Substance Use Disorders

BACKGROUND

Use and abuse of alcohol and narcotic substances have occurred throughout history. Advances in chemistry during the 19th and 20th centuries led to the formulation of more potent preparations as active ingredients were identified and then used to search for other agents. At one time, cocaine and opiates were widely prescribed and readily available, often being included in various elixirs and tonics. By 1914, an awareness of the potential for abuse led to federal regulation so that opiates and cocaine could only be prescribed by physicians. Similarly, the advent of Prohibition meant that alcohol was no longer freely available; as a result (until the repeal of Prohibition in 1933), there was an extensive black market in alcohol, as there now is in other substances (see Musto, 1999, for an historical review). With the creation of the U.S. Federal Bureau of Narcotics (now the Drug Enforcement Administration) in 1930, the federal government took a more active role in regulating substances with potential for abuse. Throughout the second half of the 20th century and to the present time, there have been major societal shifts in the acceptance and use of various substances—including marijuana, alcohol, and tobacco.

Pharmacologic advances have improved our understanding of brain processes and the mechanisms that may underlie substance abuse. Until recently, most of the research on substance abuse and substance dependence has come from work with adults. There has been less research on children and adolescents. Unsurprisingly, adolescents who abuse drugs or alcohol have high risk for developing dependence in adulthood (Hopfer et al., 2018).

DEFINITIONS

Drug addiction refers to a group of chronic and relapsing disorders that are characterized by compulsion to seek and take a drug, loss of control in limiting drug use, and experience of negative emotional states, such as dysphoria, anxiety, or irritability, when access to the drug is prevented (Koob & Volkow, 2016).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013) combined what was previously conceptualized as two separate disorders—substance abuse and substance dependence—into one category of substance use disorders. Substance use disorders are defined by the presence of cognitive, behavioral, and physiologic symptoms and indicate that a person continues to use a substance
despite experiencing significant problems. Substance use disorders are also classified by severity based on the number of symptoms endorsed and by course specifiers. The criteria for these diagnoses are described in Table 22.1.

The second category of substance-related and addictive disorders in the current edition of the DSM is substance-induced disorders. This category includes intoxication, withdrawal, and other disorders such as substance-induced depression or substance-induced psychotic disorder. Substances of potential abuse are divided into ten classes of known drugs: alcohol, caffeine, cannabis, stimulants, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedative-hypnotic, and other (or unknown) categories. As a practical matter, in children and adolescents, substance use disorders are more frequently encountered than substance-induced disorders that are characterized by withdrawal syndromes (Hopfer et al., 2018).

The various substances of abuse vary in both their physiologic effects and potential for addiction. A person’s individual factors (e.g., genetic risk for substance abuse) as well as route
of administration (e.g., intravenously), can all be important in determining how rapidly one may develop a substance dependency.

TABLE 22.1 Criteria for Substance Use Disorder, Intoxication, and Withdrawal

Substance Use Disorder: Two or more within a 12-month period

Impaired Control

1. Taken in larger amounts or over a longer period than intended

2. Persistent desire or unsuccessful effort to cut down or control use

3. Great deal of time spent to obtain, use, or recover from substance

4. Craving, or strong desire or urge to use

Social Impairment

1. Failure to fulfill major role obligations

2. Continued use despite social or interpersonal problems

3. Reduction in important social, occupational, or recreational activities

Risky Use

1. Recurrent use in physically hazardous situations

2. Continued use despite knowledge of physical or psychological problem

Pharmacologic Effect

1. Tolerance (need for increased amount or diminished effect)

2. Withdrawal (withdrawal syndrome or use to relieve/avoid withdrawal)

Intoxication

A. Recent ingestion

B. Problematic behavior or psychological changes

C. One or more sign or symptom attributable to the substance

D. Not attributable to another medical condition, mental disorder, or substance

Withdrawal

A. Cessation or reduction in heavy, prolonged use

B. Two or more signs or symptoms attributable to cessation or reduction in use

C. Clinically significant distress or impairment in important areas of functioning

D. Not attributable to another medical condition, mental disorder, or substance

Reprinted with permission from Hopfer, C., Hinckley, J. D., & Riggs, P. (2018). Substance use disorders. In A. Martin, M. H. Bloch, & F. R. Volkmar (Eds.), Lewis’s child and adolescent psychiatry: A comprehensive textbook (5th ed., p. 569). Wolters Kluwer.

Alcohol is often the first substance adolescents use and accounts for much of adolescent substance use and abuse (e.g., group drinking at parties). According to national surveys, about 6% of adolescents met criteria for alcohol abuse or dependence in the previous year. Acute alcohol intoxication is characterized by sedation, slurred speech, decreased heart rate, poor coordination, and reduced blood pressure. Repeated drinking can lead to tolerance and, occasionally, adolescents can even experience alcohol withdrawal states. As with adults, alcohol withdrawal may require emergency medical management. Severe alcohol intoxication can also be an emergent medical problem and can lead to death at high levels. Impaired judgment and coordination also contribute to accidental death and injuries.

Nicotine in tobacco products can lead to dependency and is associated with a number of medical problems. The effects of nicotine are prompt after inhalation or ingestion (e.g., from chewing) and include central nervous system (CNS) stimulation followed by symptoms of withdrawal. The mechanism of nicotine on acetylcholine receptors is well known. With a half-life of several hours, nicotine can accumulate in the body over the course of the day. Cessation of use can result in irritability, characteristic craving, and problems in mood and concentration. One of the major concerns about tobacco use is its potential for serving as an entry to use of other substances. Over the past two decades, there has been a considerable decline in adolescent cigarette smoking. The nationwide percentage of 12th-grade students who reported ever smoking a cigarette dropped dramatically from 65% to 24%. Rates dropped among younger students, as well, from 55% to 20% in 10th graders, and 41% to 9% in eighth graders (Miech et al., 2020). In contrast, nicotine vaping among U.S. adolescents has increased at a record pace from 2017 to 2019, prompting new national policies to reduce access to flavors of vaping products preferred by youth. Vaping has decreased since 2020 in response to decreased accessibility of vaping products and increased awareness of health risks. However, nicotine vaping remains highly prevalent in adolescents, with 40% lifetime prevalence rates in latest surveys (Miech et al., 2021).

Marijuana is the most frequently used illicit drug by adolescents, and marijuana dependence is the most frequently cited reason for adolescent admissions to substance abuse treatment. The mechanisms of the active ingredient Δ-9 tetrahydrocannabinol (THC) have been increasingly studied. This agent binds to the cannabinoid receptor (CNR1), which is widely distributed in the brain. Effects on anxiety, appetite, and pain are reported, as are analgesic effects and enhancement of appetite. Hallucinogenic effects can also be noted. Cannabis withdrawal syndrome, which is now recognized in DSM-5, consists of symptoms including irritability, anger, aggression, anxiety, sleep disturbance, restlessness, and depressed mood (Hasin, 2018).

Abuse of heroin and prescription opiates has increased over the past decade and has become a source of increasing national concern. The opioid epidemic has gained public awareness within the past two decades, with nonmedical prescription opioid use emerging as a national crisis and declared a public health emergency. A recent survey suggests that as many as 1 in 20 twelfth graders in high school reported using prescription opioids illicitly (Carmona et al., 2020). Frequent nonmedical opioid use is the most significant risk factor for heroin use (Compton et al., 2016). The price of heroin has decreased over the years, and the use of various routes of administration of purer heroin, including smoking and snorting, has likely contributed to this increase. Heroin has a very significant potential for addiction, and its use is associated with a range of problems impacting adolescents at home and in school.

Cocaine has various psychological effects, including a sense of mental clarity and lack of fatigue. Physical effects include increased heart rate, temperature, and blood pressure, as well as dilated pupils. The route of administration leads to major differences in the duration of cocaine’s effects (e.g., smoking leads to a more intense but shorter high than snorting). About 6% of users become dependent within 1 year (Hopfer et al., 2018).

Amphetamines have a long history of legitimate use in medicine, including in the treatment of attention-deficit disorders. Various street names for methamphetamine include ice, speed, crystal, glass, and crank. This agent can be used in a host of ways, including injection, inhalation,
and smoking. Similar to cocaine, dependence can develop quickly and is associated with a rapid decline in functioning. Associated effects can include psychotic behavior, aggression, and various neuropsychological deficits, such as memory loss. Appetite suppression is common, as is decreased need for sleep. Euphoria is often noted. Physical effects include hyperthermia, increased respiration, and increased risk for seizures.

MDMA (3,4-methylenedioxymethamphetamine) (“Ecstasy”) is another frequently abused agent with both stimulant and psychedelic effects. Taken orally, the psychedelic effects of the agent last for several hours. Mental status changes can include anxiety, paranoia, depression, and sleeplessness. Physical symptoms can include blurred version, a sense of muscle/body tension, nausea, and sweating; occasionally, severe hyperthermia develops. Available data suggest that most users stop use of the agent in young adulthood, although some who become dependent continue.

GHB (γ-hydroxybutyrate), known colloquially as G, grievous bodily harm, or liquid Ecstasy, was originally used as a muscle growth agent and sold in health food stores before its effects on the CNS were recognized. A CNS depressant, many of the effects of GHB are similar to those of alcohol. Effects last for several hours. Dependence can develop along with a withdrawal syndrome similar to that sometimes seen with benzodiazepines. About 2% of high school seniors report use of this agent in the previous year (Hopfer et al., 2018).

Approximately 5% of U.S. high school students report having tried inhalants at least once in the past year; however, rates of inhalant abuse or dependence are much lower, as only 0.1% of adolescents report abuse or dependence on inhalants (Hopfer et al., 2018). Inhalants are volatile organic compounds that include many gases and fumes that are deliberately taken in order to achieve intoxication. These organic fumes and gases are more frequently abused by younger adolescents probably because of greater accessibility. These compounds can be sprayed into the mouth or inhaled either through putting the material into a cloth and inhaling it (“huffed”) or via a bag (“bagged”). Psychological effects include euphoria and disorientation. A period of drowsiness or confusion may follow. A variety of materials are inhaled. They have the potential for causing relatively rapid neurologic features and changes in cognition. Their continued use can lead to neurotoxicity, making detection and treatment important public health problems.

Approximately 0.6% to 2.0% of male U.S. high school students report having used anabolic steroids within the past year, down by approximately half among younger adolescents over the past decade (Hopfer et al., 2018). The main goal of steroid use is building muscle mass, so intrinsically, abuse of these agents differs from that of other substances in which the desired effect is psychological. There are many different medical sequelae, including stopping growth prematurely and testicular shrinkage, and psychological problems that can include pronounced mood swings and even psychosis.

EPIDEMIOLOGY AND DEMOGRAPHICS

There have been major changes in adolescent drug use over the past decade in the United States. As noted in Table 22.1, there have been some fluctuations in patterns of substance abuse, although the most consistently used substances in adolescents have included alcohol, tobacco, and marijuana. About one-third of high school seniors report use of some illegal substance (apart from marijuana) at some point in their lives. Variations in patterns of substance abuse are noteworthy but not always well understood. There has been a noteworthy decrease in smoking in adolescents during the past two decades. Despite substantial long-term declines in alcohol use, there has been some increase in the prevalence of binge drinking over the past 2 years (2019-2020). By the end of high school, nearly two out of three students (61.5%) have consumed alcohol, and a quarter of students (26%) had done so by the eighth grade (Johnston et al., 2021).

Age-related data from publicly funded substance abuse treatment programs are also presented in Table 22.2. For younger adolescents, marijuana is most frequently cited as the primary substance of abuse, but for the oldest adolescents and young adults, marijuana combined with alcohol continues to be a major problem along with a variety of other substances.

TABLE 22.2 Primary Admitting Substance of Abuse (% of Total Admissions), by Age, from the Treatment Episode Data Set

Substance	Age 12-14 (%)	Age 15-17 (%)	Age 18-19 (%)	Age 20-24 (%)
Other/none	5.9	2.7	2.5	1.9
Alcohol only	6.9	4.3	9.0	11.1
Alcohol + secondary drug	6.4	8.3	11.7	12.3
Opioids, heroin	0.3	2.0	15.3	25.9
Opioids, other	0.8	1.7	6.9	12.1
Cocaine, smoked	0.2	0.2	0.6	1.0
Cocaine, other route	0.2	0.4	0.9	1.3
Marijuana	77.0	75.5	44.2	24.4
Methamphetamine/amphetamine	1.4	3.7	7.1	8.3
Tranquilizers	0.3	0.5	1.0	1.0
Sedatives	0.1	0.1	0.2	0.1
Hallucinogens	0.2	0.4	0.5	0.2
Phencyclidine	<0.05	<0.05	0.1	0.2
Inhalants	0.4	0.1	0.1	0.1
Total percent	100	100	100	100
(Total, N)	(17,842)	(83,823)	(54,509)	(244,893)
From TEDS. (2005). Treatment episode data set: 2003 highlights. National Admissions to Substance Abuse Treatment Services. DASIS Series: S-27. DHHS Publication No. SMA 05-4043. Department of Health and Human Services, with permission. https://wwwdasis.samhsa.gov/dasis2/teds_pubs/2003_teds_highlights_rpt.pdf