Clinical tips: substance abuse disorder

Substance abuse disorder isn’t just about opioids or illicit drugs, writes Karalyn Huxhagen

When we think of substances that are abused we mainly consider illicit drugs and medications such as benzodiazepines or opioids. Medications that affect the central nervous system are next in line e.g. quetiapine, phentermine.

The Headspace definition is: ‘A substance can be anything that is ingested in order to produce a high, alter one’s senses, or otherwise affect mood, perception and consciousness. There are nine separate classes of drugs identified in the DSM-5  that can be involved in a substance use disorder: alcohol; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances.’ ‘ Where use is prolonged, heavy, or creating social or personal problems, it may meet a diagnosis for a substance use disorder.’

The reality of pharmacy is that there are many medications that are purchased with a form of abuse in mind. For example the use of laxatives in very large amounts; the use of Loperamide and weight reduction pills.

A recent patient gave me significant reason to think about substance abuse. Her best friend contacted me and asked whether I would speak with this person.

The person is a lady in her early sixties married several times but currently single. She has been a very important person in the community over the years and always strikes a fashion statement at the events she attends.

She has a body that is lean and toned and tanned. She lives in an apartment at the beach and always looks immaculate in high heels with makeup and hair perfect. Her friend’s concern related to this lady’s obsession with her body. Let us call the lady Minni.

Minni was purchasing at least six pallets of bottled water each week and was drinking this water non stop. She still functioned, ate healthy meals and worked out every day at the gym.

Her friend had concerns as to the amount of water she was drinking and the effect on her body. On discussion with Minni she informed me that she felt she was ‘addicted’ to the water and craved it constantly. She stated that she was very fearful of being a little old lady and was working hard to keep her figure and stunning looks.

We eventually worked through this issue and her water intake returned to a realistic intake. The potential for harm with her high water intake was real and was happening without her awareness. The product that is abused does not have to be illicit to cause harm.

In Australia the research on substance abuse disorder has identified criteria, risk factors and family and peer backgrounds that may contribute to the development of substance abuse disorder. I refer you to the website for Headspace on substance abuse disorder. See

This website provides a short synopsis of this disorder with useful material for clients and/or families and carers.

The close relationship between substance abuse disorder and other mental health disorders requires the clinician to spend time to tease out which one came first, how the problem started and what are the treatment options.

The length and number of appointments required to allow the clinicians to form a diagnosis is often a barrier to these clients working through their problems and identifying positive ways to manage the disorder.

These patients are often missed, partly as they are clever at hiding the substance abuse, but also as their other clinical presentation e.g. anxiety, depression, mood swings is attributed to other comorbidity diagnosis.

In pharmacy we need to be vigilant to asset in identifying patients who may be trying to manage their mental health condition with other substances. Looking at dispensing histories to determine whether they are having their prescriptions dispensed on time is a start.

Building a rapport to enable discussion about the adverse effects of the substance they are abusing is another area. For example these patients may present with sleep issues, anxiety, panic attacks, tremors and palpitations.

Be watchful for the patient asking about escalating doses or adding in other medications e.g. sleeping tablets, sedating antihistamines, Loperamide.

Substance abuse disorder patients are often missed in the medical system as they appear functional within their own private enclave of friends and families but when placed outside of this comfort area they may present with significant mental and health crisis e.g. seizures, altered awareness, palpitations, hallucinations.

Our role is to be vigilant, supportive and provide advice and counselling. When significant harm issues are escalating our role is to provide advice on interventions and if harm is significant report the abuse to the appropriate authority before significant harm occurs.

Karalyn Huxhagen is a community pharmacist and was 2010 Pharmaceutical Society of Australia Pharmacist of the Year. She has been named winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management and is group facilitator of the Mackay Pain Support Group.


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