Substance use disorder

, late 19th century Substance use disorders (SUDs) are highly prevalent and exact a large toll on individuals' health, well-being, and social functioning. Long-lasting changes in brain networks involved in reward, executive function, stress reactivity, mood, and self-awareness underlie the intense drive to consume substances and the inability to control this urge in a person who suffers from addiction (moderate or severe SUD). Biological (including genetics and developmental life stages) and social (including adverse childhood experiences) determinants of health are recognized factors that contribute to vulnerability to or resilience against developing a SUD. Consequently, prevention strategies that target social risk factors can improve outcomes and, when deployed in childhood and adolescence, can decrease the risk for these disorders. This section divides substance use disorder causes into categories consistent with the biopsychosocial model. However, it is important to bear in mind that these categories are used by scientists partly for convenience; the categories often overlap (for example, adolescents and adults whose parents had—or have—an alcohol use disorder display higher rates of alcohol problems, a phenomenon that can be due to genetic, observational learning, socioeconomic, and other causal factors); and these categories are not the only ways to classify substance use disorder etiology. Similarly, most researchers in this and related areas (such as the etiology of psychopathology generally), emphasize that various causal factors interact and influence each other in complex and multifaceted ways. Social determinants Among older adults, being divorced, separated, or single, having more financial resources, lack of religious affiliation, bereavement, involuntary retirement, and homelessness are all associated with alcohol problems, including alcohol use disorder. Issues may often be interconnected: people without jobs are more likely to abuse substances which then makes them unable to work. Not having a job leads to stress and sometimes depression which in turn can cause an individual to increase substance use. This leads to a cycle of substance abuse and unemployment. The likelihood of substance abuse can increase during childhood. Through a study conducted in 2021 about the effect childhood experiences have on future substance use, researchers found that there is a direct connection between the two factors. Individuals that had experiences in their childhood which left them traumatized in some way had a much higher chance of substance abuse. While SUD is often viewed as a person-centered issue, it is also a family disease. Individuals struggling with substance abuse frequently damage relationships with loved ones, and in severe cases, SUD can lead to family separation through divorce or intervention by government agencies like Child Protective Services (CPS). Unfortunately, it may even result in suicide, leaving families to grieve. SUD is commonly associated with a range of emotional and psychological problems, including anger, guilt, depression, anxiety, and violence. These issues not only affect the individual but also their family and community. To effectively combat SUD, it's crucial to address its causes particularly in mental health challenges. By improving access to mental health care, people can help prevent and treat substance use more effectively. There are many programs available to support individuals and families affected by SUD. These include therapy centers, support groups, and dedicated treatment facilities such as Bear River Health, Sacred Heart, Harbor Hall, and ATS. Peer support plays a vital role in recovery. Organizations like Al-Anon/Nar-Anon, AA/NA, Celebrate Recovery, and DHARMA provide the support to individuals and families navigating the challenges of substance use. Psychological determinants Psychological causal factors include cognitive, affective, and developmental determinants, among others. For example, individuals who begin using alcohol or other drugs in their teens are more likely to have a substance use disorder as adults.), and lack of familial support and supervision. Biological determinants Children born to parents with who have a substance use disorder have roughly a two-fold increased risk in developing a substance use disorder compared to children born to parents without this disorder. Other factors such as substance use during pregnancy, or the persistent inhalation of secondhand smoke can also influence a person's substance use behaviors in the future. == Signs and symptoms ==

Symptoms for a substance use disorder include behavioral, physical and social changes. Changes in behavior include being absent from school or work; changes in appetite or sleep patterns; personality and attitude changes; mood swings, and anxiety. Signs include physical changes such as weight gain or loss; tremors, and bloodshot eyes. Different substances used can give different signs and symptoms. There are a number of psychological changes associated with substance use disorders, including anxiety and depression. Anxiety and depression symptoms are closely linked to greater substance use over time, especially in adolescents. Some adolescents who are current or lifetime users can experience clinical levels of anxiety and depression, screenable through the PHQ-4. Hallucinations can also occur due to the use of psychoactives such as cannabis, which may lead to onset of disorders like schizophrenia. The list of physical health conditions associated with various substance use disorders is comprehensive; different substances tax the body in different ways, and each organ system experiences some form of distress or disruption as a result of substance use disorders. Some of the many health conditions are as follows: • Language and Coordination impairment • Memory loss • Liver failure • Hypertension • Kidney failure • Deep comatose states • Transmission of HIV and other diseases carried on needles • Osteoporosis • Immunodeficiencies == Diagnosis ==

It is important when diagnosing substance use disorder to define the difference between substance use and substance abuse. "Substance use pertains to using select substances such as alcohol, tobacco, illicit drugs, etc. that can cause dependence or harmful side effects."On the other hand, substance abuse is the use of drugs such as prescriptions, over-the-counter medications, or alcohol for purposes other than what they are intended for or using them in excessive amounts. Individuals whose drug or alcohol use cause significant impairment or distress may have a substance use disorder (SUD). The most commonly used guidelines are published in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The quantity of criteria met offer a rough gauge of the severity of illness, but licensed professionals will also take into account a more holistic view when assessing severity which includes specific consequences and behavioral patterns related to an individual's substance use. The index assesses potential problems in seven categories: medical, employment/support, alcohol, other drug use, legal, family/social, and psychiatric. Screening tools There are several different screening tools that have been validated for use with adolescents, such as the CRAFFT, and with adults, such as CAGE, AUDIT and DALI. Laboratory tests to detect alcohol and other drugs in urine and blood may be useful during the assessment process to confirm a diagnosis, to establish a baseline, and later, to monitor progress. However, since these tests measure recent substance use rather than chronic use or dependence, they are not recommended as screening tools. Along with CRAFFT, CAGE, AUDIT, and DALI, there are a number of specific screening tools which can be utilized for adolescents. Focusing specifically on tobacco and alcohol use, the S2BI, BSTAD, and TAPS are reliable tools which can screen for DSM diagnoses across the three types of addiction. The S2BI is useful for identifying a broader range of addictions, and TAPS is useful in clinical settings for a more comprehensive screening of substance use disorders. One of the greatest challenges related to screening adolescents is parental consent. IRB regulations require that research on individuals under the age of 18 includes informed consent from the parents or legal guardians, yet these studies ask participants to report behaviors which are violations of law at that age. Notably, this produces a selection bias in which participants whose parents provided consent were less likely to experience substance use issues. ==Management==

Withdrawal management Withdrawal management is the medical and psychological care of patients who are experiencing withdrawal symptoms due to the ceasing of drug use. Depending on the severity of use, and the given substance, early treatment of acute withdrawal may include medical detoxification. Of note, acute withdrawal from heavy alcohol use should be done under medical supervision to prevent a potentially deadly withdrawal syndrome known as delirium tremens . Therapy Several factors contribute to the rehabilitation of SUD, including coping, craving, motivation to change, self-efficacy, social support, motives and expectancies, behavioral economic indicators, and neurobiological, neurocognitive, and physiological factors. These can be treated in a variety of ways, such as by cognitive behavioral therapy (CBT), which is an intervention treatment that helps individuals identify and change harmful thought patterns that may influence their emotions and behaviors negatively. Other treatment options include motivational interviewing (MI), a technique used to help motivate doubtful patients to change their behavior, and combined behavioral intervention (CBI), which involves combining elements of alcohol interventions, motivational interviewing, and functional analysis to help the clinician identify skill deficits and high risk situations that are associated with drinking or drug use. Therapists often classify people with chemical dependencies as either interested or not interested in changing. About 11% of Americans with substance use disorder seek treatment, and 40–60% of those people relapse within a year. Treatments usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention approaches to specific influences that affect addictive behavior, using therapeutic interviews in an effort to discover factors that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain. From the applied behavior analysis literature and the behavioral psychology literature, several evidence-based intervention programs have emerged, such as behavioral marital therapy, community reinforcement approach, cue exposure therapy, and contingency management strategies. In addition, the same author suggests that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious. Medication Medication-assisted treatment (MAT) refers to the combination of behavioral interventions and medications to treat substance use disorders. Certain medications can be useful in treating severe substance use disorders. In the United States five medications are approved to treat alcohol and opioid use disorders. There are no approved medications for cocaine, methamphetamine. Medications, such as methadone and disulfiram, can be used as part of broader treatment plans to help a patient function comfortably without illicit opioids or alcohol. Medications can be used in treatment to lessen withdrawal symptoms. Evidence has demonstrated the efficacy of medication-assisted treatment at reducing illicit drug use and overdose deaths, improving retention in treatment, and reducing HIV transmission. Potential vaccines for addiction to substances Vaccines for addiction have been investigated as a possibility since the early 2000s. The general theory of a vaccine intended to "immunize" against drug addiction or other substance abuse is that it would condition the immune system to attack and consume or otherwise disable the molecules of such substances that cause a reaction in the brain, thus preventing the addict from being able to realize the effect of the drug. Examples of addictive substances that have been floated as targets for such treatment include nicotine and opioids. Vaccines have been identified as potentially being more effective than other anti-addiction treatments, due to "the long duration of action, the certainty of administration and a potential reduction of toxicity to important organs". Specific addiction vaccines in development include: • NicVAX, a conjugate vaccine intended to reduce or eliminate physical dependence on nicotine. This proprietary vaccine is being developed by Nabi Biopharmaceuticals of Rockville, MD with the support from the U.S. National Institute on Drug Abuse. NicVAX consists of the hapten 3'-aminomethyl nicotine which has been conjugated (attached) to Pseudomonas aeruginosa exotoxin A . • TA-CD, an active vaccine developed by the Xenova Group which is used to negate the effects of cocaine. It is created by combining norcocaine with inactivated cholera toxin. It works in much the same way as a regular vaccine. A large protein molecule attaches to cocaine, which stimulates response from antibodies, which destroy the molecule. This also prevents the cocaine from crossing the blood–brain barrier, negating the euphoric high and rewarding effect of cocaine caused from stimulation of dopamine release in the mesolimbic reward pathway. The vaccine does not affect the user's "desire" for cocaine—only the physical effects of the drug. • TA-NIC, used to create human antibodies to destroy nicotine in the human body so that it is no longer effective. As of September 2023, it was further reported that a vaccine "has been tested against heroin and fentanyl and is on its way to being tested against oxycontin". == Epidemiology ==

Rates of substance use disorders vary by nation and by substance, but the overall prevalence is high. On a global level, men are affected at a much higher rate than women. United States In 2020, 14.5% of Americans aged 12 or older had a SUD in the past year. Rates of alcohol use disorder in the past year were just over 5%. Approximately 3% of people aged 12 or older had an illicit drug use disorder. which is a threefold increase from 2002. Overdose fatalities from synthetic opioids, which typically involve fentanyl, have risen sharply in the past several years to contribute to nearly 30,000 deaths per year. Tobacco remains the leading cause of preventable death, responsible for greater than 480,000 deaths in the United States each year. These harms are significant financially with total costs of more than $420 billion annually and more than $120 billion in healthcare. Canada According to Statistics Canada (2018), approximately one in five Canadians aged 15 years and older experience a substance use disorder in their lifetime. In Ontario specifically, the disease burden of mental illness and addiction is 1.5 times higher than all cancers together and over 7 times that of all infectious diseases. Across the country, the ethnic group that is statistically the most impacted by substance use disorders compared to the general population are the Indigenous peoples of Canada. In a 2019 Canadian study, it was found that Indigenous participants experienced greater substance-related problems than non-Indigenous participants. Statistics Canada's Canadian Community Health Survey (2012) shows that alcohol was the most common substance for which Canadians met the criteria for abuse or dependence. Further, in an Ontario study on mental health and substance use among Indigenous people, 19% reported the use of cocaine and opiates, higher than the 13% of Canadians in the general population that reported using opioids. Australia Historical and ongoing colonial practices continue to impact the health of Indigenous Australians, with Indigenous populations being more susceptible to substance use and related harms. For example, alcohol and tobacco are the predominant substances used in Australia. Although tobacco smoking is declining in Australia, it remains disproportionately high in Indigenous Australians with 45% aged 18 and over being smokers, compared to 16% among non-Indigenous Australians in 2014–2015. As for alcohol, while proportionately more Indigenous people refrain from drinking than non-Indigenous people, Indigenous people who do consume alcohol are more likely to do so at high-risk levels. About 19% of Indigenous Australians qualified for risky alcohol consumption (defined as 11 or more standard drinks at least once a month), which is 2.8 times the rate that their non-Indigenous counterparts consumed the same level of alcohol. In 2016, Indigenous persons were 2.3 times more likely to misuse pharmaceutical drugs than non-Indigenous people. == Patient record confidentiality ==

In the United States, treatment records for substance use disorders have historically received heightened federal confidentiality protections under 42 CFR Part 2, first enacted in 1975. These regulations, administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), restricted the disclosure of patient records from federally assisted SUD treatment programs more strictly than general medical records, requiring specific written patient consent for most disclosures and prohibiting the use of SUD records in criminal proceedings without a court order. In February 2024, the U.S. Department of Health and Human Services (HHS) issued a final rule implementing Section 3221 of the CARES Act, substantially aligning 42 CFR Part 2 with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. The rule, effective April 16, 2024, with a compliance date of February 16, 2026, permits a single patient consent for all future uses and disclosures of SUD records for treatment, payment, and health care operations, and allows HIPAA-covered entities that receive Part 2 records to redisclose them in accordance with HIPAA regulations. The rule also applied HIPAA breach notification requirements to Part 2 records, extended patient rights to obtain an accounting of disclosures, and created new protections for SUD counseling notes analogous to HIPAA's psychotherapy notes provisions. Proponents argued the alignment would improve care coordination by reducing barriers to sharing SUD treatment information, while critics expressed concern that relaxed consent requirements could expose patients to discrimination or legal consequences. ==See also==