Substance Abuse: Ch. 10

Effects of Cocaine Intoxication

(All effects are short-lived) - Increased alertness - Euphoria - Feelings of power and confidence - Increased heart rate and blood pressure - Insomnia - Appetite suppression - Paranoia

Opiate and heroin: law/treatment intersection

- Access through police stations: making it so you can turn in drug stuff to police department and then you're turned to treatment (not arrested) - but these programs are expensive - Harm reduction policies: 1) Needle exchanges 2) Access to Naloxone (Narcan): can prevent overdoses (debate is now how available it should be) - opiate deathers are highest when there's less Narcan available

Populations at highest risk for substance abuse disorders

- Adolescents - Males - Individuals of lower SES and with less education

Substance-Related Disorders: List of possible substances in the DSM

- Alcohol - Cannabis - Hallucinogens - Inhalants - Caffeine (may NOT be diagnoses as substance use disorder) - Opioids - Tobacco - Sedative/hypnotic/anxiolytics - Stimulants - Other/unknown

Examples of Substance Use Disorders

- Alcohol Use Disorder - Cocaine Use Disorder - Opioid Use Disorder - Cannabis Use Disorder

Substance-Related Disorders: Examples of Serious Health Consequences

- Alcohol implicated in: multiple cancers, cardiovascular disorders, liver disorders, motor vehicle accidents (20%), self-inflicted injuring (11), homicides (24%) and suicides - Smoking is the most preventable cause of disease and death in North America

Class of drugs

1) Depressants 2) Stimulants 3) Opiates 4) Hallucinogens 5) Other

Impulse Related Disorders

1) Intermittent Explosive Disorder (acting on aggressive impulses) 2) Kleptomania (stealing) 3) Pyromania (setting things on fire)

Biological Treatments for substance disorders

1) detoxification 2) Antagonist treatments 3) Agonist Substitution 4) Aversive treatments

Alcohol Use Prevalence

50% of adults in US use alcohol

Cocaine Use Disorder: Course

Course is characterized by cycles of abuse, withdrawal and apathy, followed by resumed abuse

Course of alcohol abuse

Course is variable: - Early use is predictive of later alcohol-related disorders - Moderate alcohol-related difficulties in early adulthood, with more severe symptoms present by age 30, serious long-term health and life problems by age 40 - Response to the sedative effects to alcohol (e.g. slurred speech, poor motor control) may predict later use - Alcohol does not cause aggression, but may increase likelihood of impulsive behavior

Substance Disorders & Classical conditioning effects

Cues in the environment become associated with feelings of anticipation or pleasure

Substance Use Disorder - Diagnosis

Problematic pattern of substance use, leading to impairment and distress, with at least 2 symptoms

Cocaine Use Disorder: Prevalence of Cocaine Use

World-wide use of cocaine: 5%

Cocaine and Dopamine

Typically, dopamine increases in response to natural rewards such as food. When cocaine is taken, dopamine increases are exaggerated, and communication is altered.

Withdrawal

Unpleasant or dangerous reactions to stopping or reducing use of substance(s)

Changes between DSM 4 and DSM 4 re: Substance Use Disorders

= DSM 4 distinguished between: 1) "Substance abuse disorder" (use impairs functioning) and 2) "Substance Dependence Disorder" (more severe symptoms including tolerance or withdrawal may be present) - This distinction does not exist in the DSM-5, as they've been combined (combining criteria for abuse and dependence) into "Substance Use Disorder" - which is specified by the type of substance and severity (# of symptoms met indicates level of severity) - Other changes in DSM 5: elimination of "legal problems" criteria and addition of "craving" criteria

Other Substances: Examples

???

Opioid Use Disorder: Long-term outcomes

Very poor long-term outcomes, including increased mortality by overdose and suicide

Substance Related Disorders: Heritability Estimates

- Alcohol: 51-73% - Smoking: 0-60% - Cannabis: 30-80%

Principles of AA (examples)

- Alcoholism is a progressive, chronic illness - Alcoholics have permanently lost the ability to control drinking - Only viable alternative is total and lifelong abstinence - Acceptance and reaching out to fellow alcoholics are key steps towards improvement - Faith in a higher power is a key principle

Cannabis Use Disorder: Effects of Cannabis

- Altered perception - Heightened sensory experiences and emotional reactions - With variability in individual responses

How the brain adjusts to cocaine (excess dopamine)

- Chronic cocaine abuse leads dopamine receptors to down-regulate, so that fewer areas/receptors in the brain can feel or experience pleasure - This makes the brain less sensitive to cocaine and probably naturally-occurring rewards

Cocaine Use Disorder: Addictiveness and effects of continued use

- Cocaine is highly addictive - Continued use associated with increased cravings and tolerance, sleep disruption, increased paranoia, social isolation; withdrawal characterized by apathy and anhedonia

Other CBT treatments

- Community Reinforcement Training: multidimensional approach (relationships, employment, etc.) - Relapse prevention

Agonist Substitution: Methadone

- Controversial (no one wants a methodone clinic in their backyard; not getting people off the drug, just giving them an alternative) - Benefits - Compared to other forms of treatment, methodone: - Reduces drug use - Reduces medical comorbidity - Decreases transmission of HIV - Reduces mortality (bc of lower risk of overdosing) - Improves social functioning

Treatment goal: Abstinence vs. Controlled Use

- Debate over which is best/most effective - Controlled use can be good for getting people's foot in the door - Abstinence is good for high-risk drugs

Prevention of substance-related disorders

- Education-based Prevention programs (like DARE): little evidence for effectiveness - Comprehensive, community-based programs: for example, limiting under-age access, stricter enforcement of laws - Changing social views and acceptability: for example, changing social views and laws about smoking

Key concept of treatment: recovery as a process

- Effective treatment requires adequate time - Attention to relapse prevention is necessary

Treatments: Social Context Interventions

- Emphasis on broader social community - Can be used to motivate change - Ex: AA

Opioid Use Disorder: Immediate Effects of Opiods

- Euphoria - Drowsiness - Pain relief - Slowed breathing (at high doses, respiration can be entirely depressed resulting in death)

Social-Cultural Factors and substance exposure

- Exposure to substances through media and peers - Family factors, especially monitoring/supervision and onset in adolescence - Religiosity appears to be a protective factor - Family and peer beliefs, attitudes, and behaviors

Family Involvement and Treatment

- Families members are often the ones that present for treatment 1) Al-Anon: almost like AA to support family members (helps lessen stress on family members, not much effect on getting family member to stop using) 2) Johnson intervention: not found to be very effective 3) Community reinforcement training (for partner): helps spouse recognize where they're reinforcing behaviors in their partners substance abuse (cleaning up throw up, etc.)

Newer high risk drugs

- Fentanyl (opioid sometimes mixed with heroin) - K2/Spice (synthetic cannabinoid) - "bath salts" (synthetic cathinones: Stimulant - sometimes found in Molly/MDMA)

Neurotransmitter Systems Influenced by Alcohol

- GABA (inhibitory NT) - Glutamate (excitatory NT associated with learning and memory) - Serotonin (associated with mood, sleep, eating)

Substance Related Disorders: Genetic Factors

- Genes may affect how people experience particular substances (they have a genetic reaction that makes them more or less likely to drink/use a lot - ex: amount of dopamine, facial flushing, etc.) - Polygenetic influences, no specific genes identified - Addictive personality: Impulsivity and sensation seeking personality traits predict substance use and disorders

Treatment matching

- How do factors such as a client's personality, reasons for substance use, and motivation/readiness to change influence the effectiveness of different treatments? - Research found no clear benefit for matching treatments, as all treatments had same efficacy, whether or not they "matched"

Effects of alcohol intoxication

- Initial effects include slowing of inhibitory centers of brain (e.g. increased sociability) - Continued consumption associated with impaired motor coordination, reaction time, judgment, and vision/hearing

Long-term health risks of heavy drinking

- Liver disease - Pancreatitis - Cardiovascular disorders - Brain damage (including dementia and Wernike-Korsakoff Syndrome) - Fetal Alcohol Syndrome (FAS)

Psychological Treatments: Motivational Interviewing/Enhancement

- May be a preperatory or primary intervention - Addresses readiness and motivation to change - Explores ambivalence about change, helps client to advocate for their own change - Intended to address problem of poor treatment engagement - Often seen with court-mandated therapy

Antagonist Substitution Study

- Naltrexone and CBT treatment was more effective than Placebo and CBT treatment

Opioid Use Disorder: Withdrawal symptoms

- Nausea - Vomiting - Chills - Muscle aches - Diarrhea - Insomnia

Substance-Related Disorders: Psychological Factors - Cognitive and Learning Processes

- Positive reinforcement - Negative reinforcement - Expectancy effects - Classical Conditioning effects

Drug use trends across the US

- Regional differences are seen in substances used - Laws and policies can have impacts on overdoses - There are newer high risk drugs out there

Alcoholism Risk: Genetics

- Serotonin transporter gene has been liked to binge drinking in college students - Genetic variants for enzymes that metabolize alcohol have been identified - Genes that effect serotonin and GABA are involved

Substance-Related Disorders: Clinical Picture

- Severe impact on behavioral functioning (disrupted sleep, sexual dysfunction, high-risk behaviors, relationship problems) - Potential for legal problems and criminal behavior - Serious health consequences

AA

- Social context intervention - 52,000 groups in US (1.2M members) - "12 step" program - Most widely used substance use program - Not run by professionals - Found to work for people who stick with it - It's kind of religious and has some bold assumptions, which turns off some people to it - There can be quality control issues for people who are running the groups (with limited training)

Substance Use Disorder: List of Symptoms

- Substance taken in larger amounts or for longer period than intended - Desire or unsuccessful efforts to reduce use - Much time devoted to obtaining, using, or recovering from use - Craving or strong urge to use - Use results in failure to fulfill major role obligations - Continued use despite social/interpersonal problems caused by use - Important social, occupational, recreational activities given up due to use - Recurrent use in physically hazardous situations - Continued use despite knowledge of associated physical/psychological problems - Tolerance - Withdrawal

Aversive Treatment: Antabuse

- Take it in the AM - Triggers vomiting if they drink later in the day - Poor compliance - Within 3 days it's out of your system (and you can drink again)

Key concepts in treatment of substance-related disorders

- Treatment needs to be readily available - Only 25% of people with these disorders seek treatment - Treatment may occur in multiple different settings - Treatment does NOT need to be voluntary to be effective - No clear benefits of inpatient vs. outpatient treatment

Heavy Drinking Withdrawal Symptoms

- Tremors - Anxiety - Agitation - Hallucinations - Nausea - Extreme symptoms associated with delirium tremens (DTS): include body tremors and intense hallucinations

Psychological Treatments: CBT

- Working with people around the way they think about substances - Emphasis on expectancies (finding evidence that goes against beliefs they have that support their substance abuse: is it always fun when you're drunk?) - Drink/drug refusal and coping skills for dealing with triggers for use, both intrapersonal (e.g., mood states, stress) and interpersonal (e.g., conflicts with others) - Cue exposure (ask people to be around things that make them want to use, like needles, and then work on controlling the urge) - Lapse episodes as learning experiences

Does AA work?

- Works best for those who participate fully - 12 step programs may work as well as CBT - May be helpful after formal treatment to maintain sobreity

"Smart Recovery"

AA alternative peer-led group - Uses CBT and Motivational Interviewing principles - Also delivered b peers

Depressants: Examples

Alcohol and sedative-hypnotic (anxiolytic) drugs, including: barbiturates and benzodiazapines

Hallucinogens: Immediate effects

Altered sensory perception, mood changes, hallucinations, dellusions

Suboxone

Buprenorphine combined with naloxone (opiate antagonist) - Not as effective as Buprenorphine

Stimulants: Examples

Caffeine, nicotine, amphetamines, cocaine

Cannabis Use Disorder: Prevalence of Use

Cannabis us the most commonly used illegal substance (5-15%)

Depressants: Immediate Effects

Decreased Central Nervous System activity, reduced inhibition and arousal, relaxation

Substance abuse

Defined by degree of functional impairment

Cannabis Use Disorder: Effects of Frequent Use

Frequent use may be associated with impaired memory and concentration, as well as cannabis-related social and occupational problems

Opiates: Examples

Heroin, morphine, codeine

Opiates: Addictive Potential

High

Stimulants: Addictive potential

High

Substance-Related Disorders: Comorbidity

High rates of comorbidity: - Poly-substance use is common, for example: 58% of heavy drinkers also smoke; common combined cocaine and alcohol use - Mood disorders (40%) - Anxiety disorders (25%)

Substance-Related Disorders: Prevalence

High rates of relapse - Up to 70-80% of treated alcoholics relapse over the long term Lifetime prevalence - Alcohol abuse: 13.2% - Alcohol dependence: 5.4% - Drug abuse: 7.9% - Drug dependence: 3.0% - Any substance use disorder: 14.6%

Study: Alcoholism Risk - Differences in Response to Alcohol

High risk individuals: when sober, respond intensely to stress (high heart rate) - when intoxicated, show less stress (lower heart rate) -- this becomes reinforcing

Cannabis Use Disorder: Tolerance and Withdrawal Symptoms (& addictive potential)

Inconsistent findings with regard to tolerance and withdrawal symptoms; seemingly lower addictive potential

Stimulants: Immediate effects

Increased arousal, alertness, increased energy and excitement

Influence of Cocaine on the brain

Influences dopamine system (blocks uptake), with activation of pleasure pathways and associated "high"

Buprenorphine

It'a a partial opiate agnoist: - Acts on heroin receptors - It reduces the cravings without the same high (so prevents withdrawal) - Can be provided in medical settings with restrictions to prevent illegal use - It's 3 times more common than methadone treatment - Hard to get enough of this to enough people (due to many restrictions)

Hallucinogens: Examples

LSD, Cannabis (marijuana), psilocybin, mescaline, Phencyclidine (PCP

Tolerance

Larger doses needed to achieve earlier effects

Biological Treatment: Detoxification

Medically supervised withdrawal from a substance; may include medications to reduce withdrawal symptoms - First stage of treatment: by itself, does little to change long-term use and outcomes

Depressants: Addictive potential

Moderate (alcohol, benzodiazepines) to high (barbiturates)

Substance use

Moderate ingestion, without significant interference in social, educational, work functioning

Biological Treatment: Aversive treatments

Prescribed drug makes ingestion of substance unpleasant (e.g., Antabuse)

Biological Treatment: Antagonist treatments

Prescribed drug that blocks or changes the effects of the abused substance (ex: naltrexone)

Trends in illicit substance use

Most commonly used: 1) Marijuana (1 in 10 Americans) 2) Benzodiazapines 3) Cocaine 4) Ecstacy Most ER visits: 1) Crack & Cocaine 2) Marijuana 3) Benzodiazepines 4) Heroin Gaining users: 1) Heroin (doubled) 2) LSD 3) Marijuana 4) Ecstacy 5) Oxycodone Losing users: 1) Crack 2) Meth 3) PCP 4) Inhalants

Biological Treatment: Agonist substitution

Prescribed substitute drug under medical supervision - that has a similar effects to the drug of abuse but without the same harmful effects - Ex: methadone, nicotine replacement - Big piece in treating opiate addiction

Opioid Use Disorder: Other health risks

Other health risks associated with intravenous (IV) use

Alcoholism Risk: Problematic Parenting

Parental alcoholism leads to: - Ineffective monitoring (of children's' behaviors) - Stressful events - Negative affect All of the above, when experienced by children, leads to substance abuse in those children

Substance Disorders & Positive Reinforcement

Pleasurable experiences are associated with substance use

Substance Disorders & Negative reinforcement

Reduced negative experiences (e.g. less stress, tension, etc.) are associated with substance abuse

Opiates: Immediate Effects

Reduced pain, reduced emotional tensions, induced euphoria

Substance Disorders & Expectancy effects

Reinforcement eventually leads to expectancy effects: anticipation that substances will be rewarding, leading individuals to seek them out

Substance dependence

Term may be used to describe addiction or physiological dependence on the substance, including: 1) tolerance, 2) withdrawal

Study w/ Methadone treatment

Tested 2 treatments: 1) Keeping people on methadone for a year 2) half year with methadone then tapering off to therapy Found: People are more likely to relapse with only half a year of methadone (even with therapy)