Substance Use Disorders

These substances all directly activate the brain reward system and produce feelings of pleasure. The activation may be so intense that patients intensely crave the substance and neglect normal activities to obtain and use it. These substances also have direct physiologic effects, including

The specific manifestations and treatment of intoxication and withdrawal vary by the substance or substance class and are discussed elsewhere in THE MANUAL.

Substance-induced psychiatric disorders are psychiatric changes produced by substance use or withdrawal that resemble independent psychiatric disorders (eg, depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , psychosis Introduction to Schizophrenia and Related Disorders Schizophrenia and related psychotic disorders— brief psychotic disorder, delusional disorder, schizoaffective disorder, schizophreniform disorder, and schizotypal personality disorder—are characterized... read more , anxiety Overview of Anxiety Disorders Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more , or neurocognitive disorders).

For a psychiatric disorder to be considered substance-induced, the substance involved must be known to be capable of causing the disorder. Substances can be members of the 10 classes of drug that typically cause substance-related disorders Overview of Substance Use Substance-related disorders involve substances that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific characteristics... read more or many others (eg, anticholinergics and corticosteroids may cause temporary psychotic syndromes). In addition, the psychiatric disorder should

* Certain neurocognitive disorders caused by alcohol, inhalants, or sedative-hypnotics and perceptual disorders caused by hallucinogens may be long-lasting.

People with a substance use disorder usually progress from experimentation to occasional use and then to heavy use and sometimes a substance use disorder. This progression is complex and only partially understood. The process depends on interaction between the drug, user, and setting.

Diagnosis of substance use disorder is based on identifying a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM5-TR) gives 11 criteria divided into 4 categories. Individuals meeting 2 or more of these criteria within a 12-month period are considered to have a substance use disorder.

Impaired control over use

Social impairment

Risky use

Pharmacologic symptoms

Note that some drugs, particularly opioids Opioid Use Disorder and Rehabilitation “Opioid” is a term for a number of natural substances (originally derived from the opium poppy) and their semisynthetic and synthetic analogs that bind to specific opioid receptors. Opioids... read more , sedative/hypnotics Sedatives Sedatives include benzodiazepines, barbiturates, and related drugs. High doses can cause decreased level of consciousness and respiratory depression, which may require intubation and mechanical... read more , and stimulants Amphetamines Amphetamines are sympathomimetic drugs with central nervous system stimulant and euphoriant properties whose toxic adverse effects include delirium, hypertension, seizures, and hyperthermia... read more , can result in tolerance and/or withdrawal symptoms even when taken as prescribed for legitimate medical reasons and for relatively brief periods (< 1 week for opioids). Withdrawal symptoms that develop following such appropriate medical use do not count as criteria for diagnosis of a substance use disorder.

The severity of the substance use disorder is determined by the number of symptoms:

Treating substance use disorder is challenging and includes one or more of the following:

Different treatment phases may be managed with drugs and/or counseling and support. Specific measures and issues are discussed under the specific substance elsewhere in THE MANUAL, including Alcohol Use Disorders Alcohol Use Disorder and Rehabilitation Alcohol use disorder involves a pattern of alcohol use that typically includes craving and manifestations of tolerance and/or withdrawal along with adverse psychosocial consequences. Alcoholism... read more and Opioid Use Disorder Opioid Use Disorder and Rehabilitation “Opioid” is a term for a number of natural substances (originally derived from the opium poppy) and their semisynthetic and synthetic analogs that bind to specific opioid receptors. Opioids... read more .

With increasing evidence and greater understanding of the biologic processes underlying compulsive drug-taking, substance use disorders have become much more firmly established as medical illnesses. As such, these illnesses are amenable to various forms of treatment, including support groups (Alcoholics Anonymous and other Twelve Step programs); psychotherapy (eg, motivational enhancement therapy, cognitive-behavioral therapy, relapse prevention); and medications, ranging from agonist therapy (eg, nicotine replacement therapy for tobacco use disorder, methadone and buprenorphine for opioid use disorder) to novel approaches currently under investigation. Focus on accurate identification of patients with substance use disorders and referral for specialty treatment will help greatly in reducing individual consequences as well as societal impact.