On behalf of the American Osteopathic Academy of Addiction Medicine, let me welcome you to this presentation on the medical complications of substance use disorders. The narrator for this particular presentation is Dr. Gregory Landy, and I would like to submit at this point that I have no ethical or financial conflicts in relation to this presentation. During our time together, I hope that you will learn about some of the common medical problems that are associated with substance use disorders, with a focus principally on their epidemiology and their diagnosis. Once again, in the time that we'll be spending together, here is a broad presentation outline. We'll begin with an overview of the history and physical, with particular reference to the more common substance use disorders and their accompanying medical consequences. With that in mind, we'll start with the alcohol use disorders and the tobacco use disorders, which when combined, do have the greatest morbidity in terms of substance use disorders. We will also spend some time on cannabis use disorders and their medical consequences, along with cocaine and the other similar stimulant use disorders. A little bit of time on the opioid use disorders, and we'll finish with the medical consequences of steroids misuse. Now, where it lends itself to this presentation, each of the substance use disorders metabolic consequences will be discussed in terms of their pathology on particular organ systems, such as the cardiovascular system, the patic, renal, metabolic, gastrointestinal system, of course, the lungs or pulmonary system, neurologic disorders, infections, and yes, we'll spend a little bit of time looking at the consequences in terms of their effects on sleep and endocrine and reproductive systems. Now, when we begin the assessment, there are a few points I'd like to keep in mind. Consider these as caveats, if you will. This presentation will primarily focus on the medical consequences of substance use disorders, meaning chronic problems. Now, of course, it's impossible not to have some overlap with the symptoms and signs that accompany intoxication, overdose, and withdrawal, but by and large, where it lends itself to such an analysis, we're going to focus on the chronic use of substances and the resulting medical problems. The other thing to keep in mind when it comes to the history and physical assessment of an individual with a substance use disorder is to keep in mind that individuals with a substance use disorder many times are reluctant to engage the healthcare system. Their problems may not come immediately to the forefront of your attention, and during a history and physical, they may not share important information. But with those particular caveats in mind, let's now pivot to a discussion of some of the medical consequences of a substance use disorder that may be revealed through your history. Now, as an additional thought at this point, the discussion here is not meant to be a comprehensive discourse on physical diagnosis. It's well beyond the scope of this presentation. The goal really is to identify certain areas that may pique your interest and remind you about these sequelae. But when we're doing the general medical history, we do want to focus on any prior illnesses the individual may have had, certainly any surgeries, and chronic disorders that the individual has been suffering with. When it comes to substance use disorders, we are, of course, interested in the individual's lifestyle choices, such as the occupation they have chosen, the degree to which they travel, their diet and otherwise their nutritional status. Of course, when it comes to substance use disorders, we want to know their social supports that they have available. Now, as you know, mental illness and substance use disorders are highly co-occurring. This is an important area to remember and to identify in your history. There are special risk categories that we want to keep in mind with those particular populations, such as with adolescence and with pregnancy. Moving on to the physical exam, this may disclose substance use disorder related medical consequences. Again, let me hasten to add, this is not meant to be a road trip through physical diagnosis, but merely some signposts that can remind us of the importance of the physical exam. But with that in mind, facial wrinkles may be suggestive of a tobacco use disorder. When you're looking in the mouth, in the oral cavity, you may see tobacco stained teeth. Oral lesions inside the mouth may be suggestive of a tobacco use disorder or the toxic effects of alcohol. When you're palpating the abdomen, you may notice a small or possibly cirrhotic liver or an enlarged liver, which would be suggestive of a substance use disorder related hepatitis. As you continue your physical examination, you may notice enlarged lymph nodes, which again may be suggestive of a substance use disorder related infection, such as tuberculosis, chancroid, syphilis, or HIV. Now, when you're performing the cognitive examination of your patient, you may detect neurologic disorders such as dementia. Now, among those individual patients that you have in your practice with a known substance use disorder, you may want to consider targeted clinical tests. The CBC, for example, may reveal an elevated MCV, suggestive of ongoing alcohol use. Your chemistry panel may reveal elevated glucose levels, creatinine, and liver function tests, which again may reveal important information. A routine urine drug screen should not be dismissed because it may be revealing information about the individual's renal status. A lipid panel may reveal, for example, hypertrichlyceridemia, which could be associated with an alcohol use disorder. Tests for sexually transmitted diseases might be indicated for HIV, syphilis, chlamydia, and of course, exposure-based testing for infectious diseases such as COVID-19 or TB, may well be indicated. Now, let's take a closer look at the medical consequences of alcohol use disorders. Let me add that almost every organ can become a potential target of an alcohol use disorders noxious influence. But let's begin with alcohol-induced osteoporosis. Now, you'll notice that I put in parentheses, it needs further research. As we proceed through this presentation, you'll see this at several points. The need for that is evident because while we see this in clinical practice, the scientific research is as yet to confirm this with some degree of certainty. But beginning with the first statement on the slide, and I quote, chronic alcohol abuse is one of the modifiable risk factors in osteoporosis. Now, again, as we go through this presentation, you will see a superscript. If you look down to the bottom of the slide, you will see the reference from which that quotation was drawn. You can refer to that reference for more information on this particular topic. What we need to keep in mind is that alcohol can be toxic. In suppressing bone formation, there's also increased evidence of fractures in individuals with alcohol use disorders. Now, we're not talking about things like motor vehicle accidents. Now, the relationship between alcohol use and an increased incidence of fractures is imperfectly understood. But one hypothesis would lead us to believe that it's related to alcohol's interference with nutrient metabolism, along with diets that are deficient, and that leads to a loss of calcium and phosphate, which of course are critical to bone formation. This leads some clinicians to suggest that among your patients with an alcohol use disorder, supplemental vitamin D may be an advantageous choice. When you first look at this slide, it certainly looks very busy, almost overwhelming. But I included it because it really dramatizes the impact that alcohol can have on many organs in a human's body. Although it may be tedious, let's take a moment and go through this in a little bit of detail. Now, if we start with the central nervous system, some of the issues that may arise could be a polyneuropathy, or Wernicke-Korsakoff syndrome, and we'll talk more about that a little bit later. In the upper GI tract, we could be seeing things like esophagitis, gastric reflux, or gastritis. In the cardiovascular system, we have hypertensive arrhythmias and cardiac myopathies. If we move over to the reproductive system, we can have gonadal atrophy as a consequence of chronic alcohol use. Among men, effeminization. Among women, dysmenorrhea, amenorrhea, and even early menopause. Now, we may not think of alcohol as affecting the lungs, but chronic alcohol use can be associated with chronic obstructive lung diseases and even pulmonary infections, which leads us to the effect alcohol has on the immune system, associated with increased infections, macrocytic anemias, and coagulopathies. Now again, we may not think of alcohol as affecting the kidneys, but it can. There are clinical reports of hepatorenal syndromes associated with chronic alcohol use. In the lower GI tract, we've talked a bit about malabsorption already. In the skin, eczema, spider knee vibe, and who would have thought, even acne. Now, alcohol can also have effects on the pancreas and of course the liver. We'll talk about those in more detail in just a little bit. But in terms of cancer, chronic alcohol use is associated with esophageal cancers, lung cancer as we mentioned, pancreatic cancer, ovarian, and breast cancer. So it really is a situation where chronic alcohol use can affect nearly every organ system in the body. Now, let's drill down a bit and look at some of the effects on some discrete organs and let's start with the gastrointestinal system. Now, the first contact aside from, of course, the mouth that alcohol exposes an individual to is at the gastrointestinal level. The direct toxic effect it produces is based on the concentration of the alcohol, the proof, if you will, the frequency of alcohol's use, and the presence of any buffers such as individual having eaten a meal. Now, alcohol inhibits smooth muscle motility, and there can be esophageal inflammation. Heartburn is a fairly common complaint, otherwise, of course, known as gastroesophageal reflux disease or GERD. Gastritis and ulcers are slightly more serious problems. But then we get to the cancers, the esophageal cancer and stomach cancer. There's less evidence to support stomach cancer, but it's still within the realm of an informed consent to one of your patients. Now, alcohol-induced pancreatic disorders. Now, here we have chronic alcohol use being a leading cause of acute pancreatitis. Chronic pancreatic inflammation can lead to subsequent fibrosis, and that may be a medical consequence of its chronic use. Now, when we think about chronic alcohol use, our minds naturally gravitate to its nefarious effects on the liver. Alcohol does indeed exert a profound effect in terms of its chronic use and sequelae on the liver. It's a prime target. Alcohol is metabolized in the liver. Once again, the concentration of the alcohol can affect the outcome here. Now, the impact of chronic alcohol use on liver cannot be underestimated, since the liver is so important in a person's general metabolism. Now, with that said, we can then say that alcohol use disorders are a leading cause of hepatic-related deaths. Now, alcohol use disorders can really produce three types of liver problems. The fatty liver, hepatic inflammation, otherwise known as alcoholic hepatitis, and of course, hepatic fibrosis or cirrhosis. Now, the fatty liver comes about as a result of an alcohol-related impairment in a person's metabolism, which leads to an accumulation of fat in the liver. The liver enlarges as a consequence. Now, the good news here is that this is reversible with abstinence. We next move to alcoholic-induced hepatitis. Now, here we have an inflammation in the liver along with cell damage. This too can be reversible with abstinence. But if the individual in a stepwise progression ignores these two issues of fatty liver and the hepatitis, they may very well then proceed to cirrhosis. This is an irreversible scarring of the liver with cell death. As a consequence of which, among other things, the individual may end up with a hepatic encephalopathy as a result of the impaired metabolism. Now, alcohol is the main but not sole predictor of hepatic injury. But with that caveat in mind, many of us wonder how much alcohol consumption does it take to put an individual at significant risk for serious hepatic injury? Clinical research has answered this question to a degree. Here we have a reference that you can spend more time perusing. But in general, these researchers reported that serious hepatic injury can result when an individual exceeds a lifetime baseline amount of alcohol consumption, which for men would be about 600 kilograms, a prodigious amount, and 150-300 kilograms for women. Now, when this is put into terms that is more clinically useful, that would equate to male consumption of around 10-12 drinks per day for 10 years, and among women, three drinks a day for 10 years. Now, the alcohol use disorders are associated with the production of decreased antioxidants to counter the damaging free radicals. Now, in one regard, these free radicals are a consequence of alcohol's metabolism. Acetaldehyde, in this case, increases free radical production in the liver. Now, complicating this issue is that the chronic use of alcohol also can result in lower levels of vitamins A and E. These are antioxidants that can theoretically and practically scrub the liver of these increased free radicals. Now, alcohol use disorders can also be associated with increased levels of cytokines. Now, we've heard the term the telescoping effect. This is a situation that applies to women who, with lower levels of alcohol, suffer major medical consequences when compared to men. We should never forget the role genetics and an individual's susceptibility to the medical consequences of substance use disorders. There are, for example, polymorphisms related to alcohol's metabolism that can sway that particular risk. Now, let's talk about alcohol-induced cardiovascular disorders. Now, I begin with one of the caveats. Alcohol presumptively has both beneficial and injurious cardiovascular effects. But for the purposes of this presentation, I'm only going to discuss the nefarious or injurious cardiovascular effects. Now, alcohol use disorder, chronic use meaning, is associated with elevated blood pressure. Now, why that comes about remains uncertain. Part of the conundrum here is that alcohol initially dilates blood vessels and lowers the blood pressure. But through the chronic use of the substance, it appears that the increased release of noradrenergic neurotransmitters and the subsequent sympathomimetic response elevates the blood pressure over that longer time period. It may also be related to incidences of withdrawal, some obvious perhaps some sub-threshold. Now, the alcohol-induced hypertension then can increase the risk of hemorrhagic stroke. It's interesting to note that 30 percent of cardiomyopathies can be traced to the chronic use of alcohol. Similarly, when we are presented with atrial fibrillation, we should not discount alcohol's potential contribution to that arrhythmia. Now, alcohol-related neurologic disorders is another area that we commonly associate with alcohol. We can begin this discussion with the alcohol neuropathies. The actual mechanism by which this is produced also remains a bit uncertain, but it may be related to a B12 deficiency, or once again, that acetaldehyde toxicity we just talked about. Now, alcohol use disorders can be associated with subarachnoid hemorrhages, seizure disorders, general cerebellar dysfunction. But then we come to Wernicke's encephalopathy and Korsakos, which you're probably familiar with. Wernicke's encephalopathy is a triad of confusion, ataxia, and ophthalmoplegia, which really beckons the clinician to administer thiamine to reverse that course and prevent its leading to the more serious complication of Korsakos. Korsakos is an actual loss of neurons that leads to an anterior grade and retrograde amnesia. The individual will present with confabulation, they're apathetic, they lack insight, and perhaps the individual was socially ebullient at one time, but now as a result of the Korsakos, they are less conversational. We should not forget substance-induced alcohol, in this case, major neurocognitive disorders, otherwise known as dementia. Now, I've included this slide from DSM-5 to give you an idea of how ICD-10 looks at these mild and major neurocognitive disorders and the principal substances that have related diagnoses. And of course, alcohol, which I've highlighted in red, leads the list with three potential diagnostic choices for clinicians, being non-amnestic confabulatory types, amnestic confabulatory types, and a mild neurocognitive disorder. Now, I've highlighted in green, inhalants. Inhalants can cause profound changes in the central nervous system and can lead to a mild or a major neurocognitive disorder. The same can be said for sedative, hypnotic, or anxiolytic substances that are misused. And if the mild or major neurocognitive disorder comes from a different class of substances that are misused, the clinician can simply insert that particular agent into their diagnostic classification. Now, when it comes to alcohol use disorders, we may not always think of it causing problems for the kidneys, but it can. Chronic alcohol use or even acute alcohol use, in this case, can produce an acute renal failure secondary to a rhabdomyolysis, which can result from alcohol intoxication or a prolonged period of immobility as a consequence of a profound sedative state. Alcohol, of course, can result in fluid and electrolyte changes. And then there's this thing called alcoholic ketoacidosis. Now, sleep may not be one of the principal things that clinicians would be thinking when it comes to alcohol use. And in many cases, it does remain a subterranean issue even for patients. Let's keep in mind that for some individuals, their stated reason for drinking in the beginning was to help their sleep. So let's take a moment to look at how that unfolds. So let's imagine for a moment that an individual goes to sleep at night with high blood alcohol level. The body tries to adjust to that, but the sedative effects have taken hold and the individual falls asleep, perhaps fairly quickly within 15 to 20 minutes. Now, the downside or the footnote to all this is that the sedative effects do wear off and the individual needs to increase their consumption over time to realize that same sedative effect. But in any event, the metabolism of alcohol is fairly certain. And as the night progresses, that sedative effect wears off. And so that the second half of their night's sleep is punctuated by increasing numbers of arousals for wakefulness, which of course is unsatisfactory sleep. Now, the other thing that alcohol does is it suppresses REM sleep. So the early night of their sleep is relatively devoid of dream sleep. But in the latter half of the night, when the suppressing effects of alcohol have abated through metabolism, there is a profound REM rebound. And individuals will characterize this not as nightmares, but as disturbing, vivid, and perhaps colorful dreams. Now, alcohol can also be considered a risk factor for obstructive sleep apnea. Alcohol worsens obstructive sleep apnea by relaxing the upper airway muscles. Now, another factor going on here is that alcohol use impairs the normal arousal response an individual has to an airway obstruction. This shows up on a polysomnogram as the respiratory effort-related arousals. Now, let's move on to tobacco use. And I've underlined here that it is the leading cause of preventable mortality worldwide, which certainly justifies our taking a few minutes to look at the medical consequences of tobacco use disorders. Now, the consequences do depend on how the product is used, whether it's smoked or it's smokeless tobacco or vaped, for example, each of which can confer different medical problems. But in general terms, we're thinking of the oral cavity, the larynx, the esophagus, bladder and kidney, the pancreas, stomach, and cervical cancers. Well, of course, when we think of tobacco use disorders, we're immediately reminded of its effects on the lungs. Tobacco use is the leading cause of chronic obstructive pulmonary diseases, meaning chronic bronchitis and emphysema, which accounts for 20% of the tobacco use disorder-related deaths. It's also a leading cause of pulmonary cancer, which accounts for another 20% of tobacco use disorder-related deaths. But tobacco use can also contribute to pulmonary hypertension. But it's important to keep in mind and remind our patients that quitting tobacco can confer significant health benefits. Now, this is certainly a Rubik's Cube sort of looking diagram. I included it because it really sort of encapsulates the problems that cigarette smoking can cause. And if we follow the lines down in a couple of instances, we can see what's going on. So cigarette smoking can lead to dyslipidemias, arterial stiffness, and even contribute to diabetes mellitus, which in turn leads to endothelial dysfunction, decreased insulin sensitivity, which in turn can produce hypercoagulability, which then can result in an atherothrombotic event, such as a myocardial infarction, a stroke, sudden cardiac death, all of which can terminate in death. Now, tobacco use disorders can also be associated with their impact on the kidneys. And I quote, smoking increases the risk of kidney disease and end-stage renal failure in the general population with a hazard ratio of up to 1.69 for heavy smokers compared with nonsmokers. So I would invite your attention to this reference, which is listed at the bottom of this slide for additional information about this particular issue. So chronic kidney disease may result as a consequence of the elevated catecholamines that tobacco use produces subsequently increases the blood pressure. Smoking also contributes, as we just looked at, arterial endothelial damage. Again, because of most likely the large amounts of free radicals that are produced. The net result in this case could be arterial atherosclerosis. And as the previous slide also noted, it's a risk factor for type two diabetes mellitus. Now, this particular slide looks at the consequence of chronic tobacco use on the reproductive system. The risk for perinatal mortality, stillbirths and neonatal deaths, sudden infant death syndrome are increased among women who use tobacco products. And if you look across, the evidence is sufficient to infer a causal relationship here. Pretty good evidence. Women who smoke have increased risks for conception delay and infertility. Low birth weight. I think most of us are familiar with this. Infants born to women who smoke during pregnancy have lower average birth weights. Again, the evidence is sufficient to infer a causal relationship. And then there are pregnancy complications, including abruptio placenta, placenta previa, and there's a modest increase in the risk for preterm delivery. All of which, again, the evidence is sufficient to infer a causal relationship. Now, here we have a slide that looks at some of the other medical consequences of tobacco use. Now, who would have thought that tobacco use is associated with cataracts? But women who smoke have an increased risk for cataracts. Now, in a very general sense, of course, chronic tobacco use is associated with diminished health. Hip fractures. Women who currently smoke have an increased risk fracture for hip fractures compared with women who do not. And again, the evidence is sufficient to infer a causal relationship between smoking and hip fractures among women. Low bone density, of course, goes along with this. Post-menopausal women who currently smoke have lower bone density. And peptic ulcer disease. The relationship between cigarette smoking and death rates from peptic ulcer, especially gastric ulcer, is confirmed. This is particularly evident in individuals who are positive for the heliobacter pylori. Now, it's interesting to me that with the literally mountains of research that have been conducted on tobacco and its many different problems, it causes medical and society at large, but there's only a small fraction that has been devoted to the effect of tobacco use on sleep. So clearly, this is an area that would benefit from a bit more clinically-oriented scientific research. But that doesn't mean we know nothing about it. Tobacco use does interfere with sleep. It makes it harder to fall asleep and stay asleep. Both of which, of course, would contribute to daytime fatigue. Overall, when you look at the polysomnogram of a tobacco use disorder individual, they have less time asleep throughout the study. Now, smoking, of course, may also cause inflammation of the upper airways. Now, there is this untested clinical hypothesis, which I present to you just for your interest and to see what you think of it. But it has been proposed that individuals with undiagnosed obstructive sleep apnea, which is probably a fair number of individuals, these individuals have somehow intuitively found out that they can self-medicate that sleep problem with tobacco, meaning the nicotine. How is that? Well, nicotine is associated with a higher arousal threshold which produces less sleep interruptions. And of course, the stimulant impact of nicotine helps fight that daytime drowsiness associated with obstructive sleep apnea. It's an interesting idea. Now, let's turn our attention to cannabis use disorders. And again, I wanna draw your attention to what I've underlined here, is that the current research has substantial limitations in this area. And there really is a need for ongoing research to better typify and with some certitude, identify the medical consequences of cannabis use disorders. But let's begin. Cannabis use disorder individuals may be at a greater risk of viral and some bacterial infections because of a decrease in their immune cell reactivity, which of course suppresses the individual's inflammatory response. Now, when it comes to whether or not chronic cannabis use can contribute to lung or bladder cancer, the research findings are contradictory. So we really have to leave this as plus minus. We should still inform our patients about the unsettled nature of the research nonetheless. Now, cannabis use disorders may be associated with chronic bronchitis, excess mucus production and wheezing. In terms of the use of cannabis on the cardiac system, again, the research is unsettled. It may produce an increased incidence of myocardial infarctions. The literature also has this term cannabinoid arteritis. There are unresolved neurologic problems associated with the use of cannabis. Does it impair learning, memory? Does it produce an increased risk of CNS vascular insults? And is there an increased incidence of tardy dyskinesia with chronic cannabis use? Other possibilities that have been looked at in literature include decreased male spermatogenesis and female infertility. Now let's move on to cocaine use disorders and the other stimulant use disorders. We're going to combine those to a degree. And perhaps not surprisingly, the primary medical consequences of stimulant use disorder would impact the cardiovascular system. And the most common complaint arising in this area is simply chest pain. Now acute myocardial infarction as a result of cocaine use disorders and other stimulant use disorders ranges anywhere in the literature from 0.7 to 6%. But look at this, who would have thought? Aortic dissection among this group as a medical consequence can range from 0.5 to 37%. That's a frightening outcome. Now other medical consequences include strokes. In particular with amphetamine use disorders, it's estimated that 5% of cardiomyopathies can be traced to the use, chronic use of amphetamines. In terms of the kidneys, cocaine and other stimulant-induced rhabdomyolysis has been reported along with cocaine use disorders. Now, I'm not going to go into the details of this, but rhabdomyolysis has been reported along with acute renal failure and hypertension naturally. In terms of the lungs, there are a wide variety of potential medical consequences here. It depends really on how the substance is used, for example, crack. In terms of neurologic disorders, the use of these particular agents can cause structural changes in the basal ganglia and there can be decreased volume in the cortical and cerebellar regions. Now let's turn to the medical consequences of opioid use disorders. And here, we're mostly talking about injection drug use, be it heroin or any other associated drug. And when we're thinking along those lines, there's a long list of medical problems, including bacterial endocarditis, infections such as HIV and hepatitis, pneumonia, cardiovascular insults, hepatic granulomatosis, which comes about as a result of the adulterants that are in the injected substance. And then there's the renal nephrotic syndromes. Opioid use disorders can result in cardiac dysrhythmias. Now, it's important to note that hepatotoxicity from unadulterated opioid agonists is rare, but opioid use disorders can be associated and it's reported in the literature with rhabdomyolysis. There is something called thrombotic microangiopathic anemia. Again, that's associated with people who inject drugs. There can be GI problems, of course, reduced motility, bowel obstruction can result. In the lungs, approximately 20% of opioid-related medical problems reside within this organ system, characterized by such issues as edema, bronchospasm, bronchitis, of course, respiratory depression, infections, and even chronic obstructive pulmonary diseases. And opioid use disorders can be associated with seizures and strokes, of course, the latter again being with people who inject drugs. So now we're going to talk briefly about the medical consequences of anabolic androgenic steroid misuse. Now, this may be an area that's not on every clinician's radar, and it does require some focus in this area since it typically involves fairly discreet subpopulations of individuals such as athletes or individuals aiming for a very aesthetic appearance. But nonetheless, the anabolic androgenic steroid misuse over long periods of time can produce certain medical problems that we should be aware of as clinicians. And so this slide sort of summarizes that. And so these are the possible long-term adverse effects of anabolic androgenic steroid misuse. And as you see, looking at the plus signs, there are two principal areas where this is an issue. The cardiovascular effects of chronic use can be atherosclerosis and cardiomyopathies. And then there are the neuropsychiatric effects, of course, the major mood disorders. And of course, we can have an abuse of anabolic androgenic steroid use disorder as a consequence of long-term use of these substances. So I wanted to end this presentation with a clinical case and invite your attention to this and see what you think is the most likely diagnosis in this presentation. This is a 42-year-old man who was admitted with hematemesis. He had three previous admissions with alcohol-related problems, and he had twice bled from esophageal varices. He had a history of excessive alcohol intake over five years with no periods of absence. On presentation, this individual had gastrointestinal bleeding, was jaundiced, he had mild ascites, but no hepatosplenomegaly. Now, if you look at the lab values at the bottom of the slide, that might give you a little bit more information to unravel this little mystery here. You see the bilirubin is a little bit elevated, as are the other liver function tests. So what do you think is going on here? Well, if you said cirrhosis, then you are correct. And if you learn more about this particular case, it was published. And as I mentioned before, the superscript, look down at the bottom of the slide, you can go to this particular reference and learn more about this clinical case. These are the resources that I used in preparation of this discussion today. Many of these I've highlighted as we went through our time together. Again, this was not meant to be a thorough, detailed analysis and presentation looking at the medical consequences of substance use disorders, but to highlight some of the key areas. I hope you found this presentation useful. And I invite you to look at these resources and learn more about this area. And so with that, again, on behalf of the American Osteopathic Academy of Addiction Medicine, let me thank you for your time and attention.

substance use disorders

medical consequences

alcohol use disorders

tobacco use disorders

cannabis use disorders

cocaine use disorders

opioid use disorders

anabolic androgenic steroid misuse