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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 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 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 that 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 use is common to many substances with abuse potential.

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 can be misused (eg, benzodiazepines), 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 2018, 164.8 million Americans (60.2% of the population) used a substance, including alcohol, tobacco, or illicit substances in the past month. More than half (51.1%; 139.8 million) of Americans reported current (ie, past month) alcohol use. Nearly one in four Americans (24.5%; 67.1 million) reported binge drinking (ie, five or more drinks for men and four or more drinks for women), and 6.1% (16.6 million) reported heavy drinking (ie, binge drinking on five or more occasions) over the past month. Approximately one-fifth (21.5%; 58.8 million) of Americans reported current tobacco use. During the time frame of 2002 to 2018, cigarette use declined overall; however, this may be due in part to electronic cigarettes. Regarding illicit drug use, one in five Americans (19.4%; 53.2 million) reported past year use, with cannabis and prescription pain relievers being most common (Figure 37–1).1 The NSDUH findings indicate that substance use is wide ...

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