Substance use disorder Study Guide

📖 Core Concepts Substance Use Disorder (SUD) – Persistent drug/alcohol use despite significant harm to self or others. Co‑occurring disorder – Simultaneous presence of a mental‑health disorder and an SUD. DSM‑5 severity – Mild (2‑3 criteria), Moderate (4‑5), Severe (≥6) of the 11 diagnostic criteria. Addiction vs. Dependence – Addiction = compulsive use despite harm; Dependence = physiological adaptation producing withdrawal when use stops. Tolerance – Need for higher dose to achieve the same effect after repeated use. Withdrawal – Physical/psychological symptoms after cessation of a drug. Sensitization (reverse tolerance) – Drug effect intensifies with repeated use. 📌 Must Remember DSM‑5 criteria groups: loss of control, interpersonal strain, hazardous use, pharmacologic effects. Severity cut‑offs: 2‑3 = mild, 4‑5 = moderate, ≥6 = severe (addiction). Risk multipliers: Parental SUD → 2× personal risk. Early initiation (<25 y) ↑ lifetime SUD risk. High impulsivity / low conscientiousness ↑ risk. Screening tools: Adolescents – CRAFFT. Adults – CAGE, AUDIT, DALI. Medication‑Assisted Treatment (MAT): methadone, buprenorphine, naltrexone (opioids); disulfiram, naltrexone (alcohol). No FDA‑approved meds for cocaine/methamphetamine. Withdrawal emergency: Acute alcohol withdrawal can progress to delirium tremens → requires supervised medical care. 🔄 Key Processes Diagnostic Assessment Conduct clinical interview → tally DSM‑5 criteria. Determine severity (mild/moderate/severe). Assess functional impairment, cravings, withdrawal. Screening Flow Choose tool (CRAFFT, CAGE, AUDIT). Score → if above threshold → full assessment. Withdrawal Management (Alcohol example) Identify signs (tremor, agitation, seizures). Initiate benzodiazepine protocol, monitor vitals, prevent delirium tremens. MAT Initiation (Opioid) Confirm opioid dependence → start methadone or buprenorphine (induction). Combine with behavioral therapy → schedule follow‑ups. 🔍 Key Comparisons Addiction vs. Dependence Addiction: compulsive seeking, loss of control, continued use despite harm. Dependence: physiological adaptation; withdrawal occurs when drug stops. Tolerance vs. Sensitization Tolerance: decreasing effect → need higher dose. Sensitization: increasing effect with same dose (reverse tolerance). DSM‑5 vs. ICD‑11 classification DSM‑5: single “substance‑use disorder” category, severity based on criteria count. ICD‑11: separates “harmful pattern of use” and “substance dependence.” ⚠️ Common Misunderstandings “Prescribed opioids = disorder.” Use alone isn’t an SUD; disorder requires additional criteria (e.g., loss of control, harmful use). “Withdrawal = addiction.” Withdrawal is a physiological response; addiction involves compulsive behavior and loss of control. “Screening tests diagnose.” Tools like CAGE/CRAFFT flag risk; definitive diagnosis requires full DSM‑5 evaluation. 🧠 Mental Models / Intuition Risk‑Factor Stack: Think of genetics, early exposure, personality, and social stressors as stacked plates—removing any one plate (e.g., improving environment) can prevent the stack from toppling into SUD. Brain Disease Model: Repeated drug use “rewires” reward circuitry (ΔFosB accumulation) → the brain starts to treat the drug as a primary need, similar to hunger. 🚩 Exceptions & Edge Cases Alcohol Withdrawal without Tremor: Some patients present with only anxiety or insomnia; still require monitoring for delayed seizures. MAT in Pregnancy: Buprenorphine is preferred over methadone in many protocols, but dosing must be individualized. Adolescent Screening: CRAFFT is validated; CAGE performs poorly in teens due to lower prevalence of severe use. 📍 When to Use Which Screening Tool Choice Adolescents: CRAFFT. Adults (general): CAGE (quick), AUDIT (detailed alcohol), DALI (drug‑specific). Therapy Selection High ambivalence: Motivational interviewing first. Relapse risk due to cues: Cue‑exposure therapy + CBT. Poor adherence: Contingency management (tangible rewards). MAT vs. Psychotherapy Only Opioid dependence: MAT + CBT is evidence‑based. Alcohol dependence with no severe withdrawal: CBT or MI may suffice; MAT (naltrexone/disulfiram) adds benefit. 👀 Patterns to Recognize Early‑Onset + Impulsivity → high likelihood of later severe SUD. Co‑occurring anxiety/depression → increased relapse risk; need integrated treatment. Sudden functional decline (work/school absenteeism) + physical signs (tremor, weight change) → screen for SUD. Repeated “just one more” requests in interviews → cue for loss‑of‑control criterion. 🗂️ Exam Traps “All prescribed opioid use is an SUD.” – Wrong; must meet additional DSM‑5 criteria. Confusing “severity” with “addiction.” – Only severe (≥6 criteria) aligns with the term “addiction.” Choosing CAGE for adolescents. – CAGE lacks sensitivity in this age group; CRAFFT is preferred. Assuming MAT cures addiction. – MAT reduces use and mortality but is part of a chronic‑care model; behavioral therapy remains essential. Equating withdrawal with “detox” cure. – Detox treats acute symptoms; without ongoing therapy, relapse rates are high.