is Characterized by the Continued Desire or Craving for a Substance

Summary

Substance-related disorders are a class of psychiatric disorders characterized by a craving for, the development of tolerance to, and difficulties in controlling the use of a particular substance or set of substances. There are two groups of substance-related disorders: substance-induced disorders and substance use disorders (SUDs). Substance-induced disorders include intoxication, withdrawal, and substance-induced mental disorders. SUDs (e.g., opioid use disorder and alcohol use disorder) have unique features but are all characterized by cognitive and behavioral changes and physical symptoms related to the continued use of one or more substances despite negative consequences. The addictive potential of these substances results from how they act on the brain's reward system and affect emotion, mood, and perception, often inducing a euphoric state colloquially referred to as a "high." Individuals with SUD may participate in high-risk or illegal behaviors (e.g., exchanging sex for drugs, unsafe needle practice, erratic or aggressive behavior, theft), either as a result of substance use or in pursuit of substances, which can lead to social isolation, housing instability, and worsening of mental illness (e.g., comorbid bipolar disorder, major depressive disorder, or anxiety disorder). Treatment for SUD involves counseling (e.g., motivational interviewing), psychotherapy, and/or pharmacotherapy.

Definition

Substance use disorder ^[1] ^[2] ^[3]

Description: a chronic condition in which an uncontrolled pattern of substance use leads to significant physical, psychological, and social impairment or distress, with continued use despite substance-related problems.
Epidemiology
- Sex: ♂ > ♀
- Alcohol and nicotine use are most common.
Characteristics: features that are typical for all substance use disorders ( ≥ 2 features must occur within 1 year to fulfill the DSM-V criteria)
- Impaired control
  - Using a substance in l arger amounts and/or for a longer time than originally intended
  - Repeated failed attempts to cut down on use
  - A great deal of time spent on substance-related activities (e.g., seeking out, buying, using, recovering from use)
  - Intense desire to obtain and use substance ( craving )
- Social impairment
  - Problems fulfilling work , school , family , or social obligations (e.g., not attending work or school, neglecting children or partner)
  - Problems with interpersonal relationships directly related to substance use (withdrawal from relationships, marital issues)
  - Reduced social, occupational, and recreational activities (e.g., less time socializing with friends, neglecting hobbies)
- Risky use
  - Use in physically hazardous situations ; ( e.g., driving a car under the influence, unprotected sex , operating heavy machinery)
  - Continued use despite awareness of problems related to or exacerbated by substance use (e.g., continued alcohol use despite having cirrhosis)
- Pharmacologic indicators
  - Drug tolerance : t he need to continuously increase the dose of a substance to achieve the same desired effect
  - Drug withdrawal : a substance-dependent collection of symptoms that appear after cessation of prolonged heavy drug use accompanied by a strong urge to readminister the substance
Exception: patients undergoing supervised treatment with certain psychoactive substances (e.g., stimulants, cocaine, opioids, nitrous oxide, sedative-hypnotic drugs, anxiolytic drugs, cannabis) ^[4]

Withdrawal from some substances, such as alcohol, benzodiazepines, and barbiturates, can be fatal!

Related definitions

Abuse
- In the context of substance use, the term "abuse" should generally be avoided due to its impreciseness and the historical burden of stigma.
- "Substance use" is generally the preferred term in this context, with "substance misuse" being appropriate in the context of prescription drugs.
Drug-seeking behavior
- A maladaptive behavioral response to substance addiction that involves manipulative and/or demanding behaviors to obtain the desired substance
- Often indicative of an underlying substance use disorder
- Examples of drug-seeking behavior
Medication-assisted treatment (MAT): treatment for substance use disorder that combines counseling with pharmacological and behavioral therapy, tailored to each patient's needs. ^[5]

Classification

Overview

Overview of substance intoxication and withdrawal ^[6]
Intoxication							Withdrawal
Substance		Pupils	Cardiovascular system	Concomitant symptoms			Withdrawal
Depressants
Alcohol		Slowed pupil reaction	Hypotension Tachycardia	Disinhibition Nausea and vomiting Dysarthria, ataxia, nystagmus Emotional lability Blackouts Stupor or coma			Autonomic symptoms (e.g., palpitations, sweating , ↑ blood pressure ) Anxiety, insomnia Nausea, vomiting Alcohol withdrawal seizures Alcohol withdrawal delirium See "Alcohol withdrawal" for details.
Opioids		Miosis (pinpoint pupils)	Hypotension Bradycardia	Respiratory depression (barbiturates > benzodiazepines) Sedation Coma (severe intoxication)	CNS depression Euphoria Seizures Absent gag reflex		Flu-like symptoms (e.g., chills, myalgia, piloerection ) Gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea ) Sympathetic hyperactivity (e.g., mydriasis, tachycardia ) CNS stimulation (e.g., insomnia, anxiety, agitation ) See "Opioid withdrawal" for details.
Barbiturates		Miosis (pinpoint pupils)			Hypothermia		Delirium Severe hypotension, possibly cardiovascular collapse
Benzodiazepines		Normal (mild intoxication) Mydriasis (severe intoxication)			Hyporeflexia Ataxia Slurred speech Elderly individuals: ↑ risk of paradoxical reaction to benzodiazepines See "Benzodiazepine overdose" for details.		Autonomic symptoms (e.g., sweating, hypertension) Gastrointestinal symptoms (e.g., nausea, vomiting) Neurological symptoms (e.g., seizures, tremors ) Psychiatric symptoms (e.g., depressive moods, insomnia )	See "Benzodiazepine dependence" for details.
Inhalants		Normal (mild intoxication) Mydriasis (severe intoxication)	Hypertension or hypotension Tachycardia	Nystagmus, tremor, areflexia Slurred speech Euphoria, disinhibition				Severe hallucinations, delusions
Stimulants
Amphetamines		Mydriasis	Tachycardia Hypertension, arrhythmias (especially cocaine)	Euphoria, l oss of inhibition Arousal, ↑ vigilance, impaired judgment Severe agitation, sleep disorders, prolonged wakefulness, hyperalertness Hallucinations, delusions, paranoia, psychosis Hyperthermia, sweating Seizures	Grandiosity Bruxism ↑ Energy and concentration, ↓ sleep Delusional parasitosis	↓ Appetite, weight loss ↑ Libido	Physiologic crash after use due to receptor downregulation characterized by: Dysphoria, anhedonia, anxiety ↓ Energy, depression with suicidal thoughts ↑ Appetite Sleep disturbance, agitation
Cocaine						Angina, sudden cardiac death Nasal septum perforation Tactile, acoustic, and optic hallucinations
Synthetic cathinones					Aggression, confusion Muscle spasms		Anxiety, insomnia, depression, tremor
Caffeine			Hypertension followed by hypotension Tachycardia , cardiac arrhythmias	Psychomotor agitation, excitement, insomnia, tremor Incoherent speech and/or chaotic flow of thoughts Flushed face			Depressed mood, irritability Drowsiness, fatigue Difficulty concentrating Flu-like symptoms, muscle pain
Nicotine		Normal or mydriasis	Hypertension and tachycardia (mild intoxication) Hypotension, bradycardia, arrhythmias (severe intoxication)	Euphoria Restlessness, anxiety, insomnia ↑ Gastrointestinal motility, weight loss			Frustration, anger Restlessness, anxiety, insomnia Dysphoria, depressed mood Impaired concentration ↑ Appetite, weight gain
Hallucinogens
Cannabinoids		Mydriasis	Hypertension Tachycardia, arrhythmias	Perceptual changes (e.g., distorted sense of time) Euphoria, joviality Paranoid delusions, psychosis, hallucinations Agitation, anxiety, panic Impaired judgment	Conjunctival injection (red eyes) ↑ Appetite, dry mouth Impaired reaction time, concentration, and motor coordination Social detachment		Irritability, anxiety, depression ↓ Appetite, anorexia Restlessness, sleep disturbances
Lysergic acid diethylamide (LSD)					Flashbacks (rarely unsettling)		None
MDMA					Bruxism Severe agitation Hyponatremia Hyperthermia, diaphoresis Severe intoxication: serotonin syndrome		Changes in sleep and appetite Difficulty concentrating Fatigue, depression, anxiety
Phencyclidine (PCP)		Miosis		Behavioral changes ( violence, belligerence, psychomotor agitation ) Horizontal or vertical nystagmus; ataxia, dysarthria Muscle rigidity Hyperthermia			Seizures Agitation, hallucinations, depression Cognitive problems Muscle twitching, myopathy
Gamma-hydroxybutyric acid (GHB)	Low dose	Miosis or mydriasis ^[7]	Hypotension, bradycardia Bradypnea	Intensification of sensory experience Enhanced empathy and libido Disinhibition			Diaphoresis, agitation CNS stimulation (e.g., irritability, insomnia, psychosis ) Autonomic instability: tachycardia, hypertension Tremor, ↑ muscle tone Death
	High dose		Hypotension, bradycardia Bradypnea	Lightheadedness and loss of consciousness Agitation, emergence delirium, self-injurious behavior, tics
	Overdose		Respiratory arrest	Coma, seizures Ataxia, sudden loss of motor control

Toxidromes

Management of substance use disorder

SUD screening ^[8]

Indications

Tobacco use: all adults and pregnant individuals ^[9]
Unhealthy alcohol use: adults in primary care settings ^[10]
Unhealthy drug use: adults, if treatment can be offered ^[11]

Validated screening tools

Alcohol use disorders identification test-concise (AUDIT-C) ^[10]
Single alcohol screening question (SASQ) ^[10]
Tobacco, alcohol, prescription medication, and other substance use tool (TAPS) ^[11]
National Institute on Drug Abuse (NIDA) quick screen ^[11]

The harms of screening for unhealthy drug use outweigh the benefits when treatment cannot be provided or when findings may result in punitive actions (e.g., some US state laws penalize pregnant individuals who use substances or seek addiction treatment). ^[11]

SUD assessment ^[5]

Indications
- Positive SUD screening
- History of SUD
- Classic toxidrome or findings that suggest drug intoxication or withdrawal, e.g.:
  - Altered mental status, acute agitation
  - Acute cardiopulmonary symptoms
  - Needle or track marks
- Prior to initiating a long-term opioid or benzodiazepine prescription
Components
- Reasons, amount, frequency, route, and duration of substance use
- Impact on overall well-being
- Prior experiences with treatment for SUD
- Current level of interest in treatment
Further evaluation
- Screen all patients for coexisting disorders (e.g., intimate partner violence, mood disorders, anxiety).
- Consider drug testing if results will impact management.

The screening, brief intervention, and referral to treatment (SBIRT) model may be used to identify and assess SUD in any care setting. ^[5]

Drug testing ^[12] ^[13]

Definition: the testing of biological samples for the presence of drugs and drug metabolites
Urine drug test
- Used to evaluate for metabolites of common drugs and/or illicit substances
- Can be performed using enzyme multiplied immunoassay or mass spectrometry
Blood/serum drug test: used to assess intoxication or impairment in emergency situations
Laboratory methods
- Immunoassays: rapid presumptive results for many substances (e.g., point-of-care urine drug tests)
- Mass spectrometry: definitive results

Urine drug test immunoassays can generate false-positive and false-negative results because of cross-reactivity with other medications (e.g., rifampin with opioid assays, sertraline with benzodiazepines, metformin with amphetamines). ^[12]

Always confirm qualitative point-of-care drug test results (i.e., with mass spectrometry) when the results might have legal, financial, or employment implications.

Management

Treatment options depend on the respective substance being used (e.g., "Management of alcohol withdrawal" and "Opioid withdrawal") and patient preferences.
Utilize person-centered language, motivational interviewing, and harm reduction strategies. ^[14]
Manage withdrawal, if present.

Disposition ^[15] ^[16]

The most appropriate treatment setting may change over time and is influenced by: ^[17]

The presence and severity of withdrawal symptoms and/or comorbid conditions
Patient preference and social history
- Current circumstances
- Social support
Need for medication oversight (e.g., methadone)

Withdrawal management settings ^[15] ^[16]
Setting	Indications	Description
Hospital	Significant comorbidities, e.g.: Sepsis Co-ingestions Suicidality Heart failure Need for 24-hour respiratory and/or hemodynamic monitoring, e.g.: Severe withdrawal symptoms Clinically unstable High medication dosages	Inpatient treatment program Daily physician evaluations Addiction services
Residential	Severe withdrawal Need for 24-hour support Outpatient withdrawal treatment is neither safe nor feasible.	Inpatient treatment program Access to a physician Addiction services
Intensive outpatient	Patients with: Need for daily support Reliable means to access care (e.g., transportation) A supportive living environment	Outpatient programs in specialized centers High patient oversight Direct administration of medications (e.g., methadone)
Outpatient	Stable patients with: Less than daily support needs A secure living environment High general functioning	Home or clinic setting Lower patient oversight than intensive outpatient WM Physicians prescribe medications for outpatient use.

Forced treatment is not recommended as it is often followed by relapse and a loss of trust in treatment services and providers.

Alcohol-related disorders

Caffeine-related disorders

Substance: caffeine (usually ingested with coffee, tea, soda, or energy drinks) ^[6] ^[18]
Mechanism of action: adenosine antagonist → increased cAMP → neurological excitation and facilitated catecholamine release ^[18]
Epidemiology:
- Caffeine is the most widely consumed psychoactive substance in the world. ^[19]
- ∼ 7% of the US population expericence symptoms consistent with caffeine intoxication. ^[1]
Clinical features of intoxication
- To meet the DSM-V criteria for caffeine intoxication, individuals must exhibit at least five of the following symptoms shortly after caffeine intake. ^[1]
  - Psychomotor agitation
  - Excitement
  - Insomnia
  - Incoherent speech and/or chaotic flow of thoughts
  - Muscle twitching
  - Flushed face
  - Cardiac arrhythmias or tachycardia
  - Severe restlessness
  - Anxiety, nervousness
  - Inexhaustibility
  - Diuresis
  - Gastrointestinal disturbance
- The following features may be also present: ^[1] ^[18] ^[19]
  - Tremor
  - Light flashes
  - Tinnitus
  - Seizures
  - Headache
- Doses of about 10 g of caffeine can be lethal. ^[18]
Clinical features of withdrawal: The DSM-V requires at least three of the following symptoms to be present within 24 hours after abrupt reduction of caffeine intake to account for caffeine withdrawal ^[1]
- Caffeine withdrawal headache
- Depressed mood, irritability
- Drowsiness, fatigue
- Difficulty concentrating
- Flu-like symptoms , muscle pain
Related disorders
- Caffeine-induced anxiety disorder (see "Anxiety disorders")
- Caffeine-induced sleep disorders (see "Delayed sleep phase disorder")
Treatment ^[20] ^[21]
- Overdose: supportive therapy (e.g., beta-blockers for tachyarrhythmia)
- Withdrawal: Symptoms typically manifest within 24 hours after the last intake and resolve spontaneously within 10 days .

Cannabis-related disorders

Substance: cannabis
Street names: weed, grass, pot, ganja, skunk, spliff
Forms of preparation (most commonly smoked; vaporized; ingested orally via pill, capsules, oil, food)
- Marijuana: dried leaves and buds of the cannabis plant
- Hashish (hash): resin of the cannabis plant
- Medical marijuana (e.g., dronabinol)
  - Used to increase appetite and treat nausea/vomiting in terminally ill patients (e.g., those undergoing chemotherapy) and in patients with AIDS
  - Relieves pain in cancer patients
  - Reduces intraocular pressure in individuals with glaucoma
Mechanism of action: tetrahydrocannabinol (THC; main active component) interacts with cannabinoid receptors CB1 and CB2 → inhibition of adenylate cyclase
Clinical features of intoxication:
- DSM-V requires the following features to be present: ^[1]
  - Any of the following behavioral/mental disturbances must occur during or shortly after cannabis consumption
    - Euphoria
    - Perceptual disturbances (e.g., distorted sense of time)
    - Impaired reaction time , concentration, and motor coordination
    - Social detachment
    - Impaired judgment
    - Joviality, anxiety , panic
  - At least two of the following symptoms must be present within two hours after cannabis consumption:
    - Tachycardia
    - Conjunctival injection (red eyes) , mydriasis
    - Increased appetite
    - Dry mouth
- Additionally, the following features may be present ^[1] ^[22]
  - Paranoid delusions , hallucinations
  - Increased or decreased blood pressure
Clinical features of cannabis withdrawal : DSM-V requires ≥ 3 of the following features to occur within one week following cessation of prolonged cannabis use ^[1]
- Irritability , aggression
- Anxiety
- Depression
- ↓ Appetite and/or weight loss
- Restlessness
- Sleep disturbances
- Anorexia
- At least one of the following physical symptoms must also be present: headaches, tremors, abdominal pain, fever, chills, sweating.
Treatment:
- Intoxication: symptomatic treatment ^[23]
- Withdrawal: psychosocial support and interventions ^[24]
Complications ^[25]
- Cannabis; -induced psychosis with paranoia, delusional thoughts, and/or hallucinations
  - Possible association between regular use and the development of schizophrenic psychoses
  - Higher rates of other psychiatric disorders (including bipolar disorder, major depressive disorder, personality disorders, etc.)
- Cannabis-induced anxiety disorder
- Cannabis -induced sleep disorder
- Higher lifetime probability of other substance use disorders
- Cannabinoid hyperemesis syndrome ^[26]
- Cannabis use disorder : DSM-V requires ≥ 2 of the following features to occur within a 1-year period of cannabis use, accompanied by agitation and severe impairment of functioning
  - Using cannabis in larger amounts or over a longer period than intended
  - Persistent desire to cut down the amount of cannabis used or repeated unsuccessful efforts to stop using it
  - A large amount of time is spent using cannabis, trying to acquire it, or recovering from its effects
  - Strong craving to consume cannabis
  - Cannabis use has a negative impact on social and professional function (e.g., at work, school, or home)
  - Continued cannabis use despite social or interpersonal problems that are directly caused or exacerbated by its use
  - Loss of interest in activities that were important to user prior to regular cannabis use
  - Recurrent use of cannabis in situations in which its use is associated with the risk of physical harm (e.g., driving a car)
  - Continued cannabis use despite persistent or recurrent psychological or physical problems that can most likely be attributed directly to the use of cannabis
  - Tolerance, which can manifest as:
    - The need to markedly increase the amount of cannabis to achieve the desired effect/intoxication
      and/or
    - A reduced effect over time when the same amount of cannabis is used
  - Withdrawal, which can manifest in the form of:
    - Clinical features of cannabis withdrawal (see above)
      and/or
    - Substance use to alleviate or avoid withdrawal symptoms
- Long-term effects include pulmonary problems (e.g., wheezing, shortness of breath), immunosuppression, and sex hormone imbalance.

DroNABINOl is an example of medical canNABINOids.

Osmosis: Cannabis Use Disorder - causes, symptoms, diagnosis, treatment, pathology

Hallucinogen-related disorders

Because hallucinogens are not typically associated with symptoms of withdrawal , the information about the clinical features provided below pertains specifically to the issues associated with intoxication with the corresponding substances.

Phencyclidine use disorder

Substances
- Primary drug: Phencyclidine (PCP); the liquid form is often sprayed on tobacco or cannabis and smoked.
- Related drugs: ketamine, dextromethorphan, dizocilpine
Street names: angel dust, peace pill, elephant tranquilizer, hog ^[28]
Mechanism of action ^[28]
- Inhibits dopamine , serotonin , and norepinephrine reuptake
- Antagonizes NMDA receptors → stimulant or depressive neurological effects (dose dependent)
- Binds to the sigma receptor complex
Clinical features
- Phencyclidine use disorder
  - Signs of injury, e.g., due to fights, accidents
  - Memory and speech deficits
  - Cognitive impairment
- Intoxication: The DSM-V requires the following features to be present to account for phencyclidine (or pharmacologically similar substance) intoxication ^[1] ^[29]
  - Behavioral changes ( violence, belligerence, psychomotor agitation, impulsiveness, impaired judgment ) must develop during or shortly after the use of phencyclidine or similar substance
  - At least 2 of the following signs should be present within an hour after the use of phencyclidine or similar substance
    - Hypertension , tachycardia , dysrhythmias
    - Horizontal or vertical nystagmus
    - Ataxia
    - Dysarthria
    - Muscle rigidity
    - Hyperacusis
    - Seizures or coma
    - Decreased sensation to pinprick (increased pain tolerance)
  - The following features may be also present ^[1] ^[30]
    - Miosis
    - Hyperthermia
    - Synesthesia
    - Confusion, disorientation
    - Delirium
    - Amnesia
Phencyclidine-induced mental disorders: psychosis ; ( e.g., hallucinations ), mania
Treatment of intoxication ^[28] ^[29]
- Reduction of environmental stimuli
- Gastric lavage to increase drug elimination
- Supportive care
- Sedation with benzodiazepines (for severe agitation) or haloperidol (if psychotic symptoms are present)
Complications
- Trauma (commonly accompanied by intracranial hemorrhage)
- Seizures
- Rhabdomyolysis
- Reabsorption of the drug in the gastrointestinal tract may lead recurrence of symptoms.

Other hallucinogen use disorder

General considerations

Clinical features: DSM-V requires the following features to be present during or shortly after the use of hallucinogens (other than phencyclidine) for the diagnosis of intoxication ^[1]
- Behavioral/mental (paranoid ideation, anxiety, depression, fear of "going crazy", impaired judgment)
- Perceptual (synesthesia, derealization, depersonalization, illusions)
- At least 2 of the following somatic symptoms
  - Tachycardia
  - Palpitations
  - Mydriasis
  - Diaphoresis
  - Tremor
  - Incoordination
  - Blurred vision
Complications
- Hallucinogen persisting perception disorder ( HPPD ; flashbacks ) ^[31]
  - Spontaneous recurrence of acute hallucinogen intoxication due to reabsorption of the intoxicating substance from bodily stores
  - Episodic or continuous symptoms ( optical hallucinations, depression, and panic ) that occur weeks after the initial intoxication
- MDMA: serotonin syndrome ^[32]
Treatment ^[6]
- Supportive care (e.g., antipsychotics for psychoses, benzodiazepines for anxiety, external cooling for hyperthermia )
- Reassurance
- MDMA -induced hyponatremia
  - Mild cases (asymptomatic): fluid restriction
  - Severe cases (with seizure, confusion, cerebral edema): 3% hypertonic saline

Tryptamine derivatives ^[6]

Substances : : lysergic acid diethylamide
Street names: LSD, acid
Mechanism of action: 5HT_2A-serotonin-receptor agonist (increased serotonin concentrations in the synaptic cleft → hallucinations )
Specific clinical features of intoxication
- Mental changes: marked anxiety and paranoia , psychosis
- Perceptual changes: depersonalization, visual and/or auditory perceptual distortion , and synesthesia are particularly noticeable
- Flashbacks (rarely unsettling)
- Mydriasis
Treatment of intoxication

Phenethylamine derivatives

Substances: MDMA , mescaline
Street names ^[6]
- MDMA : ecstasy , XTC
- Mescaline: mesc, buttons
Mechanism of action
- 5HT_2A-serotonin-receptor and D₂-receptor agonists and serotonin and dopamine reuptake inhibitors: increases serotonin and dopamine concentrations in the synaptic cleft → hallucinations ^[33]
- MDMA increases secretion of antidiuretic hormone → thirst → increased water intake without electrolyte repletion → hyponatremia ^[34] ^[35]
Specific clinical features of intoxication
- Grinding teet h ( bruxism )
- Hyponatremia with increased risk of seizures and life-threatening cerebral and pulmonary edema ^[35]
- Mental changes: euphoria and hyperactivity followed by severe agitation, anxiety, and paranoia
- Perceptive changes: distorted time and sensory perception, hallucinations
- Diaphoresis
- Cold extremities (due to peripheral vasoconstriction) ^[36]
- Tachycardia with arrhythmias , hypertensio n (can be life-threatening)
- Hyperthermia
- In severe MDMA intoxication: features of serotonin syndrome ^[32]
Clinical features of withdrawal: Although hallucinogens are generally not associated with withdrawal, the following withdrawal symptoms have been reported for MDMA. ^[37]
- Fatigue
- Difficulty concentrating
- Depression
- Changes in sleep and appetite
- Anxiety

Inhalant-related disorders

Substances: hydrocarbon-based inhalants (e.g., glue, paint thinners, fuel, nitrous oxide , alkyl nitrites) ^[1] ^[38]
Street names: poppers (alkyl nitrite); whippits (nitrous oxide)
Epidemiology: most prevalent in high-school-aged individuals ^[38]
Mechanism of action : : Inhalants generally work by depressing the CNS . ^[38]
Inhalant use disorder
Clinical features of inhalant intoxication ^[1] ^[38]
- Short duration of symptoms (rapid onset and resolution)
- Lingering odor of inhalant substance
- Slurred speech, headache, diplopia, agitation, hallucinations, gait disturbance, somnolence
- Euphoria, disinhibition, dizziness , confusion, lethargy, disorientation, drowsiness
- Nausea and vomiting
- Nystagmus , muscle weakness, tremor, hyporeflexia, ataxia
- Overdose: asphyxia, suffocation, seizure, coma, death (due to respiratory depression )
Clinical features of withdrawal: usually no withdrawal symptoms, but regular users may develop symptoms of CNS excitation (e.g., tachycardia, irritability, hallucinations, dysphoria, insomnia, headache)
Treatment ^[38]
- Supportive treatment , reassurance
- Intubation may be necessary
- Psychotherapy
Complications ^[38]
- Impaired cognition
- Peripheral neuropathy
- Malignancy
- Aplastic anemia
- Myocarditis and myocardial infarction
- Urinary calculi
- Glomerulonephritis

Opioid-related disorders

Substance: opiates (fentanyl, oxycodone, hydrocodone; heroin)
Street names: smack and dope (heroin)
Forms of preparation: illegal or prescription drugs for oral ingestion, injection, smoking, snorting
Mechanism of action
- κ-, δ-, and μ-receptor agonists (morphine, heroin, codeine, fentanyl)
- Mixed agonist/antagonist action (buprenorphine)
Epidemiology: about 70% of deaths due to pharmaceutical overdose involve opioids . ^[39]
Clinical features
- Opioid use disorder: chronic, uncontrolled opioid use with significant physiological and psychological symptoms and social impairment; often associated with a high level of tolerance and significant withdrawal symptoms on abrupt cessation
- See opioid intoxication .
- See opioid withdrawal .
- Opioid-induced disorders: commonly occur in patients with opioid use disorder
  - Depressive disorder, anxiety disorder, sleep disorder, sexual dysfunction, delirium
- Opioid-induced neurotoxicity
  - A syndrome characterized by acute delirium, myoclonus, hallucinations, and hyperalgesia in individuals with a history of chronic morphine, hydromorphone, or hydrocodone use
  - It is believed to result from the accumulation of active metabolites of these opioids over time.
Treatment of opioid use disorder
- Opioid maintenance therapy : long-term pharmacotherapy involves substituting addictive opioids ; , (e.g., heroin ) with a less euphoria-inducing but l onger-acting opioid (e.g., methadone , buprenorphine ).
- Pharmacological treatment should be administered along with psychosocial treatment (e.g., cognitive behavioral therapy).
- Treat associated comorbidities of IV opioid addiction (e.g., HIV , hepatitis C , endocarditis ).

Overdose with opioid analgesics is the most common cause of death in adults < 50 years of age .

Osmosis: Opioid dependence & opioid use disorder

References:^[39] ^[40]

Sedative, hypnotic, and anxiolytic related disorders

Stimulant-related disorders

Definition: stimulant-related disorders encompass conditions caused by cocaine, amphetamines, amphetamine substituted substances, and synthetic cathinones.
Clinical features of stimulant intoxication: DSM-V requires the following features to be present during or shortly after for the use of a stimulant for the diagnosis of the corresponding intoxication. ^[1]
Clinical features of stimulant withdrawal: At least 2 of the following symptoms should be present within hours to days after stimulant cessation to fulfill the criteria for stimulant withdrawal. ^[1]
Diagnosis
- Urine drug screen is the best initial test to evaluate for potential cocaine and/or amphetamine intoxication or overdose.
- Synthetic cathinones cannot be detected with routine urine toxicology screening.

Cocaine

Substances: cocaine, crack cocaine (free base form of cocaine)
Street names: coke, blow
Forms of preparation: powder or rocks that are insufflated, smoked, or injected intravenously.
Mechanism of action ^[41]
- Inhibition of dopamine , serotonin , and norepinephrine uptake → increased dopamine in the synaptic cleft of the endogenous reward system
- Inhibition of Na⁺channels causes local anesthetic action by blocking nerve action potential transmission.
Clinical features
- Snorting can cause damage to the nasal vessels and result in nosebleeds .
- Local vasoconstriction may cause ischemic necrosis, resulting in a perforated nasal septum .
- Cocaine intoxication ^[42]
  - Euphoria , arousal , increased vigilance, impaired judgment, alertness, grandiosity
  - Anxiety, irritability, mood swings, psychotic symptoms (e.g., paranoia,hallucinations)
  - Sweating, tachycardia , hypertension , chest pain / angina
  - Mydriasis
  - Tachyarrhythmia
  - Can result in sudden cardiac death
  - Paranoia , tactile, acoustic, and optic hallucinations
  - Malignant hyperthermia
- Cocaine withdrawal ^[41]
  - Depression, fatigue, lethargy, sleep disturbance, difficulty concentrating, anhedonia, increased appetite, vivid dreams
  - Physiologic crash: severe depression with suicidal ideation, constricted pupils, psychomotor agitation
Treatment
- Intoxication ^[41] ^[42]
  - Benzodiazepines
  - Control hypertension, tachycardia , and arrhythmias with n onselective alpha/beta antagonists such as labetalol (use of selective beta-adrenergic blockers remains controversial because of the possibility of unopposed α-stimulation) ^[43]
- Withdrawal: supportive care (withdrawal usually resolves within 72 hours ; may last ∼ 2 weeks with heavy use)
- Cocaine use disorder: psychotherapy , group programs
Complications
- Cocaine -induced vasospasm ^[44]
  - Decreased reuptake of norepinephrine → increased α- and β₁‑stimulation → vasoconstriction and vasospasm → myocardial infarction , cerebrovascular accident , or ischemic colitis
  - Treatment
    - Same as STEMIs (percutaneous angioplasty or thrombolysis , aspirin , nitrates )
    - Calcium-channel blockers and α-blockers can reduce vasospasm .
- Rhabdomyolysis: seen in 20% of cocaine overdoses
  - Likely due to alterations in skeletal muscle in individuals who use cocaine chronically
  - Risk of acute renal tubular necrosis due to myoglobinuria

β-blockers can cause unopposed α- agonism , which worsens vasospasm!

Suspect cocaine use in individuals with weight loss, behavioral changes, and erythema of the turbinates and nasal septum.

Osmosis: Cocaine Dependence - causes, symptoms, diagnosis, treatment, pathology

References:^[45]

Amphetamines

Substance: amphetamines
- Classic drugs: dextroamphetamine, methamphetamine, methylphenidate; these substances can be synthesized illicitly from pseudoephedrine and ephedrine , which are available as over-the-counter cold medicines
- Substituted amphetamine drugs: MDMA, MDEA
Street names: speed (methylphenidate-like substances); uppers; crystal meth (methamphetamines); Molly (MDMA)
Mechanism of action : : increased release and inhibited reuptake of adrenaline , norepinephrine , serotonin , and dopamine → sympathetic stimulation and hallucinogenic effects ^[46]
Clinical features of intoxication
- Autonomic symptoms
  - Diaphoresis
  - H ypertension, t achycardia with arrhythmias
  - H yperthermia
  - I ncreased libido
  - Mydriasis
  - D ecreased appetite , weight loss
  - G rinding teeth (can lead to broken teeth ) , itching (can lead to excoriations)
- Neuropsychiatric symptoms
  - Severe agitation , psychosis
  - Euphoria, paranoia
  - Sleep disorders, prolonged wakefulness, hyperalertness
  - Megalomania
  - Disorganized thinking, delusional parasitosis (the delusion that the body is infested with parasites or bugs)
  - Seizures
- Amphetamine overdose: See "Serotonin syndrome" for details.
Clinical features of amphetamine withdrawal ^[47]
- Clinical features are similar to those of cocaine withdrawal
- Physiologic crash after use due to receptor downregulation characterized by
  - Dysphoria
  - Anhedonia
  - Anxiety
  - Decreased energy, depression with suicidal thoughts
  - Increased appetite
  - Sleep disturbance
  - Agitation
Treatment ^[47]
- Similar to that for cocaine
- Acute toxicity
  - Fluid therapy
  - Control hyperthermia , hypertension , and arrhythmias .
  - Benzodiazepines ; (e.g., lorazepam ) to treat seizures and agitation (haloperidol for severe agitation)
- Withdrawal: supportive care
- Use disorder: psychotherapy and support programs
Complications
- Memory impairment (especially with chronic MDMA use)
- Risk of ongoing anxiety, mood disorders, or psychosis

References:^[35] ^[46] ^[47]

Synthetic cathinones

Substances: methylenedioxypyrovalerone (MDPV), mephedrone, methylone ^[48]
- A synthetic analog of naturally-occurring cathinones (a monoamine alkaloid derived from the khat plant)
- Chemically similar to amphetamines
Street names: bath salts , bloom, vanilla sky ^[48]
Mechanism of action : : increased release and decreased reuptake of monoamines ( norepinephrine , dopamine , serotonin ) → sympathetic stimulation and hallucinogenic effects ^[48]
Clinical features ^[49]
- Intoxication (prolonged effect lasting for days or even weeks)
  - Hallucinations, delusions, paranoia
  - Hyperthermia
  - Hypertension
  - Diaphoresis
  - Mydriasis
  - Aggression, confusion
  - Muscle spasms
  - Seizures
- Withdrawal: anxiety, insomnia, depression, tremor
Diagnosis : : based on history and clinical features; synthetic cathinones cannot be detected with routine urine toxicology screening
Treatment ^[49]
Complications ^[49]
- Acute renal failure
- Myocardial infarction
- Rhabdomyolysis

Tobacco-related disorders

Substance: nicotine from the tobacco plant (consumed in cigarettes, cigars, pipes, e-cigarettes)
Mechanism of action: stimulates nicotinic receptors in autonomic ganglia → sympathetic and parasympathetic stimulation ^[50]
Epidemiology ^[51]
- Approx. 13% of adults in the US smoke cigarettes
- Most prevalent cause of preventable morbidity and mortality in the US
Clinical features
- Tobacco intoxication ^[50]
  - Euphoria
  - Tachycardia, mild hypertension, weight loss
  - Restlessness, anxiety
  - Increased gastrointestinal motility
  - Insomnia
- Withdrawal ^[1] ^[50] ^[52]
  - Ir r itability, frustration, anger, restlessness, anxiety
  - Dysphoria, depressed mood
  - Insomnia
  - Impaired concentration
  - Increased appetite, weight gain
Assessment: Smoking history is measured in pack years, which is used to quantify a person's lifetime exposure to tobacco.
- The number of cigarette packs (20 cigarettes) that a person smokes per day multiplied by the number of years of cigarette consumption, e.g., (1 pack/day) x (10 years smoking history) = 10 pack years.
Treatment ^[50] ^[52]
- Counseling and support
- Varenicline ( alpha-4-beta-2 nACHR partial agonist ): reduces positive symptoms and prevents withdrawal
- Bupropion: reduces craving and withdrawal symptoms
- Nicotine replacement therapy ; (inhaler, lozenges ; , transdermal patch ; , nasal spray, gum )
Complications ^[50] ^[52]
- Relapse
- Chronic obstructive pulmonary disease
- Cardiovascular disease
- Cancer (e.g., lung cancer )
- See substance use during pregnancy .

Osmosis: Tobacco Dependence - causes, symptoms, diagnosis, treatment, pathology

Gambling disorder

Definition: Gambling disorder is a disorder in which the affected individual feels the compulsion to gamble despite negative consequences and/or multiple attempts to stop. Also, the gambling behavior cannot be better explained by a manic episode. ^[1]
Epidemiology ^[1] ^[53]
- Sex: ♂ > ♀
- No specific age group
Etiology: combination of factors (genetic, environmental, neurochemical abnormalities) ^[1] ^[53]
Diagnosis: ≥ 4 of the following in a 12 month period ^[1]
- Using increasing amounts of money to gamble
- Relying on others for financial support to maintain habit
- Restlessness or irritability when attempting to stop gambling
- Constant preoccupation with gambling
- Continuous gambling in an attempt to undo losses ("chasing one's losses")
- Jeopardizing relationships or careers as a result of gambling
- Numerous failed attempts to quit gambling
- Lying to others to conceal the extent of gambling
- Gambling when feeling helpless, guilty, anxious or depressed
Treatment ^[53] ^[54]
- Group therapy (Gamblers Anonymous)
- Cognitive behavioral therapy
- Treatment of underlying psychiatric conditions (e.g., bipolar disorder, substance use disorder, etc.)
- Approx. ⅓ patients recover without treatment.
- Pharmacotherapy (e.g., with serotonin reuptake inhibitors, opioid antagonists, topiramate) is still being researched.
Complications ^[1] ^[53]
- Often occurs in conjunction with other psychiatric disorders (antisocial personality disorder, depressive disorder, bipolar disorder, and substance use disorders)
- Associated with poor general health, including tachycardia and angina

Gamma-hydroxybutyric acid use

Substances: gamma-hydroxybutyric acid (GHB)
Street names: liquid ecstasy (unrelated to MDMA), liquid X, invigorate
Mechanism of action: direct agonist of GABA receptors (similar to benzodiazepines) ^[33]
Clinical features
- Intoxication ^[55]
  - Low doses: intensification of experience, enhanced empathy and libido, disinhibition
  - High doses
    - Lightheadedness and loss of consciousness ; ; may induce amnesia for the period of intoxication
    - Agitation, emergence delirium, self-injurious behavior , tics
    - Hypotension , bradycardia , bradypnea , hypothermia
    - Overdose: coma, seizures, ataxia, sudden loss of motor control, respiratory arrest
- GHB withdrawal ^[6] ^[56]
  - Similar to alcohol or benzodiazepine withdrawal
  - Diaphoresis, anxiety, agitation, confusion
  - CNS stimulation: irritability, insomnia, hallucinations, delirium, psychosis
  - Autonomic instability: tachycardia, hypertension
  - Gastrointestinal complaints: diarrhea, vomiting, abdominal pain
  - Tremor, increased muscle tone
  - Death
Diagnosis ^[6] ^[33]
- GHB is a substance that is normally present in the CNS of mammals, so screening cannot provide conclusive evidence of intake.
- Short half-life (20–45 minutes): Normal GHB-levels are reached after a few hours, making it impossible to establish the consumption of GHB.
Treatment
- Supportive
- Sedative agents (e.g., benzodiazepines)

GHB is sometimes used as an acquaintance rape drug because it is hard to detect and has amnestic effects and a rapid onset of action.

Bodypacker syndrome

Definition: toxicity and potential overdose from large amounts of substance entering the bloodstream after swallowed/inserted drug packets open inside the body (depends on the specific substance)

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