Overview of

Substance Use Disorders

Myra L. Mathis, MD
Addiction Psychiatrist
Assistant Professor, University of Rochester Department of Psychiatry
Medical Director, Strong Recovery

1
 Disclosures

• Dr. Myra L. Mathis, faculty for this educational activity, has no relevant
financial relationship(s) with ineligible companies to disclose.

2
 Target Audience

• The overarching goal of PCSS is to train healthcare

professionals in evidence-based practices for the
prevention and treatment of opioid use disorders,
particularly in prescribing medications, as well for
the prevention and treatment of substance use
disorders.

3
 Educational Objectives
• At the conclusion of this activity participants should be
able to:
▪ Identify the spectrum of substance use
▪ Use accurate clinical terminology
▪ Describe the basic epidemiology and public health
impact of substance use disorders
▪ Describe neurobiological responses to substances
▪ Describe how chronic disease treatment applies to
addiction
▪ List common comorbidities in people with substance
use disorders

4
 Outline

• Spectrum of substance use

• Accurate terminology
• Epidemiology
• Neurobiology
• Addiction as a chronic disease
• Association with other conditions
• Harm Reduction
• Integration in medical and psychiatric care

5
Spectrum of Substance Use

6
 Spectrum of Substance Use

Substance Use
Consumption Consequences
Heavy Mild, moderate, Severe
severe
Substance use
Harmful
use disorders

Unhealthy
use Risky use, at-risk
hazardous

Low-risk use

Abstinence
None None

7
modified from Saitz R, 2005
 DSM 5 Criteria for
Substance Use Disorders (SUD)

Definition: A problematic pattern of substance use leading to

clinically significant impairment or distress, as manifested by at least
two of the following, occurring within a 12-month period:

1. The substance is often taken in larger amounts or over a

longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut
down or control substance use.
3. A great deal of time is spent in activities necessary to obtain
the substance, use the substance, or recover from its effects.
4. Craving, or a strong desire or urge to use the substance.

8
APA, 2013
 DSM 5 Criteria for
Substance Use Disorders (SUDs)
5. Recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home.

6. Continued substance use despite having persistent or recurring social or

interpersonal problems caused or exacerbated by the effects of the
substance

7. Important social, occupational, or recreational activities are given up or

reduced because of substance use

8. Recurrent substance use in situations in which it is physically hazardous

9. Substance use is continued despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to have been
caused or exacerbated by the substance

9
APA, 2013
 DSM 5 Criteria for
Substance Use Disorders (SUD)

10. Tolerance, as defined by either of the following:

A. A need for markedly increased amounts of the substance to
achieve intoxication or desired effect
B. Markedly diminished effect with continued use of the same
amount of the substance.

11. Withdrawal, as manifested by either of the following:

A. The characteristic withdrawal syndrome for the substance
B. Substance (or a closely related substance) is taken to relieve
or avoid withdrawal symptoms.
*Tolerance and withdrawal do not apply when using appropriately under medical
supervision
10
APA, 2013
 DSM 5 Criteria for
Substance Use Disorders (SUD)

Specify current severity:

Mild: Presence of 2-3 symptoms
Moderate: Presence of 4-5 symptoms
Severe: Presence of 6-11 symptoms

Specify the substance being used:

(e.g., cocaine use disorder, alcohol use disorder, etc).

Of note – polysubstance use was removed from DSM 5.

For patients using multiple substances, each substance should
be listed.

11
APA, 2013
Accurate Clinical Terminology

12
 Terminology

• Unhealthy use • Toxicology Screens

▪ Harmful, hazardous ▪ Positive/negative
▪ Non-prescribed use ▪ Avoid: clean/dirty
▪ Avoid: Misuse • Return to use
• Binge ▪ Recurrence
▪ Heavy episode ▪ Remission
▪ Multiple days ▪ Avoid: Relapse
• Disorder • Medication
▪ Agonist
• Dependence ▪ Avoid: Substitution, Assisted,
▪ Physical Replacement
▪ Addiction • Neonatal withdrawal
▪ ICD, DSM IV and prior ▪ Abstinence syndrome
▪ Avoid: Addicted
13
Saitz, Miller, Fiellin & Rosenthal, 2021
Epidemiology

14
 Numbers of People Aged 12 or Older
with a Past Year SUD: 2020

15
SAMHSA, 2021
 Prevalence of disorder, ages 12+ (US)

• SUD (drugs and alcohol) - 14.5%

• Alcohol Use Disorder (AUD) – 10.2%
• Opioid Use Disorder (OUD) - 0.8%
▪ Nonmedical Prescription Opioid Use Disorder- 0.8%
− (Misuse 3.4%)
▪ Heroin Use Disorder - 0.25%
▪ Fentanyl not included in survey collection

16
NSDUH 2020: published by SAMHSA in 2021
 Prevalence of Drug Use Disorder
by Socioeconomic Status
Past 12-month prevalence of
Characteristic drug use disorder (%)(n=777)
Total 2
Male 2.8
Female 1.2
White 1.9
Black 2.4
Native American 4.9
Asian 1.4
Hispanic 1.7
18-29 years old 5.3
30-44 1.9
45-64 0.8
>65 0.2
Married 1.0
Widowed, separated, divorced 1.7
Never married 5.2
17
Compton, 2007
 Prevalence of Drug Use Disorder
by Socioeconomic Status (continued)
Past 12-month
prevalence of drug use
Characteristic disorder (%)(n=777)
<High school 2.3
High school 2.4
>Some college 1.7
$0-19,999 annual income 2.8
$20,000-34,999 1.9
$35,000-69,999 1.0
>$70,000 0.7
Urban 2.0
Rural 1.9
Northeast 2.1
Midwest 2.0
South 1.5
West 2.7

18
Compton, 2007
 Demographics of OUD

• Age/Sex
▪ Males younger than 45 have higher rates than women
▪ Women 45 and older higher rates than men
• Race/Ethnicity
▪ Rates of OUD similar across racial/ethnic groups
▪ Highest rates of overdose among Black & Indigenous populations
• Income
▪ Higher rates for lower income
• Employment (for all SUD)
▪ Higher rates for unemployed, uninsured
− BUT, over half of those with SUD employed full-time

BlueCross BlueShield, 2017; Compton, 2000; Becker, 2008, 19

Jordan 2021, Friedman & Hansen 2021
 Demographics of overdose

20
Friedman & Hansen, 2021
 Demographics of overdose
among adolescents

21
Friedman, Godvin, Shoder et al, 2022
Neurobiology

22
 Neurobiology Involved in Addiction
The fine balance in connections that normally exists
between brain areas active in reward, motivation,
learning and memory, and inhibitory control

EXECUTIVE
FUNCTION
PFC
ACG
INHIBITORY
Hipp
CONTROL OFC
SCC NAcc
REWARD
VP
MOTIVATION/
DRIVE Amyg MEMORY/
LEARNING

Becomes severely disrupted in

ADDICTION
23
Image: Compton, W. Addictions and Brain Reward System, NIDA presentation
 Drugs and
Natural Natural
Rewards Rewards
Elevate
Natural Rewards Elevate
Drugs Also
Elevate Cause Dopamine
Dopamine
Dopamine
DopamineLevels Release
Levels
Levels
1100 Accumbens AMPHETAMINE Sex
COCAINE
Food Food 400
Accumbens
Sex
2001000

DA Concentration (% Baseline)
200

DA Concentration (% Baseline)
Release

200 200
900

% of Basal Release
NAc NAc
shell shell
DA
% of Basal DA Output

800
Output

DA 300 DOPAC
150 700 150
150 DOPAC 150
Basal

HVA
600 HVA
% ofDA

500
100
100 100 200 100
% of Basal

400
300
Empty
Empty
5050
200 100
Box Feeding
Box Feeding
100
Female Present
0 Female Present
0 0 0
Drugs Also Cause Dopamine Release
0 0
0 1
60 60
Time
Time (min)
2 3
120 120 180
After
4
Amphetamine
180
5

Time (min)
hr
Number
1 2 0 3 1 4 12 5 36 2 4
Sample Sample
Number Time
7
After
3 86 47
5
Cocaine
5 hr 8

1100
250
Accumbens AMPHETAMINE
NICOTINE
250 Accumbens
Accumbens
COCAINE
MORPHINE
400
% of Basal Release

1000 Dose (mg/kg)

% of Basal Release

% of Basal Release
Di
DiChiara
Chiara 200
900 et et
al., Neuroscience,
al., 1999.,Fiorino
Neuroscience, and Phillips,
Accumbens
1999.,Fiorino J. Neuroscience,
and Phillips, 1997.
J. Neuroscience, 1997.
% of Basal Release
200 0.5
DA
800 DA Caudate 300 DOPAC
1.0
700 150 DOPAC 2.5
HVA
600 HVA 150 10
500 200
400 100
100
300
200 100
100
0 0
0 0 1 12 23 3 hr 5 hr
4 0 0
Time After Nicotine 0 1 0 2 1 3 2 4 3 5 hr 4 5hr
Time After Amphetamine Time After Morphine
Time After Cocaine 24
Bassareo, 1999; Fiorino, 1997; Di Chiara 1988 Source: Di Chiara and Imperato
250
 Repeated Drug Use Changes the Brain:
Weakens the Brain Dopamine System

Repeated use of cocaine or other drugs reduces levels of dopamine D2 receptors

25
Volkow, Fowler, Wang, Swanson & Telang, 2007
 Cocaine Craving:
Population (controls, people who use cocaine) X Film (cocaine, erotic)

Cingulate
Signal Intensity (AU)

Ant Cing

Cocaine Film
Erotic Film

IFG
Controls People who use cocaine
26
Garavan et al., 2000
 Effects of a Social Stressor on Dopamine
Receptors
Effectsand Propensity
of a Social toBrain
Stressor on Administer
DopamineDrugs
D2
Receptors and Propensity to Administer Drugs
Individually Group Dominant
Housed Housed 50 Subordinate
40

(per session)
Becomes

Reinforcers
Dominant 30
20
* *
No longer 10
stressed Cocaine (mg/kg/injection)
0
S .003 .01 .03 .1
Social Setting Can Change Neurobiology Social Support Is Correlated
with D2/3 Receptor Binding
Becomes
Subordinate

Stress remains

Morgan, D. et al. Nature Neuroscience, 2002.

Martinez D. et al., Bio Psychiatry 2010.

27
 Standard Rat Housing

• Skinner Box isolated and can give foot shocks

• Rats given access to drugs use them to death

By U3144362 (Own work) [CC BY-SA 4.0 28

(https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons
 Rat Park

29
Brucekalexander.com
 More Drug Use When Caged,
Less Drug Use When Housed

30
Alexander,1978
By Photo by SFC Peter P. Ruplenas, US Army Sp Photo Det, Pacific –
San Mateo Public Library [1], Public Domain, 31
https://commons.wikimedia.org/w/index.php?curid=3373373
 Neurobiology: Key Points

Key components that drive compulsive drug use:

• Dopamine release leads to subjective feelings of
pleasure/reward and reduction in feelings of stress (NAcc)
• Repeated use overrides impulse inhibition (dorsal striatal
circuit)
• Repeated use is also associated with discomfort when stopped
which leads to more use: withdrawal and mood dysregulation
(amygdala)
• Dysregulation of executive function (Preoccupation/anticipation:
prefrontal)
• Environmental/social conditions influence substance use

32
Addiction as a Chronic Disease

33
 Defining a disease

• A disorder of structure or function that produces specific

signs or symptoms
• Addiction has defined causes (genetics, social,
environment) and observable consequences (behavioral,
biological)

34
 Behavior change in addiction

• Choice (disordered)
• Impulse and self-control
• Learning and habit
• Some synthesis?
▪ A chronic condition of the motivational system with an
abnormally high priority given to a particular activity
− System is abnormal due to substance or other
behavior
o Sensitization, tolerance, withdrawal, mood, social effects
o Other factors (anxiety, depression, low self-esteem,
impulse control)
− Affected by environment on a normal system that
is stressed (distressing circumstances, social
relationships, isolation)
35
 Risk and Protective Factors:
Genetics
• Twin studies as well as study of specific genes
• Heritability of addiction ranges from 39-72%
• Examples of specific genes:
▪ NICOTINE: fast metabolism (CYP2A6)—smoke
more cigarettes, progress to addiction, more severe
withdrawal, harder to quit
▪ ALCOHOL
− Genetic, biological low response → higher risk
− Flushing response to alcohol → lower risk

36
 Risk and Protective Factors:
Age of Onset

97% of those with

addiction start use
before age 21

AMERICANS WHO BEGAN

USING ANY SUBSTANCE
BEFORE AGE 18 DEVELOPS
A SUD

Hingson, RW, Heeren T, Winter MR (BUSPH). Arch Pediatr Adolesc 37

Med. 2006;160(7):739-746. doi:10.1001/archpedi.160.7.739.
 Developmental Factors

• Early: temperament, attachment, parenting warmth,

stability
• Middle school: Self-control, aggression, permissive
parenting, low parental aspirations for child, parental
use attitudes, peers, school failure
• Adolescence: academic mastery, school engagement,
parental supervision, peers
• Young adulthood: adult role, leaving home, college,
peers

38
 Psychological Factors

• Depression, anxiety, psychotic disorders

• Conduct disorder, ADHD
• Stress, trauma/abuse, PTSD
• Risk-taking or impulsive personality traits, low self-
esteem (use)
• Expectancies (positive)

39
 Environmental Factors

• Access to addictive substances

▪ Liquor cabinet, sales outlets, medical marijuana, prescription opioids
• Substance use in the family (parental use); Parental anti-
use messages and expectations
• Peer influence (use and approval of use), community
tolerance and “rite of passage”
• Lax enforcement; glamorous advertising, media or direct-to-
consumer for Rx drugs
• High levels of parent-child conflict, poor communication,
weak family bonds

40
 COVID-19:
Unique Psychosocial Factor

• Social isolation
• Unemployment/economic
stress
• Higher rates of depression
• Highest recorded rates of
overdose deaths
▪ 3,442 in 1999
▪ ~107,000 in 2021

41
 Addiction as a Chronic Disease

• Comparison to chronic conditions like depression,

type 2 diabetes, hypertension, and asthma
▪ May be caused in part by genetic factors
▪ Environmental factors influence development and
course of illness
▪ Contributions of voluntary behavior
▪ Difficult to manage behaviorally

42
McLellan, 2000
 Addiction as a Chronic Disease

• Comparison to chronic conditions like depression,

type 2 diabetes, hypertension, and asthma
▪ Similar treatment adherence and relapse rates
▪ Responds to ongoing treatment
▪ Some will have to engage in lifelong
management of the condition

43
McLellan, 2000
 For individuals with more severe SUD …
Course of illness and achievement of stable recovery
can take a long time …

Full Sustained Recurrence

Addiction
Help Seeking Remission (1 year Risk drops
Onset
abstinent) below 15%

4-5 years 8 years 5 years

Self-initiated 4-5 Treatment

cessation episodes/ Continuing care/ >50% of
Opportunity
attempts mutual-help mutual-help individuals
for earlier
with
detection
addiction will
through
achieve full
screening in
sustained
non-
remission
specialty
(White,
settings like
2013)
primary
care/ED

44
Source/Courtesy of Professor John Kelly
 Addiction CAN Be Treated
Brain Function CAN Recover
Partial Recovery of Dopamine Transporters
in People Who Use Methamphetamine (METH)
After Protracted Abstinence

ml/gm

Normal Control Person who uses METH Person who uses METH
(1 month abstinence) (14 months abstinence)

45
Volkow et al, 2001
Association with Other Conditions

46
 Medical and Psychiatric Conditions
Associated with Addiction

Cardiopulmonary conditions Gastrointestinal conditions

▪ Asthma ▪ Hepatitis C
▪ COPD ▪ Cirrhosis
▪ Hypertension ▪ Pancreatic disease
▪ Gastritis
Pain conditions
▪ Arthritis Psychiatric conditions
▪ Headache ▪ Depression/Dysthymia
▪ Lower Back pain ▪ Bipolar disorder
▪ Anxiety disorders
▪ Psychosis
▪ Personality disorders

Mertens, 2003 47
Compton, 2007
 Mechanisms of Harmful Effects

• Direct, due to desired effects

▪ Intoxication, withdrawal, intentional overdose
• Direct, due to undesired effects, contaminants
▪ Lung cancer, cirrhosis, talc lung, medication
interaction, unintentional overdose
• Indirect, due to method of administration
▪ Endocarditis, pneumothorax, HIV, Hepatitis C (HCV)
• Indirect, due to associated behavior
▪ Sexually transmitted diseases, assault/injury, intimate
partner violence, motor vehicle crash

48
 Harmful Effects of Injection

• Collapsed veins
• Endocarditis, septic phlebitis
• Hepatitis A, B, C, delta
• HIV, other STDs
• Cellulitis, septic arthritis, pneumonia, osteomyelitis,
epidural abscess, skin abscess, mycotic aneurysm,
malaria, tetanus
• Pulmonary hypertension, talc granulomatosis,
septic emboli, pulmonary embolism (including
needle), pneumothorax, hepatic granulomatosis
• Kidney failure, amyloidosis

49
 HCV and HIV among
Persons Who Inject Drugs (PWID)
• HCV
▪ 1/3rd of young (18–30) PWID
▪ 70-90% of older and former PWID

• HIV
▪ 11% prevalence among PWID
▪ 9% attributable risk among PWID

50
Spiller, Broz, Weinert, Nerlander & Paz-Bailey, 2015; CDC, 2017
Harm Reduction

51
 Harm Reduction

• Spectrum of practical strategies aimed at mitigating

the medical consequences and social stigmas of
substance use

• Ranges from abstinence to managed use

• Person-centered care

Harm Reduction Coalition. Principles of harm reduction. Available 52

at: https://harmreduction.org/about-us/principles-of-harm-reduction/.
 Harm Reduction

• Change route of administration

▪ Oral >rectal>intranasal>inhalation>injection
• Don’t use alone
• Avoid mixing drugs
• Stagger use
• Plan not to drive or take on a large task

53
 Harm Reduction Services
• Safer injection/Infection Prevention
▪ Free syringe service programs
▪ Sterile injection or smoking equipment & technique
▪ Prevent 43% of new incident HCV by eliminating nonsterile injection
techniques
▪ PrEP

• Overdose prevention
▪ Naloxone kits and training
▪ Fentanyl tests strips
▪ Overdose Prevention Centers

• Medications for addiction treatment

▪ Associated with decreased rates of HIV/HCV
▪ Decreased risk of overdose

Note: Not all harm reduction views are supported by the federal government and SAMHSA,
though some approaches have demonstrated promising results.

Platt et al 2018 54
Peckam & Young 2020
Integrating Addiction Treatment

55
 Engagement in Addiction Treatment

• 10% of all patients with addiction receive any

treatment (withdrawal management/detox, inpatient or
outpatient services)

• Only 50% of patients who receive withdrawal

management/detox go on to further treatment

• Of those who go on to further treatment (inpatient or

outpatient), only 50% complete

56
57
 Choosing Healthier Drinking Options
in Primary Care (CHOICE) Trial

• Patients with high-risk unhealthy use or alcohol use

disorders (73%)
• Nurse care management for 1 year
• Results:
• more use of alcohol use disorder medications (32% vs 8%)
• no differences in specialty alcohol treatment or mutual help
• no difference in % heavy drinking days (35% and 39%)
• no difference in “good drinking outcome” (20% and 15%)

58
Bradley KA et al, 2017
 Integrating Care

O'Malley SS et al. Arch Intern Med 2003

CBT vs. Primary Care Management w/ naltrexone → similar outcomes
Oslin et al. J Gen Intern Med 2014
Medication management w/ naltrexone vs. Specialty care
• Better engagement
• Less heavy drinking
Lucas GM et al. Ann Intern Med 2010
Integrated care in HIV clinic vs referral-based treatment
• More opioid agonist treatment
• Less substance use
• More primary care use

59
 • Referred
• Collaborative care-training and care coordinators
• Any OUD/AUD treatment (brief evidence-based therapy,
medications for addiction treatment) (39% v. 17%)
• Abstinence from opioids or alcohol at 6 months (33% v. 22%)

60
Watkins, et.al, 2017
 Emergency Department Integration

• D’Onofrio et al. 2015 → buprenorphine induction in the ED

vs referral vs brief intervention
▪ At 30-day mark, 78% of those inducted on bup were
engaged in SUD treatment
− 37% for referral; 45% for brief intervention
▪ Days of opioid use decreased
▪ No significant diff in tox screens

• Herring et al. 2021 → demonstrated safety of high-dose

buprenorphine induction in the ED
▪ Patients given >12 mg; no respiratory depression or
sedation reported
▪ Rate of precipitated withdrawal no associated with
dose

D’Onofrio, et. al, 2015 61

JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
It Takes a Team!

62
 Multidisciplinary teams
in addiction treatment

• Medical, psychiatric and addiction specialists

• Prescribers
▪ Physicians, Advanced Practicing Nurses
(APRNs), Physician Assistants (PAs)
• Nursing
• Pharmacists
• Counselors/therapists
• Social work
• Vocation/Psych Rehab therapists
• Peers
63
 Conclusion

• Substance use varies. Individuals can have low-risk use,

risky or hazardous use, or harmful use that can meet DSM
5 criteria for a substance use disorder.
• Accurate language is important to use.
• Substances work on many areas of the brain, including
reward and pain pathways and dopamine systems.
• There exist many theories behind addiction. Most likely
etiologies are combined: an abnormal motivational
system, neurobiology, and environmental factors.

64
 Conclusion

• SUDs are associated with a range of mental health disorders

and medical conditions.
• More evidence is needed on the benefits of chronic care
management for SUDs.
• Harm reduction provides practical strategies to reduce the
harms associated with substance use.
• Integrated care is advantageous.
• Multidisciplinary teams are needed.

65
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• https://pixabay.com/en/photos/puzzle%20piece/

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 PCSS Mentoring Program

• PCSS Mentor Program is designed to offer general information to

clinicians about evidence-based clinical practices in prescribing
medications for opioid use disorder.

• PCSS Mentors are a national network of providers with expertise in

addictions, pain, evidence-based treatment including medications
for opioid use disorder (MOUD).

• 3-tiered approach allows every mentor/mentee relationship to be unique

and catered to the specific needs of the mentee.

• No cost.

For more information visit:

https://pcssNOW.org/mentoring/
71
PCSS Discussion Forum

Have a clinical question?

Ask a Colleague
A simple and direct way to receive an
answer related to medications for opioid
use disorder. Designed to provide a
prompt response to simple practice-
related questions.

http://pcss.invisionzone.com/register

72
PCSS is a collaborative effort led by the American Academy of Addiction
Psychiatry (AAAP) in partnership with:
Addiction Technology Transfer Center
American Academy of Family Physicians
American Academy of Pain Medicine
American Academy of Pediatrics
American Pharmacists Association
American College of Emergency Physicians
American Dental Association
American Medical Association
American Osteopathic Academy of Addiction
Medicine
American Psychiatric Association
American Psychiatric Nurses Association
American Society of Addiction Medicine
American Society for Pain Management Nursing
Association for Multidisciplinary Education and
Research in Substance use and Addiction
Council on Social Work Education
International Nurses Society on Addictions
National Association for Community Health Centers
National Association of Social Workers
National Council for Mental Wellbeing
The National Judicial College
Physician Assistant Education Association
Society for Academic Emergency Medicine
73
 Educate. Train. Mentor

@PCSSProjects www.pcssNOW.org

www.facebook.com/pcssprojects/ pcss@aaap.org

Funding for this initiative was made possible (in part) by grant no. 6H79TI081968 from SAMHSA. The views expressed in written conference materials or
publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does
mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. 74