User:Ongmianli/Portfolios/Substance use disorder

Substance Use Disorder

Substance Use Disorder is a DSM disorder in the Substance-Related and Addictive Disorders chapter. It is characterized by the use of substances in a manner that leads to clinically significant impairment or distress.

Demographic Information

Setting	Base Rate	Demography	Diagnostic Method
General population of North Carolina	6.7%	North Carolina, aged 12 or older	National Survey on Drug Use and Health (NSDUH), 2009 to 2013
United States General Adult Population: National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Grant et al., 2007)	17.8 (0.5) Alcohol Abuse; 12.5 (0.4) Alcohol Deedence; 7.7 (0.2) Drug Abuse; 2.6 (0.1) Drug Dependence	43,093 individuals, 18+ years old collected between 2001 and 2002	National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule- DSM IV Version (AUDADIS-IV)
United States General Adult Population: National Comorbidity Survey Replication (NCS-R)	13.2 (0.6) Alcohol Abuse; 5.4 (0.3) Alcohol Deedence; 7.9 (0.4) Drug Abuse; 3.0 (0.2) Drug Dependence	9,282 adults, 18+ years old ; collected between 2001 and 2003	World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) which generates DSM-IV and International Classification of Diseases, 10th revision diagnoses
Urban General Medicine Practice	7.9%	New York, low-income primary care patients, 75% Hispanic,	Patient Health Questionnaire
Incarcerated females	70.2%	Chicago prison - 40 % African American, 33% White, 25 % Hispanic	National Institute of Mental Health Diagnostic Interview Schedule Version 11I-R (NIMH DIS-III-R)
Incarcerated females (updated) (Proctor 2012)	70% dependent	Minnesota State Prison System- 801 females, 18-58 years old, 57.7% Caucasian, 21.5% African American, 13.2% Native American	Substance Use Disorder Diagnostic Schedule-IV (SUDDS-IV)
Incarcerated male youths	56.4%	Texas state prison – 45 % African American, 33% White, 20% Hispanic	Structured Clinical Interview for DSM IV – Substance Use Disorders Module
Individuals with schizophrenia across settings	47%	New Haven, CT; Baltimore, MD; St. Louis, MO; Durham, NC; Los Angeles, CA	National Institute of Mental Health (NIMH) Diagnostic Interview Schedule
HIV+ men in community health clinics	24.4%	Alleghany County, PA	Structured Clinical Interview for DSM-III-R
Internal medicine inpatients	10.9%	Denmark	Symptom Check List (SCL-8)

Diagnosis

Diagnostic Criteria for DSM 5

Essential features of substance use disorders:

• Cluster of cognitive, behavioral and physiological symptoms
• Underlying change in brain circuits that may persist beyond detoxification (e.g. repeated relapses and intense drug craving)

Additional Criteria:

• Impaired Control
  • Taking the substance in larger amount than originally intended
  • Expressing a persistent desire to cut down with unsuccessful efforts to discontinue use
  • Sending a great deal of time obtaining the substance, using the substance or recovering from use
  • Experiencing intense cravings that may occur at any time
• Social Impairment
  • Failing to fulfill major role obligations at work, school or at home
  • Continuing use despite recurrent social/interpersonal problems
  • Giving up important social, occupation or recreational activities because of use
• Risky Use
  • Using in situations that are physically hazardous
  • Continuing use despite knowledge of having a persistent physical or psychological problem that is brought on by use
• Pharmacological Criteria
  • Experiencing tolerance where an increased dose is required to achieve the desired effect
  • Experiencing withdrawal where blood or tissue concentrations of a substance decline in an individual who had maintained prolonged use

Severity Scale:

• 0-1 criteria met: no disorder
• 2-3 criteria met: mild substance use disorder
• 4-5 criteria met: moderate substance use disorder
• 6 or more criteria met: severe substance use disorder

Diagnostic Changes

DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV.

Rather, criteria are provided for:

• substance use disorder

• accompanied by criteria for intoxication

• withdrawal

• substance/medication-induced disorders

• unspecified substance-induced disorders, where relevant.

The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single list, with the following exceptions:

• The DSM-IV recurrent legal problems criterion for substance abuse has been deleted from DSM-5, and a new criterion, craving or a strong desire or urge to use a substance, has been added.
• In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV substance dependence.
• Cannabis withdrawal is new for DSM-5, as is caffeine withdrawal (which was in DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”).
• Of note, the criteria for DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, DSM-IV did not have a category for tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in DSM-5.
• Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed: 2–3 criteria indicate a mild disorder; 4–5 criteria, a moderate disorder; and 6 or more, a severe disorder.
• The DSM-IV specifier for a physiological subtype has been eliminated in DSM-5, as has the DSM-IV diagnosis of polysubstance dependence.
• Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained re-mission is defined as at least 12 months without criteria (except craving).
• Additional new DSM-5 specifiers include “in a controlled environment” and “on maintenance therapy” as the situation warrants.

Recommended Diagnostic Interviews

• Diagnostic Interview Schedule- IV
• Structured Clinical Interview for DSM-IV
• The Psychiatric Research Interview for Substance and Mental Disorders
• International Classification of Diseases, version 10
• The Mini International Psychiatric Interview (M.I.N.I)

Table 2: Areas Under the Curve (AUCs) and Likelihood Ratios for Potential Screening Measures for PBD

Screening Measure (Primary Reference)	AUC	LR+ (Score)	LR- (Score)	Citation	Clinical Generalizability
Timeline Follow Back	-- (N=113)	6.82	.0.28	(Fals-Stewart, O'Farrell, Freitas, McFarlin & Rutigliano, 2000)	Moderate: The sample was drawn from 113 patients entering outpatient substance abuse treatment.
Bayesian Alcoholism Test (Korzec, de Bruijn & van Lambalgen, 2005)	.989 (N=114)	47	.06	(Korzec, de Bruijn & van Lambalgen)	Moderate: The BAT was tested against a broad spectrum of alcoholism in 114 male participants – heavy drinkers were measured against social drinkers – groups were further divided into treatment-seeking and non-treatment seeking.
Alcohol Use Disorder Identification Test	.56	3.67	.74	(Morton, Jones, & Manganaro, 1996)	Low: 120 Male VA outpatients 65 years or older
K6 Screening Scale	.84 (N=41,770)	3.96 (13+)	.0.296 (0-12)	(Swartz & Lurigio, 2006)	High: The sample of 41,770 was drawn from initial surveys that were carried out in 14 countries.
Alcohol, Smoking and Substance Involvement Screening Test	.84 (N=1,047)	2.76	0.28	(Humeniuk, R. et al., 2008)	High: The sample of 1,047 participants was drawn from drug treatment and primary health care settings in Australia, Brazil, India, Thailand, the United Kingdom, the U.S. and Zimbabwe.
Brief Screening for Alcohol, Tobacco, and Other Drugs (BSTAD)	0.96 (N = 525)	31.67	.05	Kelly et al., 2014	Unsure- was administered in adolescents and no information is known about it’s utility in strictly clinical or adult populations.
Simple Screening Instrument for Alcohol and Other Drug Abuse (SSI-AOD)	0.6 (N = 201)	1.86	.82	Small et al., 2007	Low: validity assessed in 201 college students
Drug Abuse Screening Test	.78 (N = 395)	4.43	0.33	Hearon et al., 2015	Moderate: evaluated in a primary care setting of patients with psychiatric illness
CAGE	.70 (N = 358)	1.86	.49	Cook et al., 2005	Questionable: sample was young adults 15-24 years attending urban clinic for sexually transmitted disease treatment and who reported alcohol use in the last year
Drug Use Disorders Identification Test (DUDIT)	0.95 (N=153)	6	.12	Voluse et al, 2012	High: 153 participants from outpatient and residential substance use treatment programs

Note: “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000).

Search terms: [substance use OR substance use disorders] AND [sensitivity OR specificity] in Google Scholar and PsycINFO

Treatment

In the United States, according to SAMHSA, of the 8.9 million adults with a dual diagnosis, 44% received some form of treatment in the past year. Given the frequent co-occurrence of mood disorders and substance use disorders, the recommended first step in treatment is for clinicians to deliver a comprehensive screening evaluation that will inform their treatment approach. There are a host of empirically supported treatments for substance use disorders, though medication interventions and psychotherapy are most common.

Specifically, medications have been shown to be most effective in the treatment of alcohol and opioid dependence. Naltrexone (50 mg/day) administered for 12 weeks has been shown to decrease cravings for alcohol and the number of days in which alcohol was consumed. Disulfiram (250 mg/day), administered for one year, has been shown to help reduce drinking frequency after relapse. In the context of opioid dependence, Methadone has been the gold standard medication treatment for over 30 years.

According to numerous studies, patients on higher doses of methadone (>50mg/day) report less illicit opioid use, as well as increased retention rates in treatment. Buprenorphine is an alternative to Methadone to treat opioid dependence and research similarly supports its clinical efficacy. Buprenorphine (60 mg/day) has been shown to bring about improved retention rates, as well as reduced illicit opioid use.

While medication serves as an effective intervention for some with drug dependence, behavioral interventions are also empirically supported. A number of studies suggest that CBT is an effective intervention for substance use. In a 2010 review, McHugh, Hearon and Otto found that CBT for substance use, which synthesizes cognitive and motivational elements, as well as skills-building interventions, is effective both as a stand-alone treatment and when combined with other treatments. Acceptance and Commitment Therapy (ACT) has also been used to treat substance-using populations with encouraging results. Specifically, Lanza and Menéndez employed a 16-session ACT in the treatment of incarcerated females. In this population, abstinence rates, as well as anxiety sensitivity and other comorbid psychopathology showed improvement. Another behavior intervention that has been successfully implemented is Mindfulness Therapy for Substance Use. Research indicates that this modality is effective across a range of populations through use of methods that help patients to develop nonreactive, acceptance behaviors.

One common technique implemented as a treatment method across psychiatric disorders is contingency management, wherein the problematic behavior of the individual is closely monitored and reinforcers are delivered contingent upon detection of a target behavior. In the case of substance use, abstinence is monitored via urine screens or other objective methods and the patient is rewarded for abstinence through prizes or vouchers, which are conversely withheld in the event that the patient does not remain abstinent as determined by urine screening or related methods. Recent work has demonstrated that contingency management can be an effective method for delaying time to first use after treatment and achieving short-term sobriety in individuals with substance use disorders. However, the effects of this intervention seem to be contingent upon the magnitude of the reward, and effects are not evident long-term.

Motivational Interviewing is a treatment option that seems to be particularly useful for individuals who are ambivalent about changing behavior. This type of intervention requires the therapist to build a collaborative relationship with the patient, using empathic and non-confrontational approaches to help the patient enhance personal motivation to change. Finally, behavioral activation therapy attempts to address comorbid diagnoses commonly occurring with substance use disorders (i.e., depression) in an attempt to improve outcomes for individuals who may be harder to treat. This technique aims to increase positive reinforcers and decrease intensity and occurrences of negative consequences and life events. This treatment approach has been effective in reducing severity of depression and anxiety symptoms, and increasing enjoyment and reward value of posttreatment activities as compared to treatment as usual.

Process and Outcome Measures

Table 3. Clinically Significant Change Benchmarks with Common Instruments and Mood Rating Scales

			Cut* Scores			Critical Change (Unstandardized Scores)
Measure			A	B	C	95%	90%	SEdifference
Benchmarks Based on Published Norms
Rutgers Alcohol Problem Index			.8	4.9	4.0	4.1	3.5	2.1
Alcohol Dependence Scale			1.2	9.9	7.8	1.4	1.2	.7
Drug Abuse Screening Test			0.1	2.6	1.8	1.6	1.3	0.8

"A" = Away from the clinical range, "B" = Back into the nonclinical range, "C" = Closer to the nonclinical than clinical mean.

Search terms: [substance use OR substance use disorder] AND [clinical significance OR outcomes] in Google Scholar and PsycINFO

Web Based Resources

National Institute on Drug Abuse http://www.drugabuse.gov

Substance Abuse and Mental Health Services Administration (SAMHSA) http://www.samhsa.gov/treatment/

The Addiction Recovery Guide http://www.addictionrecoveryguide.org/

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