Drug and alcohol abuse is a common societal problem worldwide.
Drugs abuse refers to the excessive use of drugs that tends to activate brain reward system that reinforces behaviors and the production of memories. Substance abuse has been adopted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to include 10 separate classes of drugs, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics and anxiolytics, stimulants, tobacco and other substances. These drugs produce such an intense activation of the reward system that normal activities may be neglected. Instead of achieving reward through adaptive behaviors, drugs of abuse directly activate the reward pathways. Each class of drug produces different pharmacological mechanisms, but the drugs typically activate the system and produce a feeling of pleasure, often referred to as a high.
Substance-induced disorders include intoxication, withdrawal and substance-induced mental disorders such as psychotic disorders, bipolar disorder, depressive disorder, anxiety disorder, obsessive-compulsive disorder, sleep disorders, sexual dysfunction, delirium, and neurocognitive disorders.
Alcohol abuse refers to drinking too much alcohol on occasion, as well as habits of drinking alcohol that result in harm to health, ability to work behavior, and judgment. Alcohol abusers generally are not dependent on alcohol. Alcohol dependence, on the other hand, means a person needs alcohol to get through his or her day. Alcohol abuse and alcohol dependency were previous terms used in DSM-IV. DSM-5 has combined alcohol abuse and alcohol dependence to create a unified disorder, alcohol use disorder (AUD).
Family Risk Factors
Individual Risk Factors
Peer Risk Factors
Community Risk Factors
There is a high rate of co-occurring mental disorders among adolescent youth (12 to 18 years) who use substances or have a substance use disorder, including:
In studies children 13 to 18 years of age with a mental disorder, rates of a co-occurring substance use disorder (SUD) have ranged from 61% to 88%.
Alcoholism is etiologically complex, with a variety of other vulnerability factors
It has been estimated that there is a 7-fold risk of alcoholism in first-degree relatives of alcohol-dependent individuals, with male relatives of male alcohol-dependent individuals having the greatest risk for the disorder.
Among type 1 and type 2 alcoholics (typologies developed by Cloninger), type 1 alcoholics are characterized by the late onset of problem drinking, the rapid development of behavioral tolerance to alcohol, prominent guilt and anxiety related to drinking, and infrequent fighting and arrests when drinking. Cloninger also termed this subtype “milieu-limited,” which emphasizes the etiologic role of environmental factors. In contrast, type 2 alcoholics are characterized by early onset of an inability to abstain from alcohol, frequent fighting and arrests when drinking, and the absence of guilt and fear concerning drinking. Cloninger postulated that transmission of alcoholism in type 2 alcoholics was from fathers to sons, hence term the male-limited alcoholism. Type 1 alcoholics are characterized by high-reward dependence, high-harm avoidance, and low-novelty seeking. In contrast, type 2 alcoholics are characterized by high-novelty seeking, low-harm avoidance, and low-reward dependence. Cloninger also hypothesized that specific neurotransmitter systems underlie personality structure. Specifically, dopamine is hypothesized to modulate novelty seeking, which is characterized by frequent exploratory behavior and intensely pleasurable responses to novel stimuli. Serotonin is hypothesized to modulate harm avoidance, which is a tendency to respond intensely to aversive stimuli and their conditioned signals. Finally, norepinephrine is hypothesized to modulate reward dependence or the resistance to extinction of previously rewarded behavior.
Some studies show a decreased sensitivity to the effects of alcohol in adult children of alcoholics. Other data indicate the effects of the alcohol metabolizing enzymes aldehyde dehydrogenase and alcohol dehydrogenase polymorphisms in individuals of Asian ancestry, in which aversive reactions to the effects of alcohol are associated with reduced risk of alcohol dependence. Flushing reaction happens to individuals homozygous for the gene that codes the enzyme, aldehyde dehydrogenase (ALDH2). This enzyme breaks down acetaldehyde, one of the byproducts of alcohol metabolism include the GABRG1 and GABRA2 genes that encode the gamma-1 and alpha-2 subunits of the GABA-A receptor, COMT Val158Met, and DRD2 Taq1A, which may affect dopamine receptor sensitivity, and KIAA0040. Genes may influence which individuals are more susceptible to alcohol-related comorbidities like alcoholic liver disease.
It is proposed that alcoholism is caused by repeated use of alcohol to “self-medicate” negative affective states such as anxiety and depression.
Substantial proportions of youth surveyed had tried illicit drugs at least once in the countries that follow
Nearly half of 12th graders in the United States reported smoking marijuana daily, and 1 in 7 reported having been a daily marijuana smoker at some time for at least a month.
The rate of current illicit drug use among European youth ages 12 to 17 was 9.5% in 2012, with the percentage of users as follows:
Alcohol use disorder is a common disorder in the United States. The 12-month prevalence of alcohol use disorder is estimated to be 4.6% among 12 to 17-year-olds and 8.5% among adults aged 18 years and older in the United States. Rates of the disorder are greater among adult men (12.4%) than among adult women (4.9%). Twelve-month prevalence of alcohol use disorder among adults decreases in middle age, being greatest among individuals 18 to 29-years-old (16.2%) and lowest among individuals age 65 years and older (1.5%). Twelve-month prevalence varies markedly across race/ethnic subgroups of the US population. For 12 to 17-year-olds, rates are greatest among Hispanics (6.0%) and Native Americans and Alaska Natives (5.7%) relative to whites (5.0%), African Americans (1.8%), and Asian Americans and Pacific Islanders (1.6%). In contrast, among adults, the 12-month prevalence of alcohol use disorder is clearly greater among Native Americans and Alaska Natives (12.1%) than among whites (8.9%), Hispanics (7.9%), African Americans (6.9%), and Asian Americans and Pacific Islanders (4.5%).
The 2011 US National Survey on Drug Use and Health estimated that of Americans over the age of 12 in the past 30 days:
As with most behavioral and psychiatric disorders, the interplay between genetic risk, temperamental traits, and the environment may predispose to early use of substances of abuse. Once exposed to substances, brain reward systems reinforce substance use, resulting in repeated use and lower ability to control substance use.
The pathophysiology of alcohol use disorder is not known, but its development may be the result of a complex interplay of genetics, environmental factors, personality traits, and cognitive functioning.
Substance use and/or substance use disorders (SUDs) are associated with many negative consequences among youth, including accidents, death, health effects, crime, unplanned pregnancy, and lower achievement. Substance use contributes to accidents, death, and a variety of hazardous behaviors. Sexual behaviors are increased during adolescent substance use. Toxic effects of different drugs of abuse include following:
Excessive alcohol consumption is the third leading preventable cause of death in the United States. More than 85,000 deaths a year in the United States are directly attributed to alcohol use.
A detailed history is necessary to establish the diagnosis of drug abuse.
Patient’s social history can provide information about risk factors for unhealthy substance use and the impact of substance use on the patient’s role functioning. Look for Partner with a substance use disorder, poor socio-economic society, violence, and high school alcohol and other drug availability. A family history of substance use disorder (SUD) has been shown to be a risk factor for the development of a Substance abuse disorder. Heritability estimates range from:
Dig deep into a history of Disrupted familial and social relationships, Failure to fulfill responsibilities at school or work (e.g., loss of job, poor grades in school. Ask questions about past history of violent behavior, child abuse, financial problems and sexual history (multiple partners, sex habits, etc.)
During the physical examination, look for:
Mental State Exam
This examination should be performed and look for following symptoms and signs:
Ask about current and past alcohol use and treatment, family history of alcohol problems and treatment, and a detailed history regarding the quantity and frequency of alcohol use.
Physical features accompanying alcohol abuse range from a normal physical exam to features of alcohol withdrawal (tachycardia, tremor, agitation, clouding of the sensorium) to features of the advanced liver disease in case of chronic alcoholism (spider angiomata, palmar erythema, gynecomastia, testicular atrophy, hepatic or splenic enlargement).
DSM-5 Diagnostic Criteria for Substance Use Disorder
Two or more of the following in a 12-month period manifests a problematic pattern of use leading to clinically significant impairment or distress:
Disorder Severity: DSM-5 specifies mild, moderate, and severe based on the number of diagnostic criteria met by the patient at the time of diagnosis:
DSM-5 Diagnostic Criteria for Alcohol Use Disorder
Disorder Severity: The severity of alcohol use disorder at the time of diagnosis can be specified as a subtype based on the number of symptoms present:
Diagnosis of alcohol problem can be made in the outpatient department by using CAGE questionnaire which includes the questions: (need to) cut down, annoyance (on drinking), guilt (about drinking), an eye-opener
Screening tools like the 10 question Alcohol Use Disorder Identification Test (AUDIT) and the abbreviated 3-question audit-consumption (Audit-C) are recommended for screening.
Laboratory tests to confirm the diagnosis include:
CBT is used to help patients learn how their thought processes play a role in developing their behavior. Cognitive awareness helps them to develop new ways of behaving, thus leading to change in thinking patterns and emotions.
Mutual Help Groups
Alcoholic Anonymous (AA), is a voluntary program for people with alcoholism/AUD, based on belief in a spiritual basis for recovery. Members attend meeting and experiences are shared and "Twelve steps towards Recovery" are discussed. Avoiding alcohol and benefits of avoiding alcohol are discussed. Abstinence is encouraged on a daily or weekly basis. Alcoholics Anonymous can be reached via their website www.aa.org.
Motivational Interviewing/Motivational Enhancement
Drug or Addiction Counseling
Prognosis depends upon follow up and motivational and cognitive behavior therapy. Support like Alcoholics-Anonymous groups play an important role in prognosis.
Substance use leads to a number of problems among youth, including accidents, death, health effects, crime, unplanned pregnancy, and lower achievement.
Psychiatric consultation is necessary.
Cognitive behavioral therapy (CBT), motivational therapy, and psychotherapy are necessary to avoid remission.
The management of alcohol and drug abuse requires an interprofessional team that includes a mental health nurse, psychiastrist, emergency department physician, internist, addiction counselor and pain specialist. Clinicians need to be proactive and identify these patients; the earlier the treatment is undertaken, the better the outcomes. In addition, healthcare workers need to curtail the liberal prescription of analgesics, hypnotics, and sedatives and offer patients alternative means of managing their pain and insomnia.
Unfortunately, the outcomes for patients addicted to alcohol and drugs are poor. Short term recovery does occur, but relapses are common. Drug and alcohol addiction has repercussions beyond health; it can destroy the family, result in job loss and lead to financial loss.
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