Substance abuse disorder is a diagnosis assigned to people who are misusing, abusing, or addicted to psychoactive chemical substances. A psychoactive chemical substance is a substance which will temporarily alter how we think, our emotions, our behaviour, and how we perceive ourselves and others. Misusing a substance can progress to abuse, which can progress to addiction.
Addiction will render life unmanageable. The addict or alcoholic will experience physical illness, psychological distress, financial losses, family and relationship problems, job loss, and often involvement with the criminal justice system.
What Are Substance Use Disorders?
According to the definitive classification of psychological disorders, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),1 Substance Use Disorder can be divided into three categories:
In prior editions of the DSM, the terms used to describe the same disorders were:
- Substance use disorder NOS (Not Otherwise Specified). This is what is called a wastebasket diagnosis; there are symptoms present, but the symptoms don’t fit with abuse or dependence.
- Substance Abuse
- Substance Dependence, also known as addiction or alcoholism2
Substance abuse disorder can be applied to psychoactive drugs in any of the following classes:
In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are 11 criteria for substance use disorder:1
- The substance is taken in larger amounts and/or a longer period than intended.
- Unsuccessful efforts to control the substance use.
- An inordinate amount of time is used getting, using, and recovering from the effects of the substance.
- Cravings to use the substance.
- Inability to meet responsibilities at work, school, or home as a direct result of substance use.
- Continued use despite adverse consequences as a direct result of substance use.
- Normal social, occupational or recreational activities are forfeited due to substance use.
- Repeatedly using the substance physically hazardous environments or activities- e.g., driving a motor vehicle.
- Continued substance use despite awareness of having an ongoing physical or psychological ailment resulting from or worsened by the substance use.
- Tolerance for the substance, as indicated by either:
- Larger amounts of the substance are needed to get the sought effect.
- The same amount of substance does not produce the desired effect
- Withdrawal, as indicated by either:
- The presence of anticipated withdrawal symptoms associated with the substance.
- The substance or a similar type is used to manage or relieve the withdrawal symptoms.
The number of symptoms determines the severity of the substance abuse disorder:
- Mild: Two or Three criteria out of 11.
- Moderate: Four or Five criteria out of 11.
- Severe: Six or more criteria out of 11.
Signs of Substance Use Disorder: What It Looks Like
Signs of substance abuse will vary depending on the individual and the type of substance they are using, how much they have used, and how long they have been using.There may not be any noticeable health effects when someone first starts using, but there will be subtle physical signs.
General signs of substance abuse include:
- Pupil Dilation: Uppers will cause pupils to dilate or grow larger than normal for the amount of light. Downers and opiates will cause pupils to shrink to a pinpoint, even in dim light.
- Hands sweating/shaking: Recent use of uppers such as cocaine or amphetamines will cause hands to shake and sweating at room temperature. Coming down from alcohol will also cause sweating and shaking.
- Rapid speech: Recent use of uppers will cause rapid speech. The person will repeat the same points over and over, and gesture dramatically. What they say will be very dramatic and exaggerated, and they will describe very unlikely plans and ideas that don’t make sense.
- Loss of appetite/insomnia: Use of uppers will cause loss of appetite and insomnia.
- Scratching one’s own skin: Prolonged use of uppers can result in the sensation of insects or worms crawling on or under the skin. This will result in scratching, digging and picking of the skin.
- Intense relaxation: Someone on opiates will be very relaxed. Their speech will be unusual. they will draw out vowels and speak in a very carefree, indifferent manner. Their face will be flushed. They will nod. Their eyes will close, their head will droop forward, and they will awake with a start.
- General neglect of appearance: Prolonged use of almost any substance will result in gradual, progressive neglect of appearance and hygiene, neglect of responsibilities, and money problems as money is diverted from bills to buying drugs. Prized possessions may be sold. There will be a series of lies which will grow progressively implausible and complicated, and unwarranted secrecy.
Signs of Substance Use Disorder In teens
The human body is highly resilient and will repair damage promptly, especially in younger people. Substance use becomes apparent when the damage is done faster than the body can repair itself. There are other indicators. Teens are going to start the process of separating from their parent’s control and asserting their independence.
This means they are going to have some secrets, and they will want privacy. They will change friends, they will have mood swings as their bodies change, and may get annoyed with adults trying to assert control as they reach for independence. Not all the signs below are conclusive and must be considered within the context of the behavior.
In teens things to watch for that can indicate substance use include:
- New friends who appear shady or sketchy.
- Failing school.
- Family members missing money or possessions.
- Unusual secrecy.
- Shoplifting or stealing.
- Hostility when asked about activities.
- Irritability and defensiveness.
- Weight loss.
- Neglect of appearance.
- Presence of paraphernalia.
Signs of Substance Use Disorder in Adults
In addition to the physical signs, there will be behaviors and events that may indicate something is not right in the person’s life. These again are not conclusive signs that someone is using but they are nonetheless important to look out for.
Signs of substance use disorder in adults include:
- Getting fired
- Bills not paid
- Time is not accounted for.
- Change of habits- not working out, not engaging in hobbies, or seeing usual group of friends
Signs of Substance Use Disorder in Seniors
The elderly have especially poor outcomes with substance abuse.3 They tend to be all- day sippers if they drink, maintaining a constant blood-alcohol content. They may become addicted to pain medication. The elderly may be more socially isolated. They may exhibit behaviors which family suspect are senility.
Some signs which are indicators of substance use disorder in seniors are:
- Neglect of hygiene and appearance
- Neglect of living space
- Missing money that can’t be accounted for.
- Large number of medication bottles and large medication supply.
- Multiple health care providers all writing prescriptions.
Symptoms of an Overdose
An overdose is a life-threatening event. Emergency medical care must be obtained immediately if someone is overdosing. If you suspect someone is having an overdose, call 911 immediately.
Overdoses fall into two categories:
- Depressant overdose: An overdose to a depressant, including alcohol, benzodiazepines, or opiates will cause a slowed heart rate. Breathing will slow down, and short, shallow breaths will be taken. The person OD’ing may lose consciousness gradually or suddenly, and you will not be able to wake them up. Their heart rate and breathing will slow until their heart stops.
- Stimulant overdose: An overdose to a stimulant, including cocaine or amphetamines can cause a seizure, heart attack or stroke.
Generally speaking, you can’t OD on cannabinoids or psychedelics. Your body can only absorb so much of the drug, and the effects will peak before overdose can happen.
Causes & Triggers of Substance Use Disorder
What causes Substance Abuse Disorder can be viewed as a combination of genetics, environment, and free will. People are genetically wired for addiction- or not. Some people are born with a gene which lessens the production of a brain chemical called dopamine. Dopamine regulates pleasure and memory.
When we eat chocolate cake, watch a beautiful sunset over water, rappel down a rock wall, jump out of a plane with a parachute, find a $100 bill on the sidewalk, close a great business deal, win a hand of blackjack, or dig into a plate of chicken wings, our dopamine levels go up.
Then three things happen to our brain when dopamine levels increase:
- We experience how good the stimulus felt.
- The feeling gets stored in our memory.
- We feel compelled to repeat the experience.
Unfortunately, heroin, cocaine, and crystal methamphetamine all cause a release of dopamine. Here is the problem: The dopamine comes out like a firehose instead of a trickle from the faucet. It is too much. It is very compelling to use a drug again after it is used once. About 10% of the population will have a different experience the first time they use a drug. They have never had enough dopamine in their life until they used this drug.
For the first time, they feel normal. They feel fully alive. This is very bad, as they will fall in love with this feeling, and find it almost impossible to resist. These are the same people who will smoke, overeat, gamble, or go bridge diving.
This is where the environment comes in. Did you grow up in a house where your parents partied every weekend, and you did the clean up the next day by finishing the last inch or two of beer in the cups? Was substance abuse something you saw every day that disrupted your life, but after a while it became normal? Did you have adequate parental supervision and discipline, or were you overindulged and allowed to do whatever you wanted?
Or were rules excessively strict and was the discipline harsh? Is the community and neighborhoods you grew up in drug tolerant? Is your culture critical and disapproving of drug use, or excess drinking, or is the norm?
Here is the role of free will. Despite having a genetic vulnerability to addiction, and an environment which fosters addiction, what do you choose? If you know of your vulnerability and choose not to take that first drink or drug; the outcomes will be different. If you are getting started with drug abuse, you can still back off and get into treatment before you go any further. Even if addicted, there is intervention and treatment available. That begins with seeing a professional and proper diagnosis.
How Is a Substance Use Disorder Diagnosed?
An LADC, (Licensed Alcohol & Drug Counselor) MD, psychologist, or Masters-level counselor, are all clinicians, or health care professionals can diagnose a Substance Abuse Disorder. By using the DSM-5 or ICD-10 criteria, considered within the context of occurrence, and heavily weighted on the judgment of the clinician, will diagnose a substance abuse disorder.
Here are the methods that are used to diagnose substance use disorder:
1. Open Ended Interview
This is an interview between the clinician and the patient, in which information is gathered systematically. This will include basic demographics and identifying information, education and employment history, medical history, substance abuse and mental health treatment history, any involvement with the criminal justice system, and inquiring about recent or past substance use, the type of substances used, the frequency of use, and presence of tolerance, withdrawal, or compulsive use.
The open-ended interview is based on the patient’s self-report. Addicts lie. They will deny using, minimize how much and how often they use, and not tell you information. The clinician must observe the patient. As the patient is walking from the waiting room to the office, an alert and perceptive clinician should be observing them.
- How are they walking? Are they staggering, or listing to one side? Is there gait smooth or stiff, floppy?
- Is there skin tone healthy, or dry, sweating, or pale?
- How is there hygiene? Are they neat and well-groomed or disheveled and careless?
- Do they smell of alcohol or cannabis?
- Are their pupils the normal size for light in the room?
- Is there speech articulate, slurred, too slow, or rapid?
- When asked about substance use do they avert their eyes or look uncomfortable?
3. Urine Toxicology Screen
This is another objective measure to determine if someone has used recently. A urine sample is screened for the broken-down by-products of commonly abused drugs.
4. Collateral Reports
With the patient’s permission, other people in their life, such as their spouse, parent, or siblings are asked about the patient’s drug use. Past medical records and treatment records are also accessed and reviewed. If the patient has been referred by the court due to a drug or alcohol related charge, the probation/parole officer is consulted, and any affidavits of arrest are reviewed.
There are several paper and pencil test available to help with diagnosis. Though they are still called paper and pencil; many are done online; but the name has stuck. Some of the more common tests are:
- The CAGE questionnaire
- The MAST (Michigan Alcohol Screening Test)4
The tests inquire about past use, and the impact thereof. Other tests are partly observation by the clinician, and partly self-reported by the patient. Both tests below look for withdrawal symptoms, indicating the patient has been using heavily for a prolonged period.
- COWS (Comprehensive Opiate Withdrawal Scale)
- Alcohol Withdrawal Scale
Treatment of Substance Use Disorder
There are several treatment options available to those suffering from substance use disorder. Treatment of substance use disorders is possible through inpatient treatment, lifestyle changes, and various types of therapy.
Inpatient Treatment Options
28-day Rehabilitation, following a 72-96 hour detoxification is the standard protocol for inpatient substance abuse treatment. Detoxification, commonly called detox, is done under medical supervision. Acute withdrawal symptoms are monitored and managed with medication if needed, and other supportive care. Once detox is completed, the patient is transferred to a rehabilitation facility, commonly called rehab, which may be a part of the detox facility, or a separate facility.
A stay at rehab is ideally 28 days, which is the industry standard, though it can be as little as a week, depending on what health insurance the patient has. Rehabs have some common features:
- A tight schedule. You will be woken at sunrise or earlier.
- Structure. Every hour of the day will have a scheduled activity.
- Proper nutrition.
- Medical care.
- Restful sleep.
- Education about addiction.
- Therapy & teaching of coping skills.
Following a stay at rehab, outpatient therapy is needed for someone to stay clean and sober. Therapy will begin in rehab, but then must continue in order to be effective. There also may be assertive community treatment for those who continue to need ongoing care.
Outpatient therapy consists of 50-60 min Q week of therapy. Most therapy for chemical dependency is based on Cognitive Behavioral Therapy (CBT) or Rational Emotive Behavioral Therapy (REBT) and is done in either an individual, one on one session with just the therapist and patient, or in a group therapy setting.
The difference between the two methods is that CBT is based on REBT and places less emphasis on emotion. CBT is a stricter method that focuses on thinking.5 In practice, most clinicians will combine the two.
According to a meta-analysis of 30 studies, CBT is an effective method of treating Substance Use Disorder.6 This is very reliable information, as a meta-analysis is a study about studies. All the numbers from numerous studies are crunched, which gives the best information.
CBT and REBT are both types of therapy based on the Greek philosophy for stoicism. They involve learning to identify counterproductive thinking, discarding that thinking, and replacing it with new, more realistic, and useful thinking. It also involves practicing discomfort to be able to better withstand stress, and accepting that much of life other than your own reaction is out of your control.
Elements of REBT and typical topics for therapy would include:
- Cope with a person’s discomfort of emotions while sober.
- Identify drinking and drugging triggers
- Develop problem solving skills
- Develop sober social supports
- Develop sober activities
Intended Treatment Outcome & Timeline
The goal and desired outcome for treatment is to gain and maintain sobriety and abstinence indefinitely. Along with not using the substance, other goals would focus on improving quality of life, employment, better health, improve communication and problem-solving skills, no involvement with the criminal justice system, and improved healthy relationships. It is widely said that in order to maintain sobriety and abstinence, major life changes must occur.
Substance use does not occur in a vacuum but rather in the context, both the objective, eternal reality you live in day to day, and the way you perceive the world yourself and others. If the same mindset, outlook, attitude, behaviors and habits that were associated with using don’t change, it is inevitable the person will fail and go back to using.
Outside of the hour or so in therapy every week, most of the work on sobriety and abstinence will be done through changing aspects of your life.
- A structured daily routine
- Get up early and go to bed early.
- Write in a Journal.
- Eat right.
- Work out.
- Get restful sleep.
- Change associations. You can longer have any connection to people you used with, bought from, or sold to.
- Self-help through AA attendance.
- Daily independent reading about recovery and personal growth.
Inpatient vs Outpatient Treatment for Substance Use Disorder
Inpatient treatment is a need, not a preference. Most rehab facilities have a well-defined admission criterion. Someone must be using heavily for a long time, in an environment which is not conducive to gaining sobriety and is unable to stop with outpatient or self help care. Typically, someone needs to be in outpatient care for several weeks or even months without success, and involved in AA, before a rehab will admit them.
IOP (Intensive Outpatient Program) is a hybrid program. It involves therapy, several hours a day, several days a week, for several weeks. It is an alternative to inpatient as people tend to be more amenable to attending a group that they come and go to several times a week, rather than a facility where they must stay for four weeks.
How to Get Help for Substance Use Disorder
Don’t wait. Today is the day, and the time is now. Your next drunk could be your last, your next drug could be the fatal overdose. There are several ways to get out of addiction and start getting strong and healthy.
- Go to a Drug Addicts Anonymous meeting. It will not cost you a dime. No forms to fill out, no money to pay, no insurance card to show. See the resources section at the end of this article. All you must do is show up at a meeting in your area. You can sit and listen; you don’t have to say anything other than to introduce yourself to the group.
- Another route, or even better, an additional route, is to call a counselor experienced and knowledgeable about substance abuse. Again, go to the resource section of this article for several ways to get connected with a counselor.
- See your doctor. Tell him what is going on. They can make a referral to a counselor, and check you out and provide medical treatment, because if you have been using, you will probably need it.
How to Get Help for a Loved One
This is probably not going to be easy. It will be a gradual process, and it will be full of frustration and anger on your part. You will be met with denial, rationalizing, and anger. You will have to be patient and persistent.
The following three things will have to be accepted:
- You cannot force someone to change. They will change on their own schedule, in their own way, or maybe not at all.
- You must take care of yourself and know where your limits are. At what point do you end a relationship or distance yourself from a family member or end a friendship or fire an employee?
- You must brace yourself for this turning out very bad. Addiction kills, gradually, or suddenly with OD. You may have to prepare as well as you can to lose someone you care about.
How to Get Help for a Teen
This will also be an ongoing exercise in frustration, requiring a lot of patience. Much of what is listed above applies here. Your house, your rules, but it will still be very difficult to get help for someone who is not ready. You can make them go to treatment, but you can’t make them listen to the counselor, or apply what they have learned.
The choice will be there, and that will be complicating factors such as a teen feeling of invincibility, their lack of life experience, and tendency to overestimate their own ability while underestimating risk.
Substance Use Disorder Statistics
It is difficult to determine the true extent of Substance Use Disorder in the United States due to under-reporting. Many people do not seek treatment, or admit they have a problem. The data that is available is daunting.
In the US:
- $420 billion annual costs are due to Substance Use Disorder
- $120 billion in annual healthcare expenses are the result of Substance Use Disorder
- About 17% of people over age 12 reported use of an illegal drug, non-medical use of a prescribed drug, or heavy alcohol use during the past year7
- Death rates from overdose on opiates in the US increased from 10,000 per year in 2002 to nearly 50,000 in 20178
Living with Substance Use Disorder
There are many challenges to stay sober once sobriety has been gained. Depending on how long someone was using, they may be deeply integrated into the using subculture. Change of associations (people/places/things) connected with using is critical. The elements of the old life have to be discarded. This is critical to avoid triggers to using. Complacency and lack of vigilance are major factors in relapse. An addict or alcoholic who has been sober for years can delude themselves into thinking they can indulge in one drink, or a small amount of their substance of choice. Choice and free will is critical to how well sobriety is maintained.
Early recovery problems include:
- No friends, family angry at you
- Drug dealers after you to collect drug debts.
- Pending criminal charges
- Lack of social skills and coping skills
- Involuntary parenthood
- Dental problems, poor health/serious, life threatening illness
- Anxiety/Panic/agoraphobia, OCD
Common Co-Occurring Disorders
The severely and chronically mentally ill are more likely to abuse substances.9
Mentally ill people are more likely to develop substance use disorder because they:
- Are accepted by the using subculture – tolerance of strange behavior
- are vulnerable to dealer and peer pressure to use
- Efforts to self-medicate
Some common co-occurring disorders include:
Schizophrenia is a chronic, severe, and disabling psychiatric disorder. The symptoms include losing touch with reality. The person will hear voices and see things that only they can perceive. They will have very strange ideas, which are typically paranoid. They will speak strangely, jumbling words together, and will neglect their personal hygiene.1
Bipolar Disorderis a very misunderstood disorder. It has nothing to do with mood swings. It involves extreme cycling of mood over weeks or more likely months. The person who is bipolar will spend weeks or months in a deep depression, then suddenly explode with energy, power, enthusiasm, and sexuality. They will stay this way for weeks or months then crash into depression again.1
Depression is not the same as experiencing sadness, unhappiness, or grieving. Depression is much more severe and profound. The symptoms of Depression include:
- Thoughts of death/suicide
- Insomnia or hypersomnia
- Loss of libido
- Loss of appetite or overeating
- Muscle and joint aches, headaches, stomach aches1
Obsessive Compulsive Disorder
OCD (Obsessive Compulsive Disorder) is an anxiety disorder in which the person will have constant intrusive and unwanted thoughts and images popping into their head. Someone suffering from OCD will do compulsive behaviors in an effort to stop the intrusive thoughts and images. They will feel fear of what could happen if they don’t engage in the behaviors. The worst part of OCD will be the awareness that the thoughts are unwanted and the behaviors are useless. This causes constant conflict and an exhausting internal battle.1,10
Anxiety can be crippling in its worst forms. People can become unable to leave the house, or in severe cases, they are confined to a single room in the house. They only way they can reduce their anxiety enough to function is to drink or drug.1
Post-traumatic Stress Disorder is caused by a traumatizing event, either a one-time occurrence or chronic stress. People with PTSD feel that the world is no longer a safe place. This perception of safety can be ripped away suddenly or gradually eroded. People with PTSD have insomnia, nightmares, vivid memories of the trauma, and are easily startled. Use of alcohol and drugs to control symptoms is also common.1,10
People with these disorders suffer miserably, day after day, with no end in sight. This leads to feeling hopeless and helpless. In desperate need for relief, they turn to drugs and alcohol to numb their thoughts and feelings. This does not work. It is a futile effort that only compounds their mental illness and makes things even worse.
Substance Use Disorders can start out slow and take years to develop. The disorders are a combination of genetics, environment, and free will. We cannot control what we are born with. Some people are born with an innate vulnerability to becoming addicted to drugs and alcohol, while others are born with an innate resistance to addiction. If you grow up in a pro-drug or drug tolerant family and community, it can make it easier to misuse, abuse, and become addicted to drugs.
Regardless of what you were born with or grew up with, you have free will. Free will may be the most important tool that can determine if you go down the path of addiction or not. If you are already on the path, you can decide to step off.
For Further Reading
If you or a loved one is struggling with a substance use disorder, these resources may be helpful: