Ch 22: Substance-Related and Addictive Disorders

What are the four major symptom groups of a substance use disorder according to the DSM-5?

• Impaired control

• Social impairment

• Risky use

• Physical effects (intoxication, tolerance, withdrawal)

What are the DSM-5 recognized categories of psychoactive substances?

• Alcohol

• Caffeine

• Cannabis

• Hallucinogen

• Inhalant

• Opioid

• Sedative/hypnotic/anxiolytic

• Stimulant

• Tobacco

What is a process addiction, and what was the first officially recognized one?

A behavior-based addiction without substance use that activates brain reward pathways. Gambling was the first recognized process addiction in 2013.

what is addiction?

A chronic condition involving environmental, neurobiological, genetic, and experiential factors, marked by compulsive substance use despite harmful consequences.

What does intoxication mean in substance use?

It refers to the physiological and psychological effects of using a substance to excess, such as being "drunk" or "high."

What is tolerance in the context of substance use?

A state in which increasing amounts of a substance are needed to achieve the same effect once produced by a lower dose.

Define withdrawal.

A group of physical and psychological symptoms that occur when substance use is reduced or stopped. Symptoms vary by substance and can be life-threatening

What are examples of behavioral or process addictions besides gambling?

Internet gaming, social media use, shopping, and sexual activity.

what is the misuse potential of Schedule I drugs and their medical status?

High misuse potential; no accepted medical use (e.g., heroin, LSD).

what defines a schedule II drug?

High potential for abuse, dangerous, accepted medical use with prescription only (e.g., methadone, Demerol, Ritalin).

Schedule III drugs have what level of misuse potential?

Moderate to low misuse potential; prescription required (e.g., testosterone, Tylenol with codeine, Suboxone).

What are some examples of Schedule IV drugs?

Xanax (alprazolam), Ativan (lorazepam), Darvocet (propoxyphene/acetaminophen); low risk, prescription only.

What defines a Schedule V drug?

Lowest abuse potential, may be available over the counter; includes small amounts of narcotics (e.g., Lomotil, Robitussin AC, Lyrica).

what are the health risks of chronic nicotine use?

cancer, cardiovascular disease, chronic lung disease, stroke, pregnancy complications, addiction

what are the effects of high doses of alcohol?

slurred speech, nausea, impaired memory, respiratory arrest, seizures, coma, death

which drugs can cause flashbacks and hallucinogen persisting perception disorder?

LSD (Lysergic acid diethylamide)

what is primary health risk of heroin use?

Slowed or arrested breathing, addiction, fatal overdose, risk of infections (e.g., HIV, hepatitis).

Which stimulant causes severe dental problems and violent behavior?

methamphetamine

what are the acute effects of MDMA (Ecstasy)?

empathetic feelings, lowered inhibition, anxiety, teeth clenching, hyperthermia

What hallucinogen is brewed as tea and can cause vomiting and diarrhea?

Ayahuasca.

What is the main danger of inhalants (e.g., solvents, thinners)?

Sudden sniffing death, brain and organ damage, memory loss.

What drug class includes anabolic steroids and what are their health risks?

Not for intoxication; risks include heart disease, liver cysts, aggression, and hormonal imbalances.

What are withdrawal symptoms common to behavioral addictions (like gambling)?

cravings, anxiety, sleep disruption, depression

Which neurotransmitter systems are primarily involved in substance use disorders?

The opioid, catecholamine (especially dopamine), and GABA systems are most involved. Dopaminergic neurons in the ventral tegmental area (VTA) are key in reward sensation

How do environmental stressors contribute to substance use disorder risk?

Chronic stress from poverty can lead to poor living conditions, weak social support, and increased stress or depression. This may result in drug use and behavioral issues.

What socioeconomic factors are associated with a higher risk for substance use disorders?

Poverty, poor education, lack of parental supervision, limited resources, and living in high-risk neighborhoods all increase the risk.

What are the two most common types of substance use disorders?

alcohol use disorder and illicit drug use disorder

What was the most common illicit drug use disorder?

Marijuana use disorder

Is excessive caffeine use considered an official substance use disorder in the DSM-5?

No, it is not considered an official use disorder (APA, 2013), but it can cause intoxication, overdose, and withdrawal.

What psychiatric disorders are associated with excessive caffeine use?

Bipolar disorders, eating disorders, and sleep disorders.

At what dose is caffeine intoxication likely to occur?

More than 250 mg.

What are common behavioral symptoms of caffeine intoxication?

Restlessness, nervousness, excitement, agitation, rambling speech, inexhaustibility.

What are physical symptoms of caffeine intoxication?

Flushed face, diuresis, GI disturbance, muscle twitching, tachycardia, arrhythmias.

What is the treatment for caffeine overdose?

• Supportive care and hydration (oral or IV)

• Gastric lavage or activated charcoal

• Beta-blockers for tachycardia

• Vasopressors for hypotension

Is caffeine withdrawal considered medically dangerous?

No, it is not medically serious and usually doesn't require intervention.

What are common symptoms of cannabis intoxication?

Enhanced perception, depersonalization, conjunctival injection, increased appetite, dry mouth, and tachycardia.

What are the diagnostic physical symptoms of cannabis intoxication?

Two or more of: red eyes, dry mouth, tachycardia, and increased appetite.

What are symptoms of cannabis withdrawal?

Irritability, anxiety, insomnia, vivid dreams, appetite loss, abdominal pain, chills, and headaches.

What is the primary treatment approach for cannabis use disorder?

Abstinence and support through hospitalization or outpatient care, therapy, and sometimes short-term antianxiety or antidepressant medications.

What are the two categories of hallucinogens?

Classic hallucinogens (e.g., LSD) and dissociative drugs (e.g., PCP, ketamine).

What classification do hallucinogens fall under in the Controlled Substances Act?

Schedule I—no medical use and high potential for abuse.

What psychological effects are commonly associated with hallucinogen intoxication?

Paranoia, impaired judgment, intensified perception, depersonalization, derealization, illusions, hallucinations, and synesthesia.

What physical symptoms occur with hallucinogen intoxication?

Pupillary dilation, tachycardia, sweating, palpitations, blurred vision, tremors, and incoordination.

what is the primary treatment for hallucinogen intoxication?

talking the patient down, reassurance, and short-term use of antipsychotics (e.g., haloperidol) or benzodiazepines (e.g., diazepam)

What makes PCP intoxication a medical emergency?

it can cause violent, unpredictable behavior and severe physical symptoms including nystagmus, hypertension, seizures, coma, and hyperthermia

what are key physical signs of PCP intoxication?

Nystagmus, hypertension, tachycardia, diminished pain response, ataxia, dysarthria, rigidity, seizures, hyperacusis, and hyperthermia.

How is PCP intoxication managed?

supportive care, benzodiazepines (IM or IV), physical restraints if necessary, and mechanical cooling for hyperthermia

Can patients intoxicated with PCP be talked down like with other hallucinogens?

no, they often require physical restraint and medication

Is there an official hallucinogen withdrawal syndrome?

No official withdrawal pattern exists, but hallucinogen persisting perception disorder (HPPD) can occur.

What is hallucinogen persisting perception disorder (HPPD)?

Re-experiencing perceptual disturbances (e.g., visual distortions) during sobriety, especially after LSD use, impairing normal functioning.

what are volatile hydrocarbons?

toxic gases inhaled through the nose or mouth that enter the blood stream

what common products contain inhalants?

glues, adhesives, aerosol sprays, paint thinners, correction fluids, gasoline, and propane

what is sudden sniffing death?

Sudden death due to cardiac arrhythmias, particularly with butane or propane.

What are the signs of inhalant intoxication at low doses?

Disinhibition and euphoria.

What are the signs of inhalant intoxication at high doses?

Hallucinations, distorted body image, impaired judgment, aggression, stupor, amnesia, and psychosis.

What physical effects occur with inhalant intoxication?

nausea, nystagmus, diplopia, depressed reflexes, and anorexia

Is inhalant withdrawal recognized in DSM-5?

no

What are the hallmark signs of opioid intoxication?

psychomotor retardation, drowsiness, slurred speech, mitosis (pinpoint pupils), decreased bowel sounds, and reduced respiratory rate

What are the three key signs of opioid overdose?

coma, pinpoint pupils, and respiratory depression

What is the first step in managing an opioid overdose?

support breathing: clear secretions, insert airway, provide ventilation if needed

What medication is used to reverse opioid overdose and how is it administered?

Naloxone (Narcan); administered intranasally, intramuscularly, subcutaneously, or intravenously

What is the major concern with naloxone treatment?

it may precipitate acute withdrawal and has a shorter half-life than most opioids, requiring repeat doses

What are early signs of opioid withdrawal?

mood dysphoria, nausea, vomiting, diarrhea, muscle aches, fever, and insomnia

what are classic physical symptoms of opioid withdrawal?

Lacrimation, rhinorrhea, yawning, pupillary dilation, piloerection (“cold turkey”), sweating, and spontaneous ejaculation.

When do withdrawal symptoms begin for morphine, heroin, or methadone?

6-8 hours after last dose following at least a week of use

What medication is a synthetic opioid used to reduce withdrawal symptoms and block euphoria?

methadone

What is a major safety consideration when using methadone?

monitor for respiratory depression, chest pain, rash, or hallucinations; it must be dispensed through a certified program

What alpha-agonist medications are used to treat opioid withdrawal symptoms?

clonidine and lofexidine

What medication is a partial opioid agonist used to treat opioid dependence?

Buprenorphine.

Why must buprenorphine be started only after the onset of withdrawal symptoms?

It can precipitate acute withdrawal if opioids are still in the bloodstream

what is the goal of opioid maintenance therapy?

to maintain abstinence and prevent relapse after detox

what opioid antagonist is used in maintenance therapy to block the effects of opioids?

Naltrexone (oral or IM – Vivitrol).

What are common side effects of naltrexone or Vivitrol?

GI distress, dizziness, muscle cramps, appetite changes, and injection site reactions

What psychological therapies are effective in managing opioid use disorder?

CT, individual therapy, family therapy, social skills training, and 12-step groups like NA

What is the role of residential treatment in opioid use disorder?

Provides a highly structured environment for motivated individuals with peer confrontation and isolation from drug-using environments.

what cardiac signs is common in opioid intoxication?

bradycardia

what is a typical blood pressure finding in opioid intoxication?

hypotension

what body temperature changes occur with opioid intoxication?

hypothermia

what level of consciousness or alertness is associated with opioid intoxication?

sedation

what happens to pupil size in opioid intoxication?

mitosis (pinpoint pupils)

How do patients typically appear during opioid intoxication?

calm and relaxed

What cardiac sign is associated with opioid withdrawal?

tachycardia

What blood pressure change occurs in opioid withdrawal?

hypertension

What happens to body temperature during opioid withdrawal?

hyperthermia

How is sleep affected during opioid withdrawal?

insomnia

What happens to the pupils in opioid withdrawal?

mydriasis (enlarged pupils)

What is piloerection, and when does it occur?

Gooseflesh or “cold turkey” skin; seen in opioid withdrawal

What eye/nose symptoms occur in opioid withdrawal?

Lacrimation (tearing), yawning, rhinorrhea (runny nose)

What GI symptoms are typical in opioid withdrawal?

Nausea, vomiting, abdominal cramps, diarrhea

What types of musculoskeletal symptoms occur in opioid withdrawal?

Muscle spasms, bone and muscle pain

What emotional symptom is prominent during opioid withdrawal?

anxiety

What types of drugs are included in sedative, hypnotic, and antianxiety medication use disorder?

Benzodiazepines, benzodiazepine-like drugs (zolpidem, zaleplon), carbamates, barbiturates (secobarbital), barbiturate-like hypnotics (methaqualone), and most prescription sleeping and antianxiety medications.

What is a typical feature of sedative, hypnotic, and antianxiety medication use disorder?

craving

What can develop in anyone using these medications, even as prescribed?

significant tolerance and withdrawal

When is a use disorder diagnosis made for these medications?

Only when additional DSM-5 criteria are met, such as clinically significant maladaptive behavior or psychological changes.

Which age group has the highest prevalence of this disorder?

18- to 29-year-olds

What are symptoms of intoxication from these depressants?

Slurred speech, incoordination, unsteady gait, nystagmus, impaired thinking, inappropriate aggression or sexual behavior, mood fluctuation, and impaired judgment.

What is a dangerous complication of sedative, hypnotic, or antianxiety drug intoxication?

coma

What are treatments for overdose of these substances?

Gastric lavage, activated charcoal, monitoring vital signs, keeping the patient awake if conscious, IV fluids, endotracheal tube, and mechanical ventilation if needed.

What causes withdrawal symptoms from these drugs?

Rebound hyperactivity due to CNS depression and the body’s attempt to restore homeostasis.