II. Definitions

  1. Chemical Intoxication
    1. Reversible substance-specific syndrome
    2. Due to recent ingestion
    3. Behavioral or psychological maladaption
  2. Hazardous Use
    1. Substance use that puts the user at risk for harmful consequences
    2. Highest risk substances: Heroin, Methamphetamine, crack Cocaine
  3. Withdrawal
    1. Substance-specific reaction to cessation of intake
  4. Substance Misuse
    1. Substance use that does not meet criteria for Substance Use Disorder AND
    2. Substance used in hazardous situations, or Alcohol that is used more than low-risk

III. Epidemiology

  1. Prevalence (2015, U.S. over age 10 years old): 10% (>20 Million)
  2. Teenagers <14 years old who use substances will have a 33% risk of Substance Use Disorder longterm
  3. Substance use goes undiagnosed in 43% of cases in the primary care setting

IV. Pathophysiology

V. Preparations: Primary abused substances

  1. Precautions
    1. Substances of abuse are difficult to distinguish by sight
    2. White powder could be Cocaine, Methamphetamine, synthetic Opioids, NBOMe or bath salts
    3. Crystals could be Crystal Meth, U-47700
    4. Many substances of abuse are reformulated into tablets
      1. Fentanyl may be formed in tablets similar to Oxycodone or Hydrocodone
  2. Alcohol
    1. See Alcohol Abuse
    2. Ethanol-based hand sanitizer (especially in health care centers)
      1. Hand sanitizer can cause significant Alcohol Intoxication (60% Alcohol)
      2. Some abusers of hand sanitizer extract the Alcohol with salt
  3. Cannabinoids (Marijuana, K2, Spice)
    1. See Marijuana (includes Synthetic Cannabinoids such as K2)
    2. Most common drug of abuse in U.S. and progressively increasing annually among grades 8-12
  4. Opioids (e.g. Oxycodone, Morphine, Heroin)
    1. See Opioid Abuse
    2. Dextromethorphan Abuse
  5. Sedative-Hypnotics
    1. Benzodiazepine Abuse
    2. Gamma Hydroxybutyrate (GHB)
  6. Stimulants
    1. Cocaine
    2. Methamphetamine
    3. Synthetic Cathinones (Psychoactive Bath Salts)
    4. Methylenedioxymethamphetamine (MDMA, Ecstasy)
  7. Volatile Inhalants (Sniffing, Huffing, Bagging)
    1. More common drug of abuse in ages 10-14 years old
    2. Risk of Sudden Sniffing Death Syndrome
  8. Hallucinogens
    1. Ketamine Abuse (and Methoxetamine)
    2. Phencyclidine (PCP)
  9. Other intoxicants
    1. Nitrous Oxide Abuse (Laughing Gas, Whippets)

VI. Preparations: Prescription and OTC Drug Abuse

  1. Amphetamines
  2. Benzodiazepines
  3. Opioids
  4. Dextromethorphan (used at high doses as an Opioid)
    1. See Dextromethorphan Abuse
  5. Diphenhydramine
    1. Used at high doses as a Hallucinogenic
    2. Other Anticholinergic Medications have been similarly abused (e.g. Dicyclomine, Oxybutynin)
    3. Diphenhydramine Overdose also risks Seizures, coma and death

VII. Preparations: Prescribed and OTC Medications that potentiate Drugs of Abuse

  1. Albuterol
    1. Used to enhance effects of crack Cocaine
  2. Clonidine (Catapres)
    1. Use to prolong the effects of Heroin and other Opioids
  3. Bupropion (Wellbutrin)
    1. Crushed and snorted to induce a high ("poor man's Cocaine")
  4. Pseudoephedrine
    1. Used to synthesize Methamphetamine
  5. Quetipine (Seroquel)
    1. Used to enhance the effects of Heroin or for calming
  6. Loperamide (Imodium)
    1. Used in doses as high as 60 mg/day for Opioid effects or for Opioid Withdrawal symptoms
  7. Gabapentin (Neurontin) or Pregabalin (Lyrica)
    1. Used at high doses for Opioid effect or for withdrawal from Cocaine, Opioids, Alcohol
  8. References
    1. (2015) Presc Lett 22(10):59

VIII. Evaluation

IX. Diagnosis: Substance Use Disorder (DSM-5)

  1. Problematic pattern of use of intoxicating substance over a 12 month period and
    1. Not specifically otherwise classified (e.g. Alcohol, Caffeine, Cannabis, Hallucinogen, inhalant, opiod, Sedative, stimulant)
  2. Clinically Significant Impairment or distress and
  3. At least 2 of the following criteria present
    1. Consumption in larger amounts (or for longer duration) than intended
    2. Persistent desire or unsuccessful attempts to cut down or control substance use
    3. Significant time spent to obtain the substance (e.g. driving long distances between multiple prescribing doctors)
    4. Craving or a strong desire or urge to use the substance
    5. Gives up important social, occupational or recreational activities to recurrently use the substance
    6. Persistent use despite negative consequences (social, occupational, psychological, physical)
    7. Recurrent substance us in physically hazardous situations (e.g. DUI)
    8. Continued substance use despite causing or worsening physical or psychological problems
    9. Tolerance
      1. Markedly increased substance amounts needed for Intoxication or
      2. Markedly diminished effect with the same substance amount
    10. Withdrawal
      1. Characteristic withdrawal syndrome for the substance
      2. Substance is used to avoid withdrawal symptoms
  4. Qualifiers
    1. Early Remission
      1. No substance use criteria (other than craving) are met for 3-12 month period
    2. Sustained Remission
      1. No substance use criteria (other than craving) are met for >12 month period
    3. Controlled Environment
      1. Patient remains in a setting for which substance access is restricted

XI. Resources

XII. References

  1. (2013) DSM 5 Manual, APA, Washington, D.C.
  2. (2020) Presc Lett 27(11): 61-2

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