Substance use disorder: Principles for recognition and assessment in general medical care
- Michael F Weaver, MD
Michael F Weaver, MD
- Medical Director, Center for Neurobehavioral Research on Addictions
- University of Texas, Health Sciences Center at Houston
- Margaret A E Jarvis, MD
Margaret A E Jarvis, MD
- Medical Director
- Marworth Treatment Center, Waverly, Pennsylvania
All clinicians will encounter patients with substance use disorders (SUD). A study of a nationally representative sample found that eight percent of adults in the US had a SUD in the past 12 months . A study that conducted urine and blood tests on a sample of patients admitted to the hospital estimated that alcohol or drug use was involved in 14 percent of the medical admissions and 26 percent of the psychiatric admissions . Addiction affects adolescents and the elderly, all races, and all socioeconomic strata. Despite the relatively high prevalence of SUD, the disorder frequently goes undetected in clinical care .
Clinicians should evaluate all new patients for unhealthy alcohol use, and other drug use when relevant (eg, high prevalence, consideration of prescribing a potentially addictive medication); drug and alcohol use should also be considered when patients present with new symptoms, recent motor vehicle accidents or physical trauma, mood disorders, weight loss, or ongoing unexplained symptoms.
Principles for recognition and assessment of SUD in general medical care are discussed here. The epidemiology, clinical manifestations, course, diagnosis, and treatment for specific substances are discussed separately. Screening for alcohol and other drug use is also discussed separately. (See "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis" and "Pharmacotherapy for opioid use disorder" and "Acute opioid intoxication in adults" and "Cannabis use and disorder: Epidemiology, comorbidity, health consequences, and medico-legal status" and "Cannabis use and disorder: Clinical manifestations, course, assessment, and diagnosis" and "Treatment of cannabis use disorder" and "Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations, medical consequences, and diagnosis" and "Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Pharmacotherapy for alcohol use disorder" and "Psychosocial treatment of alcohol use disorder" and "Management of moderate and severe alcohol withdrawal syndromes" and "Medically supervised alcohol withdrawal in the ambulatory setting" and "Screening for unhealthy use of alcohol and other drugs in primary care" and "Brief intervention for unhealthy alcohol and other drug use" and "Prescription drug misuse: Epidemiology, prevention, identification, and management".)
Substance use disorders (SUD) are easy to recognize in the patient who has just been arrested for a motor vehicle violation or who presents with a request to discontinue using drugs. Many more patients with SUD will only be identified if specifically asked about the problem.
Patient denial is a significant barrier to identifying patients needing help for SUD. Denial may exist even when the patient is directly asked about use or confronted with behaviors suspicious for unhealthy substance use. Obtaining history from family members and employers can be helpful, but must be done in compliance with legal regulations protecting patient privacy. In the United States (US), patient privacy regulations (HIPAA and 42CFR) require that the patient sign a release of information that includes the name of the patient and the person the clinician will be communicating with, the specific information to be released to that person, the reason for the release of information, and a time frame within which the release of information remains valid.
- Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates. Arch Gen Psychiatry 2002; 59:115.
- Mordal J, Bramness JG, Holm B, Mørland J. Drugs of abuse among acute psychiatric and medical admissions: laboratory based identification of prevalence and drug influence. Gen Hosp Psychiatry 2008; 30:55.
- Miller NS, Giannini AJ, Gold MS, Philomena JA. Drug testing: medical, legal, and ethical issues. J Subst Abuse Treat 1990; 7:239.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- World Health Organization. Lexicon of Alcohol and Drug Terms. Geneva:World Health Organization; 1994. http://www.who.int/substance_abuse/terminology/who_lexicon/en/.
- Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med 2005; 352:596.
- Hartikainen S, Lönnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci 2007; 62:1172.
- Finkle WD, Der JS, Greenland S, et al. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. J Am Geriatr Soc 2011; 59:1883.
- Wunsch MJ, Weaver MF. Alcohol and other drug use during pregnancy: Management of the affected mother and child. In: Principles of Addiction Medicine, 4th ed, Ries R, Fiellin D, Miller S, Saitz R. (Eds), American Society of Addiction Medicine, Inc., Chevy Chase, MD 2009. p.1111.
- Reissig CJ, Strain EC, Griffiths RR. Caffeinated energy drinks--a growing problem. Drug Alcohol Depend 2009; 99:1.
- Fantegrossi WE, Moran JH, Radominska-Pandya A, Prather PL. Distinct pharmacology and metabolism of K2 synthetic cannabinoids compared to Δ(9)-THC: mechanism underlying greater toxicity? Life Sci 2014; 97:45.
- Gelernter J, Panhuysen C, Wilcox M, et al. Genomewide linkage scan for opioid dependence and related traits. Am J Hum Genet 2006; 78:759.
- Gordon RJ, Lowy FD. Bacterial infections in drug users. N Engl J Med 2005; 353:1945.
- Gish RG, Afdhal NH, Dieterich DT, Reddy KR. Management of hepatitis C virus in special populations: patient and treatment considerations. Clin Gastroenterol Hepatol 2005; 3:311.
- Weaver MF, Cropsey KL, Fox SA. HCV prevalence in methadone maintenance: self-report versus serum test. Am J Health Behav 2005; 29:387.
- Schuman P, Sobel JD, Ohmit SE, et al. Mucosal candidal colonization and candidiasis in women with or at risk for human immunodeficiency virus infection. HIV Epidemiology Research Study (HERS) Group. Clin Infect Dis 1998; 27:1161.
- Wilson LE, Thomas DL, Astemborski J, et al. Prospective study of infective endocarditis among injection drug users. J Infect Dis 2002; 185:1761.
- Deiss RG, Rodwell TC, Garfein RS. Tuberculosis and illicit drug use: review and update. Clin Infect Dis 2009; 48:72.
- Minkoff HL, McCalla S, Delke I, et al. The relationship of cocaine use to syphilis and human immunodeficiency virus infections among inner city parturient women. Am J Obstet Gynecol 1990; 163:521.
- Glassroth J, Adams GD, Schnoll S. The impact of substance abuse on the respiratory system. Chest 1987; 91:596.
- Masters, WH, Johnson, VE. Human Sexual Inadequacy, Little Brown & Co Inc., Boston, MA 1970.
- Williams G, Daly M, Proude EM, et al. The influence of alcohol and tobacco use in orthopaedic inpatients on complications of surgery. Drug Alcohol Rev 2008; 27:55.
- Gunderson EW, Kirkpatrick MG, Willing LM, Holstege CP. Substituted cathinone products: a new trend in "bath salts" and other designer stimulant drug use. J Addict Med 2013; 7:153.
- Ohayon MM, Schatzberg AF. Prevalence of depressive episodes with psychotic features in the general population. Am J Psychiatry 2002; 159:1855.
- Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc 2008; 83:66.
- Vincent EC, Zebelman A, Goodwin C, Stephens MM. Clinical inquiries. What common substances can cause false positives on urine screens for drugs of abuse? J Fam Pract 2006; 55:893.