11.1: Substance-Related and Addictive Disorders - Clinical Presentation

Learning Objectives

• Define substances and substance abuse.
• Describe properties of substance abuse.
• Describe how substance use disorder presents.
• Describe how substance intoxication presents.
• Describe how substance withdrawal presents.
• Define depressants and describe types.
• Define stimulants and describe types.
• Define hallucinogens/cannabis/combination and describe types.

Defining Terms and Adding Context

Substance-related and addictive disorders are among the most prevalent psychological disorders, with roughly 100 million people in the United States reporting the use of an illegal substance sometime throughout their life (SAMHSA, 2014). It is worth noting that the DSM-5 shifted terminology from drug addiction to substance use disorder, “…to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing, compulsive pattern of drug taking.” The DSM-5 acknowledges that many clinicians will use the term drug addiction to describe more severe presentations, but it is omitted from the DSM-5 due to “…its uncertain definition and its potentially negative connotation” (APA, 2022, pg. 543).

What are substances? Substances are any ingested materials that cause temporary cognitive, behavioral, or physiological symptoms within the individual. The DSM uses 10 classes of substances: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, and other (or unknown).

Repeated use of these substances or frequent substance intoxication can develop into a long-term problem known as substance abuse. Abuse occurs when an individual consumes the substance for an extended period or must ingest large amounts of the substance to get the same effect a substance provided previously. The need to continually increase the amount of ingested substance is known as tolerance. As tolerance builds, additional physical and psychological symptoms present, often causing significant disturbances in an individual’s personal and professional life. Individuals with substance abuse often spend a significant amount of time engaging in activities that revolve around their substance use, thus spending less time in recreational activities that once consumed their time.

Sometimes, there is a desire to reduce or abstain from substance use; however, cravings and withdrawal symptoms often prohibit this from occurring. Common withdrawal symptoms include, but are not limited to, cramps, anxiety attacks, sweating, nausea, tremors, and hallucinations. Depending on the substance and the tolerance level, most withdrawal symptoms last anywhere from a few days to a week. For those with extensive substance abuse or abuse of multiple substances, withdrawal should be closely monitored in a hospital setting to avoid severe consequences such as seizures, stroke, or even death.

According to the DSM-5-TR (APA, 2022), the substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders which include substance intoxication and substance withdrawal. While there are some subtle differences in symptoms, particularly psychological, physical, and behavioral symptoms, the general diagnostic criteria for substance use disorder, substance intoxication, and substance withdrawal remains the same across substances. These criteria are reviewed below, with more specific details of psychological, physical, and behavioral symptoms in the Section 11.1.5.: Types of Substances Abused.

Substance Use Disorder

The essential feature of substance use disorder, is a “…cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (APA, 2022, pg. 544) and can be diagnosed for all ten substance classes except for caffeine. Distress or impairment can be described as any of the following: inability to complete or lack of participation in work, school or home activities; increased time spent on activities obtaining, using, or recovering from substance use; impairment in social or interpersonal relationships; use of a substance in a potentially hazardous situation; psychological problems due to recurrent substance abuse; craving the substance; an increase in the amount of substance used over time (i.e., tolerance); difficulty reducing the amount of substance used despite a desire to reduce/stop using; and/or withdrawal symptoms (APA, 2022). While the number of these symptoms may vary among individuals, only two symptoms are required for a diagnosis of substance use disorder.

Substance Intoxication

For a diagnosis of substance intoxication, the individual must have recently ingested a substanc. Immediately following the ingestion of this substance, significant behavioral and/or psychological change is observed. In addition, physical and physiological symptoms present as a direct result of the substance ingested. As stated above, these behavioral, physical, and physiological symptoms are dependent on the type of substance that is ingested and, therefore, discussed in more detail within each substance category (i.e., depressants, stimulants, hallucinogens/cannabis/combination). This said, the most common changes involve disturbances of perception, wakefulness, attention, thinking, psychomotor behavior, interpersonal behavior, and judgment (APA, 2022).

Substance Withdrawal

Finally, substance withdrawal is diagnosed when there is cessation or reduction of a substance that has been used for a long period of time. Individuals undergoing substance withdrawal will experience physiological and psychological symptoms within a few hours after cessation/reduction. These symptoms cause significant distress or impairment in daily functioning (APA, 2022). As with substance intoxication, physiological and psychological symptoms during substance withdrawal are often specific to the substance abused and are discussed in more detail within each substance category later in the module.

Types of Substances Abused

For our purposes, the most abused substances will be divided into three categories based on how they impact one’s physiological state: depressants, stimulants, and hallucinogens/cannabis/combination.

11.1.5.1. Depressants. Depressants include alcohol, sedative-hypnotic drugs, and opioids are known to have an inhibiting effect on one’s central nervous system; therefore, they are often used to alleviate tension and stress. Unfortunately, when used in large amounts, they can also impair an individual’s judgment and motor activity.

While alcohol is one of the only legal (over-the-counter) substances we will discuss, it is also the most commonly consumed substance. According to the 2015 National Survey on Drug Use and Health, approximately 70% of individuals drank an alcoholic beverage in the last year, and nearly 56% of individuals drank an alcoholic beverage in the past month (SAMHSA, 2015). While the legal age of consumption in the United States is 21, approximately 78% of teens report that they drank alcohol at some point in their life (SAMHSA, 2013).

Despite the legal age of consumption, many college-aged students engage in binge or heavy drinking. In fact, 45% of college-aged students report engaging in binge drinking, with 14% binge drinking at least 5 days per month (SAMHSA, 2013). In addition to these high levels of alcohol consumption, students also engage in other behaviors such as skipping meals, which can impact the rate of alcohol intoxication and place them at risk for dehydration, blacking out, and developing alcohol-induced seizures (Piazza-Gardner & Barry, 2013).

The “active” substance of alcohol, ethyl alcohol, is a chemical that is absorbed quickly into the blood via the lining of the stomach and intestine. Once in the bloodstream, ethyl alcohol travels to the central nervous system (i.e., brain and spinal cord) and produces depressive symptoms such as impaired reaction time, disorientation, and slurred speech. These symptoms are produced due to the ethyl alcohol binding to GABA receptors, thus preventing GABA from providing inhibitory messages and allowing the individual to relax (Filip et al., 2015).

The effect of ethyl alcohol in moderation allows for an individual to relax, engage more readily in conversation, and in general, produce a confident and happy personality. However, when consumption is increased or excessive, the central nervous system is unable to metabolize the ethyl alcohol adequately, and adverse effects begin to present. Symptoms such as blurred vision, difficulty walking, slurred speech, slowed reaction time, and sometimes, aggressive behaviors are observed.

The extent to which these symptoms present are directly related to the concentration of ethyl alcohol within the body, as well as the individual’s ability to metabolize the ethyl alcohol. There are a lot of factors that contribute to how quickly one’s body can metabolize ethyl alcohol. Food, gender, body weight, and medications are among the most common factors that affect alcohol absorption (NIAAA,1997). More specifically, recent consumption of food, particularly those high in fat and carbohydrates, slow the absorption rate of ethyl alcohol, thus reducing its effects. Regarding gender, women absorb and metabolize alcohol differently than men, likely due to the smaller amount of body water and the lower activity of an alcohol metabolizing enzyme in the stomach. Another factor related to gender is weight—with individuals with more body mass metabolizing the alcohol at a slower rate than those who weigh less. Finally, various medications, both over the counter and prescription, can impact the liver’s ability to metabolize alcohol, thus affecting the severity of symptoms that present (NIAAA, 1997).

Sedative-Hypnotic drugs, more commonly known as anxiolytic drugs, have a calming and relaxing effect on individuals. When used at a clinically appropriate dosage, they can have a sedative effect, thus making them a suitable drug for treating anxiety-related disorders. In the early 1900s, barbiturates were introduced as the main sedative and hypnotic drug; however, due to their addictive nature, as well as respiratory distress when consumed in large amounts, they have been largely replaced by benzodiazepines which are considered a safer alternative as they have less addictive qualities (Filip et al., 2014).

Commonly prescribed benzodiazepines— Xanax, Ativan, and Valium—have a similar effect to alcohol as they too bind to the GABA receptors and increase GABA activity (Filip et al., 2014). This increase in GABA produces a sedative and calming effect. Benzodiazepines can be prescribed for both temporary relief (pre-flight or before surgery) or long-term use (generalized anxiety disorder). While they do not produce respiratory distress in large dosages like barbiturates, they can cause intoxication and addictive behaviors due to their effects on tolerance.

Opioids are naturally occurring, derived from the sap of the opium poppy. In the early 1800s, morphine was isolated from opium by German chemist Friedrich Wilhelm Adam Serturner. Due to its analgesic effect, it was named after the Greek god of dreams, Morpheus (Brownstein, 1993). Its popularity grew during the American Civil War as it was the primary medication given to soldiers with battle injuries. Unfortunately, this is also when the addictive nature of the medication was discovered, as many soldiers developed “Soldier’s Disease” as a response to tolerance of the drug (Casey, 1978).

In an effort to alleviate the addictive nature of morphine, heroin was synthesized by the German chemical company Bayer in 1898 and was offered in a cough suppressant (Yes, Bayer promoted heroin). For years, heroin remained in cough suppressants as well as other pain reducers until it was discovered that heroin was more addictive than morphine. In 1917, Congress stated that all drugs derived from opium were addictive, thus banning the use of opioids in over-the-counter medications.

Opioids are unique in that they provide both euphoria and drowsiness. Tolerance to these drugs builds quickly, thus resulting in an increased need of the medication to produce desired effects. This rapid tolerance is also likely responsible for opioids’ highly addictive nature. Opioid withdrawal symptoms can range from restlessness, muscle pain, fatigue, anxiety, and insomnia. Unfortunately, these withdrawal symptoms, as well as intense cravings for the drug, can persist for several months, with some reports up to years. Because of the intensity and longevity of these withdrawal symptoms, many individuals struggle to remain abstinent, and accidental overdoses are common (CDC, 2013).

The rise of abuse and misuse of opioid products in the early-to-mid 2000s is a direct result of the increased number of opioid prescription medications containing oxycodone and hydrocodone (Jayawant & Balkrishnana, 2005). The 2015 report estimated 12.5 million Americans had abused prescription narcotic pain relievers in the past year (SAMHSA, 2016). In an effort to reduce such abuse, the FDA developed programs to educate prescribers about the risks of misuse and abuse of opioid medications.

11.1.5.2. Stimulants. The two most common types of stimulants abused are cocaine and amphetamines. Unlike depressants that reduce the activity of the central nervous system, stimulants have the opposite effect, increasing the activity in the central nervous system. Physiological changes that occur with stimulants are increased blood pressure, heart rate, pressured thinking/speaking, and rapid, often jerky behaviors. Because of these symptoms, stimulants are commonly used for their feelings of euphoria, to reduce appetite, and prevent sleep.

Similar to opioids, cocaine is extracted from a South American plant—the coca plant—and produces feelings of energy and euphoria. It is the most potent natural stimulant known to date (Acosta et al., 2011). Low doses can produce feelings of excitement, talkativeness, and euphoria; however, as the amount of ingested cocaine increases, physiological changes such as rapid breathing, increased blood pressure, and excessive arousal can be observed. The psychological and physiological effects of cocaine are due to an increase of dopamine, norepinephrine, and serotonin in various brain structures (Hart & Ksir, 2014; Haile, 2012).

One key feature of cocaine use is the rapid high of cocaine intoxication, followed by the quick depletion, or crashing, as the drug diminishes within the body. During the euphoric intoxication, individuals will experience poor muscle coordination, grandiosity, compulsive behavior, aggression, and possible hallucinations and delusions (Haile, 2012). Conversely, as the drug leaves the system, the individual will experience adverse effects such as headaches, dizziness, and fainting (Acosta et al., 2011). These negative feelings often produce a negative feedback loop, encouraging individuals to ingest more cocaine to alleviate the negative symptoms. This also increases the chance of accidental overdose.

Cocaine is unique in that it can be ingested in various ways. While cocaine was initially snorted via the nasal cavity, individuals found that if the drug was smoked or injected, its effects were more potent and longer-lasting (Haile, 2012). The most common way cocaine is currently ingested is via freebasing, which involves heating cocaine with ammonia to extract the cocaine base. This method produces a form of cocaine that is almost 100% pure. Due to its low melting point, freebased cocaine is easy to smoke via a glass pipe. Inhaled cocaine is absorbed into the bloodstream and brain within 10-15 seconds suggesting its effects are felt almost immediately (Addiction Centers of America).

Crack is a derivative of cocaine that is formed by combining cocaine with water and another substance (commonly baking soda) to create a solid structure that is then broken into smaller pieces. Because of this process, it requires very little cocaine to make crack, thus making it a more affordable drug. Coined for the crackling sound that is produced when it is smoked, it is also highly addictive, likely due to the fast-acting nature of the drug. While the effects of cocaine peak in 20-30 minutes and last for about 1-2 hours, the effects of crack peak in 3-5 minutes and last only for up to 60 minutes (Addiction Centers of America).

Amphetamines are manufactured in a laboratory setting. Currently, the most common amphetamines are prescription medications such as Ritalin, Adderall, and Dexedrine (prescribed for sleep disorders). These medications produce an increase in energy and alertness and reduce appetite when taken at clinical levels. However, when consumed at larger dosages, they can produce intoxication similar to psychosis, including violent behaviors. Due to the increased energy levels and appetite suppressant qualities, these medications are often abused by students studying for exams, athletes needing extra energy, and individuals seeking weight loss (Haile, 2012). Biologically, similar to cocaine, amphetamines affect the central nervous system by increasing the amount of dopamine, norepinephrine, and serotonin in the brain (Haile, 2012).

Methamphetamine, a derivative of amphetamine, is often abused due to its low cost and feelings of euphoria and confidence; however, it can have serious health consequences such as heart and lung damage (Hauer, 2010). Most commonly used intravenously or nasally, methamphetamine can also be eaten or heated to a temperature in which it can be smoked. The most notable effects of methamphetamine use are the drastic physical changes to one’s appearance, including significant teeth damage and facial lesions (Rusyniak, 2011).

While we are sure you are well aware of how caffeine is consumed, you may be surprised to learn that in addition to coffee, energy drinks, and soft drinks, caffeine can also be found in chocolate and tea. Because of the vast use of caffeine, it is the most widely consumed substance in the world, with approximately 90% of Americans consuming some form of caffeine each day (Fulgoni, Keast, & Lieberman, 2015). While caffeine is often consumed in moderate dosages, caffeine intoxication and withdrawal can occur. In fact, an increase in caffeine intoxication and withdrawal have been observed with the simultaneous popularity of energy drinks. Common energy drinks such as Monster and RedBull have nearly double the amount of caffeine of tea and coke (Bigard, 2010). While adults commonly consume these drinks, a startling 30% of middle and high schoolers also report regular consumption of energy drinks to assist with academic and athletic responsibilities (Terry-McElrath, O’Malley, & Johnston, 2014). The rapid increase in caffeinated beverages has led to a rise in ER visits due to the intoxication effects (SAMHSA, 2013).

11.1.5.3. Hallucinogens/Cannabis/Combination. The final category includes both hallucinogens and cannabis- both of which produce sensory changes after ingestion. While hallucinogens are known for their ability to produce more severe delusions and hallucinations, cannabis also has the capability of producing delusions or hallucinations; however, this typically occurs only when large amounts of cannabis are ingested. More commonly, cannabis has been known to have stimulant and depressive effects, thus classifying itself in a group of its own due to the many different effects of the substance.

Hallucinogens come from natural sources and have been involved in cultural and religious ceremonies for thousands of years. Synthetic forms of hallucinogens have also been created—most common of which are PCP, Ketamine, LSD, and Ecstasy. In general, hallucinogens produce powerful changes in sensory perception. Depending on the type of drug ingested, effects can range from hallucinations, changes in color perception, or distortion of objects. Additionally, some individuals report enhanced auditory, as well as changes in physical perception such as tingling or numbness of limbs and interchanging hot and cold sensations (Weaver & Schnoll, 2008). Interestingly, the effect of hallucinogens can vary both between individuals, as well as within the same individual. This means that the same amount of the same drug may produce a positive experience one time, but a negative experience the next time.

Overall, hallucinogens do not have addictive qualities; however, individuals can build a tolerance, thus needing larger quantities to produce similar effects (Wu, Ringwalt, Weiss, & Blazer, 2009). Furthermore, there is some evidence that long-term use of these drugs results in psychosis, mood, or anxiety disorders due to the neurobiological changes after using hallucinogens (Weaver & Schnoll, 2008).

Similar to hallucinogens and a few other substances, cannabis is also derived from a natural plant—the hemp plant. While the most powerful of hemp plants is hashish, the most commonly known type of cannabis, marijuana, is a mixture of hemp leaves, buds, and the tops of plants (SAMHSA, 2014). Many external factors impact the potency of cannabis, such as the climate it was grown in, the method of preparation, and the duration of storage. Of the active chemicals within cannabis, tetrahydrocannabinol (THC) appears to be the single component that determines the potent nature of the drug. Various strains of marijuana have varying amounts of THC; hashish contains a high concentration of THC, while marijuana has a small concentration.

THC binds to cannabinoid receptors in the brain, which produces psychoactive effects. These effects vary depending on both an individual’s body chemistry, as well as various strains and concentrations of THC. Most commonly, people report feelings of calm and peace, relaxation, increased hunger, and pain relief. Occasionally, negative symptoms such as increased anxiety or paranoia, dizziness, and increased heart rate also occur. In rare cases, individuals develop psychotic symptoms or schizophrenia following cannabis use (Donoghue et al., 2014).

While nearly 20 million Americans report regular use of marijuana, only 10% of these individuals will develop a dependence on the drug (SAMHSA, 2013). Of particular concern is the number of adolescents engaging in cannabis use. One in eight 8th graders, one in four 10th graders, and one in three 12th graders reported use of marijuana in the past year (American Academy of Child and Adolescent Psychiatry, 2013). Individuals who begin cannabis abuse during adolescence are at an increased risk of developing cognitive effects from the drug due to the critical period of brain development during adolescence (Gruber, Sagar, Dahlgren, Racine, & Lukas, 2012). Increased discussion about the effects of marijuana use, as well as psychoeducation about substance abuse in general, is important in preventing marijuana use during adolescence.

It is not uncommon for substance abusers to consume more than one type of substance at a time. This combination of substance use can have dangerous results depending on the interactions between substances. For example, if multiple depressant drugs (i.e., alcohol, benzodiazepines, and/or opiates) are consumed at one time, an individual is at risk for severe respiratory distress or even death due to the compounding depressive effects on the central nervous system. Additionally, when an individual is under the influence of one substance, judgment may be impaired, and ingestion of a larger amount of another drug may lead to an accidental overdose. Finally, the use of one drug to counteract the effects of another drug—taking a depressant to combat the effects of a stimulant—is equally as dangerous as the body is unable to regulate homeostasis.

Key Takeaways

You should have learned the following in this section:

• An individual is diagnosed with substance use disorder, substance intoxication, or substance withdrawal specific to the substance or substances being ingested though the symptoms remain generally the same across substances.
• Substance use disorder occurs when a person experiences significant impairment or distress for 12 months due to the use of a substance.
• Substance intoxication occurs when a person has recently ingested a substance leading to significant behavioral and/or psychological changes.
• Substance withdrawal occurs when there is a cessation or reduction of a substance that has been used for a long period of time.
• Depressants include alcohol, sedative-hypnotic drugs, and opioids.
• Stimulants include cocaine and amphetamines, but caffeine as well.
• Hallucinogens come from natural sources and produce powerful changes in sensory perception.
• Cannabis is also derived from a natural plant and produces psychoactive effects.
• Many drugs are taken by users in combination which can have dangerous results depending on the interactions between the substances.

Review Questions

1. What is a substance?
2. What is the difference between substance intoxication and substance abuse?
3. What is the difference between tolerance and withdrawal?
4. Create a table listing the three types of substances abused, as well as the specific substances within each category.
5. What are the common factors that affect alcohol absorption?
6. What are the effects of sedative-hypnotic drugs?
7. What receptors are responsible for increasing activity in alcohol and benzodiazepines?
8. What is responsible for the addictive nature of opioids?
9. Which neurotransmitters are implicated in cocaine use?
10. What are the different ways cocaine can be ingested?
11. List the common types of amphetamines.