Use drugs in moderation vs. not using drugs at all
Moderation = harm reduction (like e-cigarettes for nicotine use with decreased risk of lung cancer). Not at all = abstinence.
Substance use disorder diagnostic criteria
2+ in 12 months: Used larger amounts or longer time period, can’t cut back, lots of time spent obtaining, using & recovering, urge to use, failure to fulfill major obligations and continued use despite problems, reduced social activities, use in hazardous situations, tolerance, withdrawal
Substance use disorder specifiers
Early remission (3-12 months), sustained remission (>12 months, can have continued cravings), controlled environment (access to substance restricted). Mild severity = 2-3 symptoms. Moderate = 4-5. Severe = 6+.
Symptoms directly related to physiologic effects of the substance
Substance-induced syndrome (intoxication = depression w/alcohol & anxiety w/cocaine and withdraw = anxiety w/alcohol & depression w/cocaine). This is an additional diagnosis to SUD.
Symptoms not directly related to physiologic effects of the substance
Co-morbid condition. This is an additional diagnosis to SUD.
How do you determine if it is a substance-induced syndrome or a co-morbid illness?
History: prior associated symptoms in absence of substance abuse favors co-morbid conditions. Temporal relationship of substance abuse and symptoms favors substance-induced symptoms. Resolution of associated symptoms after abstinence from substance favors substance-induced symptoms.
46 yo female presents with recurrent episodes of depression for 21 years ago. 5 months ago she was depressed and 3 months ago she started drinking. She currently meets criteria for major depressive disorder and alcohol dependence. Are her symptoms co-morbid or substance-induced?
Co-morbid, Hx of depression w/o alcohol use and depression prior to alcohol use.
A 21 year old male presents with 2 episodes of mania lasting 2-3 days. Episodes start shortly after using ecstasy and resolve 36-48 hours later. Are his symptoms co-morbid or substance-induced?
Substance-induced. He has no prior history of mania, mania started after ecstasy use, symptoms resolve after ecstasy is discontinued.
Most common occurring psychiatric disorders that are co-morbid with substance use disorders?
Mood and anxiety disorders. Other common conditions include PTSD, ADHD and personality disorders.
Critical history to take in a mental health evaluation?
Substance use. The reverse is true for people presenting with substance use disorders. Also assess the stage of change if SUD is present, don’t overlook co-morbidities that may worsen prognosis.
Stages of Change
1) Pre-contemplation = “I don’t have a problem." 2) Contemplation = “I might have a problem.” 3) Preparation = “I’m ready to change." 4) Action = “Working to change now." 5) Maintenance = maintaining sobriety 6) Relapse = part of recovery cycle and should be anticipated
When is motivation interviewing effective
Contemplation stage and beyond. This is an exploration and inquiry of current behaviors that make change more difficult but more desirable.
Treatment of a patient with SUD and comorbid psychiatric conditions.
Concurrent and integrated treatment of SUD and co-morbid psychiatric illness has best results.
Since alcohol dependence is comorbid with an anxiety disorder, what drugs should you not give them if they have panic attacks?