alcohol drinking
- the reason for consultation
- awareness of a patient’s alcohol problem
- patient factors
- availability of intervention tools
- expectations of effectiveness of interventions
- lack of time
“To overcome the sensitive nature of excessive alcohol drinking, which is one of the most important barriers, we propose changing the frame of reference of the concept of alcohol drinking from an addictive disease to a risky lifestyle habit in doctors’ training, patient information and media campaigns.”
Aira M, et al.
Screening for AUD
Multiple options:
- Single item alcohol screening questions
- Do you sometimes drink beer, wine or other alcoholic beverages?
- How many times in the past year have you had five (four for women) or more drinks in a day?
- Positive if >0
- AUDIT or AUDIT-C
- CAGE
- CRAFFT
Treatment of AUD
Mild alcohol use disorder:
- 1+ psychosocial interventions (rather than meds)
Moderate to severe alcohol use disorder:
- Medication + structured, evidence-based psychosocial interventions + social services + participation in mutual help group
Naltrexone
- Modifies the hypothalamic-pituitary-adrenal axis to suppress alcohol consumption
- Can be initiated while the individual is still drinking
- One pill once a day or monthly injection
Acamprosate
- Thought to restore balance to GABA and glutamate activities which appear disrupted in alcohol use disorder
- Need period of abstinence before starting
- 2 pills 3 times a day
Disulfiram
- Blocks oxidation of alcohol at the acetaldehyde stage; when taken concomitantly with alcohol, there is an increase in serum acetaldehyde levels, causing uncomfortable symptoms like flushing, throbbing, N/V
- Biologically leads to adverse effects when combined with alcohol intake; should only be used by abstinent patients with the goal of maintaining abstinence
Off-label therapies to consider in patients who either can’t tolerate first-line therapies or those who are not achieving treatment goals on first-line therapy: topiramate, baclofen, or gabapentin
Take-Home Points!
- SUDs involve a problematic pattern of use leading to clinically significant impairment or distress
- Unhealthy alcohol use = ≥5 drinks/day in men (or ≥14 drinks/wk) or ≥4 drinks/day in women (or ≥7 drinks/wk)
- Unhealthy alcohol use and AUD carry significant negative health consequences, yet we as practitioners do not do the best job of screening for unhealthy alcohol use, likely due to a variety of reasons
- It may be helpful to change framework to view alcohol use as a risky lifestyle habit instead of an addictive disease
- Screening tools: Single questions, AUDIT, AUDIT-C, CRAFFT, CAGE
- Treatment of alcohol use disorder: psychosocial intervention, group therapy, social work support, and medications (naltrexone, acamprosate, disulfiram)
Blog post based on Med-Peds Forum talk by Ann Ding, PGY3