Substance use disorder (SUD) is complex a condition in which there is uncontrolled use of a substance despite harmful consequence. People with SUD have an intense focus on using a certain substance(s) such as alcohol, tobacco, or illicit drugs, to the point where the person’s ability to function in day to day life becomes impaired. People keep using the substance even when they know it is causing or will cause problems. The most severe SUDs are sometimes called addictions.
People with a substance use disorder may have distorted thinking and behaviors. Changes in the brain’s structure and function are what cause people to have intense cravings, changes in personality, abnormal movements, and other behaviors. Brain imaging studies show changes in the areas of the brain that relate to judgment, decision making, learning, memory, and behavioral control.
Repeated substance use can cause changes in how the brain functions. These changes can last long after the immediate effects of the substance wears off, or in other words, after the period of intoxication. Intoxication is the intense pleasure, euphoria, calm, increased perception and sense, and other feelings that are caused by the substance. Intoxication symptoms are different for each substance.
Stages of substance use disorder
There are several stages of drug use that may lead to addiction. Young people seem to move more quickly through the stages than do adults. Stages are:
- Experimental use – Typically involves peers, done for recreational use; the user may enjoy defying parents or other authority figures.
- Regular use – The user misses more and more school or work; worries about losing drug source; uses drugs to “fix” negative feelings; begins to stay away from friends and family; may change friends to those who are regular users; shows increased tolerance and ability to “handle” the drug.
- Problem or risky use – The user loses any motivation; does not care about school and work; has obvious behavior changes; thinking about drug use is more important than all other interests, including relationships; the user becomes secretive; may begin dealing drugs to help support habit; use of other, harder drugs may increase; legal problems may increase.
- Addiction – Cannot face daily life without drugs; denies problem; physical condition gets worse; loss of “control” over use; may become suicidal; financial and legal problems get worse; may have broken ties with family members or friends.
Causes of substance use disorder
The exact cause of substance use disorder is not known. A person’s genes, the action of the drug, peer pressure, emotional distress, anxiety, depression, and environmental stress can all be factors.
Many who develop a substance use problem have depression, attention deficit disorder, post-traumatic stress disorder, or another mental problem. A stressful or chaotic lifestyle and low self-esteem are also common.
Children who grow up seeing their parents using drugs may have a high risk of developing substance use problem later in life for both environmental and genetic reasons.
Commonly used substances include:
- Opiates and other narcotics are powerful painkillers that can cause drowsiness, and sometimes intense feelings of well-being, elation, happiness, excitement, and joy. These include heroin, opium, codeine, and narcotic pain medicines that may be prescribed by a doctor or bought illegally.
- Stimulants are drugs that stimulate the brain and nervous system. They include cocaine and amphetamines, such as drugs used to treat ADHD (methylphenidate, or Ritalin). A person can start needing higher amounts of these drugs over time to feel the same effect.
- Depressants cause drowsiness and reduce anxiety. They include alcohol, barbiturates, benzodiazepines (Valium, Ativan, Xanax), chloral hydrate, and paraldehyde. Using these substances can lead to addiction.
- LSD, mescaline, psilocybin (“mushrooms”), and phencyclidine (PCP, or “angel dust”) can cause a person to see things that are not there (hallucinations) and can lead to psychological addiction.
- Marijuana (cannabis, or hashish).
Risk Factors of Substance substance use disorder?
Use and abuse of substances such as cigarettes, alcohol, and illegal drugs may begin in childhood or the teen years. Certain risk factors may increase someone’s likelihood of abusing substances.
Family history factors that influence a child’s early development have been shown to be related to an increased risk of drug abuse, such as
- Chaotic home environment,
- Ineffective parenting,
- Lack of nurturing and parental attachment,
- Parental drug use or addiction.
Other risk factors for substance abuse are related to the substance abuse sufferer him- or herself, like
- Male gender,
- Childhood attention deficit hyperactivity disorder (ADHD),
- History of anxiety or other mood disorders,
- Conduct disorder or antisocial personality disorder.
Factors related to a child’s socialization outside the family may also increase the risk of drug abuse, including
- Inappropriately aggressive or shy behavior in the classroom,
- Poor social coping skills,
- Poor school performance,
- Association with a deviant peer group or isolating oneself from peers altogether,
- Perception of approval of drug-use behavior.
Symptoms of substance use disorder
Symptoms of substance use disorders may include:
Behavioral changes, such as:
- Drop in attendance and performance at work or school
- Frequently getting into trouble (fights, accidents, illegal activities)
- Using substances in physically hazardous situations such as while driving or operating a machine
- Engaging in secretive or suspicious behaviors
- Changes in appetite or sleep patterns
- Unexplained change in personality or attitude
- Sudden mood swings, irritability, or angry outbursts
- Periods of unusual hyperactivity, agitation, or giddiness
- Lacking of motivation
- Appearing fearful, anxious, or paranoid, with no reason
Physical changes, such as:
- Bloodshot eyes and abnormally sized pupils
- Sudden weight loss or weight gain
- Deterioration of physical appearance
- Unusual smells on breath, body, or clothing
- Tremors, slurred speech, or impaired coordination
Social changes, such as:
- Sudden change in friends, favorite hangouts, and hobbies
- Legal problems related to substance use
- Unexplained need for money or financial problems
- Using substances even though it causes problems in relationships
Complications of substance use disorder
Drug use can have significant and damaging short-term and long-term effects. Taking some drugs can be particularly risky, especially if you take high doses or combine them with other drugs or alcohol. Here are some examples.
- Methamphetamine, opiates and cocaine are highly addictive and cause multiple short-term and long-term health consequences, including psychotic behavior, seizures or death due to overdose.
- GHB and flunitrazepam may cause sedation, confusion and memory loss. These so-called “date rape drugs” are known to impair the ability to resist unwanted contact and recollection of the event. At high doses, they can cause seizures, coma and death. The danger increases when these drugs are taken with alcohol.
- Ecstasy or molly (MDMA) can cause dehydration, electrolyte imbalance and complications that can include seizures. Long-term, MDMA can damage the brain.
- One particular danger of club drugs is that the liquid, pill or powder forms of these drugs available on the street often contain unknown substances that can be harmful, including other illegally manufactured or pharmaceutical drugs.
- Due to the toxic nature of inhalants, users may develop brain damage of different levels of severity.
Diagnosis of substance use disorder
- A doctor’s evaluation
- Sometimes a person’s self-report
Sometimes a substance use disorder is diagnosed when people go to a health care practitioner because they want help stopping use of a drug. Other people try to hide their drug use, and doctors 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. 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.
Health care practitioners also use other methods (such as questionnaires) to identify a substance use disorder. Urine and sometimes blood tests may be done to check for the presence of drugs.
Criteria for diagnosis
The criteria for diagnosing a substance use disorder fall into four categories:
- 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.
- 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.
- 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 psychologic problem.
- 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.
People who have 2 or more of these criteria within a 12-month period are considered to have 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 for substance use disorder
Although there’s no cure for drug addiction, treatment options explained below can help you overcome an addiction and stay drug-free. Your treatment depends on the drug used and any related medical or mental health disorders you may have. Long-term follow-up is important to prevent relapse.
Chemical dependence treatment programs
Treatment programs usually offer:
- Individual, group or family therapy sessions
- A focus on understanding the nature of addiction, becoming drug-free and preventing relapse
- Levels of care and settings that vary depending on your needs, such as outpatient, residential and inpatient programs
The goal of detoxification, also called “detox” or withdrawal therapy, is to enable you to stop taking the addicting drug as quickly and safely as possible. For some people, it may be safe to undergo withdrawal therapy on an outpatient basis. Others may need admission to a hospital or a residential treatment center.
Withdrawal from different categories of drugs — such as depressants, stimulants or opioids — produces different side effects and requires different approaches. Detox may involve gradually reducing the dose of the drug or temporarily substituting other substances, such as methadone, buprenorphine, or a combination of buprenorphine and naloxone.
In an opioid overdose, naloxone, an opioid antagonist, can be given by emergency responders, or in some states, by anyone who witnesses an overdose. Naloxone temporarily reverses the effects of opioid drugs.
While naloxone has been on the market for years, delivery systems such as Narcan (a naloxone nasal spray) and Evzio (a naloxone injection device) are now available, though they can be very expensive.
Evzio is a small injection device that provides voice instructions to guide the user and automatically insert the needle into the thigh to deliver the naloxone injection. Whatever the method of delivery, seek immediate medical care after using naloxone.
As part of a drug treatment program, behavior therapy — a form of psychotherapy — can be done by a psychologist or psychiatrist, or you may receive counseling from a licensed alcohol and drug counselor. Therapy and counseling may be done with an individual, a family or a group. The therapist or counselor can:
- Help you develop ways to cope with your drug cravings
- Suggest strategies to avoid drugs and prevent relapse
- Offer suggestions on how to deal with a relapse if it occurs
- Talk about issues regarding your job, legal problems, and relationships with family and friends
- Include family members to help them develop better communication skills and be supportive
- Address other mental health conditions
Many, though not all, self-help support groups use the 12-step model first developed by Alcoholics Anonymous. Self-help support groups, such as Narcotics Anonymous, help people who are addicted to drugs.
The self-help support group message is that addiction is a chronic disorder with a danger of relapse. Self-help support groups can decrease the sense of shame and isolation that can lead to relapse.
Your therapist or licensed counselor can help you locate a self-help support group. You may also find support groups in your community or on the internet.
During inpatient rehab, patients live in a substance-free facility, receiving round-the-clock medical care and therapeutic support. Structured treatment programs designed to help with all facets of addiction are offered. Inpatient rehab is the best option for people battling chronic addiction, as well as those suffering from a co-occurring mental or behavioral disorder.
During outpatient rehab, patients receive many of the same treatments and therapies as inpatient rehab programs while living at home. Patients can continue to work and care for their families while still attending treatment sessions each week.
Since outpatient rehab programs don’t separate patients from their home environment, the risk of relapse is greater. Outpatient rehab is best suited for people with mild addictions who have a firm commitment to recovery.
Substance use disorder prevention models
Prevention programs target different populations at risk for substance use disorder (SUD). Prevention programs focus on helping individuals to develop knowledge and skills, or changing environmental and community factors that affect a large population. Providers, schools, public health departments, and other organizations in the community may collaborate to implement these programs. Programs can be implemented in settings such as schools, workplaces, and communities.
Prevention efforts are divided into three categories:
- Universal preventive interventions reach an entire population to prevent substance use disorders.
- Selective preventive interventions target subgroups of the population that are at risk for substance use disorders.
- Indicated preventive interventions are aimed at individuals who are exhibiting early signs of having a substance use disorder though they have not been diagnosed.
Many SUD prevention and early intervention programs focus on children and adolescents, given that substance misuse early in life increases the chance an individual will develop an SUD. The National Institute on Drug Abuse developed a brief, Preventing Drug Use among Children and Adolescents, which describes approaches that communities can implement to prevent drug misuse among children and adolescents. These prevention programs focus on strengthening protective factors and reducing risk factors.
Some SUD prevention strategies are still being tested. For example, in March 2016, the Centers for Disease Control and Prevention (CDC) published the CDC Guideline for Prescribing Opioids for Chronic Pain, which summarizes the risks and benefits associated with prescription opioids and provides an evidence-based guide for providers and patients in shared decision-making about the use of prescription opioids. The guidelines aim to stop over-prescribing of opioids to prevent opioid use disorder. Future research will indicate the effectiveness of prescribing guidelines on rates of SUD.
There is no “best mix” of universal, selective, and indicated programs for a given population. While many SUD prevention programs have shown evidence of success, not all programs have been tested in rural populations. In addition, few prevention programs have been tested for use in workplaces or among older adults.