Substance Use Disorders: Diagnosis, Causes, and Treatment
Substance use disorders (SUD) are categorized
with more than 300 other psychiatric
diagnoses
1952 (DSM-I) by the American Psychiatric
Association, this was the first official
manual of mental disorders focusing on
clinical application. The need for such a
publication arose from growing recognition
by the United States Army and
Veterans Administration that World War
II veterans needed services addressing
what we now refer to as mental health
disorders (2). The most recent version of
the DSM, DSM-5, was released in May
2013 and continues to be viewed as the
“bible” by mental health professionals
who diagnose psychiatric illnesses in
adults and children. It uses a multidimensional
approach (i.e., consideration
of clinical syndromes, developmental
disorders and personality disorders,
physical conditions, severity of psychosocial
stressors, and highest level of
functioning) as the basis for diagnosing
mental health disorders because other
factors in a person’s life typically affect
mental health.
Compared to the DSM-IV, the DSM-5
does not differentiate between substance
abuse and dependence, but
instead, recognizes them as the same
disorder on a continuum within a new
category referred to as “addictions and
related disorders”(1). To diagnose substance
use disorder, the DSM-5 states
that two or more criteria must be
present within a 12 month period.
Severity of the SUD is based on the
from mild (2 – 3 criteria) to moderate (4-
5 criteria) to severe (6 or more criteria).
Genetic factors are recognized for
their role in causing substance use disorders.
Additional theories about the
causes of substance use disorder
include a desire to cover up or obtain
relief from an uncomfortable life situation
or chronic problem, (i.e. self-medicating
to address emotional or physical
pain) (1).
Magnitude of the Problem
• In 2012, the Center for Behavioral
Health Statistics and Quality,
Substance Abuse and Mental Health
Services Administration, and the
United States Department of Health
and Human Services published a
162-page report of findings from the
2011 National Survey on Drug Use
and Health (NSDUH) (3). This survey
is conducted annually to gather
information about the use of illicit
drugs, alcohol, and tobacco, with
data collected during the month just
preceding the survey interview. The
2011 interviews involved approximately
67,500 nonmilitary, noninstitutionalized
individuals aged 12
years or older. The following is a
snapshot of the 2012 report. Survey
results have been extrapolated to
reflect trends applicable to the larger
United States population.’’
• An estimated 22.5 million people
(8.7% of the population) were currently
using illicit drugs, defined as
marijuana/hashish, cocaine (including
crack), heroin, hallucinogens,
inhalants, or prescription-type psychotherapeutics
(pain relievers, tranquilizers,
stimulants, and sedatives)
used nonmedically.
• Slightly more than 50% of respondents
reportedly had consumed
alcohol, with slightly more than 58
million individuals (22.6% of the population)
having engaged in binge
drinking (defined as having 5 or
more drinks on the same occasion)
on at least 1 day during the 30 days
before the survey.
• Among young adults aged 18 to 25
years, binge drinking was reported
by nearly 40% of respondents, with
heavy drinking reported for more
than12%. Heavy drinking was
defined as binge drinking on at least
5 days during the past 30 days.
• Slightly more than 68 million
Americans (26.5%) reported using
tobacco products, with the majority
smoking cigarettes (22.1%), followed
by cigars (5%), smokeless tobacco
(3.2%), and pipes (<1%).
• Not quite 21 million individuals (8%
of the population) were estimated to
meet the criteria for substance
dependence or abuse, according to
the DSM-IV criteria.
• Treatment provided by medical facilities
specializing in substance abuse
(now categorized as SUD in DSM-5) is
severely lacking for those in need. Of
the nearly 22 million individuals aged
12 years or older in need of treatment
for illicit drug or alcohol abuse,
fewer than 11% received treatment.
Prevalence of Substance Use
Disorder in Individuals with
Diabetes
The NSDUH survey was conducted
among the general United States population
and did not identify participants
who had a coexisting diagnosis of diabetes.
Nonetheless, given the number
of individuals known to have diabetes
in this country (25.8 million) (4), medical
nutrition professionals/diabetes educators
inevitably will work with a number
of patients who have both diabetes and
a substance use disorder diagnosis.
Tobacco Use
Recent data from the Centers for
Disease Control and Prevention found
that 20% of adults aged 18 years or
older with diabetes reportedly smoked
cigarettes (5). Several studies have
linked cigarette smoking to an increased
risk for microvascular complications of
diabetes (6) as well as insulin resistance,
elevated blood pressure, and impaired
endothelial function (7,8). Other investigators
have reported a dose-dependent
association between cigarette smoking
and the risk for type 2 diabetes (9). Early
smoking cessation has been shown to
reduce the risk for developing type 2
diabetes to a level comparable to that of
nonsmokers (10) and to mitigate the
increased risk for coronary heart disease
and mortality (11).
Alcohol
Based on data gathered from epidemiologic
surveys and reports of those
seeking treatment, 50% to 60% of individuals
with diabetes currently are estimated
to use alcohol (12,13). Binge
drinking has been shown to increase
the risk for diabetic ketoacidosis and is
an independent risk factor for peripheral
neuropathy and retinopathy (14).
This is particularly worrisome for adolescents
and young adults with type 1
diabetes because of the risk-taking
behaviors that are common in these
age groups and the prevalence of binge
drinking, as described previously.
Other studies have shown a higher
rate of adverse health outcomes linked
to alcohol (15) or other drug use substance
disorders among those with diabetes.
Leung and colleagues (16)
reported increased hospitalizations,
longer length of hospital stays, and
more frequent and severe healthrelated
complications for Medicare
and/or Medicaid beneficiaries with type
2 diabetes and a coexisting diagnosis of
an alcohol or substance use disorder.
Finally, individuals who have substance
use disorder diagnoses are less likely to
follow diabetes treatment guidelines,
including visits to the medical team for
routine diabetes care (17).
Treatment
Research is ongoing to identify the
most effective treatment approaches
for individuals dealing with substance
use disorders and diabetes, individually
and as comorbid chronic diseases.
Several studies have documented
improved coordination of care and positive
outcomes with a team-based care
approach, as in the patient-centered
medical home (18). Some investigators
found reductions in nicotine dependence
and the negative consequences of
alcohol use with an integrated care
model (18,19). A report by Ghitza and
associates (20) found implementation
of this care model resulted in lower
total medical costs and improved
health outcomes in a variety of settings.
Ongoing social support in a one-on-one
or group setting, coupled with an open
and non-judgmental approach have
been recognized as critical components
of treatment for both diabetes and substance
use disorders. However, the
effectiveness of participation in
Alcoholics Anonymous (AA) has
revealed mixed results, as described in a
review by Kastakas (21).. The number of
people with diabetes in this review was
not identified.
As reported by McLellan and colleagues
in 2000 (22), part of the challenge
in treating substance use
disorders is fueled by a longstanding
belief held by the public and some
medical care providers that dependence
is an acute condition, rather than a
chronic illness. The researchers conducted
a literature review comparing
drug dependence to several other
chronic diseases: type 2 diabetes,
hypertension and asthma. Comparators
included diagnosis, heritability, genetic
and environmental factors, pathophysiology,
adherence to treatment, and
relapse rates. Results of the review led
the researchers to conclude that drug
dependence must be viewed as a
chronic illness, and that long term
strategies of medication management
prepare and the accompanying nutritional
concepts/benefits, which sets
the intention, putting the lesson into
a larger framework. Before the first
cooking class, a session on kitchen
sanitation and safety is very helpful
(we use a video and quiz). Obviously,
everyone must understand that they
must wash their hands before beginning
to work.
• Establish an overall learning goal of
demystifying the process of putting
food on the table. This can be accomplished
by imparting general kitchen
skills (e.g., measuring ingredients, use
of knives); techniques and shortcuts;
use of equipment; sanitation and
safety; following and modifying
recipes; preparing food from scratch
for control of nutrient content;
preparing lower fat and sodium,
higher fiber, less processed, less
expensive, better-tasting food; overcoming
fear of trying new foods; and
reducing the carbon footprint.
Specific aspects are predicated by
participants’ interests and nutrition
goals.
• Introduce new “weird” foods (e.g.,
tofu, quinoa) by weaving the familiar
with the less familiar. For example,
we make changes in traditional
southern recipes, such as preparing
collards seasoned with lemon juice
or sesame oil instead of fatback, creating
barbeque tempeh with a
homemade low-sodium sauce, crafting
a glorified version of macaroni
and cheese by sneaking in some tofu,
and developing an oriental stir fry
with gluten (affectionately dubbed
“Chinese Chitlins”). Presenting nutrient
dense foods and their role in
disease prevention and treatment
along with discussion of additional
health-related topics specific to the
audience can pique interest and
increase acceptability.
• Consider other hands-on nutrition
education activities, such as field
trips to farmers’ markets, “health
food” stores, supermarkets, restaurants,
and farms.
• Gather outcomes data with simple
pre- and posttests of objective knowledge,
food habits, attitudes, and/or
self-efficacy. Do the participants still
think of tofu as a four-letter word?
Share your results with institution
administrators to gain support for
expanding the program.
Incorporating hands-on nutrition
education into your RD toolbox can
enhance customer success while broadening
your skills, job satisfaction, and
fun quotient.
“Cook for Life” Program
“Cook for Life” was launched in
August 2011, and is the Gainesville, FL,
version of the Veterans’ Administration
Nutrition and Food Services’ “Healthy
Teaching Kitchen” project. Conducted
by two RDs, the format includes 5
weeks of 2-hour sessions. Four of the
sessions are hands-on cooking classes
(very roughly themed breakfast, lunch,
dinner, and snacks) and one session is a
“consumer savvy” field trip to a local
food market. Veterans are referred from
the MOVE weight management
program and outpatient nutrition
clinics, most commonly due to one or
more health concerns of overweight,
hypertension, or diabetes. Our mission
is to give participants the tools and
motivation to prepare healthy, tasty,
affordable meals to meet their dietary
needs. The class is usually limited to
four to eight people, and Veterans are
encouraged to bring their significant
others or family members.
Before the first class, students complete
an interest/needs survey (so we
can tailor the menu items and topics to
each cohort) and a preprogram questionnaire.
The questionnaire is designed
to discern each participant’s baseline in
terms of dietary knowledge, attitudes,
and self-efficacy. At the end of the final
session, we ask them to complete the
questionnaire again as well as a participant
evaluation of the program. Using
this material, we can generate quantitative
data to document any changes in
the dietary indices and qualitative data
about the program to help us modify
and improve it.
As of September 2012, data has been
collected from 22 of 31 participants
(several participants did not attend the
final meeting). The knowledge and attitudinal
sections of the questionnaires
produced less useful results. This may
be due to confusing wording of the
items, such as “Write the number that
best reflects how you feel right now (1 –
5 from strongly disagree to strongly
agree): Unsalted foods always taste terrible.”
There were only four or five items
in those sections. In contrast, the selfefficacy
questions revealed definitive
changes. Participants were asked to rate
their degree of confidence by recording
a number from 0 – 100 using a scale
ranging from 0 = cannot do at all to 100
= highly certain can do. One example
that they were asked to rate was: “How
certain are you that you can…..shop for
healthy food?” By tracking general
trends (grouping results: 0 to 49%, 50%
to 79%, 80% to 100% ) rather than
smaller incremental changes, the selfefficacy
data indicated a clear trend
from “clueless” to “confident” in all ten
items. These results are particularly
gratifying because the adherence literature
reveals self-efficacy to be the only
consistent indicator of behavioral
change. In other words, people who
perceive themselves as capable of
doing something are much more likely
to attempt the task and to succeed.
The program evaluation form poses
questions such as “What was the most
helpful part of this program?” and asks
for favorite and least favorite parts as
well as suggestions for improving the
program. In response to “Do you feel
that your participation in this program
will help you in achieving your health
goals?”, 19 of 22 participants answered
“yes” (plus 1 neutral and 2 “somewhat”).
Favorite and helpful parts of the
program included linking food to
health, how to prepare various foods,
new ways of cooking, exposure to new
foods, spices, ideas, group discussion
and input, gaining confidence by
hands-on cooking, getting copies of
recipes, and especially eating. Other
comments included “delightful surprise,”
“look forward to the class each week,”
and “enjoyed learning how to use a pressure
cooker.” Suggestions for future
classes included more meat, more
menu planning, more liquids, and most
commonly, more and longer sessions.
A larger data set (n=86, ) was also
collected May 2011 to May 2013 from
the SARRTP nutrition education
program, where cooking classes have
been conducted for more than 15 years.
Of 69 residents who were asked “Do you
feel that the nutrition knowledge and
skills you gained will help you in sustaining
your recovery?”, 64 wrote in “yes”, 3
“no”, and 2 “somewhat”. Although
SARRTP is voluntary, residents are often
surprised by the mandatory “Nourishing
Recovery” didactic and hands-on
cooking classes, which often lead to
some initially reluctant and even hostile
participants. Their feedback frequently
notes that they had negative impressions
initially, but then found they
actually enjoyed the classes.
Serendipitous positive outcomes
included socializing with peers, staff,
and volunteers as a means to practice
social skills; discovering an interest in
nutrition; realizing the joy of cooking in
community; and working through other
life issues via food and cooking.
Overall, “Cook for Life” participants
from both groups have found hands-on
cooking classes to be informative, motivating,
and simply fun. The dietetic
practitioners have verified that the
program is extremely gratifying for
them. Our goal as RDs is to teach and
promote healthy food preparation and
cooking habits, for a greater understanding
of how diet modulates health,
and the acquisition of practical experience
and skills to be implemented in
the home. “Cook for Life” provides this
in a patient-centered, nonjudgmental,
supportive atmosphere where RDs can
inspire creativity and confidence,
empowering our Veterans to optimum
nutritional wellness.
As the Native American proverb
states, “Tell me and I’ll forget. Show me
and I may not remember. Involve me
and I’ll understand.”
