Substance Use Disorders—Stimulants and Opioids

Adrian Palomino MD

Martin Leamon MD

Shelly L. Henderson PhD

CLINICAL HIGHLIGHTS

Substance use disorders (SUDs) occur in all demographic groups and are common in outpatient settings. Clues from the history and physical exam alert the clinician to their presence.
A SUD is a chronic medical illness that requires a long-term treatment strategy. The primary care provider’s emphasis on longitudinal relationships and preventative care is ideally suited to the management of SUDs.
Substance users are at increased risk of developing human immunodeficiency virus (HIV), hepatitis B and C, and cardiovascular complications, as well as mood and anxiety disorders.
Multiple effective office-based interventions are available for the treatment and prevention of substance-related disorders.
It is critical to complete the AMPS screening tool on all patients who present with SUDs. Two to four weeks of sobriety may be needed to rule out a psychiatric disorder due to substance use. When making this determination, one might ask the patient, “When was the last time you used no alcohol or drugs for 1 month or longer, and how did you feel during this time period?”
Clinical management of alcohol-related disorders is distinct from the management of other substance disorders.

Clinical Significance

Substance-related disorders (SRDs) are divided into substance use disorders (SUDs) and substance-induced disorders (SIDs). SRDs are ubiquitous, costly, disabling, and potentially lethal. About 10% of Americans will abuse or become dependent on illicit substances such as stimulants (cocaine and methamphetamine) or opioids (heroin and opioid-based pain relievers) within their lifetime (1). In 2006, 4 million adult Americans met the criteria for a stimulant or opioid use disorder. No demographic group is immune: By 2050, SRDs in persons over the age of 65 are expected to double, while 44% of adolescents will have used illicit drugs by age 18. Primary care SRD prevalence estimates range between 10% and 20%. Underdiagnosis remains a common problem. One study found that only one half of clinicians routinely ask their patients about SRDs. Obstacles to clinical intervention include a lack of diagnostic confidence, lack of familiarity with treatment options, and pessimism regarding treatment outcome (2).

Diagnosis

SUDs include misuse, abuse, and dependence (3). Substance dependence is characterized by an overall loss of control over substance use (Table 6.1). Tolerance and withdrawal, reflecting physiologic dependence, are included in the definition, although neither is necessary to make the diagnosis (4). The hallmark of substance abuse is persistent use despite at least one profoundly negative interpersonal, legal, behavioral, or social consequence (Table 6.2). If the criteria for substance dependence have ever been met during the patient’s lifetime, the diagnosis of abuse is precluded. Substance misuse has the potential for or is associated with some negative consequences, but does not meet formal diagnostic criteria. Addiction is a term without a formal diagnostic definition that is
often used synonymously with dependence. The term substance abuse is also commonly used in a nondiagnostic fashion for problematic use in general.

Table 6.1 DSM-IV-TR Diagnostic Criteria for Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
	1.	Tolerance, as defined by either of the following:
		a.	A need for markedly increased amounts of the substance to achieve intoxication or desired effect
		b.	Markedly diminished effect with continued use of the same amount of the substance
	2.	Withdrawal, as manifested by either of the following:
		a.	The characteristic withdrawal syndrome for the substance
		b.	The same or closely related substance is taken to relieve or avoid withdrawal symptoms
	3.	The substance is often taken in larger amounts or over a longer period than was intended
	4.	There is a persistent desire or unsuccessful efforts to cut down or control substance use
	5.	A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
	6.	Important social, occupational, or recreational activities are given up or reduced because of substance use
	7.	Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
From American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. 4th ed., text revision Washington, DC: American Psychiatric Association; 2000.

Intoxication and withdrawal are common SIDs (Table 6.3). Intoxication is a reversible syndrome caused by a recent ingestion that results in stereotypical behavioral, psychological, and physical changes. Withdrawal is a reversible substance-specific syndrome resulting from a cessation of, or reduction in, substance use.

Table 6.2 DSM-IV-TR Diagnostic Criteria for Substance Abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one of more of the following, occurring within a 12-month period:
	1.	Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
	2.	Recurrent substance use in situations in which it is physically hazardous
	3.	Recurrent substance-related legal problems
	4.	Continued substance use despite persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance.
The symptoms have never met the criteria for substance dependence in this class of substance.
From American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association; 2000.

Table 6.3 Intoxication and Withdrawal

	INTOXICATION	WITHDRAWAL
Stimulants	Time course: 24-48 hours Psychological effects: restlessness, agitation, hyperactivity, irritability, impulsiveness, repetitive behaviors Physiologic effects: hypertension, tachycardia, tachypnea, hyperthermia, pupillary dilation	Time course: peak in 2-4 days, resolution in 1 week Psychological effects: depression, increased risk of suicidality, agitation, paranoia, craving, vivid dreams Physiologic effects: fatigue, increased appetite, insomnia or hypersomnia
Opioids	Time course: 6-24 hours Psychological effects: drowsy/sedated, impaired memory, impaired attention Physiologic effects: pupillary constriction, decreased respiratory rate, decreased bowel sounds, slurred speech	Time course: Short-acting: begins in 6-8 hours, resolves in 7-10 days Long-acting: begins in 1-3 days, resolves in 10-14 days Psychological effects: restlessness, depression, irritability Physiologic effects: myalgias and arthralgias, diarrhea, abdominal cramping, lacrimation, rhinorrhea, piloerection, yawning, insomnia, temperature dysregulation

PATIENT ASSESSMENT

History

Nonspecific complaints of chronic pain, gastrointestinal symptoms, changes in memory, impaired concentration, anxiety, and sleep disturbance should all alert the clinician to a possible SUD. Lost prescriptions or request for refills more frequently than anticipated may be associated with prescription drug abuse. Hepatitis B and C viruses and HIV have strong associations with injection drug use. General life chaos, recent arrests for driving while intoxicated, and unexplained physical trauma all strongly suggest a possible SUD.

Physical Exam

Some patients with an SUD may have a normal physical exam. Chronic stimulant abuse may result in significant short-term weight loss, an emaciated appearance, and with methamphetamine, severe dental problems. Track marks, calluses that follow a subcutaneous vein, are caused by repeated injections into adjacent sites over a vein and are commonly found in accessible areas of the body such as the antecubital fossae, hands, and legs. Abnormal movements and facial gestures are hallmarks of chronic use of both methamphetamine and cocaine (5). Table 6.4 highlights clues for recognizing SUDs from the medical and social histories along with the physical exam.

Screening

All patients should receive a brief substance use screen. Some clinicians choose to incorporate questions into their general history taking, while others prefer a screening tool such as the CAGE Adopted to Include
Drugs (CAGE-AID) (6). The following is a brief overview of the CAGE-AID questions. If two or more answers are affirmative, further assessment is warranted.

Table 6.4 Clinical Clues

Commonly associated diseases
	Human immunodeficiency virus (HIV)
	Hepatitis B and C
	Systemic and cutaneous bacterial infections
	Accidents and trauma
	Hypertension
Social history
	Multiple emergency room visits
	Recent arrest for driving while intoxicated
	Poorly explained trauma
	Sudden change in behavior
	Erratic occupational history
Physical exam findings
	Rapid and significant weight loss and/or cachetic appearance
	Severe dental problems
	New-onset heart murmur
	Genital discharge, warts, ulcers, chancres
	Cutaneous track marks and infections
	Abnormal movements and facial gestures
	Cognitive impairment

Have you ever felt that you should Cut down on your alcohol or drug use?
Have people Annoyed you by criticizing your alcohol or drug use?
Have you felt Guilty about your alcohol or drug use?
Have you ever had a drink or used drugs first thing in the morning (Eyeopener) to steady your nerves or get rid of a hangover?

Collateral Information

Patients may not be forthcoming with their clinician for several reasons: They may not view substance use as a problem, they may fear social or legal repercussions, or they may not trust the provider. Collateral history is therefore essential. The goal of any collateral interview is to learn whether substance use has caused significant dysfunction with important life roles. Common sources of information include spouse or partner, peers, teachers, and other medical personnel. The need for collateral information must always be viewed in the context of the patient’s right to confidentiality of health information.

Laboratory Evaluation

Laboratory tests play a secondary role in the diagnosis of SUDs. Urine testing is widely available, noninvasive, and easy to obtain. It can detect active use, help distinguish intoxication from another co-occurring psychiatric disorder, and detect a second SUD. It does not, however, measure the level of global impairment or routinely detect several opiates (oxycodone, hydrocodone, and fentanyl) that are commonly abused.
Given the strong association between substance use and HIV, hepatitis B and C, and other sexually transmitted diseases, these infections should be routinely screened for in those who have an SUD. Suspicion for analgesic abuse should prompt evaluation of liver chemistries given the wide availability of opioid/acetaminophen combinations and the combinations and the hepatotoxicity associated with excessive consumption of acetaminophen. A recommended laboratory evaluation is included in Table 6.5.

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