This segment will consist of two modules, the first on substance use disorders and definitions and terminology, and the second will deal with the different classes of substance abuse. Two different addiction medicine specialists were very helpful in preparing this material. So first we'll talk about what used to be called substance abuse and is now called substance use disorders. So many people don't understand the meaning of a positive drug screen. So as an MRO, we are having to constantly educate people as to what a positive laboratory toxicology screen means. And it clearly does not say that there's a diagnosis of a substance use disorder, substance abuse, addiction, or impairment. It simply means the presence of a substance in a drug screen at or above a certain designated level. Because of the confusion, these terms and others are frequently confused with each other or used synonymously. Today's official definitions stem from a wonderful description of addictive disease put together by David Smith in 1990. Dr. Smith was a physician who operated a free health clinic in Haight-Ashbury during the height of the drug era in the 1960s. He later became an addiction medicine specialist and president of a very large complex of institutions in San Francisco dealing with substance abuse. Dr. Smith defined it as a pathological state with characteristic signs and symptoms. So there's a natural history of addiction regardless of the substance. And he described three aspects of it you will see later. First of all, a compulsive desire for the drug. Secondly, a loss of control when a person has the drug on board. And third, continued use despite of many adverse consequences. Official definitions of substance misuse are developed by the American Psychiatric Association and published in their Diagnostic and Statistical Manual, or DSM. The current edition is the fifth edition. And they define substance use disorder as a maladaptive pattern of substance use leading to clinically significant impairment or distress and manifested by the following at any time during a one-year period. So you'll notice that there are a number of criteria. And if you have two or three, you have a mild substance use disorder. If you have four or five, you have a moderate substance use disorder. And if you have six or more, then you have a severe problem. So what are the criteria? Well, the first several have to do with physiology. There's a strong craving or strong desire to use the substance, which was the first of Dr. Smith's criteria. When the drug is taken, the body automatically develops a tolerance for it so that higher and higher doses are required in order to get the same effect. And when the drug is stopped being taken, there's a characteristic pattern of withdrawal for each class of substances. As a result of the body's reaction, there's a continued use despite the negative consequences, which was the second of Dr. Smith's criteria. Over time, larger and larger amounts are used over a longer period. And there may be a persistent desire to cut down, which is very often unsuccessful. These additional criteria show the consequences of a person's physiologic addiction. The person begins to spend more and more time getting, using, and recovering from the substance. As a result of their preoccupation with the drug, they often give up important social or work-related or recreational activities. So they may not participate in the Rotary Club or give up a baseball team. And it certainly can affect work performance and reliability. As time goes on, they're unable to carry out major role functions at work and at school and at home. So frequently, people with a substance use disorder have had frequent jobs, they've been fired multiple times, they did not complete a school program, and they may have been kicked out of the house or divorced. People with substance use disorder will often use them in hazardous situations, such as in driving commercial vehicles or operating forklifts. And again, the third definition of Dr. Smith, they consistently continue to use it despite the persistent problems. So these are the 11 criteria. Another commonly used term is experimental drug use. Here a person is not a regular drug user, but they're having short-term use, they're experimenting with it, they may be curious to know what the effects are, or they want to actually experience an altered mood state. Often there's social pressure for people to join with friends, particularly if there's a party like a rave. So trying out or experimenting with drugs can often lead to more frequent use and even patterned use. This is often done then with other people, with friends in a social or recreational setting. I mentioned a rave. These are all-night parties that usually start late in the evening. People come into a room, they often bring drugs with them and put them in a bowl in the middle of the room, and there is music, there are refreshments, lights are low, people often dance, and in that setting people will consume whatever drugs they happen to find, and these parties will often last all night long until the dawn. Another type of drug use is called circumstantial drug use. Here a person is deliberately choosing to take a drug for a specific purpose. One example would be that commercial truck drivers, before there were limits on how many hours they could drive or how many miles that they could drive, would often take stimulants such as amphetamines in order to be able to drive for extremely long periods of time. So these are circumstantial, but often are not ones where a person has a substance use disorder. Here are the five families or classes of drugs that are tested for in the federal testing program. I mentioned them briefly in the introduction, and here you see the five classes. We'll be covering each of them in more detail in the next module. Each of these five classes of drugs can be consumed by mouth or smoked. You can see that all but marijuana can be injected or snorted, and in the case of fentanyl, it can be entered the body transdermally through a therapeutic patch. No matter what the drug, each of them can cause dependence, they can lead to intoxication and withdrawal, and they can even lead to delirium as well as mood and sleep disorders. Note that all of these drugs can lead to a psychotic disorder. That doesn't mean they cause psychosis, but they can unmask a psychosis, and all of them can be associated with hallucinations. You can also see that anxiety disorder and sexual dysfunction are frequent, and certain of these drugs have particular effects. For example, sedatives and others cause persisting amnesia where a person simply cannot remember what happened. Inhalants are associated with flashbacks where a person has a recreation of something that happened long ago, and in the case of inhalants, they can often cause brain damage which leads to persistent dementia. Instead of showing you the SAMHSA five categories, we're now looking at the categories of psychoactive substances as viewed by addiction medicine specialists, and in the next module, we will review each of them one by one.

addiction medicine

substance use disorders

drug screen

substance misuse

Diagnostic and Statistical Manual