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Upon completion of the chapter, the reader will be able to:

  1. Identify the prevalence of use for commonly used substances (ie, alcohol, opioids, central nervous system [CNS] stimulants, cannabinoids, and nicotine) in the US population.

  2. Explain the commonalities of action of abused substances on the reward system in the brain.

  3. Identify the typical signs and symptoms of intoxication and withdrawal associated with the use of alcohol, opioids, CNS stimulants, cannabinoids, and nicotine.

  4. Determine the appropriate treatment measures to produce a desired outcome after episodes of intoxication and withdrawal.

  5. Determine when a patient meets criteria for substance use disorder.

  6. Choose specific pharmacotherapeutic options based on patient-specific factors.

  7. Recommend a comprehensive medication treatment and monitoring program to help maintain recovery and prevent relapse to substance use.




Substance use disorders are highly prevalent worldwide. In the United States (U.S.), historically, tolerance of substance use and abuse has been cyclical. For example, cocaine was first isolated from coca leaves in 1860. Its use was advocated by many in the medical establishment until around the mid-1890s when it became evident chronic use might be addictive in some individuals and could have deleterious physiologic effects. Its use decreased after restriction of prescribing and dispensing in the early 20th century. In the 1980s, a smokeable formulation of cocaine (ie, crack) became available, and cocaine use again became epidemic. This historically cyclic nature of substance abuse is common to many substances of abuse.


KEY CONCEPT Pharmacotherapy has a role in treatment of some substance-related disorders, including intoxication, withdrawal, and/or long-term relapse prevention. These substances include alcohol, opioids, central nervous system (CNS) stimulants, cannabinoids (CB), and nicotine. This chapter focuses on pharmacotherapy for these common substance-related disorders. Although other substances are misused (eg, prescription sedatives and tranquilizers), those are not the focus of this chapter.




The US federal government annually conducts the National Survey on Drug Use and Health (NSDUH) using a representative sample of persons aged 12 years or older to determine the prevalence of licit and illicit drug use.1 In 2012, more than half (52.1%; 135.5 million) of Americans reported being a current (ie, past month) alcohol drinker. At least once in the 30 days prior to the survey, about one-quarter of Americans (23.0%; 59.7 million) reported binge drinking (ie, 5+ drinks), and 6.5% (17.0 million) reported heavy drinking (ie, binge drinking on 5+ occasions). Approximately one-quarter (26.7%; 69.5 million) were current users of tobacco products, with young adults aged 18 to 25 reporting the highest rates of current tobacco product use (38.1%). Regarding illicit drug use, 9.2% of the US population (23.9 million) reported current illicit drug use, with nonmedical psychotherapeutics being second only to marijuana (Figure 36–1). In 2012, there were 2.9 million illicit drug initiates, with marijuana being the first drug used in a majority of cases (65.6%). Notably, ...

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