Table Of ContentAddiction Psychiatric Medicine
Addiction Psychiatric
Medicine
A COMPREHENSIVE BOARD REVIEW
HÉCTOR A. COLÓN-RIVERA, MD, CMRO
General, Addictions and Adolescent Psychiatrist,
Faculty and Attending Physician,
University of Pittsburgh Medical Center,
Psychiatry Department, Pittsburgh, Pennsylvania
Medical Director, APM, Philadelphia, Pennsylvania
ELIE G. AOUN, MD, MRO, FAPA
General, Addictions and Forensic Psychiatrist,
Assistant Professor of Clinical Psychiatry,
Columbia University College of Physicians and Surgeons - Division of Law,
Ethics, and Psychiatry, New York, New York
LEILA M. VAEZAZIZI, MD
Clinical Instructor and Addiction Psychiatrist,
Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York
Faculty, New York University School of Medicine, New York, New York
CONTENTS
1 GENERAL PRINCIPLES OF SUBSTANCE USE 11 ASPECTS OF PAIN ...................................99
DISORDERS ................................................1
12 DRUG TESTING, FORENSIC
2 COMORBIDITIES OF SUBSTANCE USE ADDICTIONS, AND ETHICS ..................103
DISORDERS ..............................................11
13 PSYCHOSOCIAL APPROACHES
3 NEUROBIOLOGY OF ADDICTION .............19 TO SUBSTANCE USE DISORDER
MANAGEMENT .....................................109
4 ALCOHOL USE DISORDER .......................31
14 PRACTICE TESTS ...................................119
5 SEDATIVES AND HYPNOTICS ...................47
REVIEW QUESTIONS ANSWER KEY
6 OPIOID USE DISORDER............................57 (CHAPTERS 1–13)........................................145
7 TOBACCO AND OTHER NICOTINE PRACTICE TESTS ANSWER KEY
PRODUCTS ...............................................67 (CHAPTER 14) .............................................161
8 CANNABIS USE DISORDER .......................73 INDEX .........................................................189
9 STIMULANTS USE DISORDER ...................85
10 DISSOCIATIVE DRUGS, HALLUCINOGENS,
CAFFEINE, INHALANTS, AND OTHER
SUBSTANCES OF ABUSE .........................91
v
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1
GENERAL PRINCIPLES OF
SUBSTANCE USE DISORDERS
DEFINITIONS OF SUBSTANCE USE 8.Continued use despite recurrent social or
DISORDERS AND DIAGNOSTIC interpersonal problems
EVALUATIONS 9.Use resulting in important social,
occupational, or recreational activities given
Although persons with a substance use disorder (SUD)
up or reduced
use drugs or alcohol, using these substances does not
Physiological Dependence
necessarily mean that a given person meets SUD diag-
10.Tolerance
nostic criteria. Indeed, in 2012, the American Psychi-
11.Withdrawal
atric Association’s Diagnostic and Statistical Manual,
5th Edition (DSM-5) set diagnostic phenomenological
Note that for individuals developing tolerance or
parameters for SUD diagnoses. These replace older
withdrawal to a medically prescribed substance, tol-
diagnoses of substance abuse and substance depen-
erance and withdrawal do not count in diagnosing
dence from the DSM’s previous editions.
a SUD.
DSM-5 definition of SUD: A maladaptive substance
SUD severity is assessed by the number of diag-
use pattern leading to significant impairment or dis-
nostic criteria (2–3: mild; 4–5: moderate; 6 or more:
tress. This definition is met when a person meets at
severe), not by the severity of substance use or the
least two of the following 11 diagnostic criteria within
severity of any individual criteria.
a 12-month period:
A SUD diagnosis can be further qualified as:
Loss of Control
1. Substance taken in larger amount or for a ■ Early remission: When a person who previously
longer period than intended met diagnostic criteria for SUD has not met any
2. Persistent desire or unsuccessful efforts to diagnostic criteria (except for craving) for longer
control or stop substance use than three months.
3. Craving or a strong desire or urge to use the ■ Sustained remission: When a person who previ-
substance ously met SUD, diagnostic criteria has not met
4. Use continues despite knowledge of resultant any diagnostic criteria (except for craving) for
physical or psychological problems longer than 12 months.
5. Continued use in situations in which it is ■ On maintenance therapy: When a person who
physically hazardous previously met diagnostic criteria for SUD has
not met any diagnostic criteria (except for tol-
Adverse Consequences
erance or withdrawal) as a result of being pre-
6. Great deal of time spent to obtain, use, or
scribed maintenance medications (referring to
recover from effects
full or partial agonists and antagonist medica-
7. Use resulting in a failure to fulfill major role
tions such as naltrexone, buprenorphine, or
obligations
methadone).
11
2 ADDICTION PSYCHIATRIC MEDICINE: A COMPREHENSIVE BOARD REVIEW
■ In a controlled environment: When a person who tolerance described earlier. Conditioned tol-
previously met diagnostic criteria for SUD is absti- erance refers to the presence of conditioned
nent as a result of no longer having access to the compensatory responses in response to using
substance when in an environment where access a substance in a novel environment, rather
to the substance is restricted (such as correctional than their familiar place of use. Conditioned
detention or residential rehabilitation programs). tolerance can be seen for example when a per-
son with opioid use disorder experiences an
Physiological dependence refers to the state result-
opioid overdose when they use heroin in a new
ing from repeated use of a substance marked by toler-
environment.
ance and/or withdrawal symptoms:
3. Incentive salience refers to yet another phenom-
■ Tolerance to a given substance is a phenom- enon. With incentive salience, specific environ-
enon marked by requiring a higher dose of mental sensory or experiential cues become as-
the substance to achieve the same intoxicating sociated with using a given substance (such as
effect (alternatively, it can be conceptualized as smells, places of use, or persons with whom one
experiencing a reduced effect if the individual uses). This leads to a physical state of expecta-
consumed their usual dose). tion of substance use when encountering these
■ Withdrawal is a syndrome occurring following dis- cues. For example, someone using cocaine at a
continuation or reduction of substance use marked nightclub will experience a strong urge to use co-
by symptoms opposite to the expected effects of caine again every time they go to the nightclub.
that substance. Resuming substance use would 4. Incentive salience is driven by operant condi-
reverse the withdrawal and relieve these symptoms. tioning (conditioning using positive or nega-
tive reinforcement) or classical conditioning
The 4 C’s is another commonly used working descr-
(Pavlovian conditioning).
iption of the components of SUD.
Working Definitions of Addiction:
■ Compulsion SUD SEVERITY AND PATIENT
■ Loss of Control PLACEMENT CRITERIA
■ Consequences
■ Craving The American Society of Addiction Medicine (ASAM)
patient placement criteria (PPC-2R) offer a standard-
Know This: ized approach to connect a person’s SUD severity and
characteristics with the treatment level they require.
1. Rebound symptoms and pseudo-withdrawal
Using the PPC-2R, persons with SUD are assessed for
are two phenomena that are distinct from sub-
their treatment needs in six dimensions (each scored
stance withdrawal. Rebound symptoms refer
0–4 based on the associated complication risks):
to situations in which symptoms preceding
the drug use affected by the use worsen after ■ Dimension 1: Intoxication and withdrawal pote-
discontinuation (e.g., persons with insomnia ntial
using benzodiazepines to sleep might experi- ■ Dimension 2: Biomedical conditions and com-
ence worsening insomnia after benzodiaz- plications
epines discontinuation). Pseudo-withdrawal ■ Dimension 3: Emotional, behavioral, or cogni-
refers to placebo-type symptoms experienced tive complications
when a person using a substance considers or ■ Dimension 4: Readiness to change (trans-theo-
expects the substance’s discontinuation. These retical model of change or stages of change)
symptoms resemble symptoms that would like- ■ Dimension 5: Relapse or continued use potential
ly occur with drug discontinuation. ■ Dimension 6: Recovery environment (including
2. Conditioned (or learned) tolerance refers to a social, legal, vocational, educational, financial,
different phenomenon than the physiological and housing factors)
1 GENERAl PRINCIPlES OF SuBSTANCE uSE DISORDERS 3
Treatment type needs for every dimension are 2. Do not confuse placement matching and mo-
determined and classified by level: dality matching. “Placement matching” refers
to the required intensity of treatment resources
■ Level 0?
as identified in the PPC-2R, whereas “modal-
■ Level 0.5: Early intervention
ity matching” refers to whichever clinical ap-
■ Level I: Outpatient treatment
proach might be optimal in treating a patient’s
■ Level II.1: Intensive outpatient
problems (such as using contingency manage-
■ Level II.5: Partial hospitalization
ment for stimulant use disorders, buprenor-
■ Level III.1: Clinically managed low-intensity res-
phine for opioid use disorder, or dialectical
idential services
behavioral therapy [DBT] for borderline per-
■ Level III.3: Clinically managed medium-inten-
sonality disorder).
sity residential treatment
Child and adolescent levels of care utilization ser-
■ Level III.5: Clinically managed high-intensity
vices (CAlOCuS) is a model similar to PPC-2R that
residential treatment
is specific for identifying necessary levels of care for
■ Level III.7: Medically monitored intensive inpa-
adolescent SuD. Basic services or prevention repre-
tient treatment
sent the least restrictive level of care in the CAlOCuS
■ Level IV: Medically managed intensive inpatient
model (level 0), whereas a secure 24-hour medical
treatment
management program is the most restrictive level
When applicable, subspecifiers are used to denote (level 6).
treatment types further:
■ D: Detoxification
STATISTICS AND EPIDEMIOLOGICAL
■ OMT: Opioid maintenance treatment
■ BIO: Capable of managing complex medical TIDBITS
comorbidity
It is not uncommon for the boards to ask a couple of
■ AOD: Alcohol or drug treatment only
basic statistical questions, most commonly addressing
■ DDC: Dual diagnosis capable (the treatment facility
sensitivity, specificity, positive and negative predictive
can identify co-occurring psychiatric problems and
values, or the types of biases in scientific research.
refer to outside mental health treatment centers)
Test positive Test negative
■ DDE: Dual diagnosis enhanced, capable on-site
Condition True positive False negative
of managing patients with co-occurring psychi-
present (TP) (FN)
atric problems
Condition False positive True negative
The PPC-2R model is presented as a matrix grid in absent (FP) (TN)
which illness dimensions are listed on the Y-axis and
Sensitivity and specificity present the means to assess
treatment types on the X-axis.
how accurate a diagnostic test demonstrates the pres-
For example, a patient with alcohol use disorder
ence or absence of a condition. They address the likeli-
and depression seeking treatment might require initial
hood of a given test outcome for persons who have or do
care in a Level IV-D (inpatient detoxification) followed
not have the condition. A test with high specificity will
by a II.5-DDE (partial hospital program that is dual
help Rule-In the condition (Specificity – IN → SPIN),
diagnosis enhanced)
whereas a high sensitivity test will help Rule-Out the
Know This: condition (Sensitivity – OUT → SNOUT). For example,
gamma-glutamyl transferase is a highly specific but not
1. The role of coercion in treatment or the impact very sensitive biomarker of alcohol use disorder.
of one’s experienced adverse consequences of In contrast, positive predictive value (PPV) and
substance use affects their motivation for treat- negative predictive value (NPV) address the likelihood
ment and is assessed in Dimension 4 (readiness of having a condition for persons who test positive
to change). or negative. As such, a test with high PPV will have a
