The constant high levels of dopamine may cause the brain to downregulate dopamine receptors and decrease its usual release. Individuals no longer feel reward from behaviors that once brought gratification because those behaviors do not release a large amount of dopamine. 175,176 Although dopamine is a key player, it has also been suggested that glutamate, GABA, serotonin, norepinephrine, and acetylcholine are involved. Further study is needed in this area, both in biology and psychology, to find the sources of addiction. 175,176 Beyond the brain’s neurobiological mechanisms, researchers suggest a variety of risk factors may contribute to developing addiction, although they are not well understood. Genetic predisposition is one proposed risk factor for addiction or substance use disorder. Certain structural alterations in the brain, such as impairments in the reward circuitry, may increase an individual’s vulnerability for addiction. Additional causes may include stress, impulsivity, mood disorders such as depression and anxiety, and other comorbid psychological issues. Another factor is environmental influences. Individuals may be trying to offset trauma or abuse, they may be surrounded by substance use by family or friends, or they may have easy access to these substances. Age can be an important factor, with a majority of those with addiction having started drug use at an early age. Additionally, some research suggests that using one addictive substance can “prime” the brain and make it more prone to becoming addicted to another substance. Having one or more of these risk factors does not mean someone will become addicted, but it does increase the odds. The more risk factors present, the greater the chance an individual will develop the disease. 177 Substance Use Disorder The many types of addiction defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and referred to as “substance use disorders”. Prolonged, repeated use of illicit or nonprescribed substances, such as opioids, at high doses or high frequencies can lead to substance use disorder (SUD). The Diagnostic and Statistical Manual (DSM-5) uses a list of 11 equally weighted symptoms when diagnosing substance use disorders. Patients who display fewer than two symptoms on the list are not considered to have a substance use disorder; those with two or three symptoms are considered to have mild substance use disorder; those with four or five symptoms are considered to have moderate substance use disorder; and those with six or more symptoms are considered to have severe substance use disorder, commonly referred to as addiction. 173 The following symptoms are used in the diagnosis of substance use disorder: 173 • Wanting to cut down or stop using a substance but not being able to. • Using a substance for longer than intended or in larger amounts. • Spending a lot of time getting, using, or recovering from use of a substance.
• Cravings to use a substance. • Not managing commitments because of substance use. • Continuing to use even when it causes relationship problems. • Giving up important activities because of substance use. • Continuing to use substances even when they put the patient in danger. • Continuing to use substances even when the patient knows that he has a physical or psychological problem that may be worsened with use. • Developing tolerance. • Withdrawal symptoms develop when not using a substance. According to a 2020 report from the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 40 million Americans had a substance use disorder in the past year. However, only an estimated 4 million Americans received any substance use treatment in the past year. 178 Substance use disorders are responsible for a number of negative outcomes. Patients with drug use disorders have difficulties performing their major life tasks with both work and family. They are also at a higher risk for suicide, comorbid mental disorders, and infectious diseases such as HIV and hepatitis. Comorbid mental disorders that may occur with drug use disorder include major depressive disorder, generalized anxiety disorder, bipolar I, post-traumatic stress disorder, and other personality disorders. Infectious diseases are also a concern. 179 Opioid Use Disorder Within the last decade, opioid addiction has become a national epidemic, affecting people in all demographics. According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2019, U.S. overdose deaths have quadrupled, and over 70% percent of overdose deaths in 2019 were attributed to opioids. 180 The Substance Abuse and Mental Health Services Administration (SAMHSA) reported in 2020 that approximately 9.5 million Americans misused opioids in 2020, and 2.7 million people had a diagnosis of opioid use disorder within the past year. 178 An estimated 70,000 Americans died from opioid overdose in 2019. The CDC reports that death rates involving synthetic opioids has increased by over 15% from 2018 to 2019, and prescription opioid death rates have decreased by approximately 7%, reflecting a change in availability and choice of opioids among users. 180 Risk Factors Recognizing risk factors for opioid use disorders can help providers, friends and family identify and prevent potential disease development. Risk factors for behaviors that can indicate an opioid use disorder may include: 181 • Young age. • Poor social support systems. • Smoking.
• Personal or family history of substance abuse. • History of substance abuse treatment. • Psychological stress, trauma, or disease. • Use of psychotropic substances. • Sexual abuse in pre-adolescent years. • Pain with an unclear etiology or that is exaggerated. • Pain that results in nonfunctional status. • Stress from uncontrolled pain. • History of legal issues. • Focusing on opioids or other prescription drugs. • Childhood adversity. • Mood swings. • Thrill-seeking behaviors. • Social environments that encourage illicit substance use. Assessment for Opioid Use Disorder When evaluating a patient for opioid use disorder, a complete history of substance use should be taken in order to evaluate the severity of the patient’s condition. The history should address what substances the patient uses, how frequently they are consumed, the amount consumed, age of first use, problematic consequences associated with use, and treatment history, if any. This can help providers determine the potential severity of withdrawal symptoms and correctly diagnose the severity of opioid use disorder. 182 Collecting information and assessing patients with a suspected substance use disorder can often be an emotional, confrontational, or stressful experience. Providers must make an effort to minimize emotional responses and prevent escalation in order to provide compassionate care. A non-judgmental, culturally sensitive environment should be utilized to encourage candid conversation between the patient and their provider. Providers are also encouraged to collaborate with other clinicians who specialize in the treatment of substance use disorder, behavioral health, care management, and psychosocial support in order to provide the best possible care to their patients. 183 A physical examination should also be conducted in order to determine if the patient is experiencing common complications of opioid use disorder. If the patient utilizes an intravenous route of administration, callouses or scars caused by repeated injections known as track marks can be found along the course of subcutaneous veins. Examination of nasal tissue can uncover signs of intranasal insufflation of opioids such as septum perforation. Infectious signs such as lymphadenopathy, cellulitis, abscesses, and new heart murmur may also be observed. Patients who are acutely intoxicated with opioids may present with drowsiness, pinpoint pupils, slurred speech, respiratory depression, or impaired cognition. Urine drug screens can be utilized to determine the current presence of opioids or their metabolites. Opioid use disorder is diagnosed based on the criteria for substance use disorder, discussed earlier in this course. 182,184
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