With misuse at low doses, people feel drowsy, disinhibited, and intoxicated; at higher doses, they begin to stagger and develop slurred speech and confusion, possibly resulting in coma and respiratory depression leading to death. 63 Withdrawal symptoms include difficulty sleeping, agitation, tremor, hallucinations, high temperature, and seizures. Hallucinogens: Limited Medical Uses Hallucinogens are synthetically made or plant- based and are marked by sensory and psychic effects that include perceptual distortions. 65 Physiological effects of the class can include elevated heart rate, increased blood pressure, dilated pupils, nausea, and vomiting. Medical research into the use of Schedule I hallucinogens has been increasing. Most are drugs that are used recreationally (e.g., hallucinogenic mushrooms, LSD, and MDMA or “ecstasy”). Few have medical indications with a notable exception being ketamine, a Schedule III drug with accepted medical uses for short-term sedation and anesthesia. 66 Ketamine is a dissociative anesthetic, distorting sight and sound and giving the patient a sense of detachment from pain and the environment. For this reason, it has been researched as a treatment for some types of intractable pain. In addition, the FDA has approved a nasal spray version of the S(+) enantiomer of ketamine (esketamine) for treatment-resistant depression that is only available at a certified doctor’s office or clinic. 66 Ketamine misuse may lead to moderate or low physical dependence or high psychological dependence. Overdose can occur with ketamine and when serious can lead to respiratory depression, coma, convulsions, seizures, and death due to respiratory arrest. 66
Stimulants Schedule II stimulants include amphetamine, methamphetamine, methylphenidate, lisdexamfe- tamine, and dextroamphetamine. 4 Prescriptions have increased significantly, 4 and involvement in overdose deaths is increasing. During 2015–2016, age-adjusted psychostimulant-involved overdose death rates increased by 33.3% as part of what has been called a “growing polysubstance land- scape.” 67 From 2016 to 2017, death rates involving cocaine and psychostimulants increased across age groups, racial/ethnic groups, county urbanization levels, and multiple states. 67 Among all 2017 drug overdose deaths, 10,333 (14.7%) involved psy- chostimulants that include prescription drugs, such as dextroamphetamine and methylphenidate. 67 Opioids frequently contribute to stimulant- involved overdose deaths. 67 However, stimulant deaths are also increasing without opioid involvement. Death rates involving cocaine and psychostimulants, with and without opioids, have increased, and synthetic opioids frequently are involved. 67 Responses should evolve to improve access to care, focus on protective and risk factors for substance use, and improve risk reduction messaging. 67 Harm reduction might also include expanded surveillance measures and naloxone availability. Effects of stimulants as a class include increased alertness, wakefulness, and concentration. 68 Common medical indications include ADHD, obesity, and narcolepsy. Stimulants are associated with adverse effects such as tolerance, risks with withdrawal, and potential for misuse and SUD. 68 With abrupt cessation, withdrawal can be marked by depression, anxiety, and extreme fatigue. 68 Signs of a stimulant overdose include high fever and convulsions, and cardiovascular collapse may precede death. 68 Physical exertion can increase these hazards.
Carisoprodol
Carisoprodol is the only muscle relaxant that is a scheduled drug (Schedule IV). 69 It metabolizes meprobamate with hypnotic, anti-anxiety, sedative, anticonvulsant, and some indirect muscle relaxant properties that can cause drowsiness and dizziness. This medication is not recommended for long-term use or by those with a history of addiction. Because of its limited clinical effectiveness and elevated risks, general use of this medication is best avoided. Recognizing Substance-Use Disorder The American Society of Addiction Medicine (ASAM) refined its definition of addiction in 2019. Its brief description may help HCPs view the condition as the “treatable, chronic medical disease” that it is, one which involves “complex interactions among brain circuits, genetics, the environment, and life experiences.” 176 The ASAM further described how behaviors become compulsive and often continue despite harmful consequences and suggested that prevention and treatment generally succeed on a par seen with other chronic diseases. 70 Clinically, an SUD is diagnosed using DSM-5 criteria; OUD is specified if opioids are the drugs used (Table 5). 71,72 A minimum of 2-3 criteria are required for a mild OUD diagnosis, while 4-5 is moderate, and >6 is severe. Addiction, while not a DSM-5 diagnosis, is a frequently used term and typically describes severe SUD. The presence of tolerance and physical dependence does not contribute to the diagnosis of OUD if opioids are prescribed, and the patient takes the medication as prescribed.
Table 5. Criteria for Opioid-Use Disorder from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: • Opioids are often taken in larger amounts or over a longer period of time than was intended • There is a persistent desire or unsuccessful efforts to cut down or control opioid use • A great deal of time is spent in activities to obtain the opioid, use the opioid, or recover from its effects • Craving, or a strong desire or urge to use opioids • Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home • Continued opioid use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of opioids • Important social, occupational, or recreational activities are given up or reduced because of opioid use • Recurrent opioid use in situations in which it is physically hazardous • Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that’s likely to have been caused or exacerbated by the substance • Tolerance,* as defined by either of the following: a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of an opioid • Withdrawal,* as manifested by either of the following: a. The characteristic opioid withdrawal syndrome b. The same—or a closely related—substance is taken to relieve or avoid withdrawal symptoms *This criterion is not met for individuals taking opioids solely under appropriate medical supervision. Severity: mild = 2–3 symptoms; moderate = 4–5 symptoms; severe = 6 or more symptoms.
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