Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Comorbidities of Substance Use Disorders


PSYCHIATRIC COMORBIDITIES OF SUBSTANCE USE DISORDERS

When thinking about the psychiatric manifestations of substance use disorder (SUD), one has to differentiate between:

  • 1

    The substance’s effects: Drugs and alcohol intoxication or withdrawal cause psychiatric signs and symptoms that are part of a given substance’s toxidrome. For example, feeling euphoric after using cocaine or anxious when going through alcohol withdrawal are expected effects of cocaine intoxication or alcohol withdrawal and should not be labeled as a manic or anxiety syndrome.

  • 2

    Substance-induced disorders: This category refers to the presence of psychiatric symptoms that:

    • ■

      Vastly exceed the expected effects of being intoxicated with or withdrawing from a substance.

    • ■

      Present with symptoms of an other psychiatric disorder (psychotic, bipolar, depressive, anxiety, obsessive-compulsive, sleep sexual or neurocognitive disorder), albeit there is no requirement to meet all the diagnostic criteria for the disorder.

    • ■

      Develop during or soon after substance intoxication or withdrawal.

    • ■

      The symptoms improve after a period of abstinence.

  • 3

    Co-occurring primary psychiatric disorders: This category refers to psychiatric disorders that either preceded or followed the onset of a SUD, but neither condition played a causative role in the other’s onset. For example, tobacco use disorder and schizophrenia often co-occur. Still, schizophrenia does not cause the onset of a tobacco use disorder, and tobacco use disorder does not cause the onset of schizophrenia.

  • 4

    Secondary psychiatric disorders: This category refers to psychiatric disorders that follow the onset of a SUD, with the SUD playing a causative role in the onset of the co-occurring psychiatric disorder. Unlike substance-induced disorders, with secondary psychiatric disorders, the symptoms do not improve after a period of abstinence.

We review below some high-yield psychiatric comorbidities of SUD:

  • ■

    Early-onset anxiety disorders are associated with an increased risk of developing a SUD in adolescents. In contrast, adolescents with SUD are at an increased risk of developing depressive disorders.

  • ■

    In women with SUD, the most common comorbid psychiatric disorders are anxiety, depression, or posttraumatic stress disorder (PTSD). Other SUDs, attention deficit/hyperactivity disorder (ADHD), or antisocial personality disorder are more common in men.

  • ■

    Overall, two-thirds of persons with cannabis or stimulant use disorders and one-third of those with nicotine or alcohol use disorder (AUD) will have a comorbid mood, anxiety, or personality disorder.

Know This:

  • ■

    Panic attacks related to substance use are seen most commonly with marijuana and lysergic acid diethylamide (LSD) intoxication and alcohol withdrawal.

  • ■

    Untreated substance-induced psychiatric disorders are associated with an increased risk of relapse.

  • ■

    Substance use, substance use disorders, and withdrawal syndromes are associated with a significantly increased risk of suicidal behaviors including completed suicides.

  • ■

    Drug use is associated with a significantly increased risk of violence perpetration. Alcohol use is associated with a significantly increased risk of violence perpetration and victimization.

  • ■

    Forty percent of patients with schizophrenia have a SUD. The most commonly used substance by people with schizophrenia is nicotine (85%) followed by alcohol (35%), cocaine (30%), and cannabis (30%).

  • ■

    Patients with bipolar disorder have the highest rates of co-occurring SUD.

  • ■

    The prevalence of persistent psychosis among methamphetamine users is 11 times higher than the general population.

  • ■

    ADHD treatment, including the use of stimulants, does not increase SUD risk. In fact, recent data suggest that it might reduce the risk.

  • ■

    In patients with SUD, the most common comorbid personality disorder is an antisocial personality disorder.

  • ■

    The misuse of prescription stimulants for treating ADHD is seen most commonly among friends of persons with ADHD rather than among individuals with the disorder themselves.

  • ■

    Alcohol-related sleep impairments include decreased rapid eye movement (REM) sleep and slow-wave sleep, increased sleep latency, and decreased sleep efficiency and total sleep time.

  • ■

    In patients with alcohol or sedative use disorders, insomnia is an independent risk factor for relapse on alcohol and benzodiazepines.

  • ■

    The relationship between marijuana use and the onset of a psychotic disorder is not fully elucidated. It appears that although marijuana does not cause psychotic disorders, it might precipitate their onset, as such persons would have an earlier onset and a more severe course for their psychosis. Having the AKT1 mutation increases the lifetime risk of having a psychotic disorder in persons who use cannabis.

  • ■

    The most common psychiatric disorders comorbids with cannabis use disorder are other SUDs followed by anxiety and depressive disorders.

NONPSYCHIATRIC, MEDICAL COMORBIDITIES OF SUBSTANCE USE

This section will review the impact of substance use on major bodily systems rather than list the medical conditions associated with every substance.

Know This:

  • 1

    Medical comorbidities of excessive alcohol use, including alcohol-related liver disease, cardiovascular complications, and neurologic problems, affect women more frequently and more severely than men. This is because women have lower levels of gastric alcohol dehydrogenase. As a result, less alcohol is metabolized at the gastric level resulting in higher circulating alcohol levels.

  • 2

    The impact of race on SUD rates is minimal. However, due to disparate access to care and medical services, serious adverse consequences of SUD disproportionately affect minority populations. For example, even though Black individuals have a later onset of heavy drinking and a lower prevalence of AUD, they are more likely to experience adverse medical consequences, including death, than White individuals. Similarly, liver cirrhosis-related mortality rates are higher in the Hispanic populations.

Cardiovascular Comorbidities of Substance Use

Excessive alcohol use can cause significant problems in cardiovascular function, including:

  • ■

    Alcoholic cardiomyopathy (a dilated cardiomyopathy marked by hypercontractility, reduced cardiac output with increased systemic vascular resistance) caused by both the toxic effects of alcohol and acetaldehyde accumulation

  • ■

    Portal venous diseases and portal hypertension are marked by a hyperdynamic cardiovascular function with increased cardiac output with decreased systemic vascular resistance

  • ■

    Hypertension

  • ■

    Arrhythmias including atrial fibrillation (holiday heart)

Excessive stimulant use can cause:

  • ■

    Hypertension with increased cardiac workload, increased systemic vascular resistance, and vasoconstriction

  • ■

    Left ventricular hypertrophy

  • ■

    Coronary artery disease with vasculopathy and vasoconstriction

  • ■

    Hyperthrombotic states

  • ■

    Myocardial infarctions, angina, and strokes

  • ■

    Aortic dissection and rupture

  • ■

    Arrhythmias

  • ■

    Mesenteric vasoconstriction and mesenteric ischemia

Know This:

Cocaine-related angina and myocardial infarction medical treatment should include benzodiazepines in addition to the standard protocols used for non–cocaine-related cardiac events. Benzodiazepines are necessary to manage hypertension and tachycardia and decrease the central stimulatory effects of cocaine.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts