Substance-Related Disorders: Textbook of Psychiatry

The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRY
Fifth Edition
Edited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.
© 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 9
Substance-Related Disorders
Martin H. Leamon, M.D., Tara M. Wright, M.D.,
Hugh Myrick, M.D.
Slide show includes…

Topic Headings
Tables and Figures
Key Points
The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, 1
Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 9 • Topic Headings
CLASSIFICATION SYSTEMS OPIOIDS CLUB DRUGS
NEUROBIOLOGY Epidemiology Epidemiology
Intoxication Intoxication
APPROACH TO THE PATIENT Withdrawal Withdrawal
TREATMENT: GENERAL PRINCIPLES Treatment Treatment and Medical Complications
Intoxication and Withdrawal Medical Complications
Substance Use Disorders INHALANTS
NICOTINE Epidemiology
Psychotherapies
Epidemiology Intoxication and Withdrawal
Outcomes
Intoxication and Abuse Treatment and Medical Complications
ALCOHOL Diagnosis
Epidemiology Treatment and Withdrawal ANABOLIC–ANDROGENIC STEROIDS
Intoxication Medical Complications Epidemiology
Withdrawal Intoxication
Diagnosis SEDATIVE-HYPNOTICS Withdrawal
Treatment Epidemiology Treatment
Acute Withdrawal Intoxication Medical Complications
Relapse Prevention Withdrawal
Treatment CO-OCCURRING SUBSTANCE USE
Medical Complications DISORDERS AND OTHER
CANNABIS HALLUCINOGENS PSYCHIATRIC DISORDERS
Epidemiology Epidemiology Diagnostic Considerations
Intoxication and Withdrawal Intoxication Treatment Considerations
Diagnosis and Treatment Withdrawal Psychosocial Treatments
Medical Complications Treatment Pharmacological Treatments
Medical Complications
STIMULANTS GENDER CONSIDERATIONS
Epidemiology PHENCYCLIDINE AND KETAMINE
Intoxication Epidemiology CONSIDERATIONS IN ADOLESCENTS
Withdrawal Intoxication CONSIDERATIONS IN OLDER ADULTS
Treatment Withdrawal
CULTURAL/ETHNIC CONSIDERATIONS
Medical Complications Treatment
Medical Complications
CHAPTER 9 • Tables and Figures
Table 9–1. DSM-IV-TR classification of substance-related disorders
Table 9–2. DSM-IV-TR diagnostic criteria for substance intoxication
Table 9–3. DSM-IV-TR diagnostic criteria for substance withdrawal
Table 9–4. DSM-IV-TR diagnostic criteria for substance abuse
Table 9–5. DSM-IV-TR diagnostic criteria for substance dependence
Table 9–6. DSM-IV-TR diagnoses associated with class of substances
Table 9–7. ICD-10 classification of substance use disorders
Table 9–8. Maximum alcohol consumption for low-risk drinking
Figure 9–1. Neural circuitry implicated in the process of addiction.
Table 9–9. Percentage of past-year substance users with abuse or dependence, by substance: 2004
Table 9–10. The CAGE questions, adapted to include drugs
Table 9–11. Basic components of substance use disorder evaluation
Table 9–12. Stages of change
Table 9–13. American Society of Addiction Medicine Patient Placement Criteria levels and dimensions
Table 9–14. The Twelve Steps
Table 9–15. Twelve-Step group Web sites
Table 9–16. Empirically based psychosocial interventions
Table 9–17. Blood alcohol level and corresponding symptoms of intoxication in the nontolerant patient
Table 9–18. DSM-IV-TR diagnostic criteria for alcohol withdrawal
Table 9–19. Laboratory abnormalities associated with harmful levels of drinking
Figure 9–2. Alcohol Use Disorders Identification Test (AUDIT).
(continued)
CHAPTER 9 • Tables and Figures (continued)
Figure 9–3. Clinical Institute Withdrawal Assessment for Alcohol—Revised (CIWA-Ar).
Table 9–20. Comparison of U.S. Food and Drug Administration–approved medications for the treatment
of alcohol dependence
Table 9–21. Symptoms of cannabis intoxication
Table 9–22. Cannabis withdrawal symptoms
Table 9–23. DSM-IV-TR diagnostic criteria for cocaine or amphetamine intoxication
Table 9–24. DSM-IV-TR diagnostic criteria for cocaine or amphetamine withdrawal
Table 9–25. DSM-IV-TR diagnostic criteria for opioid intoxication
Table 9–26. Management of acute opioid overdose
Table 9–27. Signs and symptoms of opioid withdrawal
Table 9–28. Opioid detoxification medication protocols
Table 9–29. DSM-IV-TR diagnostic criteria for nicotine withdrawal
Table 9–30. Smoking cessation information Web sites
Table 9–31. Principles of treatment for nicotine dependence
Figure 9–4. Fagerström Test for Nicotine Dependence.
Table 9–32. First-line pharmacotherapies approved for use for smoking cessation by the U.S. Food and
Drug Administration
Table 9–33. DSM-IV-TR diagnostic criteria for sedative-hypnotic withdrawal
Table 9–34. Sedative-hypnotics and their phenobarbital withdrawal equivalents
Table 9–35. DSM-IV-TR diagnostic criteria for polysubstance dependence
Table 9–36. CRAFFT questionnaire to identify problem drinking in adolescents
Summary Key Points
DSM-IV-TR defines a substance as “a drug of abuse, a medication, or a toxin” (American Psychiatric
Association 2000) and classifies disorders attributable to substance use according to the schema in
Table 9–1. Eleven classes of substances that include the commonly recognized abusable drugs are
described, and other medications or toxins that could cause disorders are grouped into the class of
other or unknown.
TABLE 9–1. DSM-IV-TR classification of substance-related disorders
Included in the DSM-IV-TR classification of substance-related disorders are the substance-induced
disorders of intoxication and withdrawal (Tables 9–2 and 9–3) and the substance use disorders of
abuse and dependence (Tables 9–4 and 9–5).
TABLE 9–2. DSM-IV-TR diagnostic criteria for substance intoxication
TABLE 9–3. DSM-IV-TR diagnostic criteria for substance withdrawal
TABLE 9–4. DSM-IV-TR diagnostic criteria for substance abuse
TABLE 9–5. DSM-IV-TR diagnostic criteria for substance dependence
Other substance-induced disorders are classified with their phenomenologically similar disorders; for
example, substance-induced mood disorder is included in the DSM-IV-TR mood disorders section. Not all
types of disorders are recognized for all classes of substances (Table 9–6).
TABLE 9–6. DSM-IV-TR diagnoses associated with class of substances
Source. Adapted from American Psychiatric Association 2000, p. 193.
The World Health Organization’s (2006) International Statistical Classification of Diseases and
Related Health Problems, 10th Revision (ICD-10) is similar to DSM-IV-TR in its recognition of
intoxication, withdrawal, and dependence syndromes. Instead of the disorder of substance abuse,
however, ICD-10 includes the disorder of harmful use, which has somewhat broader diagnostic
criteria (Table 9–7).
TABLE 9–7. ICD-10

classification of
substance use disorders
Another classification system, used only for alcohol, is that of high-risk and low-risk drinking (Table
9–8) (National Institute on Alcohol Abuse and Alcoholism 2005). Unlike the DSM-IV-TR system,
which focuses on the behavioral consequences of dysfunctional use, the high-/low-risk system
focuses exclusively on volumetric and frequency criteria, based on the association of these
parameters with risks of general medical sequelae to alcohol use (Rehm et al. 2003).
TABLE 9–8. Maximum alcohol

consumption for low-risk
drinking
Source. Adapted from National Institute on Alcohol Abuse

and Alcoholism 2005. Public domain.
A number of different neuronal
circuits and neurotransmitters
have been implicated in the
process of addiction. In addition to
dopamine, the neurotransmitters
glutamate, -aminobutyric acid
(GABA), and opioid neuropeptides
are important in this circuitry
(Figure 9–1).
FIGURE 9–1. Neural

circuitry implicated in
the process of
addiction.
GABA = -aminobutyric acid.
Source. Reprinted from Kalivas PW, Volkow ND:

“The Neural Basis of Addiction: A Pathology of
Motivation and Choice.” American Journal of
Psychiatry 162:1403–1413, 2005. Used with
permission.
There is ample epidemiological and experimental evidence that susceptibility to addiction is
influenced by genetics and that the genetic contribution is determined by multiple genes and is
modulated by environmental influences. One of the environmental factors does seem to be the type of
drug used. The 2004 National Survey on Drug Use and Health revealed large differences between
substances in the percentage of past-year users meeting criteria for abuse or dependence (Table 9–9).
TABLE 9–9.
Percentage of
past-year
substance users
with abuse or
dependence, by
substance: 2004
Source. Substance Abuse and

Mental Health Services
Administration 2005.
Because patients with a substance use disorder may present in a number of different ways, all patients
should be routinely and consistently screened for substance use disorders. One useful screening
instrument is the CAGE-D (Table 9–10).
TABLE 9–10. The CAGE

questions, adapted to
include drugs
Source. Reprinted from Brown RL, Rounds LA:

“Conjoint Screening Questionnaires for Alcohol
and Drug Abuse.” Wisconsin Medical Journal
94:135–140, 1995. Used with permission.
There is a large societal stigma
against people with substance use
disorders, and patients may be quite
averse to acknowledging substance-
related problems. Questions must be
asked with nonjudgmental empathy
and caring professional interest.
Confrontational challenging is not
always useful and may disrupt
therapeutic rapport. The basic areas
of inquiry are listed in Table 9–11.
TABLE 9–11. Basic

components of substance use
disorder evaluation
Source. Adapted from Workgroup on Substance Use

Disorders 2006. Used with permission.
The Stages of Change model (Prochaska and DiClemente 1992) is useful for conceptualizing a patient’s
motivation to address substance use problems. The model, derived from research on tobacco
cessation, divides the recovery process into sequential stages, with stage-specific goals to achieve
before progression (Table 9–12). The practitioner matches interventions to the patient’s stage to
enhance commitment to change and to increase the probability of successful change in substance use.
TABLE 9–12. Stages of change
Source. Prochaska and DiClemente 1992.
A motivated patient ideally should be
enrolled in a treatment program of an
intensity commensurate with his or her
level of problems. The Patient Placement
Criteria algorithm developed by the
American Society of Addiction Medicine
assigns a patient within five levels of care
(with sublevels) based on six dimensions
(Table 9–13). Patients matched to treatment
placements based on this algorithm have
been shown to have better outcomes than
mismatched patients, and although further
research continues, it already has been
widely implemented (Magura et al. 2003).
TABLE 9–13. American Society of

Addiction Medicine Patient Placement
Criteria levels and dimensions
Source. Mee-Lee et al. 2001.
The most prevalent and widely used psychosocial interventions for substance disorders are the mutual
self-help groups based on the 12 Steps of Alcoholics Anonymous (AA) (Table 9–14). In studies of
alcohol dependence, more frequent AA attendance has been associated with better outcomes. For
individuals who find the 12 Steps’ emphasis on spirituality unacceptable, lay alternatives do exist, but
there is much less research supporting their effectiveness.
TABLE 9–14. The Twelve

Steps
Source. The Twelve Steps are reprinted with permission

of Alcoholics Anonymous World Services, Inc. (AAWS).
Permission to reprint the Twelve Steps does not mean
that AAWS has reviewed or approved the contents of this
publication, or that AAWS necessarily agrees with the
views expressed herein. AA is a program of recovery from
alcoholism only—use of the Twelve Steps in connection
with programs and activities which are patterned after AA,
but which address other problems, or in any other non-AA
context, does not imply otherwise.
(continued)
TABLE 9–14. (continued)
Table 9–15 lists Web sites for other substance abuse self-help groups modeled on AA.
TABLE 9–15. Twelve-Step group Web sites
A number of professional psychosocial interventions and psychotherapies have been shown in large
studies to be effective for substance use disorder treatment (Table 9–16). Although effectiveness in
general has been shown, much work remains to be done in being able to determine exactly which type
of psychotherapy is best for which individual patient.
TABLE 9–16.
Empirically based
psychosocial
interventions
(continued)
The degree of clinical impairment from alcohol intoxication is dependent on the individual’s tolerance,
the amount and type of alcoholic beverage ingested, and the amount absorbed. Table 9–17 lists blood
alcohol levels and typical corresponding clinical features of intoxication in an individual who has not
developed any tolerance.
TABLE 9–17. Blood alcohol level and corresponding symptoms of intoxication in the
nontolerant patient
Source. Adapted from Mack et al. 2003.
Alcohol withdrawal typically begins
6–8 hours after the last drink, peaks
24–28 hours after the last drink, and
generally resolves within 7 days
(Myrick and Anton 2004). The spectrum
of alcohol withdrawal symptoms is
wide, and the more common
presentations are outlined in Table
9–18. Only about 5% of individuals with
alcohol dependence will develop more
than mild to moderate withdrawal
symptoms.
TABLE 9–18. DSM-IV-TR

diagnostic criteria for alcohol
withdrawal
Laboratory data and biological markers can be clues to an alcohol use disorder in a patient. Table 9–19
lists possible laboratory abnormalities in the setting of alcohol abuse or dependence.
TABLE 9–19. Laboratory

abnormalities associated with
harmful levels of drinking
Several questionnaires are available for
the detection of drinking-related
problems. A positive response to any of
the questions on the CAGE (see Table
9–10) should lead the clinician to
investigate problem drinking with the
patient further. The Alcohol Use
Disorders Identification Test is another
10-item questionnaire used for the
screening of alcohol use disorders
(Figure 9–2).
FIGURE 9–2. Alcohol Use

Disorders Identification
Test (AUDIT).
Source. Reprinted from Babor TF, Higgins-Biddle JC,

Saunders J, et al.: AUDIT, the Alcohol Use Disorders
Identification Test, 2nd Edition. Geneva, Switzerland, World
Health Organization, 2001. Available at:
http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf
Accessed July 30, 2006. May be reproduced without
permission for noncommercial purposes.
(continued)
FIGURE 9–2. (continued)
Source. Reprinted from Babor TF,

Higgins-Biddle JC, Saunders J, et al.:
AUDIT, the Alcohol Use Disorders
Identification Test, 2nd Edition.
Geneva, Switzerland, World Health
Organization, 2001. Available at:
http://whqlibdoc.who.int/hq/2001/WH
O_MSD_MSB_01.6a.pdf Accessed
July 30, 2006. May be reproduced
without permission for noncommercial
purposes.
The Clinical Institute Withdrawal Assessment
Scale for Alcohol—Revised is a short test
rating the severity of alcohol withdrawal as
observed by a health care professional
(Figure 9–3). This 10-item assessment tool
can be used to quantify the severity of alcohol
withdrawal syndrome and to monitor and
medicate patients going through withdrawal.
FIGURE 9–3. Clinical Institute

Withdrawal Assessment for
Alcohol—Revised (CIWA-Ar).
CNS = central nervous system.
Source. Adapted from Sullivan et al. 1989.
(continued)
FIGURE 9–3. (continued)
Source. Adapted from Sullivan et al. 1989.
As of July 2007, only four medications had U.S. Food and Drug Administration (FDA) approval for use
in the maintenance treatment of alcohol dependence: disulfiram, naltrexone, a long-acting
intramuscular formulation of naltrexone, and acamprosate. Table 9–20 offers a comparison of these
medications.
TABLE 9–20.
Comparison
of U.S. Food
and Drug
Administration–
approved
medications for
the treatment of
alcohol
dependence
Cannabis intoxication (Table 9–21) has been associated with increased risk of automobile accidents.
No specific treatment is generally indicated.
TABLE 9–21. Symptoms of cannabis intoxication
A cannabis withdrawal syndrome has recently been described (Table 9–22). It begins 2–3 days after
cessation of use and is generally mild, but the duration has been variable in studies, from 12 to 115
days. No specific treatment is generally needed.
TABLE 9–22. Cannabis

withdrawal symptoms
Source. Center for Substance Abuse Treatment

2006 and Copersino et al. 2006.
Cocaine and amphetamine intoxication have similar
symptoms (Table 9–23). The differences in clinical
presentation are due to the respective half-lives of
the drugs, which are approximately 40–60 minutes
for cocaine and 6–12 hours for methamphetamine.
TABLE 9–23. DSM-IV-TR diagnostic criteria

for cocaine or amphetamine intoxication
As with intoxication, the symptoms of cocaine and amphetamine withdrawal are similar, distinguished
primarily by time course (Table 9–24).

diagnostic criteria for cocaine
or amphetamine withdrawal
The pleasurable sensation derived from the ingestion of an opioid drug is referred to as a “rush.” The
onset, duration, and intensity of the rush are dependent on the particular drug that is used, how much is
used, and the route of administration (oral ingestion, inhalation, intravenous injection). The characteristic
symptoms of opioid intoxication are listed in Table 9–25.

diagnostic criteria for
opioid intoxication
Overdose involving opioid drugs is a life-threatening situation. Table 9–26 reviews the steps necessary
in the management of an opioid overdose (Zimmerman 2003).
TABLE 9–26. Management

of acute opioid overdose
Table 9–27 outlines the most common signs and symptoms of opioid withdrawal. With any opioid, after
acute withdrawal symptoms have subsided, a protracted abstinence syndrome, including disturbances
of mood and sleep, can persist for 6–8 months.
TABLE 9–27. Signs

and symptoms of
opioid withdrawal
Source. Adapted from Collins and Kleber 2004.
Management of acute opioid withdrawal involves a combination of general supportive measures
in conjunction with pharmacotherapy (Table 9–28).
TABLE 9–28. Opioid

detoxification medication
protocols
(continued)
Given that tobacco use is legal and its acute use causes minimal behavioral disruption, treatment of
nicotine dependence focuses on managing withdrawal and cravings (Table 9–29) and developing other
behaviors that promote abstinence and prevent relapse.

nicotine withdrawal
Evidence-based clinical practice
guidelines for nicotine dependence are
readily available (e.g., Fiore et al. 2000),
as are self-help Web sites and phone
lines (Table 9–30).
TABLE 9–30. Smoking cessation

information Web sites
Treatment principles for nicotine dependence are
listed in Table 9–31. The issue of concurrent
treatment of nicotine and other substance use
disorders continues to be debated (Ziedonis et al.
2006). In two recent review articles, one group
recommended concurrent and the other sequential
treatments (Kalman et al. 2005; Metz et al. 2005).
TABLE 9–31. Principles of treatment for

nicotine dependence
Source. Adapted from U.S. Department of Health and Human Services

Public Health Service 2000. Public domain.
Although the diagnosis of nicotine dependence is made according to DSM-IV-TR criteria, other rating
scales may be useful in treating the disorder. The number of cigarettes smoked per day correlates
negatively with ease in quitting and, in many studies, with response to formal treatment. The Fagerström
Test for Nicotine Dependence (Figure 9–4) similarly predicts difficulty in quitting.
FIGURE 9–4. Fagerström Test for Nicotine Dependence.
Source. Adapted from Heatherton et al. 1991. (continued)
FIGURE 9–4. (continued).
Source. Adapted from Heatherton et al. 1991.
Pharmacotherapies
used to treat nicotine
dependence are listed
in Table 9–32.
TABLE 9–32. First-line

pharmacotherapies
approved for use for
smoking cessation
by the U.S. Food and
Drug Administration*
Source. Adapted from Agency for

Healthcare Research and Quality 2001.
Abrupt discontinuation of sedative-
hypnotics in individuals who are
physically dependent on them can lead
to significant withdrawal symptoms, the
most serious being death. Table 9–33
identifies the most common signs and
symptoms seen in sedative-hypnotic
withdrawal.

sedative-hypnotic withdrawal
The phenobarbital substitution option has the broadest use for sedative-hypnotic withdrawal and can be
used for barbiturate, benzodiazepine, or combined alcohol/sedative-hypnotic withdrawals. Phenobarbital
is long-acting, has little variation in blood levels between doses, and has both a low abuse potential and a
high therapeutic index. The patient’s average daily sedative-hypnotic dosage is calculated (Table 9–34)
and then divided into three doses spread out over the day.
TABLE 9–34.
Sedative-
hypnotics
and their
phenobarbital
withdrawal
equivalents
Source. Adapted from

Smith and Wesson 2004.
(continued)
Polysubstance dependence (Table 9–35) may be less common and may be associated with poorer
outcome and greater impairment than dependence on a single substance (Medina et al. 2006;
Schuckit et al. 2001). All substances must be addressed during treatment for dependence, and the
patient may have different levels of motivation for recovery from different substances.
TABLE 9–35. DSM-IV-TR diagnostic criteria for polysubstance dependence
CRAFFT (Table 9–36) is a useful mnemonic-based questionnaire to screen for possible substance
disorders in adolescents (Knight et al. 2002). An answer of “yes” to two or more questions is indicative
of harmful substance use.
TABLE 9–36. CRAFFT questionnaire to identify problem drinking in adolescents
Source. Reprinted from Knight JR, Sherritt L, Shrier LA, et al: “Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients.” Archives of
Pediatrics and Adolescent Medicine 156:607–614, 2002. Used with permission.
CHAPTER 9 • Key Points
 Worldwide drug and alcohol use disorders, excluding tobacco, are the sixth
leading cause of disease burden in adults, whereas tobacco use and
exposure to tobacco smoke are the leading preventable causes of death.
 Looking at lifetime risk, the National Comorbidity Survey, conducted in the
early 1990s, found that around one-third of the subjects who had smoked
cigarettes at least once developed nicotine dependence, 15% of subjects who
had ever drunk alcohol developed alcohol dependence, and about 15% of
subjects who had ever tried other drugs developed drug dependence.
 Physicians should inquire about all classes of substances (e.g., alcohol,
opioids, sedative-hypnotics, stimulants, cannabis, nicotine), including
prescription medications, as well as legal and illegal substances, because
patients may not regard abuse of some substances to be as significant as
that of others.
 Although psychosocial and behavioral approaches are the cornerstones of
treatment for substance dependence, medications are increasingly used to
augment the treatment of alcohol, opioid, and nicotine dependence.
Developing medications for the treatment of stimulant dependence is a
federal research priority.
(continued)
CHAPTER 9 • Key Points (continued)
 There are currently four medications with FDA approval for the maintenance
treatment of alcohol dependence: disulfiram, naltrexone, a long-acting
intramuscular formulation of naltrexone, and acamprosate.
 The use of buprenorphine for detoxification or maintenance treatment in opioid
dependence is increasingly common, in part because buprenorphine can be
prescribed in a physician’s office with up to 1 month’s prescription at a time.
 Although it may take several tries, the overall success rate in helping patients
quit smoking is relatively good. The long-term (e.g., 12 months) quit rates for a
single attempt are less than 10%, whereas the lifetime long-term quit rate is
approximately 50%.
 Polysubstance abuse is common; 56% of patients admitted to publicly funded
treatment programs in 2002 reported abuse of more than one substance, and
more than 70% smoked cigarettes. If undetected, polysubstance abuse can
complicate the treatment of substance intoxication, withdrawal, abuse, or
dependence.
 Substance use disorders and other psychiatric disorders commonly co-occur,
and the relationship is complex and bidirectional.
 The recent increase in the rates of nonmedical use of prescription pain killers
(specifically opioids) in adolescents is notable and of concern.

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TABLE 9–1. DSM-IV-TR classification of substance-related disorders

TABLE 9–2. DSM-IV-TR diagnostic criteria for substance intoxication

TABLE 9–6. DSM-IV-TR diagnoses associated with class of substances

Source. Adapted from American Psychiatric Association 2000, p. 193.

TABLE 9–7. ICD-10

TABLE 9–8. Maximum alcohol

Source. Adapted from National Institute on Alcohol Abuse

FIGURE 9–1. Neural

Source. Reprinted from Kalivas PW, Volkow ND:

Source. Substance Abuse and

TABLE 9–10. The CAGE

Source. Reprinted from Brown RL, Rounds LA:

TABLE 9–11. Basic

Source. Adapted from Workgroup on Substance Use

TABLE 9–12. Stages of change

Source. Prochaska and DiClemente 1992.

TABLE 9–13. American Society of

Source. Mee-Lee et al. 2001.

TABLE 9–14. The Twelve

Source. The Twelve Steps are reprinted with permission

TABLE 9–15. Twelve-Step group Web sites

Source. Adapted from Mack et al. 2003.

TABLE 9–18. DSM-IV-TR

TABLE 9–19. Laboratory

FIGURE 9–2. Alcohol Use

Source. Reprinted from Babor TF, Higgins-Biddle JC,

Source. Reprinted from Babor TF,

FIGURE 9–3. Clinical Institute

CNS = central nervous system.

Source. Adapted from Sullivan et al. 1989.

Source. Adapted from Sullivan et al. 1989.

TABLE 9–21. Symptoms of cannabis intoxication

TABLE 9–22. Cannabis

Source. Center for Substance Abuse Treatment

TABLE 9–23. DSM-IV-TR diagnostic criteria

TABLE 9–24. DSM-IV-TR

TABLE 9–25. DSM-IV-TR

TABLE 9–26. Management

TABLE 9–27. Signs

Source. Adapted from Collins and Kleber 2004.

TABLE 9–28. Opioid

TABLE 9–29. DSM-IV-TR

TABLE 9–30. Smoking cessation

TABLE 9–31. Principles of treatment for

Source. Adapted from U.S. Department of Health and Human Services

FIGURE 9–4. Fagerström Test for Nicotine Dependence.

Source. Adapted from Heatherton et al. 1991. (continued)

Source. Adapted from Heatherton et al. 1991.

TABLE 9–32. First-line

Source. Adapted from Agency for

TABLE 9–33. DSM-IV-TR

Source. Adapted from

TABLE 9–35. DSM-IV-TR diagnostic criteria for polysubstance dependence

TABLE 9–36. CRAFFT questionnaire to identify problem drinking in adolescents

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