substance abuse disorder case study

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

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Substance Abuse, Depression, and Social Anxiety: Case Study and Application of Cognitive Psychotherapy

Feda abu al-khair.

Assistant Professor in Clinical Psychology, Al-Ahliyya Amman University, 19328, Amman, Jordan

Associated Data

The data used to support the findings of this study have not been made available because of the privacy issues.

A 20-year-old male was referred by a psychiatrist to the clinic for treatment. He was diagnosed with social anxiety disorder (SAD), depression, and substances abuse. He complained of depressive mood and severe anxiety symptoms. These symptoms are triggered in social situations, as well as when talking to others, being in public areas, and going to malls or any crowded places. Because of his symptoms, he avoided getting into the situation, which affected his daily life. The patient was diagnosed with SAD, major depression, and substance abuse and underwent 20 separate sessions of cognitive behavioral therapy (CBT). The application of CBT led to a decrease in the number of anxiety attacks and angry outbursts that the patient suffers from. It also helped him learn some techniques to use in his interactions within the society, as well as other techniques, such as cognitive reorganization of dysfunctional thoughts, and gradually exposed him to the social situations. He also learned to practice some relaxation techniques, to teach him integration in social situations and confrontation instead of avoidance.

1. Introduction

Social anxiety disorder (SAD), one of the most common anxiety disorders, is rapidly increasing and disproportionately affects young people [ 1 ]. It is the third most common mental disorder after depression and alcohol dependence. According to epidemiological reports, the current prevalence is 5%–10%, and the lifetime prevalence is 8.4%–15% [ 2 ]. However, based on prevalence studies in seven countries, researchers found that the global prevalence of social anxiety is significantly higher than previously reported, and more than one-third of respondents met the threshold for SAD Standard. If left untreated, it can cause many serious problems in people's lives [ 1 , 3 ].

People with SAD experience significant fear and/or anxiety, in one or more types of situations on the social level, where they think others will judge and negatively evaluate them. The danger they feel during these situations is excessive compared to the feelings of a regular person, in form and intensity, when the two are placed in the same sociocultural context [ 4 ].

Comorbidity factors: SAD commonly occurs alongside other anxiety disorders, major depressive disorder, and substance use disorders. Typically, SAD emerges before the onset of these other disorders, except for specific phobia and separation anxiety disorder. Prolonged social isolation resulting from SAD can lead to the development of major depressive disorder. Among older adults, there is a significant comorbidity between SAD and depression. Individuals may turn to substances as a form of self-medication to cope with social fears. However, the symptoms of substance intoxication or withdrawal, such as trembling, can also intensify social anxiety. Body dysmorphic disorder frequently coexists with SAD, and generalized SAD often co-occurs with avoidant personality disorder. In children, there is a high prevalence of comorbidities between SAD and high-functioning autism spectrum disorder, as well as selective mutism [ 4 ].

A review highlighted the significance of the relationship between alcohol use and individuals suffering from SAD who believe that consuming alcoholic beverages will have a positive effect on them. People suffering from disorders, such as SAD and alcohol use disorder (AUD), expect alcohol to have more positive effects in social settings (such as decreased tension and social assertiveness) than those not suffering from AUD and those with lower levels of anxiety [ 5 – 7 ].

Many studies have been conducted on cannabis, nicotine, and other dependencies; however, many others concentrate on alcohol, when investigating the co-occurrence of alcohol and substance use disorder (ASUD) and SAD [ 8 ]. It is widely acknowledged that people with SAD will more likely be the consumers of alcoholic beverages and/or abuse drugs. Comorbid SAD and ASUD are clinically significant because they are linked to higher morbidity, poorer treatment outcomes, and decreased therapy seeking.

People with anxiety conditions are typically advised to begin using drugs (self-medication) to treat their symptoms. However, due to alterations in the biology of the brain, substance use can cause or contribute to a person's susceptibility to suffer from anxiety [ 5 , 6 , 9 ].

The study aims to determine the efficacy of cognitive psychotherapy in cases of SAD, depression, and substance abuse. Cognitive behavioral therapy (CBT) should have a major impact in these cases, by reducing the patient's complaints, such as anxiety from speaking in public and from social situations, low mood, and symptoms of depression. It should also allow patients to return to their studies and social life, without having to depend on different substances.

1.1. Description of Case Study and Methods

1.1.1. case report.

The patient is a 20-year-old single man. He is unemployed and has a history of polysubstance abuse and family problems. For the past 2 years, he has used alcohol, cocaine, and medical substance (Lyrica and other medications). He has a history of social anxiety with biological symptoms, which are unresponsive to medication. He expressed low self esteem and feelings of worthlessness. He was pessimistic about the future, saying, “I don't see anything ahead for me.” He described a passive death wish, but denied having any active suicidal thoughts. He described feeling fast heartbeats, blushing, trembling, sweating, trouble catching his breath, dizziness, and panic complaints, especially when talking to people and women in specific. He also described being unable to carry out a conversation with others, feelings of being watched and laughed at, and believing that he is ugly looking. He described having these complaints since adolescence. The patient has been an addict for the past 2 years. He started with Marijuana and alcohol, and then he tried several medical drugs.

The patient talked about various upsetting memories of instances that took place during his childhood and up to his late teenage years. This included memories, such as not being given a choice or participating in decision making, his father's absence from the house due to travel, followed by the discovery of his marriage to another woman and the presence of children. His family's upbringing style is firm, authoritarian on the part of the mother, and permissive on the part of the father.

1.2. Assessment and Diagnosis

Depending on psychiatrist referral letter, Structured Clinical Interview and Several tools were used to evaluate and diagnose patient's social anxiety and depression symptoms. They varied from self to clinician administered measures, and included the following:

1.2.1. Beck Depression Inventory (BDI)

The BDI [ 10 ] is constituted of 21 items. It is self-administered and represents an assessment of the physiological, affective, and cognitive aspects of depression, and is a measure of its severity. A total score of 10 or less is considered normal. A person is considered clinically depressed, if he or she obtains a score of 20 or more, on the BDI. The BDI is characterized by its high reliability and validity. Treatment outcome research makes use of the characteristics of this scale. The scale was translated by Abdul Khaleq 1996, and it has high reliability and validity in the Arab regions, as stated in [ 11 – 14 ].

1.2.2. Liebowitz Social Anxiety Scale (LSAS)

Twenty-four items constitute the LSAS [ 15 ]. It is administered by a clinician, so that the respondent may rate his or her feelings of fear and avoidance, on a scale of 0 (none) to 4 (extreme). It was translated to Arabic by Ibrahim [ 16 ], and it has high reliability and validity in the Arab regions, as stated in [ 17 , 18 ].

To examine SAD, the LSAS, with its good psychometric properties, is often employed in treatment outcome research [ 19 ]. Cutoff scores determined by Mennin et al. [ 20 ] for social phobia are greater than 30 and greater than 60 for generalized social phobia.

1.3. Formulation

Based on the assessment of the patient's case, which was determined from the psychiatrist's letter and the information he provided during the first meeting, he was diagnosed with social anxiety and depression. The patient showed symptoms of social anxiety, which were concluded to be the signs of his low self-esteem, manifested through avoidance. Depression was also another type of manifestation he exhibited, with an experience of persistent low spirits, ruminations about the past, and feeling guilty for exhibiting angry outbursts during current times. As a result, while patient's symptoms satisfied the diagnosis for social anxiety, they seemed to result from his depression, which started during adolescence. The CBT longitudinal model [ 21 ] was thought to be the best tool to use to understand patient's depression in view of the experiences he had in earlier life. These are the core beliefs, negative in nature, he has derived in life, as well as the rigid life rules, all of which contributed to his low self-esteem and led him to demonstrate signs of depression. Social anxiety has led him to drug addiction, due to his beliefs that the drug's effects will encourage him to talk to and deal with people. It is worth noting that the patient has been undergoing pharmacological treatment with his psychiatrist since the beginning.

1.4. Therapy Program

Fennell's [ 22 ] guidelines were followed for all sessions:

• Establishing the agenda.
• Reviewing events that have taken place since the previous session, feedback on the previous session, and homework.
• Going over the agenda once more.
• Prioritizing and discussing agenda items.
• Collaboratively assigning homework.
• Checking reactions.

1.5. Techniques of Cognitive Behavioral Therapy

1.5.1. self-monitoring.

Self-monitoring refers to observing one's behaviors and experiences systematically during various occasions for a certain time.

It is used in the therapy as a method of intervention, as it helps patients examine thoughts, emotions, and behaviors. It helps them identify the situations they are afraid of and find the best course of action for dealing with them.

Drastic changes occur from self-monitoring, according to Kazdin [ 23 ]. Korotitsch and Nelson-Gray [ 24 ] concluded that an immediate change is among the therapeutic effects of self-monitoring, despite their small scale. The clinician required the patient to track his thoughts, feelings, behaviors, as well as any differences he notices in himself.

1.5.2. Cognitive Reorganization

The four stages of cognitive reorganization, according to Beck et al. [ 25 ] are: (i) identifying dysfunctional thoughts, (ii) cognitive reorganization, (iii) modifying dysfunctional thoughts, and (iv) assimilating the new functional thoughts. On the second stage, patients begin to recognize their automatic or dysfunctional thoughts, as well as the emotions associated with them. For instance, a recurring thought for the patient was that others see him as an ugly, insignificant person. This notion contributed to his feelings of anxiety and fear.

Nevertheless, another adaptive thought that he can adopt instead is: “I may not like everyone, but there are those who love me as I am”.

As a result, the patient was taught during all sessions to use adaptive thoughts instead of negative thoughts. Part of six of his sessions was dedicated to discussing a record he kept of his dysfunctional thoughts.

1.5.3. Relaxation

Relaxation techniques were used to treat a patient's symptoms, particularly those that resulted from his anxiety and depression and were physiological in nature.

According to Jacobson's technique, there are certain breathing and muscle relaxation exercises in use, which can be beneficial in a patient's case. As such, the clinician worked on teaching him these exercises over eight sessions, to help him manage the physical symptoms he suffers from. The patient was taught to use deep breathing and some short muscle relaxation techniques in his day-to-day life, particularly when confronted with an unpleasant situation [ 26 ].

1.5.4. Training in Assertiveness and Motivation

Assertiveness training can be beneficial in cases where the patients suffer from depression, anxiety in social settings, addiction, and issues related to unspoken anger.

Since it is now known that assertiveness is learned rather than an inborn trait, assertiveness training can be employed in enhancing self-esteem and ameliorating interpersonal skills. It is true that some people seem more assertive, nevertheless, assertiveness can be acquired. In the patient's case, he was assisted in determining the situations where he faces more challenges on an interpersonal level, as well as the behaviors he exhibits that he needs to concentrate on in order to improve. Furthermore, the therapist assisted him in identifying the beliefs and attitudes that he may have developed, which caused him to become too passive. As part of this technique, she used role-playing exercises.

1.5.5. Clinical Sessions

The patient had one-on-one sessions for 50 min with his therapist each to complete his therapeutic treatment, over the course of 5 months. The reasons for employing CBT were examined during the first session. Educating the patient on SAD, depression, and addiction were a point of focus during therapy. Automatic thoughts and how they affect cognition were examined, helping him in identifying these types of thoughts and feelings as he experienced them.

As homework, he was given an anxiety self-monitoring diary. The therapist emphasized the issue of establishing and maintaining a good relationship between patient and clinician during the course of therapy. The patient described certain situations, as well as important events in his life where he felt that his symptoms were worse. This took place during the second session, where he also got the diary for dysfunctional thoughts as homework, after going through the explanation about cognitive reorganization and its four stages. On the third session, he learned breathing and muscle relaxation exercises, from a specialist, to acquire tools to help him relax and effectively manage his stress. Eight 20-min sessions were followed with similar exercises. He was also asked to both practice these sessions at home and track his progress on a daily basis.

From session four to session nine, time was devoted to using adaptive responses to challenge dysfunctional thoughts. Initially, there was an attempt to identify automatic negative thoughts in certain situations, during which he was asked to keep track of his moods. After recognizing patient's negative thoughts, emotions, and behaviors, the work was done to verify the evidence that supported them.

To help the patient effectively socialize with others, sessions 10–12 were dedicated to learning assertiveness skills. The therapist talked to the patient about the meaning of assertiveness for him, the reasons that prevented him from becoming assertive, and differences in behaviors, from assertiveness to aggressiveness, passing by submissiveness. This information has proved useful to him. To practice such skills, the exercises incorporating roleplay were used.

During the following sessions (13–20), situations that induce anxiety in the patient were investigated and then ordered according to the level of anxiety he feels during each. Through exposure techniques, the patient was confronted with each level of anxiety in real time, where he got to practice each step, until he signaled his confidence to proceed to the level to follow.

The last session saw the patient discussing how he got over difficult situations, including being introduced to people for the first time, visiting friends, public speaking, and participating in presentations in class. He was able to challenge his cognition in the situations he had previously identified as difficult and then employed the techniques he learned (breathing and muscle relaxation) to manage symptoms of anxiety.

Preventing relapse was discussed during the last session, as well as methods to achieve this purpose, and other methods for surmounting the difficulties and failures of the past. Finally, there was a discussion related to how to apply change to the skills he learned and how to use the new techniques he acquired on a day-to-day basis.

2. Results and Discussion

It was clearly seen that patient's levels of anxiety in daily social situations were effectively improved through CBT, in case of SAD. According to the exposure sessions, which also included a discussion of patient's efforts outside of the clinical setting, The patient had the courage to walk through a pedestrian crossing and look at people, ask a security guard for directions, and communicate with new people in public places.

Findings show that CBT helped the patient reduce his anger, cravings, and stress (see Table 1 ). Furthermore, it improved his sleep quality and assertiveness. These findings are consistent with the previous research results. Cannabis use disorder was effectively treated with CBT, a treatment method which was rendered even more effective with the use of medication. A patient's functions (physiological, psychosocial, and social) are affected by substance use and its related disorders, but CBT significantly aids in the treatment of deficits at these levels [ 27 , 28 ].

Thoughts record.

It was found that when treating alcohol and opioid withdrawal disorders in a rehabilitation facility, CBT was effective. Patients felt more at ease staying in therapeutic sessions, after the detoxification process. A previous study found that best results could be obtained from a combination of pharmacotherapy and CBT, during the treatment of patients suffering from substance use disorder.

During the current study, CBT sessions, organized, structured, and running on an individual basis between patient and therapist were conducted. Each session had a planned objective and a set agenda. The patient's cognitive reorganization, stress management, daily living functions, and lapse relapse prevention were all prioritized. The patient's depression and social anxiety significantly improved, because the results on the scales have been decreased (see Table 2 ).

Outcome measures for social anxiety and depression.

The therapeutic process of the patient investigated in this study, suffering from substance use disorder, included “skills training”, a technique also known as “skills building”. Much focus was placed on any deficits, the patients suffer from related to emotions, cognition, behaviors, organization, problem solving, and interpersonal relations, during skill building.

The treatment made use of any approach targeting individual differences between patients. The connections the patient developed with others were a point of focus because the opposite of addiction is not sobriety, but rather connection with society. The patient's interpersonal skills were also targeted in this study. Such skills aid in the resolution of relationship complications. They help enhance effective communication and allow the patient to make use of it along with social support. Assistance received from all these tools helps individuals abstain from addictive materials and promotes the establishment of healthy relationships [ 29 ].

3. Conclusion

CBT was effective in decreasing the patient's symptoms, including his low moods, avoidance of social interactions, and anger. It also affected the patient in terms of his gradual return to work and positive relationships with his family members.

Acknowledgments

The author acknowledges the support she received in editing this paper from Dahlia Eldeeb.

Data Availability

Additional points.

Study Limitations . The patient had fluctuations in motivation. The family has gone through a lot of stressful life events. The patient's father is busy and does not frequently communicate with him. The study approach was cognitive behavioral therapy (CBT), and the case had multiple problems from childhood. Perhaps it would be more useful to use some analytical or Gestalt techniques to deal with past problems.

The patient has given his consent to having the clinical information relating to his case reported in a medical publication.

Declaration of Generative Artificial Intelligence (AI) and AI-Assisted Technologies in the Writing Process: The author did not use any generative AI or AI-assisted technologies in the writing process.

Conflicts of Interest

The author declares that there is no conflicts of interest.

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DSM-5 Clinical Cases

• Rachel A. Davis , M.D.

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DSM-5 Clinical Cases makes the rather overwhelming DSM-5 much more accessible to mental health clinicians by using clinical examples—the way many clinicians learn best—to illustrate the changes in diagnostic criteria from DSM-IV-TR to DSM-5. More than 100 authors contributed to the 103 case vignettes and discussions in this book. Each case is concise but not oversimplified. The cases range from straightforward and typical to complicated and unusual, providing a nice repertoire of clinical material. The cases are realistic in that many portray scenarios that are complicated by confounding factors or in which not all information needed to make a diagnosis is available. The authors are candid in their discussions of difficulties arriving at the correct diagnoses, and they acknowledge the limitations of DSM-5 when appropriate.

The book is conveniently organized in a manner similar to DSM-5. The 19 chapters in DSM-5 Clinical Cases correspond to the first 19 chapters in section 2 of DSM-5. As in DSM-5, DSM-5 Clinical Cases begins with diagnoses that tend to manifest earlier in life and advances to diagnoses that usually occur later in life. Each chapter begins with a discussion of changes from DSM-IV. These changes are further explored in the cases that follow.

Each case vignette is titled with the presenting problem. The cases are formatted similarly throughout and include history of present illness, collateral information, past psychiatric history, social history, examination, any laboratory findings, any neurocognitive testing, and family history. This is followed by the diagnosis or diagnoses and the case discussion. In the discussions, the authors highlight the key symptoms relevant to DSM-5 criteria. They explore the differential diagnosis and explain their rational for arriving at their selected diagnoses versus others they considered as well. In addition, they discuss complicating factors that make the diagnoses less clear and often mention what additional information they would like to have. Each case is followed by a list of suggested readings.

As an example, case 6.1 is titled Depression. This case describes a 52-year-old man, “Mr. King,” presenting with the chief complaint of depressive symptoms for years, with minimal response to medication trials. The case goes on to describe that Mr. King had many anxieties with related compulsions. For example, he worried about contracting diseases such as HIV and would wash his hands repeatedly with bleach. He was able to function at work as a janitor by using gloves but otherwise lived a mostly isolative life. Examination was positive for a strong odor of bleach, an anxious, constricted affect, and insight that his fears and behaviors were “kinda crazy.” No laboratory findings or neurocognitive testing is mentioned.

The diagnoses given for this case are “OCD, with good or fair insight,” and “major depressive disorder.” The discussants acknowledge that evaluation for OCD can be difficult because most patients are not so forthcoming with their symptoms. DSM-5 definitions of obsessions and compulsions are reviewed, and the changes to the description of obsessions are highlighted: the term urge is used instead of impulse so as to minimize confusion with impulse-control disorders; the term unwanted instead of inappropriate is used; and obsessions are noted to generally (rather than always) cause marked anxiety or distress to reflect the research that not all obsessions result in marked anxiety or distress. The authors review the remaining DSM-5 criteria, that OCD symptoms must cause distress or impairment and must not be attributable to a substance use disorder, a medical condition, or another mental disorder. They discuss the two specifiers: degree of insight and current or past history of a tic disorder. They briefly explore the differential diagnosis, noting the importance of considering anxiety disorders and distinguishing the obsessions of OCD from the ruminations of major depressive disorder. They also point out the importance of looking for comorbid diagnoses, for example, body dysmorphic disorder and hoarding disorder.

This brief case, presented and discussed in less than three pages, leaves the reader with an overall understanding of the diagnostic criteria for OCD, as well as a good sense of the changes in DSM-5.

DSM-5 Clinical Cases is easy to read, interesting, and clinically relevant. It will improve the reader’s ability to apply the DSM-5 diagnostic classification system to real-life practice and highlights many nuances to DSM-5 that one might otherwise miss. This book will serve as a valuable supplementary manual for clinicians across many different stages and settings of practice. It may well be a more practical and efficient way to learn the DSM changes than the DSM-5 itself.

The author reports no financial relationships with commercial interests.

• Cited by None

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• Published: 14 September 2020

COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States

• Quan Qiu Wang 1 ,
• David C. Kaelber 2 ,
• Rong Xu   ORCID: orcid.org/0000-0003-3127-4795 1 &
• Nora D. Volkow   ORCID: orcid.org/0000-0001-6668-0908 3  

Molecular Psychiatry volume  26 ,  pages 30–39 ( 2021 ) Cite this article

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A Correction to this article was published on 30 September 2020

This article has been updated

The global pandemic of COVID-19 is colliding with the epidemic of opioid use disorders (OUD) and other substance use disorders (SUD) in the United States (US). Currently, there is limited data on risks, disparity, and outcomes for COVID-19 in individuals suffering from SUD. This is a retrospective case-control study of electronic health records (EHRs) data of 73,099,850 unique patients, of whom 12,030 had a diagnosis of COVID-19. Patients with a recent diagnosis of SUD (within past year) were at significantly increased risk for COVID-19 (adjusted odds ratio or AOR = 8.699 [8.411–8.997], P  < 10 −30 ), an effect that was strongest for individuals with OUD (AOR = 10.244 [9.107–11.524], P  < 10 −30 ), followed by individuals with tobacco use disorder (TUD) (AOR = 8.222 ([7.925–8.530], P  < 10 −30 ). Compared to patients without SUD, patients with SUD had significantly higher prevalence of chronic kidney, liver, lung diseases, cardiovascular diseases, type 2 diabetes, obesity and cancer. Among patients with recent diagnosis of SUD, African Americans had significantly higher risk of COVID-19 than Caucasians (AOR = 2.173 [2.01–2.349], P  < 10 −30 ), with strongest effect for OUD (AOR = 4.162 [3.13–5.533], P  < 10 −25 ). COVID-19 patients with SUD had significantly worse outcomes (death: 9.6%, hospitalization: 41.0%) than general COVID-19 patients (death: 6.6%, hospitalization: 30.1%) and African Americans with COVID-19 and SUD had worse outcomes (death: 13.0%, hospitalization: 50.7%) than Caucasians (death: 8.6%, hospitalization: 35.2%). These findings identify individuals with SUD, especially individuals with OUD and African Americans, as having increased risk for COVID-19 and its adverse outcomes, highlighting the need to screen and treat individuals with SUD as part of the strategy to control the pandemic while ensuring no disparities in access to healthcare support.

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Introduction.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has rapidly escalated into a global pandemic [ 1 ]. The global pandemic of COVID-19 is colliding in the United States (US) with the epidemic of opioid use disorders (OUD) and overdose mortality [ 2 , 3 , 4 ]. Currently, there is little if any quantitative analysis of the risks and outcomes for COVID-19 infection in individuals suffering from an OUD and those suffering from other substance use in the US. In addition, there is minimal data on how race and other demographic factors affect the risk and outcomes of COVID-19 among patients with SUD including OUD.

It is estimated that more than 70,000 people will die in the US from an overdose in 2019 mostly from opioid overdoses, which are driven by the respiratory depressant effects of opioids. Considering that COVID-19 affects pulmonary function this combination could be particularly lethal. Additionally, ~10.8% of adults in the US have a substance use disorders (SUD) including alcohol (AUD) and tobacco (TUD) [ 5 ]. To the extent that chronic use of tobacco, alcohol and other drugs is associated with cardiovascular (arrhythmias, cardiac insufficiency, and myocardial infarction), pulmonary (COPD, pulmonary hypertension), and metabolic diseases (diabetes, hypertension) [ 6 , 7 , 8 , 9 , 10 ] all of which are risk factors for COVID-19 infection and for worse outcomes [ 11 , 12 , 13 ] one can also predict that individuals with SUD including OUD would be at increased risk for adverse COVID-19 outcomes [ 2 ]. Preliminary reports regarding higher risk for adverse outcomes with COVID-19 and smoking have been inconclusive [ 14 , 15 , 16 ]. Currently there is little research on the effects of other drugs including opioids, cannabis, cocaine and alcohol on the susceptibility to COVID-19 infection and to adverse outcomes [ 2 ].

Material and methods

Database description.

We performed a retrospective case-control study using de-identified population-level electronic health record (EHR) data collected by the IBM Watson Health Explorys from 360 hospitals and 317,000 providers across 50 states in the US since 1999 [ 17 ]. The EHRs are de-identified according to the Health Insurance Portability and Accountability Act and the Health Information Technology for Economic and Clinical Health Act standards. After the de-identification process, curation process normalizes the data through mapping key elements to widely-accepted standards [ 18 ]. Specifically, disease terms are coded using the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), a global standard for health terms that provides the core general terminology for EHRs [ 19 ]. Previous studies showed that with this large-scale and standardized EHR database, large case-control studies can be undertaken efficiently [ 20 , 21 , 22 , 23 , 24 ], including our recent studies [ 23 , 24 ].

Study population

At the time of this study (June 15, 2020), the study population consisted of 73,099,850 unique patients, including 7,510,380 patients with a diagnosis with SUD (diagnosis made within the past year or prior) of whom 722,370 had been recently diagnosed with SUD (diagnosed within past year), 12,030 patients diagnosed with COVID-19, 1880 patients with lifetime diagnosis of SUD and COVID-19, and 1050 with recent SUD diagnosis and COVID-19. The status of COVID-19 was based on the concept “Coronavirus infection (disorder)” (SNOMED-CT Concept Code 186747009) and we further limited the diagnosis time frame to within the past year to capture the timing of new cases arising during the COVID-19 pandemic. The outcome measures were COVID-19 diagnosis, rates of death, and hospitalization. The specific types of SUD examined included alcohol use disorder (AUD), OUD, tobacco use disorder (TUD), cannabis use disorder (CUD), and cocaine use disorder (Cocaine-UD). Other types of SUDs were not investigated due to their small number of COVID-19 cases.

The status of “SUD” was based on diagnosis of “Drug dependence (disorder)” on SNOMED-CT Concept Code 191816009, or of “Substance abuse (disorder)” on SNOMED-CT Concept Code 66214007. The status of “AUD” was based on the diagnosis of “Alcohol dependence (disorder)” on Concept Code 66590003, or of “Alcohol abuse (disorder)” on Concept Code 7200002. The status of “CUD” was based on the diagnosis of “Cannabis dependence (disorder)” on Concept Code 85005007 or of “Cannabis abuse (disorder)” on Concept Code 37344009. The status of “Cocaine-UD” was based on the diagnosis of “Cocaine dependence (disorder)” on SNOMED-CT Concept Code 31956009, or of “Cocaine abuse (disorder)” on Concept Code 78267003. The status of “OUD” was based on diagnosis of “Opioid dependence (disorder)” on Concept Code 75544000, or of “Nondependent opioid abuse (disorder)” on Concept Code 191909007. The status of “TUD” was based on diagnosis of “Nicotine dependence (disorder)” on Concept Code 56294008. In our study, patients with SUD were categorized into two groups: patients with a lifetime diagnosis of SUD (diagnosed within past year or prior) and patients with a “recent” SUD (diagnosed within the past year). The first group represents patients with any SUD diagnosis (active or recovered). The second group is a subset of the first group but more likely consists of patients with active SUD. Through this manuscript we use the term SUD, following DSM-5 [ 25 ], which combines the prior categories of substance abuse and substance dependence from DSM-4.

The following analyses were performed: (1) we examined if patients diagnosed with SUD were at increased the risk for COVID-19, adjusted for age, gender, race, and insurance type. The exposure groups were patients diagnosed with SUD, the unexposed groups were patients without SUD, and the outcome measure was diagnosis of COVID-19. Separate analyses were done for patients with a lifetime SUD diagnosis and for patients with a recent SUD. Separate analyses were done for subtypes of SUD. (2) We examined how demographic factors affected COVID-19 risk among patients with recent diagnosis of SUD. The case groups were patients with SUD and one of the following demographic factors: female, senior, African American. The comparison groups were patients with SUD and one of the following corresponding demographic factors (male, adult, Caucasian). The outcome measure was diagnosis of COVID-19. (3) We examined rates of death and hospitalization among patients with COVID-19 and SUD and compared outcomes of African Americans to those of Caucasians with SUD.

Statistical analysis

The adjusted odds ratio (AOR), 95% CI and P values were calculated using the Cochran–Mantel–Haenszel method [ 26 ] by controlling for age groups (juniors age <18 years, adults age 18–65 years, senior age > 65 years), gender (female, male), race (Caucasian, African American), and insurance type (private, medicare, medicaid, self pay). Other demographic groups were not included due to insufficient sample sizes for COVID-19 cases. Two-sided, 2-sample test for equality of proportions with continuity correction were used to compare prevalence of comorbidities and outcomes. Statistical tests were conducted with significance set at P value < 0.05 (two sided). All analyses were done using R, version 3.6.3.

Patient characteristics

The baseline characteristics of the study population (as of June 15, 2020) are presented in Table  1 . Among 73,099,850 patients, 7,510,380 patients had lifetime SUD (diagnosed within the last or prior years) (10.27% of study population), including 1,264,990 with AUD (1.73% of study population), 222,680 with Cocaine-UD (0.30%), 490,420 with CUD (0.67%), 6,414,580 with TUD (8.77%), and 471,520 with OUD (0.65%). Among 73,099,850 patients, 722,370 had recent SUD (diagnosed within the last year) (0.99% of total population), including 83,100 with AUD (0.11%), 14,800 with Cocaine-UD (0.02%), 27,650 with CUD (0.04%), 611,750 with TUD (0.84%), and 43,160 with OUD (0.06%).

Among 12,030 patients diagnosed with COVID-19, 1880 patients had lifetime SUD (15.63% in COVID-19 population), including 320 with AUD (2.66%), 70 with Cocaine-UD (0.58%), 80 with CUD (0.67%), 1470 with TUD (12.22%), and 210 with OUD (1.75%). Among 12,030 patients diagnosed with COVID-19, 1050 had recent SUD (8.73% in COVID-19 population), including 130 with recent AUD (1.03%), 30 with Cocaine-UD (0.25%), 30 with CUD (0.25%), 840 with TUD (6.98%), and 90 with OUD (0.75%).

Risk associations between SUD and COVID-19

Patients with recent SUD diagnosis had significantly higher risk of developing COVID-19 compared to patients without recent SUD diagnosis, after adjusting for age, gender, race, and insurance types. The AOR between recent SUD diagnoses and COVID-19 was 8.699 [8.411–8.997]. Among patients with SUD subtypes, individuals with OUD had the largest risk (AOR = 10.244 [9.107–11.524]), followed by TUD (AOR = 8.222 ([7.925–8.530]), AUD (AOR = 7.752 [7.04–8.536]), Cocaine-UD (AOR = 6.53 [5.242–8.134]) and CUD (AOR = 5.296 [4.392–6.388]) (Fig.  1a ).

a Risk associations of recent (diagnosis made in the last year) SUD diagnoses (and its subtypes) with COVID-19; b Risk associations of lifetime (diagnosed in the last year or prior) SUD diagnoses (and its subtypes) with COVID-19. SUD substance use disorder, AUD alcohol use disorder, Cocaine-UD cocaine use disorder, CUD cannabis use disorder, OUD opioid use disorder, TUD tobacco use disorder. Subtypes without sufficient sample sizes for COVID-19 cases are not shown.

Patients with lifetime SUD diagnosis had significantly higher risk of developing COVID-19 compared to patients without SUD, after adjusting for age, gender, race, and insurance types. The AOR between those with lifetime SUD and COVID-19 was 1.459 [1.421–1.499]; for whom, individuals with OUD had the largest risk (AOR = 2.42 [2.247–2.607], followed by cocaine-UD (AOR = 1.57 [1.393–1.77], AUD (AOR = 1.417 [1.335–1.504], and TUD (AOR = 1.332 [1.294–1.372]. Among 7,510,380 patients with lifetime SUD diagnosis, 722,370 had recent diagnosis (9.6%) (Fig.  1b ).

Patients with SUD often have multiple comorbidities, including cardiovascular, pulmonary, metabolic diseases, and increased susceptibility to infections [ 6 , 7 , 8 , 9 , 10 ], which are also risk factors for COVID-19 [ 11 , 12 , 13 ]. We then examined prevalence of these known COVID-19 risk factors among adult patients with recent diagnosis of SUD and compared them to adult patients without recent SUD diagnosis. As shown in Table  2 , patients with recent diagnosis of SUD had significantly higher prevalence of asthma, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, cancer, HIV, chronic liver disease, cardiovascular diseases including hypertension, and obesity as compared to patients without recent SUD diagnosis of SUD. Patients with recent diagnosis of OUD had higher risk of COVID-19 than other SUD subtypes, however, the prevalence of risk factors for COVID-19 was not higher than for other SUD subtypes.

Individuals with OUD had the greatest risk for COVID-19 among patients with SUD (Fig.  1 ) but they did not have more comorbidities (known COVID-19 risk factors) than those with other SUDs. We then examined if medications used to treat OUD (MOUD), including methadone (though when used for OUD its dispensed through methadone clinics and not regular prescriptions), buprenorphine (which is also prescribed for pain management) and naltrexone, affected the risk of patients with OUD in getting COVID-19. There was no significant difference in risk for COVID-19 between OUD patients who were not prescribed methadone, buprenorphine or naltrexone vs. those that were (AOR = 1.064, [0.871–1.3], P value = 0.578) after adjusting for age, gender, race, and insurance types. These results indicate that these opioid medications had no significant effects on OUD patients’ risk for COVID-19. However, a limitation in this analysis is that the EHR dataset does not capture methadone given through methadone clinics, which is the authorized way when used for the treatment of OUD. Regardless, our results did not show differences in COVID risk for OUD patients prescribed methadone, buprenorphine or naltrexone compared to those who did not receive those medications.

Effects of demographics on risk of COVID-19 among patients with recent SUD

Among patients with a recent diagnosis of SUD, seniors were more likely to develop COVID-19 compared to adults (AOR = 1.307 (1.207–1.416]) and African Americans were more likely to develop COVID-19 compared to Caucasians (AOR = 2.173 [2.01–2.349], after adjusting for age, gender and insurance types. Gender had no significant effects, after adjusting for age, race, and insurance types. Of the three demographic factors examined, race had the largest effect on COVID-19 risk, which was true across individuals with SUD, AUD, OUD, and TUD with the largest effects for patients with recent diagnosis of OUD. Among patients with recent diagnosis of OUD, African Americans had significantly higher risk of COVID-19 than Caucasians (4.162 [3.13–5.533], after adjusting for age, gender, and insurance types (Fig.  2 ). We examined prevalence of known COVID-19 risk factors among African Americans and Caucasians with recent diagnosis of SUD (and its subtypes). We showed that African Americans with recent diagnosis of SUDs had higher prevalence of asthma, chronic kidney disease, type 2 diabetes, hypertension, obesity, and HIV compared to Caucasians, while prevalence of COPD, chronic liver disease, cardiovascular disorders, and cancer was similar or lower (data not shown).

Cocaine-UD and CUD were not examined due to insufficient sample sizes of COVID-19 for stratifications. Senior (age > 65 years). Adult (age 18–65 years).

Rates of deaths and hospitalizations in COVID-19 patients with SUD

Among 12,030 COVID-19 patients, 790 died (6.57%). African Americans with COVID-19 had a death rate of 7.50%, significantly higher than for Caucasians who had a rate of 6.18% ( P  = 0.007). Among 1,880 COVID-19 patients with lifetime SUD, 180 died (9.57%), a rate significantly higher than the death rate of 6.57% for all COVID-19 patients ( P  < 0.0001). African Americans with COVID-19 and lifetime SUD had a death rate of 12.99%, significantly higher than the rate of 8.57% for Caucasians with COVID-19 and lifetime SUD ( P  = 0.003). Among 1050 COVID-19 patients with recent diagnosis of SUD, 100 died (9.52%), a rate significantly higher than that for general COVID-19 patients ( P  = 0.003) and similar to that for COVID-19 patients with lifetime SUD (9.57%). Death rates for patients with COVID-19 and a recent diagnosis of SUD did not differ significantly between African Americans (12.20%) and Caucasians (9.84%) ( P  = 0.276) (Fig.  3a ). The death rates for SUD subtypes were not examined due to their small sample sizes.

a Death rates among patients with COVID-19 and SUD (African American vs. Caucasians); b Hospital admission rates among patients with COVID-19 and SUD (African American vs. Caucasians). The SNOMED-CT concepts “Hospital admission (procedure)” (ID 32485007) was used to obtain hospitalization status from patient EHRs. Explorys regularly imports from the Social Security Death index for the “deceased” status.

Among 12,030 COVID-19 patients, 3620 were hospitalized (30.09%) and the rate was significantly higher among the African Americans (35.56%) than the Caucasians (26.36%) ( P  < 0.0001). Among 1880 COVID-19 patients with lifetime SUD, 770 were hospitalized (40.96%), a rate significantly higher than for all COVID-19 patients (30.09%) ( P  < 0.0001) and also significantly higher among the African Americans (50.65%) than the Caucasians (35.24%) ( P  < 0.0001). Among 1050 COVID-19 patients with recent diagnosis of SUD, 460 were hospitalized (43.81%), a rate significantly higher than for general COVID-19 patients (30.09%) ( P  < 0.0001) and similar to that for COVID-19 patients with lifetime SUD (40.96%) ( P  = 0.144). Hospitalization rates for COVID-19 patients with a recent diagnosis of SUD were significantly higher for African Americans (53.66%), than for Caucasians (37.70%) ( P  < 0.0001) (Fig.  3b ).

Based on EHR patient data in the US we show that individuals with SUD, particularly recent OUD, were at increased risk for COVID-19 and these effects were exacerbated in African Americans compared to Caucasians. The higher prevalence of kidney, pulmonary, liver, cardiovascular, metabolic, and immune-related disorders in COVID-19 patients with SUD and also in African Americans are likely contribute to their higher risk. These findings identify individuals with SUD as a vulnerable population, especially African Americans with SUDs, who are at significantly increased risk for COVID-19 and its adverse outcomes, highlighting the need to screen and treat SUD as part of the strategy to control the pandemic while ensuring that there are no disparities in access to healthcare support for African Americans.

In the Explorys EHR database, 10.3% of the study population had a diagnosis of SUD, which is similar to the reported prevalence of 10.8% among people aged 18 or older in the US according to the 2018 National Survey on Drug Use and Health (NSDUH) [ 5 ]. However the prevalence rates for SUD subtypes from the Explorys EHR database was lower than for NSDUH (12 years or older population) except for OUD and Cocaine-UD. For TUD the rate was 10.40%, which is also lower than 13.7% of current cigarette smokers in the US adult population [ 27 ]. These discrepancies are likely to be caused by the failure of the health system to adequately screen for and accurately diagnose SUDs, which could have significantly under-estimated the risk of patients with SUD for COVID-19 illness and adverse outcomes.

The analyses showed that a recent diagnosis of SUD significantly increased the risk of COVID-19 that was highest for recent diagnosis of OUD followed by TUD, AUD and Cocaine-UD, and lowest for CUD. Patients with both SUD and COVID-19 also had significantly worse outcomes (death, hospitalization) than general COVID-19 patients. Compared to patients without SUD, patients with recent SUD had significantly higher prevalence of chronic kidney, liver, lung diseases, cardiovascular diseases, type 2 diabetes, obesity and cancer. However, the prevalence of known risk factor for COVID-19 among patients with OUD was not higher than patients with other types of SUD. These results suggest that while comorbidities associated with SUD likely contributed to the increased risk of COVID-19 and to worse outcomes among SUD patients, specific pharmacological effects of drugs of abuse (e.g., opioid induced respiratory depression) as well as behavioral and socioeconomic factors could facilitate COVID-19 infection and increase risk for adverse outcomes.

Among patients with recent diagnosis of SUD, African Americans had significantly higher risk of COVID-19 than Caucasians, an effect that was strongest for African Americans with OUD and they also had worse outcomes (death and hospitalizations). This is consistent with data from states and counties across the US showing that the coronavirus affects African Americans at a disproportionately high rate and that the they suffer a greater death toll [ 28 , 29 , 30 , 31 ]. We showed that adult African Americans with recent diagnosis of SUDs had higher prevalence of asthma, chronic kidney disease, type 2 diabetes, hypertension, obesity and HIV compared to adult Caucasians. These enriched comorbidities in African Americans with SUD could underly their higher susceptibility to COVID-19 and their risk for adverse COVID outcomes along with socioeconomic disparities. However, these comorbidities alone may not be sufficient to explain the observed several-fold increase of COVID-19 diagnosis in African Americans as compared to Caucasians or their increased death rates. Other factors including access to healthcare, socioeconomic status and other social adversity components may have contributed negatively to their increased risk of COVID-19 as well as to the adverse outcomes.

Consistent with other reports [ 12 , 13 ], our study showed that seniors were more likely to develop COVID-19 than adults, which was also expected since hypertension, diabetes, obesity, cardiovascular diseases, and weakened immune function are more common in seniors than in adults. No disparity was observed for gender.

Our study is based on retrospective analysis of patient EHR data. Patient EHR data have been widely used and accepted for observational studies including health utilization, drug utilization, epidemiology (incidence/prevalence), risk factors, and safety surveillance [ 32 , 33 , 34 ]. However patient EHR data have inherent limitations when used for research purposes: data are collected for billing purposes, often suffer from under, over, or misdiagnosis, do not include all confounding factors, have limited time-series information, limited information of medication adherence and patient outcomes, among others. The Explorys EHR Database collects data from multiple health information systems. Since EHR adoption and health IT use generally lags in rural areas due to lack of financial and technical resources, patients from rural areas are likely less represented in our study population. In our study, disease diagnoses in the patient EHR data were coded using SNOMED-CT terminology and for SUD these differ from categories used by DSM-5. A further limitation of our study is that “COVID-19” (Concept ID 840539006) was not yet included the Explorys EHRs database at the time of this study. This new concept was first included in the March 2020 SNOMED-CT International Edition Interim Release, with a planned update in July, 2020 [ 35 ]. At the time of this study, this update has not been yet incorporated in Explorys EHRs. Despite these limitations, this large nationwide database allows us to assess a wide population helping us identify large trends (not necessarily for accurate prevalence estimation) in risks, disparities and outcomes of COVID-19 in SUD patients engaged with healthcare systems.

A major limitation for this and other studies of COVID-19 has been the limited number of individuals who are tested for COVID-19, which can underestimate prevalence in the general population. For our study this is further confounded by the likelihood that patients with pulmonary, cardiac, metabolic or immune conditions, many of which are co-morbid with SUD, might have been more likely to be tested. It is also confounded by the likelihood that patients with specific SUDs (e.g., Cocaine-UD and OUD) might have been less likely to be tested due to socioeconomic factors or stigma. Widespread accessibility to COVID-19 testing in the future will allow more accurate comparisons of COVID prevalence between those with and without SUD.

Additional limitations for this study include: (1) possible ascertainment bias as illicit SUD might have been underreported and individuals with SUD particularly illicit SUD are less likely to access healthcare, which would result in their lower representation in EHR, (2) the EHR database did not encode for current or active drug use, which is why we relied on a recent SUD diagnoses assuming that those patients were more likely to be active drug users, and (3) due to limited information of socioeconomic information on the EHR data, we were unable to assess the effects of social adversity and its interaction with medical conditions to COVID-19 risk, race disparity and adverse outcomes among patients with SUD. Social adversity is likely to have contributed not only to the higher risk for COVID-19 among patients with SUD but also to the even higher risk among African Americans patients with SUD.

In our study, we showed that patients with SUDs has significantly higher prevalence of comorbidities, which are known risk factors for COVID-19, as compared to patients without SUDs. Our study did not control for these comorbidities when assessing the risk associations between SUD and COVID-19 for two main reasons. First, the central hypothesis of this study was that comorbidities associated with SUD, including type 2 diabetes, hypertension, heart disease, chronic kidney, lung, and liver diseases, largely contributed to patients’ risk to COVID-19 and its adverse outcomes. Second, due to limited sample sizes for COVID-19 cases among patients with SUD (1880 cases for all SUD and 210 for OUD), the large number of SUD-associated comorbidities, as well as inter-dependency among comorbidities (e.g., diabetes, hypertension, and obesity), we are currently unable to control for these comorbidities as well as their associated medications, behaviors and other socioeconomic factors in order to assess the direct effects of addictive drugs or of SUD as a disease entity on COVID-19 risk. As more COVID-19 related data will be captured by EHR databases in the future, we will be able to investigate how SUD contributes to COVID-19 risk and outcomes in finer-grained details.

In summary, our findings at a macroscopic level provide evidence that SUD should be considered a condition that increases risk for COVID-19, a comorbidity that has particularly deleterious effects to African Americans. This has implication to healthcare as it relates to expanding testing and making decisions of who might need hospitalizations. Similarly, when vaccine or other treatments become available, this has implication for deciding who is at greater risk. They also highlight the exacerbation of healthcare disparities from COVID-19 driven by social and economic factors that place certain groups at increased risks for both SUD as well as risk and adverse outcomes from COVID-19. Finally, our findings also underscore the importance of providing support for the treatment and recovery of individuals with SUD as part of the strategy to control the COVID pandemic.

Data availability

All the data are publicly available at http://nlp.case.edu/public/data/COVID_SUD/ .

Change history

30 september 2020.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

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Acknowledgements

RX acknowledges support from Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under the NIH Director’s New Innovator Award number DP2HD084068, NIH National Institute on Aging R01 AG057557, R01 AG061388, R56 AG062272, American Cancer Society Research Scholar Grant RSG-16-049-01—MPC, The Clinical and Translational Science Collaborative (CTSC) of Cleveland 1UL1TR002548-01.

The funder of the study had no role in study design, data collection, data analysis, data interpretation, and writing of the report. The corresponding author (RX) had full access to all the data in the study and had final responsibility for the decision to submit for publication.

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Quan Qiu Wang & Rong Xu

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David C. Kaelber

National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA

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QW, RX, and NDV conceived the study, designed the study, and authored the paper. QW and RX conducted the analysis. DK contributed to Explorys EHR database-related search questions and medical informatics-related questions. All authors approved the paper. QW and RX had access to the original data.

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Wang, Q.Q., Kaelber, D.C., Xu, R. et al. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Mol Psychiatry 26 , 30–39 (2021). https://doi.org/10.1038/s41380-020-00880-7

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Published : 14 September 2020

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DOI : https://doi.org/10.1038/s41380-020-00880-7

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Addressing substance misuse in the workplace: A real-world case study

The reality of substance misuse in the workforce

Substance use disorders affect a substantial portion of American society and its workforce. The Substance Abuse and Mental Health Services Administration (SAMHSA) 2021 national survey results report 46 million Americans living with a clinically diagnosable substance use disorder (SUD). 

A staggering 75% of individuals struggling with a substance use disorder are currently employed and open to treatment. Unfortunately, due to limited access and high costs, fewer than 10% of these individuals receive the help they need. Industries such as manufacturing, retail and logistics, where safety is paramount, are particularly susceptible to the negative consequences of SUDs. 

As revealed in the Pelago 2023 Annual Substance Use Management Survey , 1 in 6 U.S. workers report missing work because of a personal substance or alcohol use problem. When factoring in workers impacted by a family member’s substance use problem, we find that nearly half of all workers are affected by a substance use disorder (SUD). 

Add in the growing direct and indirect costs of substance use disorders highlighted in new CDC data   –  which puts the annual minimum cost of substance use disorders at $15,640 per affected employee totaling more than $35 billion – and the scope and cost of the substance use management challenge becomes clear. 

Understanding the unique role and responsibility employers have in managing substance use issues, a major U.S. health technology company approached Pelago to help address the impact that SUDs were having on both employee well-being and healthcare costs. The company successfully partnered with Pelago to decrease alcohol use, improve mental health and generate a powerful return on investment among its more than 20,000 employees. 

The multifaceted impact of substance misuse

Substance misuse is closely associated with co-morbidities and other chronic conditions. Often hidden in heart and liver disease, osteoporosis, MSK, diabetes, cancer, chronic kidney disease and mental health conditions, SUDs lead to annually compounding healthcare costs. And, as the CDC study pointed out, the hard medical costs do not include business impacts related to absenteeism, presenteeism and turnover.  

It’s also estimated that about 80 million Americans engage in risky substance use behaviors . These individuals often maintain a high level of functionality, making it difficult to identify the problem. For example, 50% of individuals with severe mental health illnesses also have co-occurring substance use disorders . 

The Pelago substance use management program aimed to improve access to care, reduce stigma, improve health and happiness and decrease healthcare claims. With an emphasis on alcohol use, the company’s members engaged with Pelago’s physician-led care team, consisting of nationwide physicians and nurse practitioners as well as dedicated drug and alcohol counselors. Members were able to take advantage of telehealth consultations and psychological support, along with discreet prescription fulfillment and remote monitoring devices.

Program results and outcomes

Since its launch of the Pelago program, the company has seen an impressive 85% utilization rate among registered members. These members have benefited from an average of 46 care team interactions, surpassing industry benchmarks. Furthermore, the program's content engagement has demonstrated positive results, with members completing an average of 10 steps tailored to their individual triggers.

After just 60 days of Pelago care, the company was able to report impressive outcomes, including a 76% reduction in heavy drinking days and a 50% reduction in risk factors for problem drinking compared to industry benchmarks. 

The positive trajectory continued after three months, with participants reporting:

• An average 18 days of alcohol abstinence in the past 30 days compared to just over 11 days prior to treatment entry
• That confidence in achieving complete abstinence increased by 60%, and alcohol craving decreased by 36% during the same period
• The number of heavy drinking days decreased by 54%, accompanied by a 47% decrease in psychological problems and a 53% decrease in troubled sleep patterns

The value of substance use management

This top 10 health technology company’s partnership with Pelago for substance use management demonstrates the value of addressing substance misuse in the workplace. By implementing a comprehensive care program, the company achieved significant improvements in alcohol use, mental health and overall well-being among its employees. 

Effective substance use management that engages the workforce leads to an understanding of the impacts of substance use on one's body and managing that use to a healthy state. This case study demonstrates the power of efforts to combat substance misuse in the workplace and underscores the importance of providing accessible, quality treatment for substance use disorders – not only for the individuals affected but also for the financial health of organizations.

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Co-occurring Mental Health and Substance Use Disorders: Guiding Principles and Recovery Strategies in Integrated Care (Part 1)

Individuals with co-occurring mental health and substance use disorders (CODs) have complex treatment needs. Historically, these issues were treated separately, as competing discreet needs. Barriers in access to integrated care for substance related and mental health disorders prevented many individuals from finding relief from their COD. The structures in place that prevented integrated care were many. Public and private funding, research, and public policy all created troughs between disciplines of care. Researchers and practitioners have noted how the separation of mental health and substance abuse treatment has created additional barriers and obstacles for clients with CODs: Parallel treatment results in fragmentation of services, non-adherence to interventions, dropout, and service extrusion, because treatment programs remain rigidly focused on single disorders and individuals with dual disorders are unable to negotiate the separate systems and to make sense of disparate messages regarding treatment and recovery (Osher, Drake, 1996; Drake, Mueser, Brunette, and McHugo. 2004).

Mental health services and treatment structures for substance related disorders were on divergent paths and many professionals considered one another with skepticism. Today, some, but not all, of those barriers have been eliminated.

According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 2011 National Survey on Drug Use and Health, Mental Health Findings, more than 8 million adults in the United States have CODs. Only 6.9% of individuals receive treatment for both conditions and 56.6% receive no treatment at all (SAMHSA, 2012).

This is the first of two practice briefs that will explore eight principles of integrated care for CODs (Mueser et al., 2003). This brief will examine the first four of the following principles:

• Principle 1: Integration of mental health and substance use services
• Principle 2: Access to comprehensive assessment of substance use and mental health concerns
• Principle 3: Comprehensive variety of services offered to clients
• Principle 4: An assertive approach to care/service delivery
• Principle 5: Using a harm reduction approach to care
• Principle 6: Motivation-based and stage wise interventions
• Principle 7: Long-term perspective of care
• Principle 8: Providing multiple psychotherapeutic modalities

After a brief review of each principle, an illustrative case study will be provided and suggestions for implementing each of the principles in a client session will be offered (SAMHSA, 2009a; 2009b).

Principle 1: Integration of Mental Health and Substance Use Services

Multidisciplinary teams provide integrated services and relevant care that is client centered and longitudinal in nature. Agency policies and practices recognize the relapse potential with CODs and do not penalize clients for exhibiting symptoms of their mental health or substance related disorders. Team members may include the client and their family members or supportive persons, practitioners who are trained in substance abuse and mental health counseling, and a combination of physicians, nurses, case managers, or providers of ancillary rehabilitation services (therapy, vocational, housing, etc.) such as social workers, psychologists, psychiatrists, marriage and family therapists and peer support specialists. Based on their respective areas of expertise, team members collaborate to deliver integrated services relevant to the client’s specific circumstances, assist in making progress toward goals, and adjust services over time to meet individuals’ evolving needs (Mueser, Drake, & Noordsy, 2013). The team members consistently and regularly communicate with the client to discuss progress towards goals, and they work together to meet the individual treatment needs of each client.

Penny, 43, experienced her first depressive episode in her mid teens. During her first treatment for substance use (marijuana and alcohol) at age 17, Penny was diagnosed with attention deficit hyperactivity disorder (ADHD). However, over the next few years, she became increasingly edgy and irritable with intermittent periods of euphoria, accelerated energy and impulsive behaviors followed by periods of despair. She had repeated hospitalizations and concurrent and sequential contact with both mental health and substance abuse treatment systems over the years. Penny was labeled with a variety of diagnoses, including bipolar disorder, ADHD, major depression, anxiety disorder, borderline personality disorder, and chemical dependence.

Penny’s multi-disciplinary team consisted of her primary practitioner who held LADC/LPCC dual licenses, a primary care physician, a psychiatrist, a family therapist, a peer recovery support specialist, and a vocational specialist. Penny participated in individual therapy as well as recovery skills groups with her primary practitioner. Her primary care physician monitored Penny’s physical concerns including her diabetes and hypothyroid disorder. Penny’s psychiatrist prescribed and monitored Penny’s mood-stabilizing medications and provided case consultation to Penny’s team. The family therapist provided ongoing support to Penny and her boyfriend Don, and helped Penny and her team decide if and when to begin reparations in her relationship with her children. In addition, the family therapist provided feedback to the team about how Penny’s relationships impacted her recovery status and overall stability. The vocational specialist acted as a resource for Penny once she expressed a desire to return to work, helped Penny and her team identify resources for employment, and acted as liaison with Penny’s employer. The peer recovery support specialist helped Penny identify recovery support groups and helped Penny and her team identify barriers and resources to overcome those barriers to recovery success.

Principle 2: Access to Comprehensive Assessment of Substance Use and Mental Health Concerns

Integrated care recognizes that CODs and the resulting consequences of those conditions are commonplace. Therefore, practice protocols that standardize comprehensive biopsychosocial assessments are essential to identifying major mental illnesses and substance use. A comprehensive assessment includes screening, and when needed, further examination of substance use and mental health concerns. Practitioners utilize information collected from the comprehensive assessment to provide recommendations for treatment —such as the role one condition has on the efficacy of particular treatment strategies for the other condition(s). Screening tools for substance related disorders can include the CAGE-AID (Brown & Rounds, 1995), the Michigan Alcohol Screening Test (MAST) (Selzer, 1971), the Drug and Alcohol Screen Test (DAST) or the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al., 1993). For mental health concerns the Global Appraisal of Individual Needs-Short Screener (GAIN-SS) (Dennis, Chan, & Funk, 2006), or Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983) may be used.

When feasible, the practitioner gathers information from the client’s family and other professional resources who might have relevant information regarding symptom severity, substance use, and role functioning. Information gathered during the initial assessment can assist in a collaborative goal setting process. Ongoing assessment is critical in the treatment of co-occurring disorders and involves evaluation of changes in circumstances, substance use, stability and symptom expression, and goal attainment. Conducting a comprehensive integrated assessment helps define areas that can be addressed in treatment and identify specific treatment recommendations (Mueser et al., 2013). The context of the comprehensive assessment should occur within a recovery-oriented perspective. Progress toward recovery is individualized as described in the following definition: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (SAMHSA, CMHS, 2011).

Penny and her primary practitioner completed a comprehensive biopsychosocial assessment that included questions about distressing mental health symptoms as well as substance use patterns and periods of abstinence/remission. During her early 20s Penny entered college to become a nurse. Soon after beginning school, her anxiety increased. She experienced racing thoughts, extreme irritability, interruptions in sleep and a pronounced overconfidence followed by periods of despair and an inability to get out of bed. Penny returned to using alcohol and marijuana and eventually discontinued her education.

In her early 30s, Penny completed substance abuse treatment and was abstinent from alcohol and marijuana. She also participated in individual therapy and was prescribed lithium. She experienced a period of relative stability and returned to school. However, Penny disliked the side effects of her medication and felt she was stable enough to discontinue taking the lithium. She sought care from a physician for her anxiety and was placed on the benzodiazepine Xanax.

Penny currently lives with Don, her boyfriend of 8 years. Due to chronic conflict in their relationship, she is in danger of becoming homeless. Don has a construction business and manages to make a solid living. They both smoke marijuana most evenings as a way to wind down from the day. Don occasionally uses cocaine and in very rare situations Penny has joined him. She has been abstinent from alcohol since receiving a DWI 9 months ago. Penny has been estranged from her two adult children, Linda, 24, and Jeff, 22, for 6 months and 3 years, respectively. Her parents are deceased.

Penny’s practitioner was able to collect information from Penny’s boyfriend, her children, previous therapists, agencies and hospitals with whom she has had contact. During the assessment the practitioner discovered information about periods of increased mental illness symptoms while Penny was abstinent from substances, and a return to substance use in correlation with mental illness symptoms. The comprehensive assessment provided initial information about Penny’s current mental illness symptoms and substance use and was used to determine treatment priorities and programs that align with Penny’s needs.

Principle 3: Comprehensive Variety of Services Offered to Clients

Clients are provided with comprehensive integrated services that are cohesive, relevant and responsive to their identified needs and goals (Bipolar Disorder, n.d.). Practitioners coordinate with one another and collaborate with the client to prioritize treatment needs in a manner that does not overwhelm the client. A multidisciplinary team provides support for a broad range of issues relevant to the client population served by the agency. This includes culturally relevant information about community support systems and an array of mental health or substance related resources available to clients and their support persons.

Comprehensive services that are relevant to persons with CODs often include but are not limited to: medication assisted therapy, cognitive behavioral therapy (CBT), family therapy, life skills/ psychosocial rehabilitation, psychoeducation, and supported employment. Medication assisted therapy helps control distressing symptoms of many health and mental health dis-orders and is helpful for mood stabilization. Medication is also used in the treatment of substance use disorders to inhibit substance use, reduce cravings, reduce withdrawal symptoms, and as replacement therapy. CBT helps people with CODs learn to change harmful or negative thought patterns and behaviors.

Family therapy enhances coping strategies and focuses on improving communication and problem solving amongst family members and significant others. Life skills/rehabilitation provides clients with new information and opportunities to practice skills such as sleep hygiene practices, self-care, stress reduction and management, and medication maintenance. Psychoeducation provides information about the interacting dynamics of CODs and treatment (e.g., recognition of early signs of relapse so they can seek support before a full-blown episode occurs.) Supported employment provides opportunities for the client to contribute meaningfully in a work environment. A vocational specialist is part of the treatment team and works as a liaison with employers, client and the rest of the treatment team to support the client in the work environment. A case manager/navigator assists the client and their support persons in access-ing resources necessary to their recovery. These relationships are longitudinal in nature and supportive rather than therapeutic.

Penny and her treatment team agreed that she would benefit from mood stabilizing medication for her mental health disorder as well as cognitive behavioral therapy to help her develop coping strategies to help regulate and stabilize symptoms such as feelings of despair, racing thoughts, and behavioral dysregulation. Penny and Don recently began family counseling to explore the role and impact of substance use on their relationship, to develop communication skills and to identify strategies to help Don support Penny in her recovery from COD. Penny expressed interest in mending the relationship with her children in the future. If they are reunited, Penny identified a goal of attending family therapy with her children to improve communication and explore the impact of her COD on her relationship with them. Penny also identified a desire to return to work and will be making an appointment to discuss her work goals with the supported employment specialist.

Penny participates in a skills group to assist her in managing the symptoms of her CODs such as emotional and behavioral regulation, self care, sleep hygiene, and to manage triggers related to her substance use.

Principle 4: An Assertive Approach to Care/Service Delivery

Assertive outreach involves reaching out to individuals who are at risk or in crisis and their concerned persons, by providing support and engaging them in the change process. Sometimes this occurs by engaging the individual who seeks care for a substance use issue and providing services that stabilize a COD. An assertive approach is time unlimited and occurs in a variety of situations, including a client’s own community setting (Bond, 1991; Bond, McGrew, & Fekete, 1995). Assertive outreach includes meeting the client in community locations and providing practical assistance in daily living needs. These strategies increase or decrease in intensity depending on the client’s day-to-day living needs such as housing, transportation, money management, or seeking employment. This approach also provides opportunities to explore and address how substance use interferes with goal attainment.

Assertive outreach by Penny’s multidisciplinary team included meeting with a vocational specialist to assist Penny in looking for a job. Penny’s primary practitioner met with Penny weekly in Penny’s home and discussed progress towards her goals. Although Penny had not declared she wanted to stop using or cut down this provided Penny’s practitioner with an opportunity to introduce discrepancy by exploring how substance use interfered with taking steps toward Penny’s goals and practicing or using coping skills. Penny and her primary practitioner examined how Penny’s use impeded her ability to follow through with completing job applications and job interviews as steps toward finding steady, meaningful work.

This brief examined four of the eight principles of COD treatment. The first four principles underscore the importance of the integration of COD services and access to comprehensive assessment and care using assertive outreach and a client centered approach. The next brief will explore the latter four COD principles and implementation strategies. The final COD principles emphasize a long-term care model using a harm-reduction approach, motivation-based stage-wise treatment interventions and multiple treatment modalities (Mueser et al., 2003). The principles in both briefs place the client and their support persons, front and center as active participants, guides, resources and experts in their own recovery. Unpacking the principles of integrated treatment for CODs provides opportunities for practitioners to utilize multiple strategies to engage clients in treatment as discussed in this practice brief.

As you consider the practice of integrated care, examine your agency and your own clinical practice. Consider how you might try new strategies in an effort to implement the principles of COD treatment. We invite practitioners to engage in a dialogue surround-ing the strategies implemented in sessions to engage COD clients. Please consider the following and email us to describe successful COD strategies and challenges utilizing the principles of COD treatment.

• What strategies have you tried using one of the above principles that worked particularly well?
• What challenges have you encountered?
• Please provide suggestions for additional strategies you found helpful.

Common Comorbidities with Substance Use Disorders Research Report Part 1: The Connection Between Substance Use Disorders and Mental Illness

Many individuals who develop substance use disorders (SUD) are also diagnosed with mental disorders, and vice versa. 2,3 Although there are fewer studies on comorbidity among youth, research suggests that adolescents with substance use disorders also have high rates of co-occurring mental illness; over 60 percent of adolescents in community-based substance use disorder treatment programs also meet diagnostic criteria for another mental illness. 4

Data show high rates of comorbid substance use disorders and anxiety disorders—which include generalized anxiety disorder, panic disorder, and post-traumatic stress disorder. 5–9 Substance use disorders also co-occur at high prevalence with mental disorders, such as depression and bipolar disorder, 6,9–11 attention-deficit hyperactivity disorder (ADHD), 12,13 psychotic illness, 14,15 borderline personality disorder, 16 and antisocial personality disorder. 10,15 Patients with schizophrenia have higher rates of alcohol, tobacco, and drug use disorders than the general population. 17 As Figure 1 shows, the overlap is especially pronounced with serious mental illness (SMI). Serious mental illness among people ages 18 and older is defined at the federal level as having, at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities. Serious mental illnesses include major depression, schizophrenia, and bipolar disorder, and other mental disorders that cause serious impairment. 18 Around 1 in 4 individuals with SMI also have an SUD.

Data from a large nationally representative sample suggested that people with mental, personality, and substance use disorders were at increased risk for nonmedical use of prescription opioids. 19 Research indicates that 43 percent of people in SUD treatment for nonmedical use of prescription painkillers have a diagnosis or symptoms of mental health disorders, particularly depression and anxiety. 20

Youth—A Vulnerable Time

Although drug use and addiction can happen at any time during a person’s life, drug use typically starts in adolescence, a period when the first signs of mental illness commonly appear. Comorbid disorders can also be seen among youth. 21–23 During the transition to young adulthood (age 18 to 25 years), people with comorbid disorders need coordinated support to help them navigate potentially stressful changes in education, work, and relationships. 21

Drug Use and Mental Health Disorders in Childhood or Adolescence Increases Later Risk

The brain continues to develop through adolescence. Circuits that control executive functions such as decision making and impulse control are among the last to mature, which enhances vulnerability to drug use and the development of a substance use disorder. 3,24 Early drug use is a strong risk factor for later development of substance use disorders, 24 and it may also be a risk factor for the later occurrence of other mental illnesses. 25,26 However, this link is not necessarily causative and may reflect shared risk factors including genetic vulnerability, psychosocial experiences, and/or general environmental influences. For example, frequent marijuana use during adolescence can increase the risk of psychosis in adulthood, specifically in individuals who carry a particular gene variant. 26,27

It is also true that having a mental disorder in childhood or adolescence can increase the risk of later drug use and the development of a substance use disorder. Some research has found that mental illness may precede a substance use disorder, suggesting that better diagnosis of youth mental illness may help reduce comorbidity. One study found that adolescent-onset bipolar disorder confers a greater risk of subsequent substance use disorder compared to adult-onset bipolar disorder. 28 Similarly, other research suggests that youth develop internalizing disorders, including depression and anxiety, prior to developing substance use disorders. 29

Untreated Childhood ADHD Can Increase Later Risk of Drug Problems

Numerous studies have documented an increased risk for substance use disorders in youth with untreated ADHD, 13,30 although some studies suggest that only those with comorbid conduct disorders have greater odds of later developing a substance use disorder. 30,31 Given this linkage, it is important to determine whether effective treatment of ADHD could prevent subsequent drug use and addiction. Treatment of childhood ADHD with stimulant medications such as methylphenidate or amphetamine reduces the impulsive behavior, fidgeting, and  inability to concentrate that characterize ADHD. 32

That risk presents a challenge when treating children with ADHD, since effective treatment often involves prescribing stimulant medications with addictive potential. Although the research is not yet conclusive, many studies suggest that ADHD medications do not increase the risk of substance use disorder among children with this condition. 31,32 It is important to combine stimulant medication for ADHD with appropriate family and child education and behavioral interventions, including counseling on the chronic nature of ADHD and risk for substance use disorder. 13,32

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Case study: Adolescent with a substance use disorder

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This chapter discusses the case study of adolescent with a substance use disorder. Confidentiality is defined as an agreement between patient and provider that information discussed during the encounter will not be shared with other parties without patient permission. A confidentiality statement must be provided to adolescents at every healthcare visit. The confidentiality statement assures adolescents that information provided to the pediatric primary care provider (P-PCP) during the office visit is a standard of care that supports full disclosure and trust between the adolescent and the P-PCP, without punitive consequences for the adolescent. P-PCPs must be knowledgeable about the laws in the state in which they practice to provide accurate information to the adolescents with admitted substance use problems. The key to intercepting these behaviors is effective office-based screenings and an immediate intervention with prompt referral to treatment and interprofessional collaborative initiatives at the national, state, and local community levels.

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T1 - Case study

T2 - Adolescent with a substance use disorder

AU - Dalina, Katelyn

AU - Katinas, Mary Elizabeth

AU - Ashmawi, Samar Mohsen

AU - Hallas, Donna

PY - 2018/1/1

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AB - This chapter discusses the case study of adolescent with a substance use disorder. Confidentiality is defined as an agreement between patient and provider that information discussed during the encounter will not be shared with other parties without patient permission. A confidentiality statement must be provided to adolescents at every healthcare visit. The confidentiality statement assures adolescents that information provided to the pediatric primary care provider (P-PCP) during the office visit is a standard of care that supports full disclosure and trust between the adolescent and the P-PCP, without punitive consequences for the adolescent. P-PCPs must be knowledgeable about the laws in the state in which they practice to provide accurate information to the adolescents with admitted substance use problems. The key to intercepting these behaviors is effective office-based screenings and an immediate intervention with prompt referral to treatment and interprofessional collaborative initiatives at the national, state, and local community levels.

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CASE STUDY Jeff (alcohol use disorder, mild/moderate)

Case study details.

Jeff is a 66-year-old Caucasian man whose wife has encouraged him to seek treatment. He has never been in therapy before, and has no history of depression or anxiety. However, his alcohol use has recently been getting in the way of his marriage, and interfering with his newly-retired life. He describes drinking increasing amounts over the last year, currently consuming approximately a six-pack of beer per day. He notes that this amount “doesn’t give me the same buzz as it used to.” He denies ever experiencing “the shakes” or any other withdrawal symptoms if he skips a day of drinking.

Jeff comments that his wife is his biggest motivation to decrease his alcohol use. She tells him that he gets argumentative and irritable when he drinks, though he does not always remember these incidents. He has also fallen while intoxicated twice, causing bruises both times and hitting his head on one of the occasions.

• Alcohol Use
• Irritability
• Substance Abuse

Diagnoses and Related Treatments

2. substance and alcohol use disorders.

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• Open access
• Published: 03 June 2020

Assessment of anxiety and depression among substance use disorder patients: a case-control study

• Ikram I. Mohamed 1 ,
• Hossam Eddin Khalifa Ahmad 2 ,
• Shehab H. Hassaan 2 &
• Shymaa M. Hassan 1  

Middle East Current Psychiatry volume  27 , Article number:  22 ( 2020 ) Cite this article

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Several evidences from epidemiologic and treatment studies indicate that anxiety disorders, depression, and substance use disorders commonly co-occur, and the interaction is multifaceted and variable. Epidemiological studies and investigations within clinical substance abuse populations have found an association between anxiety disorders, depression, and substance use disorders .

The mean age was 28.1 ± 6.5 years. The majority belonged to the moderate socioeconomic status (52%). Substance use disorder (SUD) patients expressed higher levels of anxiety and depression in comparison to the control group. Most of the study group (97%) expressed different levels of anxiety. Eighty percent of them expressed high and moderate anxiety levels, and 20% of caregivers were having mild anxiety levels. Ninety-three percent of the substance users expressed different levels of depression, either mild 12%, moderate 9%, or severe 72%. The Drug Use Disorder Identification Test scores were positively correlated with anxiety ( r = 0.256 and p = 0.010) and depression ( r = 0.330 and p = 0.001). Moreover, it was found that anxiety and depression are positively correlated with each other’s ( r = 0.630 and p = 0.001).

Substance use disorders are associated with high levels of anxiety and depression. More specifically, it is associated with severe depression and anxiety. There is an obvious association between the presence of anxiety and depression on the one hand and the severity of drug-related problems on the other hand. Depression and anxiety are commonly present together in patients with SUDs.

The lifetime prevalence of any substance use in Egypt varies between 7.25% and 14.5% [ 1 ]. Substance use disorders, mood, and anxiety disorders are widespread among the general population [ 2 , 3 , 4 ] and are associated with substantial social, economic, and health loss [ 5 , 6 , 7 , 8 ]. Reports published in the Journal of the American Medical Association indicate that roughly 50% of individuals with severe mental disorders are affected by substance abuse, 37% of alcohol abusers, and 53% of drug abusers who also have at least one serious mental illness, and of all people diagnosed as mentally ill, 29% abuse either alcohol or drugs [ 9 ].

Anxiety and depression are among the most common problems reported by persons seeking treatment for drug addiction. Primary psychiatric symptoms persist behind detoxification and remission of addictive behavior. From an addiction perspective, there may be significant risks associated with concurrent depression and anxiety symptoms, regardless of etiology [ 10 ].

Anxiety can be caused by drug addiction. Anxiety commonly occurs during the acute withdrawal phase of alcohol and can persist for up to 2 years as part of a post-acute withdrawal syndrome, in about a quarter of people recovering from alcoholism [ 11 ]. Depression and anxiety symptoms are among the most common problems reported by persons seeking treatment for drug addiction. Drug addiction, anxiety, and depression account for three-quarters of the disability attributed to mental disorders [ 12 ]. Depression and drug addiction are critical, not only because of their high prevalence but also because of their negative consequences. Individuals with co-morbid mental health and drug addiction often experience severe illness, disability, and poor treatment outcomes [ 13 ].

This study was done with the aim to assess levels of anxiety and depression among drug addict people.

Study design

This is a descriptive case-control study conducted at Assiut University Neuropsychiatry Hospital. This is an educational health facility, which provides both inpatient and outpatient mental health services to the entire population of Upper Egypt. The study was conducted from December 2015 until the end of May 2016.

Participants

The study included a selective sample of 100 patients with substance use disorder. Patients had to meet the following criteria to be included in the study: (i) to be 18 years or older, (ii) to be currently diagnosed with substance use disorder (SUD) according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and (iii) to accept the participation in the study. Exclusion criteria included the following: (i) the patient had a known psychiatric diagnosis before being diagnosed with SUD, (ii) the patient was mentally retarded or has an organic brain disorder, and (iii) the patient has a chronic medical illness. The control group included 50 subjects without a history of the current or past history of SUD and free from chronic illnesses as well. They were recruited from the patients’ relatives and the hospital staff.

Data were collected using face-to-face interviews conducted by a trained study team including a psychiatrist and psychologist. The researchers introduced themselves to participants before the interview and clearly expressed the purpose of the study, and consent was obtained from every participant.

Socioeconomic assessment scale for the family

We gathered information about socio-demographic information using this scale, which is prepared by Professor Abdel Tawab Abdullah, Faculty of Education, Assiut University, in 1998 and modified in 2010. It includes four main variables: [ 1 ] the educational level of the father and mother, [ 2 ] the occupation of the father and mother, [ 3 ] total family income, and [ 4 ] lifestyle of the family [ 14 ].

Drug Use Disorder Identification Test (DUDIT) Arabic version

This scale has been developed in the original English language version by Berman in 2007 [ 15 ]. It was translated into Arabic and validated by Sfendla and colleagues in 2017 [ 16 ]. The purpose of the Drug Use Disorder Identification Test was to identify the use of patterns and various drug-related problems. It consists of 11 items, and the total score of this test was 44 points. A patient with 6 points or more probably has drug-related problems (for example, risky or harmful drug habits that might be diagnosed as substance abuse/harmful use or dependence), while a patient with 25 points or more is probably heavily dependent on drugs. The scale was reported to have good reliability using Cronbach’s alpha (0.780) and possesses a high validity using Pearson correlation, ( r = 88%) for the total scale [ 15 ].

Hamilton Anxiety Rating Scale (HAM-A)

This scale has been developed by Max Hamilton in 1959 [ 17 ] and was translated into the Arabic language by Fatim in 1994 [ 18 ]. The purpose of this scale was to measure the severity of anxiety. The Hamilton Anxiety Rating Scale consists of 14 items; each item was scored based on a five-point Likert scale ranging from (0) = Not Present to [ 4 ] = Very Severe. The total score of this scale ranged from 0 to 56 and was divided into four levels: 17 or less indicated mild anxiety, from 18 to 24 indicated mild to moderate anxiety, 25 to 29 indicated a moderate to severe anxiety, and more than 30 indicated severe anxiety.

Hamilton Depression Rating Scale (HAM-D)

The Hamilton Rating Scale for Depression (HRSD), sometimes called the Hamilton Depression Rating Scale (HDRS) and abbreviated HAM-D, is based on a multiple item questionnaire and addresses depression indicators with special attention to the evaluation of recovery from depression [ 19 ]. Initially developed by Max Hamilton in1960 [ 20 ], it has gone through numerous revisions since then. The Arabic version has high reliability and validity [ 21 , 22 ]. The Hamilton Depression Rating Scale consists of 21 items to rate the severity of depression. Mild depression is ranging from 13 to 16, moderate depression is ranging from 17 to 19, and severe depression is ranging from 20 to above.

Statistical analysis

Data were analyzed using the Statistical Package for Social Studies (SPSS) software version 20. A descriptive analysis using means with standard deviation, frequency counts, and percentages was carried out. Pearson correlation coefficients ( r ) were employed to address the relationship between caregiver burden and study variables [ 23 ].

Sociodemographic characteristics

The study included 100 SUD patients and 50 healthy control; 73% live in rural areas and 27% in urban ones. Their mean age was 28.1 years (SD = 6.5). Most of the patients were married (62%) while 38% were singles. Most of the patients were graduates of either secondary school or its equivalent (67%) or held a university degree (23%). Fourteen percent of them have no job apart from the domestic affairs, and the rest are either employed (20%), manual workers (52%), or students (10%) (Table 1 ). The majority of the participants in this study belonged to the moderate socioeconomic status group (52%), while 22% belong to the low socioeconomic class and 26% were in the high socioeconomic class. A comparison between sociodemographic data shows no statistically significant difference between the SUD patients and healthy controls ( p = 0.643) (Table 1 ).

Clinical characteristics of the study sample

The results showed that the majority of drug addict people (83%) are polydrug addict; they used several types of substances (e.g., tramadol-cannabis-opiates-alprazolam-heroin-nalbuphine), while 17% of them used only tramadol. The majority of the drug users prefer the oral route (68%), while 32% of them used drugs through several routes ( oral-inhalation-injection).

As regards the duration of substance use, 93% of the patients used a drug for more than 1 year. Sixty-seven percent of them reported that they started drug use because of many reasons such as the effect of bad friends, as an experiment, to give them strength and activity, to forget problems and feel relaxed, to improve sexual ability, to spend excessive money, and to relieve chronic pain. However, 12% of them reported that they used drugs because of the effect of bad friends only, 13% to give the patient strength and activity only, and 8% of them reported that they used drugs to forget problems and feel relaxed (Table 2 ).

The drug-related problems

The DUDIT results of the study group revealed that 95% of drug addict people are probably heavily dependent on a drug, with the mean score is 31.45 ± 2.47 . While 5% of them have probable drug-related problems, with the mean score is 22.20 ± 2.49 (Table 3 ).

Levels of anxiety and depression

According to HAM-D scale results, 72% of the study sample was found to have severe depression in comparison to 6% of the control group ( p < 0.001). It is worth noting that only 7% of the SUD group did not have depressive symptoms in comparison to 64% of the control group ( p ≤ 0.001). The results were similar as regards to anxiety. The prevalence of severe anxiety was 67% in the study group in comparison to 14% in the control group ( p < 0.001). Five percent only of the SUD group have mild anxiety symptoms in comparison to 52% of the control group ( p ≤ 0.001) (Table 4 , Figs. 1 and 2 ).

Comparison between the SUD group ( n = 100) and control group ( n = 50) regarding anxiety levels according to the HAM-A rating scale

Comparison between the SUD group ( n = 100) and control group ( n = 50) regarding depression levels according to the HAM-D rating scale

Correlation between socio-economic status, DUDIT, anxiety, and depression

The socio-economic status is positively but non-significantly correlated with Drug Use Disorder Identification Test scores ( r = 0.070 and p = 0.487), anxiety ( r = 0.008 and p = 0.935), and depression ( r = 0.048 and p = 0.638). Drug Use Disorder Identification Test score is positively and significantly correlated with anxiety ( r = 0.256 and p = 0.010) and depression ( r = 0.330 and p = 0.001). Moreover, it was found that anxiety and depression are positively and significantly correlated with each other ( r = 0.630 and p = 0.001) (Table 5 ).

The purpose of this study was to assess the levels of anxiety and depression among SUD patients. Another objective of this study was to determine the correlation between the level of anxiety and depression on the one hand and the socio-demographic variables and drug use-related problems on the other side.

The current study revealed that the majority of drug addict people were polydrug addict. This might be due to the fact that one drug is used as a base or primary drug, with additional drugs to leaven or compensate for the side effects of the primary drug and make the experience more enjoyable with drug synergy effects or to supplement for the primary drug when supply is low [ 24 ]. These results are consistent with the findings of Panebiance et al. who revealed that the majority of drug addict people were polydrug addicts [ 25 ]. On the opposite side, Jabeen et al. found that more than half of drug addict people were single drug users [ 26 ].

The present study showed that about most of the drug users’ sample had severe levels of depression in comparison to the non-users’ and about more than two thirds of the drug users’ group had a severe level of anxiety as well while the majority of drug non-addict people had a mild level of anxiety. Many theories have tried to explain the relationship between SUDs and mental illness such as causality theory [ 27 ], multiple risk factor/environmental triggers theory [ 28 ], and genetics/supersensitivity theory [ 29 ].

Some studies indicated that substance use has been linked to some kind of emotional distress prior to consumption [ 30 , 31 ]. Others indicated that substance use is often used as a method to relieve emotional problems [ 32 ], although its effects are not very durable or effective in the long term, as consumption tends to enhance depressive symptoms [ 33 ].

Many studies are in concordance with our results. For example, Hodgson et al. showed that more than two thirds of drug addict people had a severe level of anxiety [ 34 ], while the majority of drug non-addict people had a mild level of anxiety. Additionally, Pakhtunkhwa et al. demonstrated that most of the drug addict people tend to have severe levels of depression [ 35 ].

The results of this study showed a positive correlation between the presence of anxiety, depression, and substance-related problems elicited by DUDIT. Considering the mutual maintenance pattern of this comorbidity, it is not surprising that both anxiety, depression, and substance use disorders impact the course and treatment outcome for the counterpart condition. For example, studies have shown that anxiety and depressive disorders are related to increased severity of lifetime alcohol use disorders, increased lifetime service utilization among individuals with a substance use disorder, increased the severity of alcohol withdrawal, and higher relapse rates following substance abuse treatment [ 36 , 37 , 38 , 39 , 40 ].

The correlation between anxiety and depression in this study can be explained by the direct causation model which states that one disorder causes or lowers the threshold for the expression of the other disorder [ 41 ]. The shared etiology model also referred to as the correlated liabilities model [ 42 ] indicated that a common set of risk factors leads to the development of both depression and anxiety.

These findings are similar with the previous study reported by Grant et al. who found that anxiety is positively and significantly correlated with depression [ 43 ], whereas these findings are contradicted with Bellos et al. who found that anxiety is positively but non-significantly correlated with depression [ 44 ].

The prevalence of anxiety and depression among patients with substance use disorders is considerably high, and to be more specific, the level of severe depression and severe anxiety is the one we mean. There is an obvious association between the presence of anxiety and depression on the one hand and the severity of drug-related problems on the other hand. Depression and anxiety are commonly present together in the patients with SUDs. These findings throw the light on the problem of dual diagnosis and its impact on the prognosis and treatment process.

Limitations

The findings of this study should be cautiously interpreted because a small sample was used. The restriction of the sample prevents the findings from being generalized to the larger population. This study relies completely on self-reports.

Availability of data and materials

The datasets that were generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Diagnostic and Statistical Manual of Mental Disorders

Drug Use Disorder Identification Test

Hamilton Anxiety Rating Scale

Hamilton Depression Rating Scale

Substance use disorder

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The authors of this manuscript declare that no funding bodies were involved in sponsoring or funding this research, no grants were taken, and the research was conducted solely on the expense of the authors.

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Faculty of Nursing, Assiut University, Assiut, Egypt

Ikram I. Mohamed & Shymaa M. Hassan

Psychiatry Unit, Department of Neurology and Psychiatry, Assiut University, Assiut, Egypt

Hossam Eddin Khalifa Ahmad & Shehab H. Hassaan

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Ikram Mohamed contributed to the study design, interpretation of the data, and preparation and revision of the manuscript. HK contributed to the study design, collection and analysis, interpretation of the data, and preparation of the main manuscript. S. Hassaan and H. Khalifa contributed to the study design, interpretation of the data, and writing of the manuscript. Shymaa M. Hassan contributed to the analysis and interpretation of the data and revision of the manuscript. All authors approved the final manuscript.

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Correspondence to Hossam Eddin Khalifa Ahmad .

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Before starting data collection, the College of Nursing Ethical Committee approved the research in meeting no. 18 held on the 18th of December 2015 according to article 114 of its implementing regulations. Prior to the interview, written informed consent was obtained from the literate participants and was signed in the presence of a witness for illiterate ones. Privacy and secrecy of all data were assured by ensuring the anonymity of the questionnaire, interviewing the participants separately in a closed room, and keeping data files in a safe place.

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Mohamed, I.I., Ahmad, H.E.K., Hassaan, S.H. et al. Assessment of anxiety and depression among substance use disorder patients: a case-control study. Middle East Curr Psychiatry 27 , 22 (2020). https://doi.org/10.1186/s43045-020-00029-w

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Substance use, abuse, and addiction

Substance use disorder is a cluster of physiological, behavioral, and cognitive symptoms associated with the continued use of substances despite substance-related problems, distress, and/or impairment, such as impaired control and risky use.

Addiction is a state of psychological and/or physical dependence on the use of drugs or other substances, such as alcohol, or on activities or behaviors, such as sex, exercise, and gambling.

Adapted from the APA Dictionary of Psychology

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APA’s Division 28 promotes teaching, research, and dissemination of information regarding the effects of drugs on behavior.

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APA’s Division 50 promotes advances in research, professional training, and clinical practice within the broad range of addictive behaviors including problematic use of alcohol, nicotine, and other drugs and disorders involving gambling, eating, sexual behavior, or spending.

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mental health center / mental health a-z list / drug abuse article

Drug Abuse and Addiction

• Medical Author: Roxanne Dryden-Edwards, MD
• Medical Editor: Melissa Conrad Stöppler, MD

What is drug abuse and addiction disorder?

What types of drugs do people commonly abuse, what are causes and risk factors for developing a drug abuse and addiction disorders, what are symptoms of drug abuse and addiction disorders, what are warning signs that you or a loved one may have a drug abuse and addiction disorders, what happens to your brain when you take drugs, how is drug addiction diagnosed, what is the treatment for drug abuse and addiction disorders, what are complications of drug abuse and addiction disorders, what is the prognosis of drug abuse and addiction disorders, is it possible to prevent drug abuse and addictions, where can people get more information and help for drug abuse and addiction disorders.

Formerly separately called substance or drug abuse and addiction, drug use disorder, also called substance use or chemical use disorder, is an illness characterized by a destructive pattern of using a substance that leads to significant problems or distress, including tolerance to or withdrawal from the substance, as well as other problems that use of the substance can cause for the sufferer, either socially or in terms of their work or school performance. The effects of drug use disorders on society are substantial. The economic cost, including everything from lost wages to medical, legal, and mental health implications is about $215 billion. The cultivation of marijuana and the production of synthetic drugs like methamphetamine have a negative impact on soil and water supplies. Drug law infractions are a highly common reason for arrests in the United States, with more than 1.5 million occurring in 2016.

Teens are increasingly engaging in prescription drug abuse, particularly narcotics, also called opioids (which physicians prescribe to relieve severe pain ), and stimulant medications, which treat conditions like attention-deficit disorder and narcolepsy .

The term dual diagnosis refers to the presence of both a drug use disorder and a serious mental health problem in a person. Substance use disorders, unfortunately, occur quite commonly in people who also have a severe mental illness . Individuals with dual diagnoses are also at higher risk of being non-compliant with treatment.

Individuals may abuse almost any substance whose ingestion can result in a euphoric ("high") feeling. While many are aware of the abuse of legal substances like alcohol or illegal drugs like marijuana (in most states) and cocaine , less well-known is the fact that inhalants like household cleaners and over-the-counter medications like cold medicines are some of the most commonly abused substances. The following are many of the drugs and types of drugs that people commonly abuse and/or result in dependence:

• Alcohol : Although legal, alcohol is a toxic substance, especially for a developing fetus when a mother consumes this drug during pregnancy . One of the most common addictions, alcoholism can have devastating effects on the alcoholic individual's physical well-being, as well as his or her ability to function interpersonally and at work.
• Amphetamines : This group of drugs comes in many forms, from prescription medications like methylphenidate  and dextroamphetamine and amphetamine to illegally manufactured drugs like methamphetamine ("crystal meth"). Overdose of any of these substances can result in seizures and death.
• Anabolic steroids : A group of substances that are most often abused by bodybuilders and other athletes, this group of drugs can lead to devastating emotional symptoms like aggression and paranoia, as well as severe long-term physical effects like infertility and organ failure.
• Caffeine : While many people consume coffee, tea, and soda, when consumed in excess, this substance can be habit-forming and produce palpitations , insomnia , tremors, irritability, and significant anxiety .
• Cannabis : More usually called marijuana, the scientific name for cannabis is tetrahydrocannabinol (THC). Marijuana is the most commonly used illicit drug, with nearly 14 million people 12 years or older reporting having used this drug in the past year. In addition to the negative effects, the drug itself can produce (for example, infertility, difficulties with sexual performance, paranoia, lack of motivation), the fact that it is commonly mixed (cut) with other substances so drug dealers can make more money selling the diluted substance or expose the user to more addictive drugs exposes the marijuana user to the dangers associated with those added substances. People commonly cut marijuana with ingredients that include baby powder, oregano, embalming fluid, phencyclidine (PCP), opiates, and cocaine.
• Cathinones ( bath salts ): Chemically unrelated to bath salts that people use to bathe, cathinone are chemically similar to stimulant drugs, like amphetamines, cocaine, and Ecstasy (MDMA). In addition to bath salts, other street names for cathinone include "plant food," "jewelry cleaner," or "phone screen cleaner."
• Cocaine : A drug that tends to stimulate the nervous system, people can snort cocaine in powder form, smoke it when in the form of rocks (" crack " cocaine), or inject it when made into a liquid.
• Ecstasy : Also called MDMA to denote its chemical composition (methylenedioxymethamphetamine), this drug tends to create a sense of euphoria and an expansive love or desire to nurture others. In overdose, it can increase body temperature to the point of causing death.
• Hallucinogens : Examples include LSD and mescaline, as well as so-called naturally occurring hallucinogens like certain mushrooms. These drugs can be dangerous in their ability to alter the perceptions of the user. For example, a person who is intoxicated ("high" on) with a hallucinogen may perceive danger where there is none and think that situations that are truly dangerous are not. Those misperceptions can result in dangerous behaviors (like jumping out of a window because the person thinks they have wings and can fly).
• Inhalants : One of the most commonly abused groups of substances due to its easy accessibility, inhalants are usually in household cleaners, like ammonia, bleach, and other substances that emit fumes. Brain damage, to the point of death, can result from using an inhalant even just once or over the course of time, depending on the individual.
• Nicotine : The addictive substance found in cigarettes, nicotine is actually one of the most addictive substances that exist. In fact, people often compare nicotine addiction to the intense addictiveness associated with opiates like heroin .
• Opiates : People also call this group narcotics or opioids and include drugs like heroin, codeine , hydrocodone , morphine, methadone , Vicodin , OxyContin , Percocet , and Percodan. This group of substances sharply decreases the functioning of the nervous system. The lethality of opioids is often the result of the abuser having to use increasingly higher amounts to achieve the same level of intoxication, ultimately to the point that the dose needed to get high is the same as the dose that is lethal by overdose for that individual by halting the person's breathing (respiratory arrest).
• Phencyclidine : Commonly called PCP, this drug can cause the user to feel highly suspicious, become very aggressive, and have an exceptional amount of physical strength. This can make the person quite dangerous to others.
• Sedative, hypnotic, or antianxiety drugs : The second most commonly used group of illicit drugs, these substances quiet or depress the nervous system. They can therefore cause death by stopping the breathing (respiratory arrest) of the individual who either uses these drugs in overdose or who mixes one or more of these drugs with another nervous system depressant (like alcohol, another sedative drug, or an opiate).

Like most other mental health problems, drug use disorders have no single cause and are not the result of a lack of discipline or self-control. There are a number of biological, psychological, and social factors, known as risk factors, which can increase an individual's vulnerability to developing a chemical use disorder. The frequency with which substance use disorders occur within some families seems to be higher than could be explained by an addictive environment of the family. Therefore, most substance use professionals recognize a genetic aspect to the risk of drug addiction.

Psychological associations with substance abuse or addiction include mood disorders like early aggressive behaviors, depression , anxiety , or bipolar disorder , thought disorders like schizophrenia , as well as personality disorders like an antisocial personality disorder .

Social risk factors for drug abuse and addiction include male gender, being between the ages of 18 and 44 Native-American heritage, unmarried marital status, and lower socioeconomic status. According to statistics by state, people residing in the West tend to be at a somewhat higher risk for chemical dependency. While men are more at risk for developing a chemical dependency like alcoholism, women seem to be more vulnerable to becoming addicted to alcohol at much lower amounts of alcohol consumption compared to men.

Adults exposed to negative events as children are at higher risk of developing drug abuse and addiction disorders. In addition to poverty, examples of such negative events include lack of parental supervision, the presence of parental substance abuse, witnessing domestic violence , or being the victim of emotional, physical, or sexual abuse.

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According to the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ), the diagnostic reference that is written and endorsed by the American Psychiatric Association, in order to be diagnosed with substance-related use disorder, a person must exhibit a maladaptive pattern of drug use that leads to significant problems or stress , as manifested by at least two of the following signs or symptoms in the same one-year period:

• Recurrent substance use that prevents the sufferer from meeting significant responsibilities at work, school, or home
• Recurrent drug use despite significant resulting drug-related problems in the person's life (for example, in situations that may be physically dangerous, cause recurrent legal problems as a result of drug use; repeated social or relationship problems as a result of or worsened by the drug's effects)
• Recurrent legal problems as a result of drug use
• Continued drug use in spite of continued or repeated social or relationship problems as a result of, or worsened by the drug's effects
• Tolerance, which is either a markedly decreased effect of the drug or a need to significantly increase the amount of the substance used in order to experience the same high or other desired effects
• Withdrawal is defined as either physical or psychological signs or symptoms consistent with withdrawal from a specific drug or taking that drug or one chemically close to that drug in order to avoid developing symptoms of withdrawal
• Larger amounts of the drug are taken or for longer than intended.
• The person has a persistent urge to take the drug or has unsuccessfully tried to decrease or control the drug use
• A person spends excessive amounts of time either getting, using, or recovering from the effects of the drug
• Cravings/strong urges to use the substance.
• The person significantly lessens or stops engaging in important social, recreational, work, or school activities because of the substance use
• The person engages in negative decision-making, in that he or she continues to use the drug despite knowing that he or she suffers from ongoing or recurring physical or psychological problems caused or worsened by the use of the drug.

While specific symptoms that are used to diagnose drug abuse and addiction disorders are described below, warning signs that you or a loved one suffer from a drug-related problem include the following:

• Having blackouts or loss of memory
• Mood problems like irritability, sadness, or mood swings
• Repeated arguments with loved ones
• Repeatedly using drugs to cope with problems
• Physical symptoms when abstaining from drug use
• Physical problems due to drug use
• Repeatedly using more drugs or using drugs for longer than intended
• Spending less time on life obligations due to drug use
• Need more drugs to get high than the one used to

While the specific effects of drugs on the brain can vary somewhat depending on the drug that people abuse, virtually every drug that is abused has an effect on what professionals often call the executive functioning areas of the brain. The functions of those areas can be remembered by thinking about the tasks of the chief executive officer in any company: planning, organizing, prioritizing, acting when it is time to act, as well as delaying or preventing action (inhibitory functions) when appropriate.

The parts of the brain that tend to harbor the executive brain functions are the front-most parts of the brain, called the frontal lobes, including the frontal cortex and prefrontal cortex. When a person takes drugs, the inhibitory functions of the brain are particularly impaired, causing the person to have trouble stopping him or herself from acting on impulses that the brain would otherwise delay or prevent. This disinhibition can lead to the substance abuser engaging in aggressive, sexual, criminal, dangerous, or other activities that can have devastating consequences for the addicted person or those around him or her.

• Given that the brain of individuals below about the age of 25 years is in the process of actively and rapidly developing and is therefore not fully mature, drug use that takes place during the childhood or teenage years can have particularly negative effects on the younger person's ability to perform all these essential executive functions.

Similar to many mental health diagnoses, there is no one test that definitively determines that someone has a chemical use disorder. Therefore, health care professionals diagnose these conditions by thoroughly gathering medical, family, and mental health information. The practitioner will also either conduct a physical examination or ask that the person's primary care doctor perform one. The medical assessment will usually include lab tests to evaluate the person's general medical health and to explore whether or not the individual currently has drugs in their system or has a medical problem that might mimic symptoms of drug addiction.

In asking questions about mental health symptoms, specialists are often exploring if the person suffers from depression and/or manic symptoms but also anxiety , hallucinations, or delusions, as well as some behavioral problems. Practitioners may provide the people they evaluate with a quiz or self-test as a screening tool for substance use disorders. Since some of the symptoms of chemical dependency can also occur in other mental illnesses, the screening is to determine if the individual suffers from bipolar disorder , an anxiety disorder , schizophrenia , schizoaffective disorder , and other psychotic disorders , or a personality or behavior disorder like antisocial personality disorder or attention deficit hyperactivity disorder ( ADHD ), respectively. Any condition that is associated with sudden changes in behavior, mood, or think ing, like bipolar disorder, a psychotic disorder , borderline personality disorder , or dissociative identity disorder (DID), may be particularly challenging to separate from some symptoms of drug use disorder. In order to assess the person's current emotional state, health care providers perform a mental-status examination, as well.

In addition to providing treatment that is appropriate to the diagnosis, determining the history or presence of mental illnesses that may co-occur (be co-morbid) with substance abuse or dependence is important in promoting the best possible outcome for the person. As previously described, the dual diagnosis of substance abusing or addicted individuals dictates the need for treatment that addresses both issues in a coordinated way by professionals who are trained and experienced with helping this specific population.

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An unfortunate fact about the treatment of drug addiction is that it remains largely underutilized by most sufferers. Facts about the use of drug addiction treatment include that less than 10% of people with a milder substance-use disorder and less than 40% of those with a more entrenched substance-use disorder seek professional help. Those statistics do not seem to be associated with socioeconomic or other demographic traits but do seem to be associated with the presence of other mental health problems (co-morbidity).

The primary goals of drug abuse and addiction disorders treatment (also called recovery) are abstinence, relapse prevention , and rehabilitation. During the initial stage of abstinence, an individual who suffers from chemical dependency may need help avoiding or decreasing the effects of withdrawal. That process is detoxification or "detox." Medical professionals primarily perform that part of drug addiction treatment in a hospital or other inpatient setting, where medications are used to lessen withdrawal symptoms and close medical monitoring can be performed. The medications used for detox depend on the drug the person is dependent upon. For example, people with alcohol use disorder might receive medications like sedatives ( benzodiazepines ) or blood pressure medications to decrease palpitations and blood pressure, or seizure medications to prevent seizures during the detoxification process.

For many substances of abuse, the detox process is the most difficult part of dealing with the physical symptoms of addiction and tends to be short-term, lasting days to a few weeks. Physicians sometimes use medications to help addicted individuals abstain from drug use on a long-term basis also depending on the specific drug of addiction. For example,

• individuals who are dependent on opioids like Percodan (a combination of aspirin and oxycodone hydrochloride) heroin, or Vicodin, Vicodin ES, Anexsia , Lorcet , Lorcet Plus, or Norco (combinations of hydrocodone and acetaminophen ) often benefit from receiving longer-acting, less addictive narcotic-like substances like methadone ( Methadose ).
• People with alcohol addiction might try to avoid alcohol intake by taking disulfiram ( Antabuse ), which produces nausea , stomach cramping, and vomiting in reaction to the person consuming alcohol.

Often, much more difficult and time-consuming than recovery from the physical aspects of drug dependency is psychological addiction. For people who may have less severe drug use disorder, the symptoms of psychological addiction may be able to be managed in an outpatient treatment program. However, those who have a more severe addiction, have relapsed after participation in outpatient programs, or who also suffer from a severe mental health condition might need the elevated level of structure, support, and monitoring provided in an inpatient drug addiction treatment center, often called " rehab ." Following such inpatient treatment, many people with this level of drug use disorder can benefit from living in a sober living community, that is, a group-home setting where counselors provide continued sobriety support, structure, and monitoring on a daily basis.

Self-help groups for people with a drug use disorder, like Alcoholics Anonymous and Narcotics Anonymous, or for loved ones of addicted individuals, like Al-Anon, are important to drug addiction recovery. Specifically, such groups provide an emotionally safe place for people with substance use disorders and their loved ones to share their feelings and experiences, as well as benefit from the experiences of others in their efforts to abstain from using drugs.

Also important in the treatment of drug dependency is helping the parents, other family members, and friends of the addicted person refrain from supporting addictive behaviors (codependency) . Whether providing financial support, making excuses, or failing to acknowledge the drug seeking and other maladaptive behaviors of the drug abuser, discouraging such codependency of loved ones is a key component of recovery. A focus on the addicted person's role in the family becomes perhaps even more significant when that person is a child or teenager, given that minors come within the context of a family in nearly every instance. Drug dependency treatment for children and adolescents is further different from that in adults by the impact of drugs on the developing brain, as well as the younger addict's tendency to need help completing their education and achieving higher education or job training compared to addicts who may have completed those parts of their lives before developing the addiction.

The treatment options for dual diagnosis seem to be less effective when the management of the person's mental disorder is separate from the care for his or her chemical dependency. More successful are integrated treatment approaches that include interventions for both disorders. The inclusion of assessment, intensive case management, motivational interventions, behavior interventions, family treatment, as well as services for housing, rehabilitation, and medication management improve such interventions.

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Drug abuse and addiction put sufferers at risk for potentially devastating social, occupational, and medical complications. Effects of chemical dependency on families include increased risk of domestic violence. Individuals with drug use disorder are also much less likely to find and keep a job compared to people who are not drug-addicted. Children of parents with a substance use disorder are at higher risk for impaired social, educational, and health functioning, as well as being at higher risk for using drugs themselves.

In addition to the many devastating social and occupational complications of drug addiction, there are many potential medical complications. From respiratory arrest associated with heroin or sedative overdose to heart attack or stroke caused by cocaine or amphetamine intoxication, death is a highly possible complication of a drug use disorder. People who are dependent on drugs are also vulnerable to developing persistent medical conditions include: 

• Liver or heart failure or
• pancreatitis associated with alcoholism and
• brain damage associated with alcoholism or inhalants

If treated, the prognosis of alcoholism and other drug abuse and addiction disorders improves but is not without challenges. Episodes of remission (abstinence from drug use) and relapse characterize recovery from substance dependency.

A number of different prevention approaches are effective in decreasing the risk of drug abuse and addiction disorders. Lifestyle changes, like increased physical activity and using other stress-reduction techniques, help prevent drug use disorder in teens. Programs that are more formal are also helpful. For example, the Raising Healthy Children program, which includes interventions for teachers, parents, and students, helps prevent drug addiction in elementary school children when the program goes on for 18 months or more. Designing research-based prevention programs to meet the specific needs of children by age and specific community strengths and challenges contributes to the success of those programs. The prevalence of easier access to technology led to the development of computer-based prevention programs. Such programs are very promising in how they compare to more traditional prevention programs, as well as how many more people can be reached through technology.

• Al-Anon-Alateen: 888-4AL-ANON
• Alcoholics Anonymous World Services: 212-870-3400
• American Council on Alcoholism treatment referral line: 800-527-5344
• Kids Against Drugs: http://www.kidsagainstdrugs.com
• Mothers Against Drunk Driving: 800-GET-MADD
• Narconon: http://www.narconon.org/
• Narcotics Anonymous: http://www.na.org
• National Clearinghouse for Alcoholism and Drug Information: 800-729-6686
• National Cocaine Hotline: 800-COCAINE (262-2463)
• National Council on Alcoholism and Drug Dependence: 800-NCA-CALL
• National Drug Information Treatment and Referral Hotline: 800-662-HELP (4357)
• National Institute on Alcohol Abuse and Alcoholism: 301-443-3860
• National Institute on Drug Abuse: http://www.nida.nih.gov
• National Resource Center: 866-870-4979

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Glimmers of hope for patients with substance use disorder.

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Substance Use Disorder research is ongoing and the tide may finally be starting to turn.

There is arguably no area of healthcare in the U.S. that has had a greater human and economic impact while being less effectively addressed than Substance Use Disorder (SUD).

SUD is generally defined as a treatable mental disorder that affects a person’s brain and behavior, leading to their inability to control their use of legal or illegal drugs, alcohol, and other substances. Symptoms can be moderate to severe, with addiction being the most severe form of SUD.

These are some of the sobering statistics on the human cost of SUD:

• 46.8 million Americans had SUD in 2023, approximately 14 percent of everyone 12 years and older.
• 90% of those with SUD didn’t receive any care, and only 2 percent received evidence-based care.
• 56% were unhoused.
• 47% were BIPOC (Black, Indigenous, and People Of Color),
• 99% had co-morbid mental conditions.
• Nearly half of young American adults 18-25 had either a SUD or a mental illness.
• Millions of children live with parents who misuse substances or have SUD.
• 117,000 died of drug overdoses in 2023.
• Approximately 178,000 died from excessive alcohol use in 2023.

And here are some estimates of the financial cost:

• $47.3 billion was spent on SUD in 2023 by Medicaid and employer-sponsored plans.
• $15,640 is attributable per SUD patient cost to payers annually.
• $600 billion is the conservative total annual estimated cost of substance abuse in the U.S.

Increasingly Complex Treatment Challenges

As described to me by Jordan Hansen, the co-founder and CEO of an innovative new company called YourPath, which is dedicated to creating a systemic solution to the massive SUD problem, its drug-related challenges have grown and evolved significantly over the past decade.

COVID shattered already fragile connections between patients and treatment / recovery resources, then the Opioid Crisis snowballed, and more recently, Fentanyl, Methamphetamine, and other even more dangerous, illegal drugs became commonplace.

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To give you an idea of how dangerous synthetic opioids are, Fentanyl is about 50 times stronger than heroin and 100 times more powerful than morphine, and there is a recent variant called Carfentanil that is 100 times more potent than Fentanyl and 10,000 times more potent than morphine.

A single Fentanyl pill can be deadly, but even if it is not, medical treatment related to Fentanyl and drugs that are laced with it and other illicit substances is far more challenging than treatment of other substance use issues.

Naloxone, which has proven effective in treating opioid overdoses, is much less effective when the newer illicit drugs include Fentanyl or other adulterants, which they frequently do. In addition, a recent surge in the use of methamphetamine is particularly problematic because—as compared to the more sedating effects of opioids—meth can produce aggressive behaviors that can be destructive to others.

Further complicating the new treatment challenge is the fact that many SUD patients are difficult to engage with on an ongoing basis for some of the reasons mentioned in the human cost section above, including the fact that many are homeless and lack regular modes of communication or transportation.

Additionally, evidence-based practices, such as the use of medications for opioid use disorder (MOUD), still aren’t embraced by most specialty treatment providers. The tragic result, according to Hansen, is that many SUD patients get better care in correctional institutions than they do outside of them.

With that said, SUD patients are not particularly hard to find. It is estimated that 60 percent of Emergency Department patients are there because they have one or more SUDs or because of an injury related to or caused by substance use, while many other SUD patients can be found in county jails.

The problem is that because care teams in these settings are generally not capable of treating the underlying causes of SUD-related visits, they end up treating the symptoms rather than the disease and simply “boarding” SUD patients (mostly at significant taxpayer expense) until they are well enough to be released – in many cases only to return in the same or worse conditions in the future.

Emerging Solutions

Hansen and his team have created a “software and care” solution that has shown significant promise in Minnesota markets and is now being introduced in Kentucky (in the geographic center of the Opioid Crisis).

The company’s proprietary software platform enables users to quickly assess potential SUD patients and connect them virtually to local networks of company-employed or vetted third-party psychiatric, housing, food, transportation, and vocational resources. The platform also enables patients to communicate securely with these resources.

The software platform is, in many cases, used by YourPath’s trained “Peer Recovery Specialists” who are embedded in ED care teams and other settings that tend to attract large numbers of substance-impaired individuals to take the SUD hand-offs after the primary reasons for the visits have been addressed.

In other cases, the company provides implementation support to their health system or state agency clients / licensees, including the identification and training of recovery and support specialists and partners.

YourPath’s programs are showing ROIs as high as 11:1 from improved access to evidence-based care (including medications for opioid and other substance use disorders, psychiatry, and psychosocial supports), reduced boarding in ED and inpatient medical/surgical settings, and improved connectivity to longitudinal services.

Patients in the company’s ED program are 29 times more likely to engage in treatment, their open rates for text messages sent through the platform average 87 percent, and 91 average Net Promoter Scores indicate high levels of patient satisfaction.

It is way too soon to declare victory over the enormous and seemingly intractable SUD problem (including the massive supply side issues), but these and other early results from YourPath’s programs are encouraging.

Laura Schrag, MD, Medical Director of Emergency Medicine at HennepinHealthcare in Minneapolis, puts it this way:

YourPath is helping us address one of the most dangerous and stubborn gaps in Emergency Department services for people with issues related to substance use. This program has the potential to be a national model for health systems around the country.

After many years in which it has seemed as if the SUD challenge was only growing in magnitude and complexity, the efforts of YourPath and other innovative, SUD-focused companies are finally providing hope for the millions of SUD patients and their families and communities.

In addition, there is some early evidence that GLP-1 drugs that have proven effective in diabetes control and weight loss may one day help to treat SUDs. More to come on this and other promising advances in SUD treatment, but the research is ongoing, and the tide may finally be starting to turn.

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