Chapter 292: Substance Use Disorders

INTRODUCTION AND EPIDEMIOLOGY

In EDs around the world, on every shift, patients present for medical conditions related to the consequences of unhealthy drinking or drug use. The World Health Organization reported in 2012 that 5.9% of all global deaths (3.3 million people) were attributed to the consumption of alcohol.¹ From 2006 to 2014, ED alcohol-related visits increased in the United States from 827,100 to 1.46 million.^2,3 In 2015, an estimated 29.5 million people, or 0.6% of the global adult population, qualified for a drug use disorder, yet fewer than 16% were afforded treatment. The majority of worldwide illicit drug–related deaths (190,000) were attributed to opioids. In 2016, the United States accounted for more than 25% of these deaths.⁴ U.S. ED drug-related visits doubled from 2005 to 2014,⁵ fueled by increased supply and misuse of prescription opioids; social and economic determinants; and the low cost and easy availability of heroin, synthetic fentanyl, and analogs.⁶ Between July 2016 and September 2017, U.S. opioid overdose ED visits among those aged 11 years old and older increased 29.7% overall, with significant increases across all demographics examined.⁷ It is noteworthy that “available data suggest that nonmedical prescription-opioid use is neither necessary nor sufficient for the initiation of heroin use and that other factors are contributing to the increase in the rate of heroin use and related mortality.”⁸

The scope of substance use disorders (SUDs) includes unhealthy use of alcohol, use of illicit drugs, and nonmedical use of prescription drugs. Severe SUDs resemble asthma, diabetes, hypertension, and other chronic diseases in that they have genetic components and patients have problems with adherence to medication, loss to follow-up, exacerbations, repeat visits to the ED, and hospital admissions.⁹ Nevertheless, only a small fraction of those needing alcohol or drug treatment actually receive indicated therapy, compared with a much higher fraction of patients with chronic medical conditions.¹⁰ This understanding of addiction as a chronic, relapsing medical condition requires us to shift our focus toward providing linkage to ongoing integrated treatment and community support services as an addition to acute care.¹¹ The gap in SUD treatment also reflects the impact of social stigma on disparities in availability, accessibility, and affordability of services. Language is powerful, especially when talking about substance use because stigma perpetuates negative perceptions, discourages use of treatment services, and contributes to further substance use. Words do matter and the language used to discuss addiction is important to decrease stigma (Table 292-1).^12-14