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CHAPTER 1 1 B. Male gender, younger, low SES, single Young unmarried men of low SES carry the highest risk for developing alcohol use disorder (AUD). Generally speaking, most present with early symptoms of AUD before the age of 30. Other risk factors include having a family history of AUD, having comorbid depressive disorders, schizophrenia spectrum disorder or personality disorders and a personal history of abuse.…

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DEFINITIONS OF TERMS RELATING TO MODELS OF CARE Centralized model of care: Substance use disorder (SUD) treatment is integrated and offered in a single location, frequently delivered by the primary care physician with an addiction specialist providing support. Distributive model of care: SUD treatment is delivered with a focus on case management to maximize access to care for a wider selection of community services. Universal programs:…

DRUG AND ALCOHOL TESTING Drug and alcohol testing can and should be ordered in various settings. Understanding the context for which such a thing is being ordered can help determine testing procedures. For example, for parents seeking to monitor their children’s drug use, point-of-care testing at home may suffice. In contrast, when working with patients being evaluated in an emergency department setting, a urine toxicology screening…

THE NEUROBIOLOGY OF PAIN General Pain Pathways These pathways are the primary components that connect, receive, and process all the pain information generated by neurons. The pain pathway comprises three orders of neurons that transmit pain signals to the brain. Sensory or afferent neurons carrying pain are the Aδ-fibers, which are myelinated, and the unmyelinated C-fibers. Mediators of Pain ■ Beta-endorphin: A metabolite of beta-lipotropin produced…

DISSOCIATIVE DRUGS This section discusses ketamine, phencyclidine (PCP), and dextromethorphan (DXM). Nitrous oxide is an inhalant with dissociative properties and is discussed in greater detail later in the chapter. All four of these substances share the pharmacological property of being N-methyl-D-aspartate (NMDA) receptor antagonists. Recall that the NMDA receptor is an ionotropic glutamate receptor that is important for memory and synaptic plasticity. Ketamine ■ Ketamine is…

NEUROBIOLOGY AND GENERAL CHARACTERISTICS Stimulants refer to a heterogeneous class of substances with the action of stimulating the central nervous system, primarily through noradrenergic and dopaminergic effects. The stimulants discussed in this chapter include amphetamines, methamphetamines, methylphenidates, cocaine, cathinones, 3,4-methyl​enedioxy​methamphetamine (MDMA), and over-the-counter medications such as phenylephrine and pseudoephedrine. Many stimulants share a common structure, a phenethylamine component—this is present on amphetamine, methamphetamine, cathinone, pseudoephedrine, dopamine,…

GENERAL CHARACTERISTICS Cannabis is the most commonly illicitly used drug in the United States, as well as globally. The cannabis plant contains over 100 different cannabinoids, molecules that share their chemical structure with delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), the two major psychoactive components of the cannabis plant. CHEMICAL STRUCTURE AND NEUROBIOLOGY The Cannabis Family There are over 700 different types of plants within the Cannabis family;…

NICOTINE PHARMACOLOGY Chemical Structure and Mechanism of Action of Nicotine The nicotine molecule is a tertiary amine alkaloid with pyridine and pyrrolidine rings, and it exists in two enantiomeric forms. The S-enantiomer is a more potent agonist at the nicotinic acetylcholine receptor compared to the R-enantiomer. Nicotinic acetylcholine receptors are ionotropic ligand-gated ion channels found throughout the central and peripheral nervous systems. As a nicotinic receptor…

BRIEF HISTORY OF THE CURRENT OPIOID EPIDEMIC Beginning in the early 1800s, opium and morphine use became widespread; opiate-containing “patent medicines” were heavily marketed for several medical conditions, especially toward women. Morphine prescribing peaked in 1890, and in 1898, Bayer started marketing heroin as a treatment for morphine addiction. In 1914, changes in domestic and international policy, spurred in part by the Opium Wars in China,…

GENERAL CHARACTERISTICS Sedative/hypnotics are a diverse class of central nervous system (CNS) depressants with addictive liability and a wide range of therapeutic functions. Benzodiazepines are the most widely prescribed medication among sedative/hypnotics, and they are also the most widely prescribed class of all psychotropic medications. At any given time, approximately 5% of all adults in the United States have been prescribed benzodiazepines. CHEMICAL STRUCTURE AND NEUROBIOLOGY…

GENERAL CHARACTERISTICS AND HISTORY Evidence of alcohol consumption has been noted as far back as 9,000 years ago by Neolithic farmers in Northern China, and recipes for producing alcohol have been discovered worldwide for thousands of years. Dr. Benjamin Rush is believed to have been the first person to characterize excessive alcohol use as a disorder in 1784. By the late 1800s, temperance movements sprung up…

GENERAL TERMS AND CONCEPTS Following initiation of substance use, using is typically impulsive and a positively reinforcing experience. The chronic and repeated use of it leads to possible tolerance accompanied by diminishing returns on the substance’s positively reinforcing effects. In parallel, there is an increase in the negative reinforcing effects, such as using the substance to avoid withdrawal symptoms. Over time, substance use becomes less impulsive…

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…

DEFINITIONS OF SUBSTANCE USE DISORDERS AND DIAGNOSTIC EVALUATIONS Although persons with a substance use disorder (SUD) use drugs or alcohol, using these substances does not necessarily mean that a given person meets SUD diagnostic criteria. Indeed, in 2012, the American Psychiatric Association’s Diagnostic and Statistical Manual, 5th Edition (DSM-5) set diagnostic phenomenological parameters for SUD diagnoses. These replace older diagnoses of substance abuse and substance dependence…