Substance Misuse and Addiction

Definition | Classification (ICD-10 and DSM-5) | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Substance Misuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. Addiction, also known as Substance Use Disorder (SUD), is a chronic, relapsing condition characterised by the compulsive use of substances despite harmful consequences. Addiction involves physical and psychological dependence, often accompanied by tolerance and withdrawal symptoms.

Classification (ICD-10 and DSM-5)

Substance Misuse and Addiction are classified under the following diagnostic criteria:

ICD-10 Classification

In the ICD-10, Substance Misuse and Addiction are classified under:

• F10-F19 - Mental and Behavioural Disorders Due to Psychoactive Substance Use: This category includes disorders related to the use of alcohol, opioids, cannabinoids, sedatives or hypnotics, cocaine, other stimulants, hallucinogens, tobacco, and volatile solvents.
• F10.2 - Alcohol Dependence Syndrome: A specific diagnosis for chronic alcohol misuse with physical and psychological dependence.
• F11.2 - Opioid Dependence Syndrome: A specific diagnosis for chronic opioid misuse with physical and psychological dependence.

DSM-5 Classification

In the DSM-5, Substance Use Disorders (SUDs) are classified under:

• Substance Use Disorder: A single diagnostic category that covers the problematic pattern of use of intoxicating substances, leading to clinically significant impairment or distress. The diagnosis is based on criteria such as impaired control, social impairment, risky use, and pharmacological indicators (tolerance and withdrawal).
• Alcohol Use Disorder (AUD): A specific diagnosis for problematic alcohol use, characterised by the same criteria as SUDs but specific to alcohol.
• Opioid Use Disorder (OUD): A specific diagnosis for problematic opioid use, characterised by the same criteria as SUDs but specific to opioids.

Aetiology

The development of Substance Misuse and Addiction is multifactorial, involving a combination of genetic, psychological, and environmental factors:

• Genetic Factors: Genetic predisposition plays a significant role, with a higher risk in individuals who have a family history of substance use disorders. Specific genetic variations may affect the metabolism of substances and the reward pathways in the brain.
• Neurobiological Factors: Addiction involves changes in brain chemistry and function, particularly in the mesolimbic dopamine system, which is associated with reward, motivation, and reinforcement. Chronic substance use alters the brain's reward circuitry, leading to compulsive use.
• Psychological Factors: Co-occurring mental health conditions such as depression, anxiety, and trauma-related disorders increase the risk of substance misuse as individuals may use substances to self-medicate or cope with distressing emotions.
• Environmental Factors: Social and environmental influences, such as peer pressure, availability of substances, and exposure to stress or trauma, contribute to the initiation and continuation of substance misuse.
• Developmental Factors: Adolescents and young adults are particularly vulnerable to developing substance use disorders due to the ongoing development of the brain, particularly areas involved in impulse control and decision-making.

Risk Factors

Several factors increase the likelihood of developing Substance Misuse and Addiction:

• Family History: A family history of substance use disorders or other mental health conditions increases the risk.
• Early Use: Initiating substance use at a young age is associated with a higher risk of developing addiction.
• Mental Health Disorders: Co-occurring mental health conditions, such as depression, anxiety, or PTSD, can increase the risk of substance misuse.
• Social Environment: Exposure to environments where substance use is prevalent or socially accepted can increase the likelihood of misuse.
• Trauma and Stress: Experiencing significant stress, trauma, or adverse childhood experiences (ACEs) can contribute to the development of substance use disorders.

Clinical Presentation

Substance Misuse and Addiction present with a range of physical, psychological, and behavioural symptoms:

Physical Symptoms

• Withdrawal Symptoms: Physical and psychological symptoms that occur when the substance use is reduced or stopped, such as tremors, sweating, nausea, irritability, and anxiety.
• Tolerance: Needing to use larger amounts of the substance to achieve the same effect, due to the body's adaptation to the substance.
• Physical Health Complications: Chronic substance use can lead to a range of health issues, including liver disease (with alcohol), respiratory problems (with smoking), and cardiovascular problems (with stimulants).
• Poor Personal Hygiene: Neglecting self-care and hygiene due to the preoccupation with substance use.

Psychological Symptoms

• Cravings: Intense urges or desires to use the substance, often triggered by environmental cues or emotional states.
• Impaired Control: Inability to control or reduce substance use despite wanting to cut down or quit.
• Mood Swings: Frequent mood changes, including irritability, depression, anxiety, or euphoria, often linked to substance use or withdrawal.
• Paranoia and Psychosis: In some cases, especially with stimulant or hallucinogen use, individuals may experience paranoia, hallucinations, or psychotic episodes.

Behavioural Symptoms

• Neglect of Responsibilities: Failing to fulfil obligations at work, school, or home due to substance use.
• Social Withdrawal: Isolating from friends, family, or social activities that do not involve substance use.
• Risky Behaviours: Engaging in dangerous activities while under the influence, such as driving, unprotected sex, or criminal behaviour.
• Financial and Legal Problems: Spending excessive amounts of money on substances, leading to financial difficulties, or encountering legal issues related to substance use.

Investigations

The diagnosis of Substance Misuse and Addiction is primarily clinical, based on a detailed history and assessment of symptoms. Additional investigations may include:

• Substance Use History: A thorough assessment of the types of substances used, frequency, duration, and patterns of use, as well as any previous attempts to quit or reduce use.
• Screening Tools: The use of validated screening tools, such as the Alcohol Use Disorders Identification Test (AUDIT) or the Drug Abuse Screening Test (DAST), to assess the severity of substance misuse.
• Physical Examination: A physical examination to assess for signs of substance misuse, such as track marks, jaundice, or respiratory issues, and to identify any complications arising from chronic use.
• Laboratory Tests: Blood and urine tests to detect the presence of substances, evaluate liver and kidney function, and identify any metabolic complications related to substance use.
• Mental Health Assessment: A comprehensive mental health evaluation to assess for co-occurring psychiatric conditions, such as depression, anxiety, or personality disorders.

Management

The management of Substance Misuse and Addiction typically involves referring the patient to a drug and addiction service, where the patient will recieve a combination of pharmacotherapy, psychological therapies, and social support:

Pharmacotherapy

• Detoxification: Medically supervised detoxification to manage withdrawal symptoms and safely reduce substance use. Medications such as benzodiazepines for alcohol withdrawal or methadone for opioid detoxification may be used.
• Maintenance Therapy: Medications such as methadone or buprenorphine for opioid dependence, or nicotine replacement therapy for smoking cessation, to reduce cravings and prevent relapse.
• Anti-craving Medications: Medications such as naltrexone or acamprosate for alcohol dependence, or varenicline for smoking cessation, to help reduce cravings.
• Management of Co-occurring Conditions: Antidepressants, antipsychotics, or mood stabilisers may be prescribed to manage co-occurring psychiatric conditions.

Psychological Therapies

• Cognitive Behavioural Therapy (CBT): CBT helps individuals identify and change the thought patterns and behaviours that contribute to substance misuse, and develop coping strategies to manage cravings and prevent relapse.
• Motivational Interviewing (MI): A client-centred counselling approach that enhances motivation to change by exploring and resolving ambivalence about substance use.
• Contingency Management: A behavioural therapy that uses positive reinforcement, such as rewards or vouchers, to encourage abstinence and adherence to treatment.

Social Support

• Case Management: A case manager or social worker can help coordinate care, provide resources, and connect individuals with social services, housing, and employment support.
• Family Therapy: Involves the family in the treatment process, providing education and support to help manage the condition and reduce the impact on relationships.
• Residential Treatment: In some cases, individuals may benefit from a stay in a residential treatment facility, where they can receive intensive therapy and support in a structured environment.
• Relapse Prevention: Ongoing support to help individuals maintain sobriety, including aftercare planning, support groups, and continued therapy.

References

1. National Institute for Health and Care Excellence (2024) Alcohol-Use Disorders: Diagnosis, Assessment, and Management. Available at: https://www.nice.org.uk/guidance/cg115 (Accessed: 26 August 2024).
2. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Available at: https://www.psychiatry.org/psychiatrists/practice/dsm (Accessed: 26 August 2024).
3. World Health Organization (1992) ICD-10 Classification of Mental and Behavioural Disorders. Available at: https://www.who.int/classifications/icd/en/bluebook.pdf (Accessed: 26 August 2024).

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