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PSYCHOACTIVE SUBSTANCE USE DISORDERS

JaneA. Kennedy, D . 0

1. Define psychoactive substance abuse disorder, addiction, and dependence. Terms used to define substance use disorders are vaned and confusing. For the most part, loss of control, compulsion to use, and continued use despite adverse consequences are indicative of psychoactive substance use disorder. To many, the term addiction implies the psychological compulsion to use a substance, whereas the term dependence implies the physiologic components of withdrawal or tolerance. However, the Diagnostic and Statistical Manual, 4th edition (DSM-IV), of the American Psychiatric Association expands the definition of dependence. For a diagnosis of psychoactive substance dependence, three or more criteria, which may or may not include physiologic tolerance or withdrawal, must be met. Other criteria include persistent efforts to cut down or stop use; using more or for a longer time than intended; filling ones time with drug or alcohol activities, such as intoxication or drug procurement; giving up important life activities, such as work or family; and continued use despite knowledge that it will cause or worsen physical or psychological problems. For a diagnosis of psychoactive substance abuse disorder, only one criterion is needed: repeated failure to fulfill significant role obligations; recurrent use in physically hazardous situations, such as driving when intoxicated; repeated substance-related legal problems; or continued substance use despite related social or interpersonal problems. For both abuse and dependence, such maladaptive behaviors must have a duration of at least 1 month. 2. Does addiction run in families? Yes. The risk of addiction is 3 4 times higher for children of substance abusers than for children of non-substance abusers. The cause may be genetic, environmental, or a combination of factors. Familial patterns have been studied primarily in alcoholic families. Twin studies reveal a higher concordance of alcoholism in monozygotic than dizygotic twins, and adoption studies show that twins raised apart have a similar increase in prevalence of alcoholism, whether raised in non-alcoholic or alcoholic families. However, because the concordance in monozygotic twins is not loo%, environmental factors may play an equally important part in the development of alcoholism.

3. How should a physician ask about drug and alcohol problems? Most patients with alcohol or drug problems are fearful of negative reactions from their physician if they tell the truth. Start by asking questions about tobacco, alcohol, and marijuana in a matter-of-fact,
nonjudgmental manner. Questions should address how much (not whether) the patient drinks, blackouts, drunk driving, and whether the patient thinks that he or she ever drinks more than appropriate. Similar questions should be asked about each category of drugs, including routes of administration. Several screening questionnaires have been found to be useful in primary care. The Michigan Alcohol Screening Test (MAST) has 25 questions to be answered by the patient, but may be too lengthy in the primary care setting. The CAGE questionnaire, which has 4 questions, is easier to use for taking a history: 1. Have you tried to Cut down on alcohol? 2. Have you been Annoyed when someone criticized your drinking? 3. Have you felt Guilty about your drinking? 4. Have you used alcohol as an Eye-opener by having a drink in the morning? Two or more positive answers suggest alcohol problems with high sensitivity and specificity. The physician may substitute or add the word drug to get a similar screen of drug problems.
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4. What is the relationship between substance use disorders and psychiatric illnesses? Dual diagnosis of substance use disorder and psychiatric illness is a complex issue. In primary substance use disorders, chronic use may induce psychiatric symptoms; for example, psychosis from stimulants or hallucinogens or depression from alcohol dependence. In substance use disorders secondary to psychiatric illnesses, patients may self-treat their symptoms; for example, alcohol may be used to relieve anxiety or to decrease manic symptoms. In addition, patients may have independent syndromes of substance abuse and major mental illness. The diagnosis of comorbid psychiatric and substance use disorders is significant, and the reported prevalences may depend on the populations surveyed. In the general population, 27% have a diagnosis of substance abuse or dependence at some time during their lifetime. On the other hand, nearly half of patients with schizophrenia have a substance use disorder, and substance abuse or dependence is found in 84% of patients with antisocial personality disorder. Substance abuse or dependence is seen in 24% of patients with anxiety disorders and 32% of patients with affective disorders; in patients with bipolar illness, the prevalence of substance use disorder is 56%. In addition, comorbid substance use disorders are seen in approximately 90% of prisoners who have schizophrenia, bipolar disorder, or antisocial personality disorder. About 50% of patients admitted to public psychiatric hospitals and 40-50% of hospitalized medical patients have comorbid substance abuse or dependence. It is best to wait 2-3 weeks after a patient becomes abstinent before diagnosing a psychiatric disorder; often the symptoms of depression, anxiety, or psychosis disappear as the patient clears. However, in patients with a definite history of psychiatric disorder before onset of substance abuse or during periods of abstinence, treatment should be initiated immediately. 5. Does treatment work? Yes, but no one treatment works for all patients. Some people stop alcohol use without formal treatment or with brief interventions, such as advice from their physician. Many types of formal treatment modalities are discussed in the following chapters about specific substances. In general, substance use disorders are chronic and relapsing; the treatment goal is to decrease the frequency and duration of relapses as well as morbidity and mortality. Like other chronic diseases such as hypertension or diabetes, the aim is management rather than cure. Stopping the substance use must be the primary goal. In the early phases of treatment, patients need external controls, such as urine or breath monitoring, behavioral contracting, and involvement of family or employer to help them stop. Once the patient is abstinent, the focus is prevention of relapse, which includes reducing accessibility of the substance, identifying stimuli that may trigger cravings, understanding feelings, and developing coping responses and improved social skills. Relapse is high during the first year of treatment, but as periods of abstinence lengthen, the likelihood of relapse decreases. Ongoing treatment should involve a biopsychosocial model, attending to health and psychiatric problems as well as marital, occupational, legal, financial, and social functioning. For any substance use disorder, a worse prognosis is associated with unemployment, lack of social support system, and presence of psychopathology, especially antisocial personality disorder.
6. Is inpatient treatment better than outpatient treatment? The long-term benefit of inpatient hospitalization vs. outpatient treatment has not been documented. Patients with complicated medical or psychiatric problems, severe withdrawal, suicidality, or risk of seizure require inpatient treatment, but extended hospital stays have not been associated with increased long-term abstinence.

7. Should patients be completely abstinent? Or can they learn to control their use? At this time little evidence suggests that controlled use can be achieved; abstinence should be the goal for most patients. Some patients want to abstain from their drug of abuse but use other subbtmces in moderation; this practice is a potential trigger for relapse. Not infrequently, patients switch substances (quit heroin and become dependent on alcohol) or develop a second dependence (continue alcohol and add benzodiazepines).

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8. Should all patients attend a self-help group? Self-help groups can be extremely beneficial. Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), Rational Recovery (RR), and other such groups provide structure and support, decrease stigma, and offer hope as patients see others recover. However, outcome research shows that the drop-out rate in the first year of AA attendance is high (50-75%) and that although AA is helpful to those who stay, others may need to seek professional treatment. Self-help programs can be used in combination with professional treatment.
9. What is a therapeutic community? Therapeutic community refers to residential, long-terni (6-12 months) treatment, usually with gradual re-entry into society. In general, the approach is based on milieu therapy and is highly confrontive, with strict limits and structure. Graduates of the program often become staff members, having increased their level of responsibility as they progressed through the program. The drop-out rate in the first few months of treatment is high (75-go%), but graduates have improved outcome in terms of drug use, crime, and employment.

10. Should family members be included in alcohol or drug treatment? Yes. Behavior associated with substance use disorders significantly affects family members, who may participate indirectly or directly in maladaptive patterns. They should be included in the patients treatment, both for themselves and to help monitor and provide external control for the patient. Part of relapse prevention should be an agreement that the spouse will contact the treatment provider if concern develops about relapse. Note that family members can find personal support as well as education through groups such as Al-Anon.
BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

Washington, DC, American Psychiatric Association, 1994. 2. Arif A, Westemeyer J: Manual of Drug and Alcohol Abuse. New York, Plenum, 1988. 3. Ciraulo DA, Shader RI: Clinical Manual of Chemical Dependence. Washington, DC, American Psychiatric Press, 1991. 3a. Frances RS, Miller ST: Clinical Textbook of Addictive Disorders. New York, Guilford Press, 1998. 4. Friedman LS, Fleming NF, Roberts DH, Hymen SE: Source Book of Substance Abuse and Addiction. Baltimore, Williams & Wilkins, 1996. 5 . Galanter M, Kleber HD: Textbook of Substance Abuse Treatment., 2nd ed. Washington, DC, American Psychiatric Press, 1999. 6. Institute of Medicine: Broadening the Base of Treatment for Alcohol Problems. Washington, DC, National Academy Press, 1990. 7. Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-111-R psychiatric disorders in the United States. Arch Gen Psychiatry 51 :8-19, 1994. 8. Lowinson JH, Ruiz P, Millmau RB, Langrod JG: Substance Abuse: A Comprehensive Textbook. Baltimore, Williams & Wilkins, 1997. 9. Milhorn HT Jr: Chemical Dependence: Diagnosis, Treatment, and Prevention. New York, Springer-Verlag, 1990. 10. Miller NS: Comprehensive Handbook of Drug and Alcohol Addiction. New York, Marcel Dekker, 1991. 11. Regier DA, Fanner ME, Rae DS, et al: Comorbidity of mental disorders with alcohol and other drugs. JAMA 264:2511-2518, 1990.