Overview · Web viewWhy Do Some People Become Addicted While Others Do Not? No single factor can predict whether a person will become addicted to drugs. Risk for addiction is influenced

Substance Misuse (Drugs) Tip Sheet

I. Overview

According to the DSM-5, substance-related disorders consist of 10 distinct classes of drugs, and including alcohol, cannabis, caffeine, hallucinogens, inhalants, sedatives (hypnotics or anxiolytics), stimulants, opioids, tobacco, and other or unknown substances. These drugs tend to have common mechanistic processes, such that when taken in excess, they activate the mesolimbic reward pathway of the brain. Intense activation of this reward pathway can result in powerful reinforcement of drug-taking behavior, and leave a lasting impression on memory. Although the mechanisms by which certain drugs activate the reward system differ, many induce feelings of pleasure and a “high” state (American Psychiatric Association, 2013; Di Chiara, 1998). Within the DSM-5, substance-related disorders encompass both substance use disorders (SUDs) and substance-induced disorders. SUDs entail clusters of cognitive, behavioral, and physiological symptoms that may result from using a substance, and continued use of the substance despite significant problems relating to its use. Substance-related impairments might include health problems, disabilities, and failure to complete major responsibilities within occupational, scholastic, or interpersonal domains (American Psychiatric Association, 2013).

Excessive use of substances can lead to SUD diagnoses within all 10 classes of substances, with the exception of caffeine. An SUD diagnosis rests on pathological behaviors surrounding substance use, including certain groupings of “impaired control, social impairment, risky use, and pharmacological criteria” (American Psychiatric Association, 2013, p. 483). Individual criteria within these groupings include taking more of a substance in larger amounts or over a greater time period than was originally intended (Criterion 1), desire to reduce or regulate use with potential unsuccessful attempts (Criterion 2), spending significant amounts of time to obtain the substance (Criterion 3), cravings (Criterion 4), failure to meet obligations at work, school, or home (Criterion 5), increased interpersonal problems caused or intensified by substance use (Criterion 6), important activities given up because of substance use (Criterion 7), recurrent substance use in hazardous situations (Criterion 8), psychological problems caused or intensified by substance use (Criterion 9), tolerance (Criterion 10), and withdrawal (Criterion 11). The amount of severity of the SUD is a product of how many criteria are met, as described by mild, moderate, or severe (American Psychiatric Association, 2013).

Substance usage, and SUDs specific to substances, have differing prevalence rates. The Substance Abuse and Mental Health Services Administration (SAMHSA) 2014 National Survey on Drug Use and Health (NSDUH) estimated that approximately 21.5 million people (aged 12 or older) had a SUD that year. With regard to specific substances, the report also estimated prevalence rates for alcohol use disorders (17.0 million) and illicit drug use disorders (7.1 million). Further, in 2014, they estimated that 66.9 million individuals were current tobacco users (with 55.2 million cigarette smokers), and that 27.0 million individuals used illicit drugs (see CBHSQ, 2015 for individual illicit drug use estimates). SAMHSA also provided estimate

rates for co-occurring mental illness and SUD, with 3.3 percent of all adults having both an SUD and any mental illness. They estimate that 22.5 million people (8.5 percent of the population) aged 12 or over needed treatment for an illicit drug or alcohol use problem, yet, only 4.2 million received any substance use treatment in that same year (CBHSQ, 2015). Although no single treatment is appropriate for everyone and depends on the type of drug and individual characteristics, the most commonly used behavioral treatment methods include cognitive-behavioral therapy, contingency management, motivational interviewing, group counseling, and varieties of family therapies (National Institute on Drug Abuse, 2012).

II. Understanding Drug Abuse and Addiction

Many people do not understand why or how other people become addicted to drugs. It is often mistakenly assumed that drug abusers lack moral principles or willpower and that they could stop using drugs simply by choosing to change their behavior. In reality, drug addiction is a complex disease, and quitting takes more than good intentions or a strong will. In fact, because drugs change the brain in ways that foster compulsive drug abuse, quitting is difficult, even for those who are ready to do so. Through scientific advances, we know more about how drugs work in the brain than ever, and we also know that drug addiction can be successfully treated to help people stop abusing drugs and lead productive lives.

Drug abuse and addiction have negative consequences for individuals and for society. Estimates of the total overall costs of substance abuse in the United States, including productivity and health- and crime-related costs, exceed $600 billion annually. This includes approximately $193 billion for illicit drugs,1 $193 billion for tobacco,2 and $235 billion for alcohol.3 As staggering as these numbers are, they do not fully describe the breadth of destructive public health and safety implications of drug abuse and addiction, such as family disintegration, loss of employment, failure in school, domestic violence, and child abuse.

III. What is Drug Addiction?

Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use, despite harmful consequences to the addicted individual and to those around him or her. Although the initial decision to take drugs is voluntary for most people, the brain changes that occur over time challenge an addicted person’s self-control and hamper his or her ability to resist intense impulses to take drugs.

Fortunately, treatments are available to help people counter addiction’s powerful disruptive effects. Research shows that combining addiction treatment medications with behavioral therapy is the best way to ensure success for most patients. Treatment approaches that are tailored to each patient’s drug abuse patterns and any co-occurring medical, psychiatric, and social problems can lead to sustained recovery and a life without drug abuse.

Similar to other chronic, relapsing diseases, such as diabetes, asthma, or heart disease, drug addiction can be managed successfully. And as with other chronic diseases, it is not uncommon for a person to relapse and begin abusing drugs again. Relapse, however, does not signal treatment failure—rather, it indicates that treatment should be reinstated or adjusted or that an alternative treatment is needed to help the individual regain control and recover.

IV. What Happens to Your Brain When You Take Drugs?

Drugs contain chemicals that tap into the brain’s communication system and disrupt the way nerve cells normally send, receive, and process information. There are at least two ways that drugs cause this disruption: (1) by imitating the brain’s natural chemical messengers and (2) by overstimulating the “reward circuit” of the brain.

Some drugs (e.g., marijuana and heroin) have a similar structure to chemical messengers called neurotransmitters, which are naturally produced by the brain. This similarity allows the drugs to “fool” the brain’s receptors and activate nerve cells to send abnormal messages.

Other drugs, such as cocaine or methamphetamine, can cause the nerve cells to release abnormally large amounts of natural neurotransmitters (mainly dopamine) or to prevent the normal recycling of these brain chemicals, which is needed to shut off the signaling between neurons. The result is a brain awash in dopamine, a neurotransmitter present in brain regions that control movement, emotion, motivation, and feelings of pleasure. The overstimulation of this reward system, which normally responds to natural behaviors linked to survival (eating, spending time with loved ones, etc.), produces euphoric effects in response to psychoactive drugs. This reaction sets in motion a reinforcing pattern that “teaches” people to repeat the rewarding behavior of abusing drugs.

As a person continues to abuse drugs, the brain adapts to the overwhelming surges in dopamine by producing less dopamine or by reducing the number of dopamine receptors in the reward circuit. The result is a lessening of dopamine’s impact on the reward circuit, which reduces the abuser’s ability to enjoy not only the drugs but also other events in life that previously brought pleasure. This decrease compels the addicted person to keep abusing drugs in an attempt to bring the dopamine function back to normal, but now larger amounts of the drug are required to achieve the same dopamine high—an effect known as tolerance.

Long-term abuse causes changes in other brain chemical systems and circuits as well. Glutamate is a neurotransmitter that influences the reward circuit and the ability to learn. When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to compensate, which can impair cognitive function. Brain imaging studies of drug-addicted individuals show changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control. Together, these changes can drive an abuser to seek out and take drugs compulsively despite adverse, even devastating consequences—that is the nature of addiction.

V. Why Do Some People Become Addicted While Others Do Not?

No single factor can predict whether a person will become addicted to drugs. Risk for addiction is influenced by a combination of factors that include individual biology, social environment, and age or stage of development. The more risk factors an individual has, the greater the chance that taking drugs can lead to addiction. For example:

Biology. The genes that people are born with—in combination with environmental influences—account for about half of their addiction vulnerability. Additionally, gender, ethnicity, and the presence of other mental disorders may influence risk for drug abuse and addiction.

Environment. A person’s environment includes many different influences, from family and friends to socioeconomic status and quality of life in general. Factors such as peer pressure, physical and sexual abuse, stress, and quality of parenting can greatly influence the occurrence of drug abuse and the escalation to addiction in a person’s life.

Development. Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction vulnerability. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it will progress to more serious abuse, which poses a special challenge to adolescents. Because areas in their brains that govern decision making, judgment, and self-control are still developing, adolescents may be especially prone to risk-taking behaviors, including trying drugs of abuse.

VI. Prevention is Key

Drug addiction is a preventable disease. Results from NIDA-funded research have shown that prevention programs involving families, schools, communities, and the media are effective in reducing drug abuse. Although many events and cultural factors affect drug abuse trends, when youths perceive drug abuse as harmful, they reduce their drug taking. Thus, education and outreach are key in helping youth and the general public understand the risks of drug abuse. Teachers, parents, and medical and public health professionals must keep sending the message that drug addiction can be prevented if one never abuses drugs.

VII. Tools and Screeners

NIDA Quick Screen V1.01

Patient Name: _______________________________________ Sex: ( ) F ( ) M Age ______ Interviewer: _________________________________________ Date: ____/____/____

STEP 1 – Ask the NIDA Quick Screen QuestionInstructions: Using the sample language below, introduce yourself to your patient, then ask about past year drug use, using the NIDA Quick Screen. For each substance, mark in the appropriate column. For example, if the patient has used cocaine monthly in the past year, put a mark in the “Monthly” column in the “illegal drug” row.Introduction (Please read to patient)Hi, I’m __________, nice to meet you. If it’s okay with you, I’d like to ask you a few questions that will help me give you better medical care. The questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record those if you have taken them for reasons or in doses other than prescribed. I’ll also ask you about illicit or illegal drug use––but only to better diagnose and treat you.

If the patient says “NO” for all drugs in the Quick Screen, reinforce abstinence. Screening is complete.If patient says “Yes” to one or more days of heavy drinking, note that patient is an at-risk drinker. Please see NIAAA website “How to Help Patients Who Drink Too Much: A Clinical Approach” http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm, for information to advise, assess, assist, and arrange help for at risk drinkers or patients with alcohol use disorders.If patient says “Yes” to use of tobacco: Any current tobacco use places a patient at risk. Advise all tobacco users to quit. For more information on smoking cessation, please see “HelpingSmokers Quit: A Guide for Clinicians” http://www.ahrq.gov/professionals/clinicians-providers/ guidelines-recommendations/tobacco/clinicians/references/clinhlpsmkqt/If the patient says “Yes” to use of illegal drugs or prescription drugs for non-medical reasons, proceed to Question 1 of the NIDA-Modified ASSIST.

Modified ASSIST V2.0 (Questions 1-8)

STEP 2 – Ask about any lifetime drug use (Question 1)Instructions: Now ask the patient about any lifetime drug use. This form may be completed by your patient or any health care professional in your office. Screening personnel should offer to read the questions aloud in a private setting and complete the form for the patient. To preserve confidentiality, a protective sheet should be placed on top of the questionnaire so it will not be seen by other patients after it is completed.

Given the patient’s response to the Quick Screen, the patient should not indicate “NO” for all drugs in Question 1. If they do, remind them that their answers to the Quick Screen indicated they used an illegal or prescription drug for nonmedical reasons within the past year and then repeat Question 1. If the patient indicates that the drug used is not listed, please mark ‘Yes’ next to ‘Other,’ write in the name of the drug, and continue to Question 2 of the NIDA-Modified ASSIST.If the patient says “Yes” to any of the drugs, proceed to Question 2 of the NIDA-Modified ASSIST. NIDA-Modified ASSIST V2.0 (Questions 1-8)

NEXT – Ask about more recent drug use (Questions 2-8)Instructions: Next, ask questions 2 through 8. On the line below, record the name of the substance the patient reported using in Question 1 (use a separate form for each drug reported ‘ever’ used). Circle the number corresponding to patient answers, then add all circled numbers (Questions 2-7 only) to determine patient risk level (Substance Involvement Score) for each drug used.Name of the substance used: ______________________________________________________

Determine patient’s risk level based on patient substance involvement (SI) Score:

For more information on NIDA screening and brief intervention recommendations, please refer to NIDA’s Clinician Resource Guide (http://www.drugabuse.gov/sites/default/files/resource_guide.pdf).Additional Screening RecommendationsIf patient reports any prior or current intravenous drug use, recommend that they get tested for HIV and Hepatitis B/C.If patient reports using a drug by injection in the past three months, ask about their pattern of injecting during this period to determine their risk levels and the best course of intervention.o If patient responds that they inject once weekly or less OR fewer than 3 days in a row, provide a briefintervention including a discussions of the risks associated with injecting.o If patient responds that they inject more than once per week OR 3 or more days in a row, refer for furtherassessment.

The CAGE and CAGE-AID Questionnaires

1. Have you ever felt you ought to cut down on your drinking or drug use?

2. Have people annoyed you by criticizing your drinking or drug use?

3. Have you ever felt bad or guilty about your drinking or drug use?

4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to

get rid of a hangover?

Note. The plain text shows the CAGE questions. The italicized text was added to produce the

CAGE- AID. For this study, the CAGE-AID was preceded by the following instruction: “When

thinking about drug use, include illegal drug use and the use of prescription drugs other than as

prescribed.”

"The prevalence and detection of substance use disorder among inpatients ages 18 to 49: An

opportunity for prevention" by Brown RL, Leonard T, Saunders LA, Papasouliotis O.

Preventive Medicine, Volume 27, pages 101-110, copyright 1998, Elsevier Science (USA),

reproduced with permission from the publisher.

The CAGE and CAGE-AID Questions

The original CAGE questions appear in plain type. The CAGE questions Adapted to Include

Drugs (CAGE-AID) are the original CAGE questions modified by the italicized text.

The CAGE or CAGE-AID should be preceded by these two questions:

1. Do you drink alcohol?

2. Have you ever experimented with drugs?

If the patient has experimented with drugs, ask the CAGE-AID questions. If the patient only

drinks alcohol, ask the CAGE questions.

CAGE and CAGE-AID Questions

1. In the last three months, have you felt you should cut down or stop drinking or using drugs?

Yes No

2. In the last three months, has anyone annoyed you or gotten on your nerves by telling you to

cut down or stop drinking or using drugs?

Yes No

3. In the last three months, have you felt guilty or bad about how much you drink or use drugs?

Yes No

4. In the last three months, have you been waking up wanting to have an alcoholic drink or use

drugs?

Yes No

Each affirmative response earns one point. One point indicates a possible problem. Two

points indicate a probable problem.

Reference: The Society of Teachers of Family Medicine. Project SAEFP Workshop Materials,

Screening and Assessment Module, page 18. Funded by the Division of Health Professionals,

HRSA, DHHS, Contract No. 240-89-0038. Used with permission. A7012-DA-4W

VIII. Recommended Reading For information on understanding drug abuse and addiction, please see Drugs, Brains, and

Behavior—The Science of Addiction at www.drugabuse.gov/publications/drugs- brains-behavior-science-addiction/drug- abuse-addiction.

For more information on prevention, please visit the Prevention Research information page at www.drugabuse.gov/related- topics/prevention.

For more information on treatment, please visit the Treatment Research information page at www.drugabuse.gov/related- topics/treatment.

To find a publicly funded treatment center in your State, please call 1-800-662-HELP or visit https://findtreatment.samhsa.gov/.

ResourcesAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th Ed.). Arlington, VA: American Psychiatric Publishing.

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/data/.

Di Chiara, G. A. (1998). Motivational learning hypothesis of the role of mesolimbic dopaminein compulsive drug use. Journal of Psychopharmacology, 12(l), 54-67.

National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-based guide (NIH Publication No. 12–4180). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/acknowledgments.

National Drug Intelligence Center (2011). The Economic Impact of Illicit Drug Use on American Society.Washington D.C.: United States Department of Justice. Availableat: http://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf (PDF, 2.4 MB)

Centers for Disease Control and Prevention. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Morbidity and Mortality Weekly Report. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm

Rhem, J., Mathers, C., Popova, S., Thavorncharoensap, M., Teerawattananon Y., Patra, J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet, 373(9682):2223–2233, 2009.