Topic Resources
The substances involved tend to be members of the 10 classes of drug that typically cause substance-related disorders.
Ten Drug Classes Commonly Associated With Substance-Related Disorders
CaffeineCaffeine |
Cannabis (including marijuana and synthetic cannabinoids) |
Hallucinogens (including LSD, phencyclidine, psilocybin, 3,4-methylenedioxymethamphetamine [MDMA])(including LSD, phencyclidine, psilocybin, 3,4-methylenedioxymethamphetamine [MDMA]) |
Inhalants (such as paint thinner and certain glues) |
Opioids (including fentanyl, morphine, and oxycodone)(including fentanyl, morphine, and oxycodone) |
Stimulants (including amphetamines and cocaine) |
Other (including anabolic steroids and other commonly abused substances) |
The specific manifestations and treatment of intoxication and withdrawal vary by substance or substance class.
The term "substance use disorder" is more accurate, clearly defined, and has fewer negative connotations than "addiction," "abuse," or "dependence."
Use of illegal drugs, although problematic from a legal standpoint, does not always involve a substance use disorder. On the other hand, legal substances, such as alcohol and prescription drugs (and marijuana in an increasing number of states in the United States), may be involved in a substance use disorder. Problems caused by use of prescription and illegal drugs cut across all socioeconomic groups.
Recreational drug use has existed in one form or another for centuries. People have used drugs for a variety of reasons, including the following:
To alter or enhance mood
As part of religious ceremonies
To gain spiritual enlightenment
To enhance performance
People who take drugs recreationally may take them occasionally in relatively small doses, often without doing themselves harm. That is, users do not develop drug withdrawal, and the drug does not physically harm them (at least not in the short term). Drugs usually considered recreational include opium, alcohol, nicotine, marijuana, caffeine, , and the drug does not physically harm them (at least not in the short term). Drugs usually considered recreational include opium, alcohol, nicotine, marijuana, caffeine,hallucinogenic mushrooms (see also Mushroom [Toadstool] Poisoning), and cocaine. Many recreational drugs are considered "natural" because they are close to their plant origin. They contain a mixture of low-concentration psychoactive ingredients rather than an isolated, more concentrated psychoactive compound.
Recreational drugs can be taken by mouth, inhaled, or injected.
Physiologic Effects of Substance Use
These substances all directly activate the brain's reward system and produce feelings of pleasure. The activation may be so strong that people intensely crave the substance. They may neglect normal activities to obtain and use the drug. These substances also have direct physiologic effects, including
Intoxication
Withdrawal
Substance-induced mental health disorders
Intoxication
Intoxication refers to the immediate and temporary effects of a specific drug. Intoxication impairs the person's mental function and judgment and may alter mood. Depending on the drug, the person may feel a sense of excitement or an exaggerated feeling of well-being (or euphoria), or the person may feel calmer, more relaxed, and sleepier than usual.
Many drugs impair physical functioning and coordination, leading to falls and vehicle crashes. Some drugs trigger aggressive behavior, leading to fighting. As larger amounts of the drug are used (called an overdose), adverse effects become more obvious, with serious complications and sometimes risk of death.
Tolerance means that people need more and more of the drug to feel the effects originally produced by a smaller amount. People can develop tremendous tolerance to drugs such as opioids and alcohol.
Withdrawal
Withdrawal refers to symptoms that develop when people stop taking a substance or take significantly less than usual. Withdrawal causes various unpleasant symptoms that differ depending on the substance involved. Withdrawal from some drugs (such as alcohol or barbiturates) can be serious and even life threatening. Most people who experience withdrawal know that taking more of the substance will reduce their symptoms.
Whether withdrawal occurs depends only on the substance and how long it is used, not whether the person has a substance use disorder, is using the substance recreationally, or the substance is illegal. Some prescription drugs, particularly opioids, sedatives, and stimulants, can result in withdrawal symptoms even when taken as prescribed for legitimate medical reasons and for relatively brief periods (less than 1 week for opioids).
People who have withdrawal symptoms were previously termed physically dependent upon the substance. However, "dependence" has negative connotations suggesting illicit drug use, so doctors prefer to avoid this terminology.
Causes of Substance Use Disorders
People usually progress from experimentation to occasional use and then to heavy use and sometimes to a substance use disorder. This progression is complex and only partially understood. The process depends on interactions between the drug, user, and setting.
Drug
Drugs in the 10 classes vary in how likely they are to cause a substance use disorder. The potential for misuse of these drugs depends upon a combination of factors, including the following:
How the drug is used
How strongly the drug stimulates the brain's reward pathway
How quickly the drug works
The drug's ability to induce tolerance and/or symptoms of withdrawal
In addition, substances that are legally and/or readily available, such as alcohol and tobacco, are more likely to be used first. As people continue to use a substance, they often see less risk in using it and may begin to increase their use and/or experiment with other substances. People's perception of risk also may be influenced by the social and legal consequences of use.
During treatment of medical illness or following surgical or dental procedures, people are routinely prescribed opioids. If people do not take the whole amount prescribed, the drugs sometimes end up in the hands of people who wish to use them recreationally. Because the use of these drugs for nonmedical purposes has become such a large problem, many health care providers have responded by
Advise use of or prescribe nonaddictive pain relief medications (eg, acetaminophen, non-steroidal anti-inflammatory drugs) when appropriateAdvise use of or prescribe nonaddictive pain relief medications (eg, acetaminophen, non-steroidal anti-inflammatory drugs) when appropriate
Prescribing lower amounts of opioid drugs
Encouraging people to safely store or dispose of any leftover drugs
Expanding prescription take-back programs
User
Factors in users that may predispose to a substance use disorder include
Psychological characteristics
Circumstances and disorders
Psychological characteristics are not clearly a strong factor, although people with low levels of self-control (impulsivity) or high levels of risk-taking and novelty-seeking behaviors may have an increased risk of developing a substance use disorder. However, there is little scientific evidence to support the concept of the "addictive personality" that has been described by some behavioral scientists.
A number of circumstances and coexisting disorders appear to increase the risk of a substance use disorder. For example,
People who are sad, emotionally distressed, socially alienated, or have insecure emotional attachments may find temporary relief from drug use, which can lead to increased use and sometimes to a substance use disorder.
People with other, unrelated mental health disorders such as anxiety, depression, schizophrenia, attention-deficit disorder, and personality disorders are at increased risk of developing a substance use disorder. (People who have both a mental health disorder and a substance use disorder are said to have a "dual diagnosis.")
People with chronic pain often require opioid drugs for relief. Some of these people later develop a substance use disorder.
However, in many of these people, nonopioid drugs and other treatments do not adequately relieve pain and suffering.
Substance use disorder likely has many causes, some of which are genetic and others of which are epigenetic (effects of behaviors and the environment carried with the genes). Research into specific genetic abnormalities varies by the specific substance. Researchers have found few biochemical or metabolic differences between people who do and do not develop substance use disorder.
Setting
Cultural and social factors are very important in initiating and maintaining (or relapsing to) substance use. Watching family members (for example, parents, older siblings) and peers using substances increases the risk that people will begin using substances. Peers are a particularly powerful influence among adolescents (see Substance Use in Adolescents). People who are trying to stop using a substance find it much more difficult if they are around others who also use that substance.
Doctors may inadvertently contribute to harmful use of psychoactive drugs by overzealously prescribing them to relieve stress. Many social factors, including mass media, contribute to the expectation that drugs should be used to relieve all distress.
Diagnosis of Substance Use Disorders
A doctor's evaluation
Sometimes blood, urine, or hair testing
Sometimes a substance use disorder is diagnosed when people go to a health care professional because they want help stopping use of a drug. Other people try to hide their drug use or do not recognize that it is a problem. Doctors, family, friends, or coworkers may suspect problems with drug use only when they notice changes in a person's mood or behavior. Sometimes doctors discover signs of substance use during a physical examination or routine blood tests. For example, they may discover track marks caused by repeatedly injecting drugs intravenously. Track marks are lines of tiny, dark dots (needle punctures) surrounded by an area of darkened or discolored skin. Injecting drugs under the skin causes circular scars or ulcers. People may claim other reasons for the marks, such as frequent blood donations, bug bites, or other injuries. Or, they may find physical signs or blood test results that show liver damage from excessive alcohol use. Some people get very ill from using too much of a drug (overdose) or have effects from using (toxicity) or stopping a drug (withdrawal) and need emergency care.
Health care professionals also use other methods (such as questionnaires) to identify a substance use disorder. Urine and sometimes blood tests or tests on hair may be done under certain circumstances to check for the presence of drugs.
Criteria for diagnosis
Substance use disorders are diagnosed using standard psychiatric diagnostic criteria, which fall into 4 categories. People who have 2 or more of these criteria within a 12-month period are considered to have a substance use disorder:
The person cannot control use of the substance.
The person's ability to meet social obligations is compromised by use of the substance.
The person uses the substance in physically dangerous situations.
The person shows physical signs of use and/or dependence.
Inability to control use
The person takes the substance in larger amounts or for a longer time than originally planned.
The person desires to stop or cut down use of the substance.
The person spends a lot of time obtaining, using, or recovering from the effects of the substance.
The person craves the substance.
Social impairment
The person fails to fulfill major role obligations at work, school, or home.
The person continues to use the substance even though it causes (or worsens) social or interpersonal problems.
The person gives up or reduces important social, occupational, or recreational activity because of substance use.
Risky use
The person uses the substance in physically hazardous situations (eg, when driving or in dangerous social circumstances).
The person continues to use the substance despite knowing it is worsening a medical or psychological problem.
Physical symptoms
Tolerance: The person needs to use increasingly more of the substance to feel the desired effect.
Withdrawal: Unpleasant physical effects occur when the substance is stopped or when it is counteracted by another substance.
Note that some drugs, particularly opioids, sedative/hypnotics, and stimulants, can result in tolerance and/or withdrawal symptoms even when taken as prescribed for legitimate medical reasons and for relatively brief periods (less than 1 week for opioids). Withdrawal symptoms that develop following appropriate medical use do not warrant the diagnosis of a substance use disorder. For example, when people with severe pain due to advanced cancer become dependent (psychologically and physically) on an opioid such as morphine, their withdrawal symptoms are not considered evidence of a substance use disorder. Note that some drugs, particularly opioids, sedative/hypnotics, and stimulants, can result in tolerance and/or withdrawal symptoms even when taken as prescribed for legitimate medical reasons and for relatively brief periods (less than 1 week for opioids). Withdrawal symptoms that develop following appropriate medical use do not warrant the diagnosis of a substance use disorder. For example, when people with severe pain due to advanced cancer become dependent (psychologically and physically) on an opioid such as morphine, their withdrawal symptoms are not considered evidence of a substance use disorder.
The severity of the substance use disorder is determined by the number of criteria met:
Mild: 2 to 3 criteria
Moderate: 4 to 5 criteria
Severe: ≥ 6 criteria
Treatment of Substance Use Disorders
Varies depending on substance and circumstances
Specific treatment depends on the drug being used, but it typically involves counseling and sometimes involves use of other drugs. Family support and support groups help people remain committed to stopping use of the drug.
Substance use disorders have become widespread and have resulted in a rising number of deaths. In response to this growing epidemic, many organizations have established harm-reduction programs to provide education, counseling, and referral for treatment. Their purpose is to reduce the harm of drug use in users who cannot stop. Some provide national telephone helplines.
Because sharing needles is a common cause of HIV infection, hepatitis, and other infections, some harm-reduction programs provide clean needles and syringes so people do not reuse others’ needles. This strategy helps reduce the spread (and the cost to society) of these infections.
Screening
Routine screening for substance use disorders should be integrated into regular health maintenance visits, rather than prompted only by doctors' concerns. A screening-based approach can allow doctors to detect substance use disorders early and to intervene effectively, without stigmatizing people or prompting them to hide their substance use while their disorders worsen.
During an effective routine screening, the doctor asks about the person's use of common categories of substances, including alcohol, tobacco/nicotine, cannabis, prescription medications, and illicit drugs. The doctor may use formal assessment tools or simply ask a single question (for example, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”). During an effective routine screening, the doctor asks about the person's use of common categories of substances, including alcohol, tobacco/nicotine, cannabis, prescription medications, and illicit drugs. The doctor may use formal assessment tools or simply ask a single question (for example, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”).
If the screening questions raise concern for a substance use disorder or other problems related to substance use, the doctor will determine the severity of the use disorder, what impact it has on the person's ability to function, and any related mental health conditions the person may have. When appropriate, the doctor will provide a referral for specialized care.
Prevention
Some substance use disorders can be prevented through early identification and management of risk factors. Routine screening and age-appropriate protective strategies are important measures the doctor can use, particularly during adolescence, when substance use is most likely to begin and the person's neurobiological vulnerability to addiction is heightened.
After assessing for known risk factors, including family history of substance use disorders, the person's exposure to trauma, the presence of other mental health conditions, and early behavioral problems, doctors consider preventive interventions such as psychoeducation, cognitive and behavioral skill development, and family-based support.
Patients and families should also be educated about the risks of overdose, especially when opioids are prescribed, and be given or prescribed naloxone (eg, intranasal naloxone/Narcan) if at a high risk for overdose or a substance use disorder.Patients and families should also be educated about the risks of overdose, especially when opioids are prescribed, and be given or prescribed naloxone (eg, intranasal naloxone/Narcan) if at a high risk for overdose or a substance use disorder.
Drugs Mentioned In This Article
