Section H - Substance use disorders

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Part 1 - Alcohol abuse / harmful alcohol use
Part 2 - Harmful heroin use
Part 3 - Harmful benzodiazepine use
Part 4 - Harmful cannabis use
Part 5 - Harmful stimulant use

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This section will describe the most prevalent substance use disorders. Substance use disorders are those that relate to the taking of a drug (including alcohol) of abuse, including prescribed and over-the-counter medications, as well as illicit drugs.⁷ The substances highlighted in this section include alcohol, cannabis, heroin, benzodiazepines, and stimulants.

It must be noted that psychoactive substance use and abuse are one of the major risk factors contributing to the global burden of disease: in 2000, approximately 4% of the global burden was attributed to alcohol and 0.8% to illicit drugs.¹³⁹ In addition, alcohol and illicit drugs are associated with over 80 recognized disease and injury conditions,¹³⁹ all of which are preventable.

The clinical effects vary depending on the substance used, the duration, and dosage. The most dangerous form of substance abuse occurs when users mix several drugs. The health states described below do not consider the limitations associated with use of combined substances. For each substance, the functional limitations described refer to: abuse (chronic, mild to moderate or severe, or both), overdose, acute withdrawal with treatment, and remission. Coma is often the result of an overdose but the health state descriptions for overdose do not capture the comatose state. Coma will, however, be described in another document in this series: Neurological Disorders. There are also two sequelae specific to chronic alcohol abuse that will not be described in this chapter. Liver cirrhosis is the disease in which the major pathogenic mechanism is the gradual replacement of damaged liver tissue with connective tissue, thus leading to gradual but irreversible liver function decrease. This condition often results from long-term alcohol and other hepatotoxic substance abuse. Hepatic encephalopathy is damage to the brain and nervous system that results from liver disorder complications, and causes changes in reflexes and consciousness. Both of these conditions will be described in the Digestive Disorders document of this series.

The DSM-IV defines substance use disorders in terms of dependence and abuse, and substance-induced disorders in terms of intoxication and withdrawal; other DSM-IV diagnoses for substance use disorders, such as substance-induced delirium or substance-induced mood disorder, will not be described in this section. The criteria for diagnosis of substance dependence, substance abuse, substance intoxication, and substance withdrawal will be described below; note that these criteria are applicable to all classes of substances.

Substance dependence is diagnosed if the individual has a pattern of repeated self-administration of the substance and three or more of the following symptoms, which occur at any time in the same 12-month period: 1) tolerance (need for increased amounts of the substance to achieve the desired effect); 2) withdrawal (a change in behaviour (with physical or mental associations) that results from decreased blood or tissue concentrations of the substance); 3) use of the substance over a longer period than intended or in larger quantities; 4) persistent desire for the drug or unsuccessful efforts to control/cut-down use of the substance; 5) much time spent in activities that are necessary to obtain, use, or recover from the substance; 6) social, occupational or recreational activities are limited or avoided due to substance use; and 7) substance use continued despite knowledge of physical or psychological problems that are likely caused by or exacerbated by the substance.⁷

Substance abuse is different from dependence in that it does not include any symptoms of tolerance/withdrawal or compulsive patterns of use; substance abuse rather includes the harmful consequences of repeated substance use. In particular, an individual is diagnosed with substance abuse if their pattern of substance use leads to clinically significant impairment as shown in at least one of the following: 1) major role obligations have not been fulfilled as a result of the recurrent substance use; 2) substance use is initiated or recurrent in physically hazardous situations (e.g., driving a car); 3) use results in repeated substance-related legal problems (i.e., drug trafficking or driving under the influence); and 4) the substance use is continued despite persistent social or interpersonal problems that are caused or worsened by the effects of the substance. In addition, these manifestations must have occurred repeatedly during a 12-month period and the symptoms have never met the criteria for substance dependence (in that particular class of substances).⁷

Substance intoxication is diagnosed when a reversible substance-specific syndrome develops due to recent ingestion of (or exposure to) a substance. In addition, during or shortly after use, the physiological effects of the substance on the central nervous system cause behavioural and/or psychological changes. The most common changes are impairments in perception, wakefulness, thinking, attention, judgment, psychomotor behaviour, and interpersonal behaviour. Finally, the symptoms of substance intoxication are not due to a general medical condition or are not better accounted for by another mental disorder.⁷

When an individual stops or decreases use of a substance after heavy, prolonged use, the individual may experience substance withdrawal, the development of behaviour changes with physiological and cognitive associations. For a diagnosis, this change causes clinically significant distress or impairment in important areas of functioning, such as social or occupational, and these are not due to a general medical condition or better accounted for by another mental disorder.⁷ Most of the symptoms of withdrawal are simply the opposite as those seen in intoxication using the same substance. Individuals going through withdrawal typically have a craving to re-administer the substance in order to prevent or relieve the withdrawal symptoms.

Remission is defined by the DSM-IV in terms of four stages: an individual is in early full remission if no criteria for abuse or dependence is met for at least one month but less than 12 months, or is in early partial remission if one or more criteria for abuse or dependence is met (but the full criteria have not been met) for at least one month but less than 12 months.⁷ An individual is in sustained full remission if none of the criteria for abuse or dependence has been met at any time during the previous 12 months or longer, or is in sustained partial remission if the full criteria for dependence has not been met in the previous 12 months or more, but one or more criteria has been met for abuse or dependence.⁷ For the purposes of the health states described below, remission is defined as no symptoms present for at least one month.

Part 1 - Alcohol abuse / harmful alcohol use

Alcohol is a central nervous system (CNS) depressant that is produced by fermenting or distilling various fruits, vegetables or grains. The chemical name is ethanol or ethyl alcohol; in its pure form, it is a clear, colourless liquid. The effects of alcohol depend on the amount of pure ethyl alcohol consumed; one serving contains between 10 and 15 g of ethanol.¹⁴⁰ The alcohol enters the bloodstream from the gastrointestinal tract and is broken down by liver enzymes. As the blood-alcohol concentration (BAC) increases (i.e., the amount of alcohol in the bloodstream), the nervous system becomes more depressed; thinking, judgment, and perception are impaired and reaction times are slower.

Moderate use of alcohol (i.e., up to two drinks per day) is generally not considered harmful for most adults. An average drink equals one bottle of beer or wine cooler (12 ounces), one glass of wine (5 oz.), or one 1.5 oz. glass of distilled spirits (i.e., whisky). Binge drinking occurs when an individual consumes a large quantity of alcohol (five or more drinks for men, four or more for women)¹⁴⁰ in one sitting and is greater cause for concern. The first episode of alcohol intoxication is often in the mid-teens, despite the fact that the Canadian legal age to drink and purchase alcohol is 18 or 19 years, depending on the province.

Alcohol is the most popular drug of abuse.¹⁴¹ In 1996, a national U.S. survey found that 70% of men and 60% of women consume alcohol.⁷ About 1.1% of adults in the U.S. drink on a daily basis;¹⁴¹ the 12-month prevalence of alcohol use disorders is between 7-10%.^140,142 The highest prevalence of alcohol abuse is between the ages of 26 and 34 years.⁷ Individuals with alcoholism come from all levels of education and socioeconomic status. Alcohol is accountable for high levels of mortality, morbidity and social problems with more than 60 causes of death attributed to alcohol consumption.¹³⁹ Often the typical course consists of periodic or weekend binges with little to no alcohol consumption during the week. However, over time, episodes of drinking become more frequent. Alcoholism is a progressive disease that is often long-term, relapsing and possibly fatal. The individual with alcoholism will often devote long periods of time to consuming alcohol, despite the psychological and physical consequences.

An individual with alcoholism who is confronted about their drinking problem typically becomes hostile and defensive. The following symptoms strongly suggest alcoholism: craving (the need for daily or episodic use), impaired control (the inability to stop drinking once drinking has begun), physical dependence (withdrawal if stopped abruptly), and tolerance (the need to consume increasing amounts to achieve the same effect). It is likely that a number of factors influence the development of alcoholism. Risk factors include: genetics (individuals with a parent who abuses alcohol are more likely to abuse alcohol themselves; risk increases with the number of family members affected),⁷ nutritional deficiencies, and endocrine imbalances. Psychological factors likely also play a role: depression, desire for relief from anxiety, desire to avoid responsibility, low self-esteem, conflict in family relationships, certain personality traits such as isolation or loneliness, and/or sexual immaturity. Sociocultural factors include the availability of alcoholic beverages (including price), social attitudes that approve frequent consumption and drunkenness, lifestyle, peer pressure, and stress. In addition, individuals who start drinking at an early age (i.e., 14 years or younger) have increased risk for developing alcohol dependence at some point in their lives.¹⁴³

The ingestion of alcohol produces symptoms of intoxication that are characterized by mental and/or physical changes such as mood lability, impaired judgment, poor concentration, and inappropriate sexual or aggressive behaviour.⁷ Slurred speech, unsteady gait, lack of coordination, and impairment in memory and/or attention are also present.⁷ Severe intoxication can lead to amnesia (blackout) of the events that occurred when the drinking took place. Intoxication lowers social inhibitions, produces euphoria, increases confidence, and represses fears in the drinker. Existing emotions can also be magnified: if the individual is angry, they may become hostile or aggressive; if the individual is depressed, they feel more depressed and may be suicidal.

Individuals who abuse alcohol may consume it in dangerous situations, such as before driving a car. Therefore, the individual may encounter legal difficulties as a result (i.e., Driving Under the Influence), or cause car crashes. In fact, alcohol accounts for as many as 55% of fatal car crashes in the U.S.⁷ Almost every organ in the body is affected by alcohol and can develop serious complications that may cause premature death. Up to 15% of individuals who consume alcohol heavily over long periods of time develop liver cirrhosis and pancreatitis.⁷ Anemia is common; poor eating habits can lead to severe nutritional deficiencies. The muscles of the heart may deteriorate over time, potentially leading to heart failure. The immune system becomes weakened causing increasing susceptibility to infections. Heavy drinking over time has also been associated with the development of some cancers (e.g., throat, mouth, liver), high blood pressure, and cardiac and brain damage. Men who chronically abuse alcohol may experience reduced testosterone levels, erectile dysfunction, sterility, enlargement of the breasts and decreased testicular size. Women may experience menstrual irregularities, early menopause, and potential infertility. Alcohol use during pregnancy can lead to spontaneous abortion, or side-effects to the baby including fetal alcohol syndrome (i.e., causing growth retardation), abnormal features of the face and/or head, or potential central nervous system abnormalities (i.e., mental retardation). In general, chronic use of alcohol may reduce an individual's life expectancy by 15 years.¹⁴¹ There is a 15% lifetime risk for suicide among individuals with alcoholism,¹⁴¹ and 25% of all suicides are related to alcoholism.¹⁴⁴

Alcohol withdrawal is characterized by withdrawal symptoms that develop about four to 12 hours after the cessation of prolonged, heavy alcohol intake,⁷ and is often referred to as a "hangover". Symptoms of withdrawal include: headache, autonomic hyperactivity (i.e., sweating), hand tremors/shaking, insomnia, anxiety, anorexia, dry mouth, and nausea or vomiting. The individual may become withdrawn and profoundly depressed. Sleep disturbances can persist for months. Up to 5% of individuals with alcoholism experience severe complications of withdrawal, such as grand mal seizures, delirium or tremors.⁷ The individual will typically ingest more alcohol to avoid or ease the withdrawal symptoms.

Detecting and treating alcoholism is complicated by denial.¹⁴⁴ Treatment includes the drug naltrexone, a medication that disrupts the chemical activity in the brain sites that give pleasure from alcohol, thereby reducing the cravings associated with alcohol. Disulfiram is a medication that blocks the metabolism of alcohol, whereby producing toxic symptoms and causing the individual to vomit and/or suffer a severe headache if they have a drink. It is sufficiently uncomfortable that the individual will not risk ingesting alcohol and is therefore considered a very effective treatment if the individual is compliant. Detoxification under medical supervision can help to control the symptoms of withdrawal; an IV injection(s) of glucose may be necessary to control hypoglycemia. Supportive programs that include detoxification, rehabilitation, and aftercare achieve the best long-term results. Individuals need a strong support system; Alcoholics Anonymous (AA) is a well-known systematic support group that is very common and very effective in combating alcohol abuse. Exercise and proper nutrition are also very important aspects in preventing relapse. Individuals who are in remission must continue to avoid all alcoholic beverages—total abstinence is the only effective treatment. Once in remission, it is highly likely that an individual recovering from alcoholism will lose control after their first drink and severe problems will develop again.⁷

Alcohol abuse (mild to moderate)

ICD-9: 303.9 ICD-10 – Harmful Alcohol Use F10.1

This health state refers to an individual who harmfully uses alcohol on a mild to moderate scale. The individual continues to use alcohol despite the consequences in terms of mental and physical health. Social, occupational and familial relationships are affected. As the individual continues to drink in excess, the risk that they will become a severe abuser of alcohol and experience the functional limitations associated with the health state below (Alcohol abuse – severe) increases.^7,144

Classification (Alcohol abuse - mild to moderate)

Alcohol abuse (severe)

ICD-9: 303.9 ICD-10 – Harmful alcohol use F10.1

Alcoholism is characterized by impaired control over drinking, preoccupation with the drug alcohol, and continuing use of the substance despite adverse consequences in the individual's life.  Continuing misuse of alcohol interferes with an individual's physical and mental health, social and family relationships, and academic and/or occupational responsibilities. Impairments in memory and perception are especially common. Other signs of severe abuse include denial, blackouts, and morning drinking (to avoid withdrawal symptoms). Anxiety and depression are common, particularly among females who abuse alcohol.^7,144 Expressive speech may deteriorate, in particular, as consumption increases. Tremors and decreases in fine motor functions are likely to present.

Classification (Alcohol abuse - severe)

Alcohol overdose

ICD-9: 980.0

Alcohol affects the nervous centers responsible for respiratory and cardiovascular systems control.  An alcohol overdose can lead to depression of these involuntary actions, possibly resulting in death (e.g., due to respiratory arrest).  Warning signs include low pulse rate, decreased respiratory rate, low blood pressure, mental confusion, seizures, vomiting, and general non-responsiveness. Treatment of an alcohol overdose typically requires hospitalization and medical supervision of the individual, administration of I.V. fluids (glucose), and if necessary, a gastric lavage or intubation.^7,144

Classification (Alcohol overdose)

Alcohol treatment (acute withdrawal with treatment)

ICD-9: 291.81, 94.63

The treatment phase for an individual with alcoholism begins with management of withdrawal.  During withdrawal, the individual has many physical complaints including headaches, nausea or vomiting, and in severe cases, hallucinations and delirium. Treatment includes possible hospitalization, medication for the withdrawal symptoms, and social support therapy. Relapses are common; the outcome of treatment over time depends on the motivation and confidence of the patient.^7,144

Classification (Alcohol treatment - acute withdrawal with treatment)

Alcohol remission

ICD-9: 303.03

An individual in remission from alcohol abuse must alter their lifestyle; they must avoid the people and places that they visited while they were abusing alcohol to prevent the desire to drink.  Many also attend weekly support meetings and even take medications to avoid a relapse. Though individuals may achieve stable remission from alcoholism, many of them continually live with the constant urge to drink.^7,144

Classification (Alcohol remission)

Part 2 - Harmful heroin use

Heroin is a semi-synthetic opioid, a class of drugs that are often prescribed as analgesics, anesthetics, antidiarrheal agents, or cough suppressants.⁷ Opiates are derived from the opium poppy and depress the central nervous system while producing mind-altering effects. Some opiates are used to treat severe acute pain, such as Morphine or OxyContin, a natural substance in the opium poppy; however, opiates are not appropriate to treat chronic pain because there is a high potential for addiction. Heroin is made by chemically changing the properties of morphine. It is one of the most commonly misused drugs in the opioid class.⁷ The supply for heroin is only available through illicit markets.

Heroin use and abuse commonly begins in the late teens or early 20s and has a male to female ratio of 3:1.⁷ Prevalence for heroin is around 1% of the general population.^7,145 Increasing age is associated with increased prevalence. Dependence generally begins after age 40 years.⁷ Heroin addiction is found at every income level, age and social standing.

Heroin is typically taken by injection, but it can be smoked or ingested in tablet or liquid form. When it is heated and burned, heroin fumes are released and can be inhaled. It can also be added to cigarettes (tobacco or marijuana). Drug (urine) tests can detect heroin for 12-36 hours after administration.⁷ The effects of heroin use can be felt in seconds if the drug was administered intravenously; if the drug was snorted, inhaled or injected into a muscle under the skin, the effects can be felt in minutes. In general, mental functioning is clouded due to depression of the central nervous system; with large doses, cardiac function and breathing can be slowed so much as to cause coma or even death. The essential feature of heroin intoxication is the presence of significant behaviour or psychological changes that develop during or shortly after heroin use.⁷ Symptoms include: initial euphoria followed by apathy, pupillary constriction, drowsiness (or even coma), slurred speech, memory impairments, inattention to the environment (possibly to the point of ignoring harmful events), dysphoria, psychomotor agitation, impaired judgement, and impaired social or occupational functioning. After the initial effects, users feel drowsy. Symptoms of heroin intoxication typically last for several hours. The severity of these symptoms depends on the dose and tolerance level. At large doses, the individual cannot be aroused. With regular use, tolerance develops and therefore the individual requires more of the drug to achieve the desired effect. Over time, higher doses contribute to physical dependence and addiction.

An individual that is dependent on heroin has a regular pattern of compulsion in taking the drug and typically plans their daily activities around obtaining and using heroin. In addition, the individual has a significant level of tolerance and experiences withdrawal symptoms on abrupt termination of the substance.⁷ The physical dependence of heroin generally increases in intensity with increased dosage and duration of using. Individuals who abuse heroin but who are not dependent on the drug typically do not use as often or do not develop significant withdrawal symptoms.⁷ However, they may encounter legal difficulties due to intoxication or possession, as do individuals with dependence. Psychological dependence involves craving the drug and a compulsion to continue use.

Withdrawal develops after the cessation of heroin use that has been heavy and prolonged.⁷ It is not life threatening but causes severe discomfort. Withdrawal symptoms typically begin within 5-12 hours after the last dose, peak between 36-72 hours and are usually over within 7-10 days. Severity of the symptoms increases with the size of the dose and duration of dependence. Symptoms of withdrawal generally consist of anxiety, restlessness, and aches often located in the back and legs; sensitivity to pain and a desire to obtain heroin (i.e., cravings) tend to accompany acute withdrawal symptoms. Other symptoms include: uneasiness, irritability, diarrhea, anorexia, abdominal cramping, nausea, vomiting, runny nose, watery eyes, sweating, chills and shivering, goose bumps, muscle spasms, pain in the bones and muscles, and yawning. Anxiety and insomnia are very common and may persist for months; emotional depression can last for years.¹⁴⁶ Full recovery may not be complete for six months or longer.

Treatment of heroin addiction varies depending on the individual, but is most effective when the abuse is identified early. Typically individuals are prescribed methadone, a synthetic opiate that relieves the cravings, minimizes withdrawal symptoms, and blocks the effects of heroin (therefore individuals who continue to use will no longer feel the effect and consequently have no incentive to continue using). Methadone programs help with remission as well; methadone is medically safe even if used continuously for more than 10 years.¹⁴⁷ Through a methadone maintenance program, the individual receives a stable, legal supply of methadone which is only supplied and taken orally once per day. Despite the potential for methadone addiction, the individual is able to participate in other aspects of therapy and is slowly weaned from the drug once they are confident that they can live a more normal life.

Medication alone does not stop the addiction. Other treatment options include detoxification programs that aim to minimize the severity of the withdrawal symptoms and other medical complications. Detoxification typically takes about one week, and can be through a special clinic or at home with the help of a doctor and support from family and friends. Detoxification programs, however, are only useful when it leads into long-term treatments (e.g., methadone). The best drug-free treatments appear to be therapeutic community residential programs that last three to six months.¹⁴⁷ Cognitive interventions focus on educating and training the individual to build a new life that is socially productive. Unfortunately, relapse is common in recovering heroin addicts.

Heroin abuse / harmful heroin use

ICD-9: 304.0 ICD-10 – Harmful heroin use F11.1

Heroin is a highly addictive drug in the opioid family that has mind-altering effects on the user. Individuals who use heroin become both physically and psychologically dependent on it. When this dependence occurs, the addict's primary purpose in life becomes seeking out and using the drug. Individuals who use heroin tend to be moody, anxious, and at risk of depression. Those who use regularly over the long-term may experience infectious diseases due to injections with contaminated needles (i.e., HIV/AIDS, Hepatitis B and C, tuberculosis), needle marks, collapsed veins, immunological changes, arthritis, pulmonary disorders, abscesses, infection of the lining and valves of the heart, bacterial infections, and neurological disorders. Malnutrition typically results due to decreases in appetite. Difficulties in sexual functioning are common; women have irregular menstrual cycles and disturbed reproductive function; men often experience erectile dysfunction. Smoking heroin can often lead to pneumonia and other lung conditions. Criminal activity, violence and prostitution are also common among heroin addicts.

Classification (Heroin abuse / harmful heroin use)

Heroin overdose

ICD-9: 965.01, E850.0

Individuals who overdose on heroin can slip into a coma or even die if they do not get immediate medical attention. This health state, however, refers to an individual who has overdosed on heroin but is not in the coma state. Drugs, such as Naloxone, need to be administered in order to reverse the unconsciousness caused by a heroin overdose.¹⁴⁸ Restraints are put in place before administering Naloxone because an addict recovering from unconsciousness is agitated, delirious and combative. Observation for at least 24 hours must also occur to make sure that there is no further respiratory depression. An overdose of heroin is typically unintentional and is a particular risk on the street. Death from overdose is not uncommon.

Classification (Heroin overdose)

Heroin treatment (acute withdrawal with treatment)

ICD-9: 292.0, 94.66

Withdrawal from heroin is very physically uncomfortable but it is not life threatening. Peak intensity usually occurs 36-72 hours after the last administration of heroin, and may last up to two weeks. Some symptoms of withdrawal include: excessive yawning, bouts of chills alternating with bouts of excessive sweating, hot flashes, tremors, increased irritability, insomnia, depression, muscle spasms, and severe aching. Prescription drugs can be administered to help with the short-term symptoms of withdrawal as well as for the long-term cravings experienced by addicts. Therapy is also an important part of treatment as it helps the individual to regain their life after addiction. Most of the initial therapy occurs while the individual is living in a residential unit.

Classification (Heroin treatment - acute withdrawal with treatment)

Heroin remission

ICD-9: 304.03

Recovering heroin addicts may continue to take prescription drugs that help to alleviate their cravings for heroin, such as methadone, which can be taken indefinitely if necessary. However, they still need to make important lifestyle and behaviour changes, such as avoiding people and/or places that are associated with their former drug habit, if they want to stay drug-free. Depression, anxiety and insomnia may still remain from the withdrawal syndrome and can last for many years. Residual physical symptoms and impairments in concentration, memory and thinking may also remain. Opioid cravings typically continue over the long term; about 20-30% of individuals with opioid dependence achieve long-term abstinence.⁷ A person returning to heroin after a period of remission has a high risk of fatal overdose because they lose their tolerance.

Classification (Heroin remission)

Part 3 - Harmful benzodiazepine use

Benzodiazepines are antianxiety substances considered in the Sedative-, Hypnotic-, or Anxiolytic-Related (SHA) Disorder chapter of the DSM-IV. SHAs are a class of substances that include all prescription sleeping medications and virtually all prescription antianxiety medications. In general, these substances are central nervous system depressants. At large doses, they can be lethal, especially when mixed with alcohol.⁷SHAs are available by prescription or through the illegal market.

Benzodiazepines are the most commonly used substance in the class of SHAs, and are among the most routinely prescribed medications (e.g., Valium, Xanax) for treating chronic anxiety. Individuals seek relief from anxiety and tension, with the desired effects consisting of relaxation and calmness. Some individuals may take benzodiazepines to "come down" from cocaine or amphetamines.⁷ Sustained use of benzodiazepines often leads to physical dependence, and sudden stopping of the drug can be life threatening. Individuals using benzodiazepines for more than one month must be weaned off the drug in order to reduce the number and severity of withdrawal symptoms.

Approximately 10% of Canadians report using benzodiazepines at least once per year, and 1 in 10 of these individuals continue using for more than one year.¹⁴⁶ Women are more likely to use benzodiazepines for medical reasons,¹⁴⁶ putting them at higher risk for abuse.

An individual with physiological benzodiazepine dependence has considerable levels of tolerance and withdrawal. A diagnosis of dependence is only made, however, if the individual also shows evidence of other problems, such as intense drug-seeking behaviour and avoiding/reducing activities in order to obtain the drug.⁷ Intoxication from benzodiazepines develops during or shortly after use of the drug and closely resembles alcohol intoxication, causing clinically significant behavioural or mental changes. For example, sexual behaviour may become inappropriate and aggressiveness may be seen; judgment, social, and occupational functioning likely becomes impaired. At least one of the following signs also occurs: slurred speech; incoordination; unsteady gait; nystagmus (uncontrolled eye movements); attention or memory impairment; and/or stupor or coma.⁷ Intense and/or repeated intoxication may cause severe depression, which can lead to suicide attempts and completed suicides.

Benzodiazepine withdrawal occurs after the cessation or reduction in heavy and prolonged benzodiazepine use.⁷ Shortly after (a few hours to a few days after last use), the individual experiences at least two of the following: autonomic hyperactivity (increased heart rate, sweating); hand tremors; insomnia; nausea or vomiting; quick-passing visual, tactile, or auditory hallucinations or illusions (often in the context of delirium, particularly in severe withdrawal); psychomotor agitation; anxiety; and/or grand mal seizures.⁷ These symptoms cause clinically significant impairment in social, occupational or other areas of functioning. And finally, these symptoms cannot be due to a general medical condition and are not better accounted for by another mental disorder. Some individuals can develop a delirium that may potentially be life threatening. Grand mal seizures occur in about 20-30% of individuals who are undergoing withdrawal without treatment.⁷ In general, the longer the individual has been using benzodiazepines, as well as the higher the doses used, the longer the withdrawal will last and the more likely it is that the individual will experience severe withdrawal. Less intense symptoms are likely to persist for several months.

Individuals who are addicted to benzodiazepines must be slowly weaned off the drug or suffer extreme withdrawal symptoms. Individuals undergoing withdrawal should be supervised by experts who can safely switch their medication from short-acting to longer-acting medications, and then slowly reduce these longer-acting medications over periods of months or potentially even years. Counseling and support therapy should also be given.

Harmful benzodiazepine use (mild to moderate)

ICD-9: 304.1 ICD-10 – Harmful use of other psychoactive substances F19.1

This health state refers to an individual who harmfully uses benzodiazepines on a mild to moderate scale; for example, an elderly person who has been prescribed benzodiazepines for 30 days but finishes the pills in 10 days. The individual typically functions well, but may continually negotiate with the treating physician to escalate the dose and prescription. The longer this continues, the more likely it is that the individual become a severe abuser of benzodiazepines⁷ and experiences the functional limitations associated with the health state below (Harmful Benzodiazepine Use – severe).

Classification (Harmful benzodiazepine use - mild to moderate)

Harmful benzodiazepine use (severe)

ICD-9: 304.1 ICD-10 – Harmful use of other psychoactive substances F19.1

Severe abusers of benzodiazepines continue to use the drug after their need for it has passed, and can develop both a physical and a psychological dependence on it. Individuals use benzodiazepines in order to obtain a euphoric effect or to decrease self-awareness. Intoxication resembles drunken-like behaviour, with slurred speech and disorientation. Individuals who are addicted also experience anxiety and aggressive behaviour when they are unable to obtain more benzodiazepines and will often manipulate the health care system so that they can continue to receive their prescriptions. Work or school commitments may be neglected as a result of intoxication; social relationships may be affected due to arguments over use of the substance. Hazardous behaviour (i.e., driving after use) can occur.

Classification (Harmful benzodiazepine use - severe)

Benzodiazepine overdose

ICD-9: 969.4, E853.2

An individual who overdoses on benzodiazepines will eventually enter into a deep sleep that can progress into either a stupor or coma. This health state refers to an individual who is not in the coma state. During an overdose there is significant cardiovascular and respiratory depression. Initial symptoms of an overdose are impaired thinking, disorientation, slurred speech, muscle weakness, and lack of muscle coordination. Toxic psychoses may also occur, including hallucinations and paranoid delusions. Anxiety is mostly absent during an overdose but increases in the days following. Treatment of an overdose of benzodiazepines includes gastric lavage (stomach pumping), possible intubation (if there is respiratory arrest), and possible aspiration (if the contents of the stomach are vomited into the lungs), as well as a prolonged hospital stay. Overdose on benzodiazepines can be accidental or deliberate, but are rare in the absence of alcohol involvement or the involvement of another drug.⁷

Classification (Benzodiazepine overdose)

Benzodiazepine treatment (mild to moderate)

ICD-9: 292.0, 94.66

Treatment for an individual who uses benzodiazepines for a short duration is typically done on an out-patient basis. Mild to moderate supervised treatment by the family physician is often sufficient; hospitalization is rarely necessary. Counseling and support are highly recommended.⁷

Classification (Benzodiazepine treatment - mild to moderate)

Benzodiazepine treatment (severe - acute withdrawal with treatment)

ICD-9: 292.0, 94.66

The withdrawal from severe benzodiazepine use must be managed medically because it can be life threatening. An individual experiencing withdrawal is typically switched to a different, longer-lasting medication and then slowly weaned off of it while undergoing counseling and support. While actually withdrawing from benzodiazepines, individuals are anxious, irritable, and they experience insomnia, hallucinations and panic. Long-term hospitalization is often needed for complete withdrawal and recovery.⁷

Classification (Benzodiazepine treatment - severe-acute withdrawal with treatment)

Benzodiazepine remission

ICD-9: 304.13

An individual in remission from harmful use of benzodiazepines must find ways to relax and reduce anxiety on their own, such as meditation or exercise. They also need to avoid situations and people who may lead them back into abusing the drug.⁷

Classification (Benzodiazepine remission)

Part 4 - Harmful cannabis use

Cannabis is the most commonly used illegal drug.¹⁴⁹ It comes in three forms, each derived from the hemp plant, Cannabis sativa. One form is marijuana, the cut and dried leaves and stems of the plant; the second and third forms, hashish and hashish oil (the concentrate of hashish), both come from the dried resin that seeps out from the leaves. Typically, marijuana and hashish are smoked, but they may be taken orally when mixed with tea or food. The psychoactive effects of cannabis (the "high") come from the cannabinoid delta-9-tetrahydrocannabinol (THC). The amount of THC varies but hashish oil usually contains the most, thereby producing the strongest psychoactive effects, followed by hashish and then marijuana.

Cannabis is relatively inexpensive and rarely difficult to obtain. Cannabis users come from all age groups and all education and income levels. Prevalence of cannabis use disorders is highest among individuals between ages 18 and 30 years, and higher in males than females.7 In a study of Canadian youths, lifetime prevalence rates of marijuana use were 40%.¹⁵⁰ Overall, prevalence of use appears to decline with age.¹⁵¹

Frequently cannabis use begins in adolescence or early adulthood. Often individuals begin using because they are curious or because they want to conform to their friends; difficulty in school or boredom may contribute. Risk factors include peer drug use, parental alcoholism or drug use, low parental monitoring, criminal behaviour, and delinquency.¹⁴⁴ Chronic use can lead to mental and physical dependence. In addition, tolerance develops with repeated use; therefore regular, high-dose smokers often need to increase their daily dose to achieve the desired effects (or must abstain from using for several days in order to restore their original sensitivity). Individuals with cannabis dependence may spend hours everyday acquiring and using cannabis for a period of months or years, potentially despite knowledge of physical or psychological problems. Individuals who use cannabis to relieve stress are at higher risk for psychological dependence.¹⁴⁶

Cannabis intoxication is defined by the DSM-IV as the maladaptive behavioural or psychological changes that occur during or shortly after the use of cannabis, and are accompanied by at least two of the following: conjunctivitis (red eyes), increased appetite, dry mouth, and tachycardia.⁷ If the cannabis is smoked, intoxication is achieved within minutes and usually lasts about two to four hours, depending on the dose; if the cannabis is orally ingested, intoxication takes longer to develop but lasts longer than if smoked. Some users feel happy and talkative while intoxicated; others become quiet and withdrawn. Immediate effects of intoxication include sedation, dilated pupils, coughing, mood elevation, euphoria, talkativeness, bronchodilation, altered time perception and slow reaction time. Lethargy, psychomotor and perceptual impairment, paranoia, impaired judgment and motor coordination are other effects. In general, the larger the dose, the longer these effects may last, but it may also depend on the characteristics of the user (i.e., rate of absorption, tolerance). Short-term memory, concentration and abstract thinking generally improve after a few weeks of abstinence, but impairments may be persistent for several years.

Prolonged use of cannabis has been shown to result in low sperm counts in men and fertility problems in women¹⁴¹ and weaken the immune system. Chronic heavy users appear less motivated and ambitious than others. Cognitive impairments, particularly attention and memory, may persist even after prolonged abstinence. Adjustment problems, reduced communication and social skills, and an inability to focus attention are not uncommon with chronic use. Respiratory diseases may occur with smoking as the drug administration of choice; the lungs can be damaged and lead to persistent coughing, wheezing, asthma, emphysema, increased phlegm, and lung infections. These symptoms and effects are additive to tobacco smoking, putting individuals who smoke cannabis and tobacco at increased risk for lung, neck and head cancers at a younger age; there are even greater amounts of known carcinogens in marijuana smoke than tobacco smoke.⁷ Women who use cannabis during pregnancy are more likely to have premature or low birth weight babies.

There is no specific withdrawal syndrome defined in the DSM-IV, but in persons who chronically use large doses of cannabis, abrupt termination can lead to withdrawal symptoms such as anxiety, irritability, insomnia, loss of appetite and weight loss, dysphoria, nausea and sweating. These symptoms generally subside in less than a week, but some disturbances (i.e., sleep) can last for years. Treatment rarely includes admission to a detoxification centre or professional attention. Support, reassurance by family and friends, and lifestyle changes, such as avoiding the people, places and things that relate to cannabis use, are encouraged. In adolescents, without early intervention, developmental milestones may be disturbed or delayed.

Harmful cannabis use

ICD-9: 304.3 ICD-10 – Harmful cannabis use F12.1

Cannabis is the general term used to describe marijuana, hashish, and hashish oil. The health state described in this section refers to an individual who uses cannabis daily. These individuals experience impaired motor performance, impaired judgement, and difficulty with complex mental processes including short-term memory deficits and decreased attention/concentration span, which can interfere with work or school performance. Drowsiness and sedation generally accompany intoxication; overall lethargy and a lack of motivation and interest in life are not uncommon. Depth perception, and impaired motor coordination, including slow reaction times, cause driving and other skilled activities to be dangerous. Fatigue and anxiety are common once the effects of intoxication have worn off. Teenagers, in particular, who abuse cannabis frequently, tend to lose communication with family, experience mood swings and academic underachievement, and deny use despite obvious signs of intoxication or evidence of drug paraphernalia; they are also at increased risk for dropping out of school. Damage to the lungs can also occur due to long-term use of the drug; short-term memory deficits and concentration typically improve over a few weeks of abstinence.⁷

Classification (Harmful cannabis use)

Cannabis treatment (acute withdrawal with treatment)

ICD-9: 292.0, 94.66

An individual undergoing acute withdrawal of cannabis does not generally seek treatment. Most often, friends and family members of addicted individuals work together and form an intervention. They then provide support and reassurance to the individual as the individual withdraws from the drug and changes their lifestyle. Other times, the chronic/addicted individual relies on self monitoring and cutting down over a period of time. Symptoms of withdrawal are not life threatening; in fact, the clinical significance of cannabis withdrawal symptoms are uncertain.⁷ These symptoms include insomnia, nausea, irritability, anxiety and loss of appetite. Depression may also occur.

Classification (Cannabis treatment - acute withdrawal with treatment)

Cannabis remission

ICD-9: 304.33

Once an individual is no longer using cannabis, it is important for them to alter their lifestyle so that they are no longer coming into contact with people, places and things that may entice them to begin using again. Long-term problems with sleep often occur in individuals who have had a cannabis addiction.⁷ Residual symptoms of depression and memory loss may remain for an undetermined period of time.

Classification (Cannabis remission)

Part 5 - Harmful stimulant use

This section describes harmful use of stimulants, which includes both amphetamines and cocaine. Amphetamines are substances that can be obtained through prescriptions for obesity (many amphetamines serve as appetite-suppressants), ADHD, and/or narcolepsy,⁷ and are usually taken orally or intravenously; methamphetamine is taken intranasally ("snorted" up the nose). Cocaine is a white powder that is extracted from the coca bush and is usually taken intranasally, but can be smoked or injected. Cocaine is almost only available through the illicit market. Both amphetamines and cocaine are potent central nervous system stimulants and have similar behavioural and psychoactive effects - use typically produces an instant feeling of euphoria and confidence. The psychoactive effects of amphetamines last longer than those of cocaine⁷ and amphetamines are therefore taken fewer times per day. Possession, trafficking and prescription "shopping" of stimulants are illegal and may result in a criminal record. Stimulant use is evident in urine tests for 1-3 days following last use, but up to 7-12 days in users with repeated high doses.⁷

Stimulant use affects all races and socioeconomic groups, but is most common between the ages of 18 and 30 years,⁷ with males more commonly affected than females. Most users are episodic recreational users. Often individuals begin using to control their weight, enhance their energy, or are introduced to stimulants through illicit markets. The course usually consists of chronic or episodic use (binges alternating with brief drug-free periods; i.e., high weekend use but less during the week). In some cases the binge period ends only when the drug supply is depleted. Tolerance develops with repeated use; therefore, users often increase their daily intake over time. In 1996 in the U.S., approximately 5% of adults reported using stimulants to get "high";⁷ about 10% of the population had ever used cocaine.⁷ It is estimated that only about 5-10% of individuals who try cocaine eventually use it on a more intensive basis.¹⁴⁶

The essential feature of stimulant intoxication is significant behavioural or psychological changes that occur during or shortly after use.⁷ These changes potentially include euphoria, hypervigilance, anxiety, anger or tension, interpersonal sensitivity, impaired judgment, and/or impaired social or occupational functioning. The severity of these symptoms depends on the dose and characteristics of the individual (i.e., level of tolerance, length of use). Two or more of the following are additionally present: 1) tachycardia or bradycardia; 2) pupillary dilation; 3) elevated or lowered blood pressure; 4) perspiration or chills; 5) nausea or vomiting; 6) evidence of weight loss; 7) psychomotor agitation or retardation; 8) muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias; 9) confusion, seizures, dyskinesias, dystonias, or coma.⁷ Severe intoxication by a stimulant can lead to overdose, which may result in death.

Intoxication typically lasts less than an hour, therefore, frequent use is required to maintain a high. Dependence on stimulants can develop after using the drug for only very short periods of time.⁷ Individuals with dependence typically exhibit aggressive or violent behaviour, particularly with high doses, in which case the individual may become dangerous. Anxiety is intense; psychotic episodes are possible and resemble episodes seen in paranoid schizophrenia.¹⁴¹ Most users dependent on stimulants have a disregard for consequences of negative behaviours. Legal difficulties are likely as a consequence of possession or obtaining the drug through illegal markets. A large amount of money can be spent quickly and in short time periods, resulting in potential financial catastrophes. Theft, prostitution and/or drug dealing may be carried out in order to buy or exchange more drugs. Often users need to discontinue use for days in order to obtain additional funds for more drugs. Work or family responsibilities may be neglected because the drugs are considered more important.

Individuals that use stimulants for a long period of time often have impaired personal hygiene and signs of malnutrition. Nosebleeds are common in individuals who use intranasally; sinusitis and/or nasal septum damage may develop. Individuals who smoke stimulants are at increased risk for respiratory problems. Long-term dependence may cause sexual dysfunction, social isolation, and erratic behaviour. Heart attacks, heart palpitations and arrhythmias, stroke and sudden death have been associated with cocaine use among healthy persons.⁷

Stimulant users often use other central nervous system depressants (i.e., alcohol, cannabis) during withdrawal to help reduce their irritability and induce sleep. Stimulant withdrawal ("crashing") develops within a few hours to several days later following the cessation of (or reduction in) prolonged and heavy stimulant use.⁷ The individual experiences a dysphoric mood, and at least two of the following physiological changes: fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite; and/or psychomotor retardation or agitation. These symptoms cause significant impairment in social or occupational functioning. Often an individual experiencing withdrawal has temporary but intense, depressive symptoms; depression with suicidal ideation/behaviour can occur. The individual typically requires several days of rest to recuperate.

Treatment of harmful stimulant use generally begins with the individual admitting there is a problem. Medication can be prescribed to control the effects of withdrawal; the induction of vomiting (or performing a gastric lavage) may be necessary. Suicide precautions may be necessary, in addition to close supervision and treatment of depression. Inpatient therapy may be required but support and self-help groups (i.e., Narcotics Anonymous) are often sufficient. Cognitive-behavioural therapy can help the individual change their attitudes and behaviours toward stimulant use; recovery programs help to teach coping skills. Reassurance, counseling and supportive care should remain after the completion of treatment.

Harmful stimulant use

ICD-9: 304.4 ICD-10 – Harmful cocaine use F14.1 / – Harmful use of other stimulants F15.1

The central nervous system stimulants include both cocaine and amphetamines. Despite their individual chemical differences, the behavioural effects of these drugs are remarkably similar and they are both highly addictive. Stimulants cause an initial sense of "high" and well being shortly followed by agitation that can cause violent behaviour. Individuals using stimulants experience symptoms of anxiety, irritability, physical discomfort, insomnia and confusion. They also have impaired personal and work relationships, as well as financial and legal problems. Weight loss and malnutrition are typical, resulting from a decreased appetite when intoxicated. Prolonged use of stimulants may also lead to a paranoid psychosis, including hallucinations, delusions, and feelings of panic.⁷

Classification (Harmful stimulant use)

Stimulant overdose

ICD-9: E854.2

An overdose of stimulants causes tremors, convulsions and delirium, possibly ending in a comatose state. Arrhythmias and/or cardiovascular failure may result in death. Individuals who overdose experience extreme anxiety, which could last for days. Treatment of an overdose includes administration of IV fluids, medication for the withdrawal symptoms, close monitoring, and possible intubation; a gastric lavage may also be necessary.⁷

Classification (Stimulant overdose)

Stimulant treatment (acute withdrawal with treatment)

ICD-9: 292.0, 94.66

The functional limitations associated with withdrawal of stimulants include overwhelming fatigue, sleepiness, and depression. Attention and concentration are impaired, and the individual experiences intense hunger, eventually causing weight gain. Individuals can also become paranoid or suffer from physical complaints, such as chills, nausea, or vomiting. Individuals withdrawing from stimulants need to be closely monitored for depression because they are at a high risk for suicide.  After an individual has gone through withdrawal, they may initially need in-patient therapy followed by continuous support and reassurance.⁷

Classification (Stimulant treatment - acute withdrawal with treatment)

Stimulant remission

ICD-9: 304.43

An individual in remission from an addiction to stimulants must perform self-monitoring as the key to abstinence, as well as a strong support network.  Meetings with self-help groups are also important as is integrating new coping skills and life management strategies into their lifestyle. Cravings for the drug may continue for years; therefore the individual must avoid the people and/or places that are affiliated with using.⁷ Residual physical symptoms may remain.

Classification (Stimulant remission)