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

  1. Identify the prevalence of use for alcohol, opioids, central nervous system (CNS) stimulants, cannabinoids, and tobacco in the US population.

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

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

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

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

  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 (SUDs) are highly prevalent worldwide. In the United States, patterns of substance use and abuse have been cyclical. For example, cocaine was first isolated from coca leaves in 1860. Its use was advocated by many in the medical establishment until 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 prescribing and dispensing restrictions in the early 20th century. In the 1980s, a smokeable formulation (ie, crack) became available, and cocaine use again became epidemic. This historically cyclic nature of substance abuse is common to many substances of abuse.

image 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, and tobacco. This chapter focuses on pharmacotherapy for these common substance-related disorders. Although other substances are misused (eg, prescription sedatives and tranquilizers), they are not the focus of this chapter.


The National Survey on Drug Use and Health (NSDUH) uses a representative sample of individuals 12 years or older to determine the annual prevalence of licit and illicit substance use.1 In 2015, more than half (51.7%; 138.3 million) of Americans reported current (ie, past month) alcohol use. In the 30 days prior to the survey, nearly 1 in 4 Americans (24.9%; 66.7 million) reported binge drinking (ie, 5 or more drinks for men and 4 or more drinks for women), and 6.5% (17.3 million) reported heavy drinking (ie, binge drinking on 5 or more occasions). Approximately one-quarter (23.9%; 64.0 million) of Americans were current users of tobacco. Past month cigarette use declined in 2015; however, this may be due in part to electronic cigarettes. Regarding illicit drug use, 1 in 10 Americans (10.1%; 27.1 million) reported current use, with marijuana and prescription pain relievers being most common (Figure 36–1). Americans reporting current CNS stimulant use varied by substance (ie, 0.7% ...

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