Psych 162 Final - Ray

Psychological Model of Addiction: *Personality Factors* (3)

"Addictive personality" concept elicited considerable interest but its controversial and has weak empirical support Some normative personality traits consistently associated with addictive behavior: 1) Impulsivity: capacity for self-control of arising impulses 2) Behavioral tasks (making a gambling decision) 3) Baratt Impulsiveness Scale (BIS): questionnaire that has dimensions that show more or less of impulsivity

Behavioral Interventions for Addiction: *Couples and Family Treatment* (4)

(Relevant in adolescence) 1) Treat individuals in the context of family and social systems in which substance use may be maintained 2) Family based approaches are quite diverse and not equally effective 3) There is support for behavioral couples therapy (BCT) 4) Benefits beyond substance use: increase family adjustment, reduction of intimate partner violence

Prevalence of Alcohol Use Disorder

*12 month prevalence*: 13.9% *Lifetime*: 29.1% Prevalence was highest for men, white and native american respondents, and younger and previously married adults

Prevalence of Tobacco

*12 month*: 20% *Lifetime*: 27.9% Current smoking rate in California: 13.7% (varies by state) Smokers with at least 1 psychiatric disorder: 11.1% but smoked 53.6% of total cigarettes - Smoking cessation rates have plateaued because a big chuck of users have comorbidities with psychiatric disorders (depression, heavy mental illness) - New tobacco products ("vape")

Prevalence of Drug Use Disorders

*12 month*: 3.9% *Lifetime*: 9.9% Drug use disorder was generally greater among men, white and native american individuals, younger people, those with lower education and income, and those residing in the west (geographical trends in California)

Prevalence of Cannabis Use Disorder

*12-month*: 2.5% (average days of use per year is 225 days) *Lifetime*: 6.3% (average days of use per year is 274 days) *Only 13.2% of those with lifetime CUD participated in 12-step programs or treatment* - Many users don't think their use interferes with their performance

What is AUDIT? (3)

*A simple and fast way for screening risky or hazardous drinking*. Defines risky/hazardous drinking as a pattern of consumption that increases risk of harmful consequences for the user 1) Fairly accurate (>90% correctly identified and ~80% correctly rejected) 2) Higher scores indicate greater likelihood of hazardous drinking and alcohol dependence, but the *AUDIT can't tell you that you have a drinking problem for certain* (it's a screening, not a diagnosis) 3) There are recommended cutoff points, but not enough research to distinguish harmful drinkers from dependent drinkers using just the AUDIT *Pros*: flexibility, quick and easy, risk for dependency, accuracy *Cons*: no diagnosis, risk for false positive, could lie SCALE FOR RISK: 0-7 = low risk 8-15 = hazardous 16-19 = harmful risk >20 = possible dependent Not all hazardous drinkers become dependent, but no one develops dependence without being a hazardous drinker for some time

Behavioral Interventions for Addiction: *Harm Reduction*

*A strategy for reducing harm to drug users and people close to them; somewhat contrary to abstinence based programs/12-step programs* Examples of Harm Reduction: 1) Public education 2) Methadone maintenance (receiving high dose opioids but in a controlled environment) 3) Needle-exchange programs 4) Controlled drinking

Diagnosing an AUD: *The structured clinical interview for DSM-5* (SCID)

*A structured interview guide for making diagnoses* 1) Adminstered by a clinician or trained mental health professional to ensure that DSM diagnoses are systematically evaluated 2) Questions in the interview parallel symptoms in the DSM (so symptoms described in the DSM become tangible usable constructs) *Pros*: Diagonsis *Cons*: Not as accessible, need a clinician to do it, takes a long time

Attribution Theory vs Familiarity Hypothesis

*Attribution*: For ex: male gender, addiction to "stronger" drugs, and engagement in risky behavior *increased* stigmatizing responses *Familiarity*: Measures of familiarity such as education and having peers with Substance Use Disorder mainly *decreased* stigmatizing responses as expected

Psychosocial Treatments of Addiction *Background* (4) *and its Fundamental Principles* (2)

*Background*: 1) Changes in models of care from inpatients to outpatients 2) Still few evidence-based treatments programs available (no science based programs or reliable tests/stats) 3) Field dominated by delivery of approaches of unknown efficacy 4) Specialized treatments are unlikely to be adopted and instead core principles of effective intervention should be identified *Fundamental Principles*: 1) Addiction is marked by excessive drive based on associative learning via classical and operant conditioning 2) Neuroadaptation, neurotoxicity, and/preexisting deficits in the brain's reward circuitry can be something that makes people vulnerable

Central Nervous System Depressants (4)

*Benzodiazepines, Barbiturates, and opioids* 1) CNS depressants cause a slowing of nerve cell activity in all portions of the CNS 2) Slowing down of a portion of the brain might produce a 'speeding up' (release of inhibitors) in other brain areas, leading to behavioral excitation 3) Alcohol is an example of a CNS depressant hat produces paradoxical behavioral stimulation, know as a biphasic alcohol effects (blood level going up = stimulant effect; blood alcohol level going down = sedative effect) 4) Central nervous system (CNS) depressants, is a category that includes tranquilizers, sedatives, and hypnotics; all substances that can slow brain activity

Tobacco Use Disorder: *Pharmacological Interventions* (3)

*Can double or triple their results for success* 1) Nicotine Replacement Therapy (NRT): provides low doses of nicotine to reduce withdrawal symptoms; comes in the form of patches, gums, etc; safe without serious side effect; increase the likelihood of quitting by 50-70% 2) Varenicline (most effective): a partial nicotine receptor antagonists, stimulating a4b2 and a3b4 receptors to provide withdrawal relief while inhibiting the rewarding effects of smoking; more effective than NRT and Bupropion with abstinence rates at 6-month follow up 20-30%; cardiovascular and psychiatric side effects 3) Bupropion (Zyban): nonselective inhibitor of dopamine and norepinephrine transporters; commonly used to treat depression but also efficacious for smoking cessation; *good alternative for people with mood disorders*

Biological Model of Addiction: *Allostasis Theory* (2)

*Highlights that drug addiction has characteristics of both impulse-control disorders and compulsive disorders, and how the brain reaches homeostasis* 1) Impulse control disorders involve a sense of tension or arousal preceding an impulsive act 2) Compulsive disorders involve anxiety and stress preceding a compulsive repetitive behavior and a release of stress by performing the compulsive behavior

12-step programs: *How does it work, For whom does it work* (3), *and Clinical recommendations* (4)

*How does it work?* - 12-step facilitation is as effective as motivational enhancement and cognitive behavioral coping skills training - Common factors such as motivation, self-efficacy, and coping - Social support is also very important "sober" support system - It is a strong treatment dose (can attend multiple meetings a day) - Concepts that can be translated across treatment approaches *For whom does it work?* 1) It is most useful for patients that are in networks supportive of drinking 2) Those with less social support, less educated, less socially skilled, less religious, unstably employed 3) Those with more severe alcohol-related problems have greater benefits *Clinical Recommendations*: 1) Do not prejudge who would or would not be a good candidate for AA (let them find out themselves) 2) Be sensitive to the difficulty of and the fears about getting involved in AA (let them find the right group for themselves) 3) Focus on the potential gains of involvement; if client is not interested consider alternatives 4) Recommend high levels of AA involvement (don't just sit in)

Medical Model vs Contextual Model

*Medical Model*: person with an illness is prescribed a specific treatment that will lead to the cure or reduce the symptoms *Contextual Model*: suggests that patients improve through a combination of relationship alliance, belief that they will get better, and set of specific ingredients that address the problem - Common therapeutic factors - Empirically supported therapy relationships (ESRs): remoralizing patients ESTs are based on the medical model or technology model

Treatment of Addiction: *AA/12-step Programs* (5) *and its outcomes* (4)

*Mutual help groups - very powerful* An estimated 6% of former drinkers have used AA when quitting *12-step involves*: 1) Acceptance of having chronic, debilitating disease with no cure but abstinence 2) Surrender to a higher power and to AA fellowship 3) Taking a moral inventory 4) Making amends 5) Help others *Outcomes*: 1) AA attendance is associated with better outcomes 2) The group format is seen as a barrier by some patients (social anxiety) 3) Individuals who affiliated with AA relatively quickly and participated longer have showed better outcomes up to 8 years later (Having a sponsor can influence this) 4) AA is associated with better outcomes in dual diagnosis patients The role of religiosity and spirituality is important; serenity prayer is commonly used

Prevalence of Prescription Opioids

*Nonmedical prescription opioids use* (NMPOU) - using for recreational purposes *12-month*: 4.1% *Lifetime*: 11.3% - NMPOU increased considerably over the past decade ("opioid Epidemic")

Opioid Use Disorder: *Pharmacological treatments* (3)

*Opioid subtitution therapies (OSTs) and opioid replacement therapies (ORTs) are the gold standard for treating opioid use disorder* - Treatment address withdrawal - Work to replace short-acting opioids with longer-acting less euphoric opioids with the aim of reducing craving and withdrawal - Hard to get patients to adhere to treatment 1) *Methadone maintenance therapy*: goal is to reach an optimal dose based on assessment of withdrawal and craving, and maintaining that dose for long periods; patients have to go to the clinic daily to receive their dose 2) *Combination Buprenorphine and Naltrexone - SUBOXONE*: partial agonist; efficacious treatment; patient can't get high; poor adherence w/o physician contact; effective for treating smokers who are also concerned with weight loss 3) *Naltrexone*: opioid receptor antagonist prevents the "high" from use opiates

Psychological Model of Addiction: *Developmental Psychopathology* (5)

*Seeks to understand psychiatric conditions as maladaptive deviations from normative development* 1) Broadens lens to capture influences prior to drug use (prenatal influences, adverse childhood events) 2) Critical developmental window for addiction is from adolescence to young adult 3) "Mature out" process for many individuals, particularly alcohol use (fostered by role transition; e.g. graduate college) 4) Consistent with normative exploration and experimentation in adolescence and young adulthood (at this age, we are hardwired to explore and experiment) 5) Perspective enhanced by understanding of neurocognitive development

Sensitization: Repeated Stimulation vs. Reduced Stimulation

*Sensitization*: an important process in the development of addiction and may occur rapidly after drug intake *Repeated Stimulation*: - Decreased number of receptors - Remaining receptors less sensitive - Down-regulation or desensitization (Changes the chemistry of the brain and have significant consequences, like depletion of dopamine signaling in the brain which is apart of what causes anhedonia or flattening of affect -ex: cocaine) *Reduced Stimulation*: - Increased number of receptors - Remaining receptors more sensitive - Up-regulation or sensitization

Biological Model of Addiction: *Incentive Sensitization Theory* (3)

*The model focuses on how drug cues trigger excessive incentive motivation for drugs, leading to compulsive drug-seeking, drug-taking, and relapse (reaction to drug is strong)* 1) Suggests that the anatomy of addiction involves the mesolimbic dopamine system, with an emphasis of NAcc-circuitry 2) NAcc-circuitry is essential to provide salience (e.g. meaning) to environmental stimuli associated with drug award 3) Neuroadaptation is thought to involve long-lasting changes in the NAcc-curcuitry, such as increase in DA release in the NAcc Sensitization for addiction is subject to individual differences due to genetics, environmental factors, and their interactions. Sensitization is thought to be accompanied by a major reorganization of the brain reward system (e.g. change in length of dendrites, density of dendritic spines - the actual structure of neurons)

CNS Depressant: *Barbiturates* (3)

*There are old CNS depressant drugs that fall into the sedative-hypnotic category but have been replaced with benzodiazepines* 1) Includes: nembutal, seconal, phenobarbital (longest acting and lower dependence liability) 2) There are currently few indications for the therapeutic use of barbiturates, such as treatment of convulsions and general anesthetic 3) The withdrawal from barbiturates is particularly severe and may produce hallucinations and seizures

(11) Symptoms of someone experiencing *Substance Use Disorder*

*These symptoms show across other drugs as well* 1) Alcohol used in larger amounts or over a longer period of time than intended (lost of control) 2) Persistant desire or unsucessful attempts to cut down or control alcohol use 3) Significant time spent obtaining, using, and recovering from the effects of alcohol 4) Craving to use alcohol (*new symptom added from DSM-4*) 5) Recurrent alcohol use leading to failure to fulfil major role obligations at work, school, or home 6) Recurrent use of alcohol, despite having persistent or recurring social or interpersonal problems caused or worsened by alcohol 7) Recurrent use of alcohol, despite having persistent or recurring physical or psychological problems caused or worsened by alcohol 8) Giving up or missing important social, occupational, or recreational activities due to alcohol use 9) Recurrent alcohol use in hazardous situations (i.e., drunk driving) 10) *Tolerance*: markedly increased amounts of alcohol are needed to achieve intoxication or the desired effect, or continued use of the same amount of alcohol achieves a markedly diminished effect (problematic in opioids) 11) *Withdrawal*: there is the characteristic alcohol withdrawal syndrome, or alcohol is taken to relieve or avoid withdrawal symptoms (different class of drugs have different symptoms of withdrawal)

Psychological Model of Addiction: *Variability in Acute Drug Effects*

*Variation in the drug's subjective effects as a determinant of use and misuse* Ex: drink alcohol and feel good = positive reinforcement; drink alcohol and get flushing = negative reinforcement - Early theory that alcohol use was predicted by alcohol's ability to reduce tension in a given individual (tension-reduction model) - Stimulant and sedative effects of alcohol (stimulant effect = positive; sedation effects = negative) *Corresponds to the level of response to alcohol*

CBT focuses on "starting with the basics" early in recovery, which means?

- Focusing on recovery activities - Focusing on compliance (start slow and let it happen and let patient engage better)

CNS Depressant: *Opioids* (5)

- Narcotics are "drugs that produce sleep or grogginess" - Natural opiates are derived from the opium poppy and include morphine, codeine, and semi-synthetic compound derived from them, such as heroin - Methadone is a synthetic opioid with a long half-life. Buprenorphine (suboxone) is a synthetic opioid that has partial agonist properties.Other prescription opioids include: oxycontin, Vicodin, fentanyl 1) Works by mimicking the activities of naturally occurring peptides known as endorphins 2) Relative to other drugs, opioids have relatively few serious side effects 3) Approx. 23% of people who use heroin become dependent 4) Accidental overdose is a great risk with opioids: these can be treated with opioid antagonists such as naltrexone 5) Chronic opioids use causes large amounts of rapid tolerance buildup and severe uncomfortable withdrawal

Fundamental Principles: *Behavioral Therapies*

1) *"Shoring up the breaks": fostering executive control* - CBT focusing on developing new inhibiting and controlling behavior systems - Cognitive remediation strategies to strengthen brain functions (enhance executive function in the brain) 2) *Reducing Drives*: - Less direct effect (deconditioning of cue craving) - Most powerful effect may be in combination with pharmacotherapies - Behavioral and pharmacological treatments have different target and are thought of as complimentary

Biopsychosocial Models (3)

1) *Biological determinants*: changes in the brain or cellular level of analysis 2) *Psychological determinants*: personality/characteristics 3) *Social determinants*: access to drugs, peers who use drugs, social context

Tobacco Use Disorder: *Psychological Interventions* (2)

1) *Brief intervention*: minimal contact intervention (MCIs) - Ask, Advise, Assess, Assist, Arrange 2) *Formal treatment programs*: smoking cessation specialist treatment (3x more effective than MCIs), CBT, Contingency Management, individual or group treatment

Other Considerations for Opioid Use Disorder (5)

1) *Chronic pain*: opioids are used for pain management 2) *Infectious disease*: high rates of IV drug use are paralleled by high rates of HIV, hepatitis, and other infectious diseases 3) *Psychiatric Comorbidities*: high rates of mood, anxiety, and personality disorders; negative impact on outcomes 4) *Polysubstance use*: Patients with OUD often experience problems with other substances like alcohol, cocaine, cannabis, etc (use is driven by access) 5) *Sex effects*: Interaction between opioids and sex hormones which may affect fertility and produce sexual side effects

Opioid Use Disorder: *Psychological Treatments* (5)

1) *Cognitive behavioral therapy*: high-intensity CBT is recommended - 6+ months; teaches skills to help patients cope with urges, identify triggers, and consequences 2) *Dialectical Behavioral Therapy* (DBT): teaches individuals how to be mindful, present in the moment, communicate, problem-solving 3) *Reinforcement-based treatment*: Contingency management (use positive reinforcers to encourage patient to meet goals) and Community reinforcement approach (encourage patient to examine the important reinforcers and identify alt. positive and negative reinforcers) 4) *Motivational Interventions*: MET, MI, Both forms combined have a more robust psychological treatment 5) *Family and couples therapy*: Assumed that the quality of relationship with family members influences one's substance use behavior and vice versa; higher treatment retention and more clean urine tests

Alcohol: Psychological Interventions (4)

1) *Counseling*: includes brief advice, motivational interviewing (MI), and CBT (only works for lower levels of severity - learn better after teachable moment) 2) *Brief Interventions*: employed in primary care and ED settings; reduces drinking in low severity 3) *Longer term interventions*: CBT, MET (Motivational Enhancement Therapy) , AA; pharmacological therapy 4) *Computer-based Intervention*: redrinking thinking; walks through important steps in intervention like psychoeducation and evaluating/making a plan to reduce drinking

FDA Approved Pharmacological Interventions for Alcohol (3)

1) *Disulfiram* 2) *Naltrexone* 3) *Acamprosate* *COMBINE Study* used too

Pharmacotherapies address two broad objectivities (2):

1) *Establishing initial abstinence*: transition from using to not using, involving some level of detox or withdrawal 2) *Relapse prevention*: promote recovery

Therapeutic Considerations (2)

1) *Medication adherence*: - High rates of non-adherence/non-compliance in SUD (also true in alcohol and other drugs of abuse) - *Significant results ONLY in adherence samples* (answer different for efficacious medication) - BRENDA supportive counseling increases adherence - translated to MM (can teach providers how to sympathize and encourage adherence) 2) *Comorbidity*: - Co-occurring psychiatric disorders are common and medications may be especially important in comorbid cases - They tend to have a worse prognosis, such that its harder for them to recover

Future Directions for CNS Stimulant treatment: (2)

1) Address high rates of comorbidity ("complex patients") 2) Treatment development efforts (novel treatment targets, stimulant "vaccines")

Pharmacological Treatments: Major Classes of Drugs (4)

1) Agonists 2) Indirect agonists 3) Partial agonists 4) Antagonists

Alcohol: Interaction with other drugs (3)

1) Alcohol can increase the effects of medications that make people drowsy, alter the metabolism of medications, or reduce the effectiveness of medications 2) Alcohol interacts with oral contraceptives, which slow down the break down of alcohol leading to longer intoxication and sedation 3) Dosing and timing are critical to interactive effects between alcohol and other drugs

Marijuana: Immediate Effects (8)

1) Altered Mood (Euphoric feelings) 2) Altered perception (sensory perception, paranoia) 3) Cognitive Impairment (attention, memory) 4) Impaired coordination/balance 5) Hunger 6) Sedation/Drowsiness 7) Increased heart rate 8) Anxiety (reduced or increased)

Correlates of Drug Use Disorder (5)

1) Among respondents with 12 month DUD, *13.5%* received treatment 2) Among respondents with lifetime DUD, *24.6%* received treatment 3) Often associated with: depression, bipolar 1 disorder, PTSD, antisocial disorder (acting out behavior), borderline personality disorder, and schizotypal personality disorders 4) Most common disorder associated with DUD is using another drug, called *polysubstance disorder*; they tend to use what is available to them 5) DUD is associated with significant disability, increasing with DUD severity

Behavioral Interventions for Addiction: *Motivational Interviewing (MI)* (3)

1) Based on the principles of motivational psychology and is intended to enhance patient's intrinsic motivation for change (allow patient to talk about motivation and guide their process of self-reflection and emphasize the changes statements) 2) There is stronger support for the use of MI with alcohol than drugs (good for low level severity of alcohol use) 3) MI may be used in combination with different strategies in order to enhance treatment engagement

Marijuana: *Psychological treatments* (3)

1) Behavioral therapies: CBT, MET, CM (multicomponent treatment is most potent for adults and adolescents) 2) Online MET-CBT manuals developed as part of the marijuana treatment project 3) Parental involvement is highly recommended for youth with CUD

Basic Concepts in Addiction Biology (3)

1) Drug act as unconditioned reinforcers, in part by increasing DA output (Instrumental learning) 2) Tolerance develops in response to neuroadaptations caused by repeated drug intake, leading to escalation of drug consumption and abstinence syndrome 3) Cues paired with drugs increasingly play the role in eliciting drug-seeking habits (pavlovian learning)

Drug Classification (3)

1) Drug is any chemical (not food/water) that produces a therapeutic or non-therapeutic pharmacological effect 2) Drugs that cause an altered consciousness are called centrally active drugs (act on the CNS) 3) The Drug Enforcement Administration (DEA) classifies drugs according to a schedule (ex: one month prescription of adderall at a time) Categories include: Medicinal (therapeutic), legal (licit), and illegal (illicit)

CNS Depressant: *Benzodiazepines* (5)

1) Effective in reducing anxiety and promoting sleep 2) Anxiolytic benzodiazepines include: Xanax, Librium, and Valium 3) Hypnotic benzodiazepines include: Dalmate, Halcion, Restoril 4) These drugs increase the function of GABA in the brain (GABA agonists), which in turn suppresses anxiety 5) These are controlled substances to be used in a fixed number or doses - It is estimated that 9% of users develop benzodiazepine dependence - Individual benzodiazepines differ in their rate of absorption and metabolism (vary in the blood level) - Xanax is a popular anti-anxiety agent with evidence suggesting higher dependence liability (a little more addicting)

How to evaluate Empirically Supported Therapy (EST) (3)

1) Efficacious 2) Possibly Efficacious 3) Efficacious and specific *Efficacy - controlled trials* - Are based on the medical model or technology model

Fundamental Principles: *Social Learning Skills Training and CBT Models* (2)

1) Grounded on social learning theory and emphasize patterns associated with the maintenance or substance use of relapse (identify when people drink and what triggers them) 2) Skills training and CBT encourage behavioral change through exposure and practice of new coping behaviors

Queri Example: VA QUERI example

1) Identify gap in EBP: some are underprescripted, can lead to relapse 2) Develop and implement a strategy for change: update places to clinical guidelines 3) Test strategy 4) Document systems improvement 5) Document outcomes and quality of life improvements

Behavioral Interventions for Addiction: *Contingency Management (CM)*

1) In CM, patients receive incentives or rewards for meeting specific behavioral goals, such as verified abstinence 2) CM is based on operant conditioning models and has strong empirical support 3) CM is implemented in the context of treatment programs 4) Voucher-based incentives have been effective in reducing substance use (may be extended to outcomes other than negative toxicology)

Future Direction of EBPs (3)

1) Initial efficacy results may be "lost in translation": less generalizable to diverse and complex settings 2) Need for "practice-based evidence" 3) "Measurement-based practice": real-time outcome measurement is used to validate approaches and allow immediate feedback to patients, clinicians and programs to enable clinical improvements; future of efficient care delivery in healthcare

FDA Approved Pharmacological Interventions for Alcohol: *Naltrexone* (5)

1) Injection or oral 2) *Opioid receptor antagonist* (blunts reward effects of alcohol) 3) Side effects are generally mild, nausea being the most prevalent one 4) May work for reward drinkers 5) Promotes abstinence and reduce the number of drinks during a drinking episode *Best used in combination with behavioral treatment*

Nicotine (6)

1) Known as the most toxic drug that acts at specific receptors in the body, the nicotinic acetylcholine receptor 2) Tar (tobacco smoke) and other ingredients are the probable cause of heart disease and lung cancer in chronic smokers, yet nicotine is responsible for the chemical dependence 3) 25% of the US population smokes regularly and the number of new smokers is declining 3) 32% of smokers become dependent on nicotine (good indicator if abuse liability) 4) Myth that it helps with weight loss (end up gaining weight after quitting) 5) Excessive smoking is common among patients with severe psychiatric disorders like psychosis because it increases dopamine release 6) Babies born from mother who smoke during pregnancy are smaller, lighter, and have smaller lung capacity

Pharmacological Treatments: *Opiates* (4)

1) Methadone: agonist (substitute heroin) 2) Suboxone: Partial agonist 3) Naltrexone: antagonists (blocks opiates receptors - if patients take opiates, they won't feel a high) 4) Biomarker: Urine toxicology

Pharmacological Treatments: *Alcohol* (4)

1) Naltrexone 2) Acamprosate 3) Disulfiram 4) Biomakers: liver enzymes and BAC (biosensors?)

Pharmacological Treatments: *Nicotine* (4)

1) Nicotine Replacement Therapy (NRT): The patch, nicotine gum 2) Bupropion 3) Varenicline: agonist 4) Biomarkers: cotinine and CO readings (blow in CO machine)

Marijuana (11)

1) No known lethal dose in humans 2) Estimated 8-9% of users develop cannabis dependence (craving is a strong contributor to development and maintenance) 3) Active ingredient is THC (hard to quantify THC levels across all products available) 4) Can be used legally in the treatment of AIDS and cancer patients 5) When smoked, THC enter the circulation almost immediately reaching blood levels in 5-10 minutes 6) Primary target in the brain is cannabinoid receptors, and is distributed to CNS and outside of CNS (may be the reason why it produces effects in the body) 7) Toxicology tests available allow us to detect marijuana use for up to 30 days following past use in the case of heavy and long-term users 8) *There are withdrawals symptoms with cannabis* 9) There is association between marijuana and psychosis 10) Most commonly used psychoactive substance in the world (more prevalent among men than women) 11) Most individuals don't seek treatment Comorbidity with CUD and other substance use disorders and affective disorders is common

Fundamental Principles: *Brief and Motivational Models* (3)

1) No pressure to subscribe to a goal of complete abstinence 2) Goals do matter and vary by patients (50% coming in want to be abstinence) 3) Some substance are more amenable to brief intervention (more effect for alcohol than substance)

Why is there a 50% reduction in smoking in the US since 1960? (6)

1) Once there was more awareness of the smoking risks, people started quitting 2) Limited tobacco access to particular groups (adolescents) 3) Advertising health risks of continued smoking (PSAs) 4) Use of taxes that target vulnerable groups (can stop buying cigs bc tax is expensive) 5) Clean indoor air laws 6) Provide cessation aids

Can alcohol kill people? (3)

1) People can overdose on alcohol and die either because they suffocate on their vomit or because alcohol can shut down the brain areas that control breathing 2) Anyone who has a BAC of of 0.35% (about 14-16 drinks in a brief period of time) is in danger of an overdose 3) Chronic drinkers can die during withdrawal from alcohol (seizures, delirium tremens LTDs)

Effects of Alcohol: Brain and other organs (6)

1) People who drink heavily have memory loss, some confusion, and often problems with feelings and sensations in their hands and feet 2) Disinhibition caused by alcohol's depressant feelings effects on the PFC, causing other areas of the brain to "speed up", often leading to risky decision making (Alcohol has no specific receptor in the brain) 3) Alcohol is known to affect GABA and NMDA receptors 4) Wernicke-korasaoff Syndrome is a form of dementia caused by chronic alcohol use (marked by amnesia and confusion, due to toxicity on the hippocampus) 5) Over time, large doses of alcohol can cause toxicity to the liver, heart, brain, esophagus, and stomach 6) Major negative effects of long-term alcohol consumption are fatty liver, alcoholic hepatitis, liver cirrhosis, gastritis, STM loss, pancreatitis, mild hypertension, cardiomyopathy, and liver disease *Cirrhosis is the main cause of death directly due to drinking and it occurs in about 20% of heavy drinkers*

Future Directions for Treatment: Alcohol

1) Personalized medicine (matching patients to interventions they are most likely to benefit from, genetic predictors, clinical predictors) 2) Chronic disease model of care (consider alcohol addiction as a chronic disease)

Fundamental Principles: *Social Support, Social Networks, and Family Models* (3)

1) Promote involvement in social networks that discourage substance use 2) May or may not involve family 3) These interventions can also prevent substance use in youth

Biological Models of Addiction (4)

1) Psychostimulant Theory 2) Incentive Sensitization Theory 3) Allostasis Theory 4) Pathology of Motivation and Choice Theory

Impairment in Driving Due to Alcohol (3)

1) Reduced judgement 2) Increased reaction time 3) An euphoric "high" that makes people feel they can drive safely when they cannot The DUI legal limit is BAC 0.08% - Designated driver programs have not shown to be effect to the the "least intoxicated" individual drives, which defeats the purpose of the program

Fundamental Principles: *Contingency Management Models* (3)

1) Reward abstinence: provide reward for clean urine or clean alcohol level 2) Based on operant conditioning principles 3) Altering consequences of substance use alters behavior

CNS Stimulants: *Cocaine* (5)

1) Short-acting - doesn't last long but is potent (stays in body for 2-4 hours) 2) Comes in three forms: hydrochloride salt (IV, snorted), Free-base (smoked), Crack (made from free-base) 3) Cocaine blocks the dopamine transporter (DAT) causing an increase in DA in the synapse. The increase in DA causes the stimulatory effects of cocaine (people are energetic, powerful, grandiose) 4) Withdrawal from cocaine has been characterized as non-physiological (Symptoms are not life threatening, mostly tired, dysphoria, or negative mood) 5) Not everyone who uses cocaine becomes dependent, only approx. 17-18%

Tobacco Use Disorder: Overview (5)

1) Smoking remains a major public health problem worldwide 2) 70% of smokers report wanting to quit 3) Success rates in smoking cessation are low, but they double or triple with pharmacotherapy, medication or nicotine replacement 4) Typical success rates at 6 months post cessation 10-25% 5) Window of "readiness to quit" can be short

Pharmacological Interventions: *COMBINE Study* (3)

1) Support for naltrexone in combination with medical management (MM) 2) Combine Behavioral Intervention (CBI) integrates aspects of Motivational Interviewing (MI) and CBT 3) Patients in COMBINE study were encouraged to attend AA meetings *No empirical support for acamprosate*

Three steps in neurotransmission (3)

1) The release of neurotransmitters (following an action potential) to a receptor that is genetically designed to receive that neurotransmitter 2) Binding to change function, meaning the chemical response inside the receiving neuron. This is either excitatory or inhibitory 3) Eventually the impulse reaches its final destination and the change is seen by our thoughts, feelings, and behavior

Effects in alcohol in women (2)

1) Women metabolize alcohol more slowly than men because they have smaller amounts of alcohol dehydrogenase in their stomach, and because less enzyme is present, more alcohol passes through the stomach to the gut 2) A different fat/lean body makeup between men and women accounts for higher BACs in women than men after identical alcoholic drinks

Opioid Use Disorder

A chronic relapsing disorder and a major source of morbidity and mortality worldwide Psychosocial and pharmacological interventions are used to treat OUD and they should be used in combination

What is the most effective pharmacotherapy for smoking cessation?

A combination of varenicline and naltrexone because varenicline is effective for nicotine dependence and may reduce alcohol use, and naltrexone is moderately effective for alcohol dependence and may reduce smoking

Addiction Phenotypes

Addiction is a complex disorder attributed to the interaction of genetic and environmental factors (someone could have a higher vulnerability) Genetics factors that affect susceptibility to an addictive disorder may be involved in only certain components of the spectrum of the disorder - A framework to studying alcoholism susceptibility is to focus on the particular component of the dependence spectrum, thereby using an endophenotype approach (phenotype that is not the disorder per say, but related to it)

What is the past-month prevalence of tobacco, alcohol, and cannabis use in the U.S?

Alcohol = 52% Tobacco = 23% Cannabis = 7% Alcohol has the highest because it's the most widely used substance

Psychological Model of Addiction: *Reinforcement-Based Approach*

Also called Operant learning approach *Behavior is determined by consequences, particularly reinforcing properties of drugs* (users see consequences but uses anyways) - Substance use is fundamentally a form of instrumental learning (Positive and negative reinforcement) - Behavioral economics is a reinforcement-based model (thinking of alcohol as a commodity) - Quantifies the reinforcing value

Genetic Association Studies

Also called candidate gene studies - Association studies take a "candidate gene" approach by examining the frequency of specific genotypes among cases (affected individuals) vs. controls (unaffected individuals) - Seeks to demonstrate that the frequency of the candidate gene of interest is higher among cases relative to controls, thereby *supporting the hypothesis that the candidate gene may be associated with the disorder of interest* Success stories: - ALDHD2 gene - aldehyde dehydrogenase (asians can't metabolize alcohol gene - protects from alcoholism) - cHRNA5 - nicotinic cholinergic receptor (if occasional smoker, can tell if you'll become a continuous user)

FDA Approved Pharmacological Interventions for Alcohol: *Disulfiram*

An aldehyde dehydrogenase inhibitor that blocks metabolism of alcohol and causes patients to feel the flushing response and alcohol poisoning A conditioning period may be used to show patients what would happen when alcohol is consumed

What is true of anhedonia? (3)

Anhedonia: inability to experience pleasure and reward from natural environment 1) It represents a threat to recovery 2) It can be treated in CBT 3) It represents a normal process of brain recovery from repeated substance use

American Psychological Association (APA) Division 12 (clinical psychological) task force on empirically-validated treatments

As a clinical research society, they come together to evaluate those treatments and help consumers understand what are some of the better treatments available and weigh the evidence

Assessment and Etiology of Gambling Disorder (6)

Assessment should include: 1) current gambling patterns (when, how often) 2) Functional impact (relationships, jobs, legal troubles to gamble) 3) Reasons for seeking intervention (stealing money to go gamble) 4) Gambling related cognitions and urges 5) Comorbidities (depression and anxiety common) 6) Severity scale: Yale-Brown Obsessive Compulsive Scale modified for gambling *Etiology*: Pathological gambling is thought to indicate underlying problems with cognitive functions that are dependent on the function of corticostriatal brain circuitry, which includes domains of planning, top-down control, WM, cognitive flexibility, and temporal processing; environmental factors provide accessibility

Blood Alcohol Concentration (BAC), its Metabolizing Process (3), and Factors Influencing Metabolism (4)

BAC is an index of the amount of alcohol in a person's blood, measured in "grams %" Metabolizing alcohol process: 1) Ethanol 2) Acetaldehyde dehydrogenase 3) Acetate + water Factors influencing metabolism: 1) Food in the stomach 2) Rate of drinking 3) Amount of alcohol dehydrogenase in the stomach lining 4) Form of alcohol *Standard drink contains roughly 14 grams of absolute alcohol*

Important Trends in Alcohol Use Disorder (4)

Between 2001-2001 (NESARC-II) and 2012-2013 (NESARC-III): 1) 12-month alcohol use increased from 65.4% to 72.7% in adults 2) High-risk drinking increased from 9.7% to 12.6% 3) DSM-4 AUD increased 8.5% to 12.7% 4) Increases in these outcomes were greatest among *women*, older adults, *minorities*, and individuals with lower educational level and family income

Why is neurotransmitter dysregulation seen as a central feature of addiction?

Can be caused by a disruption of the chemical production or release, or receptors not working properly The dysregulation may be present before the person takes the drug, may be caused by acute/chronic drug taking, may be induced by a psychosocial factor, or may result from interactions

Stop-Signal task: Motor Response Inhibition

Can measure impulsivity - Individual looks at a computer screen and sees a stimulus, with an arrow pointing left or right, and the individual must push button to indicate whether the stimuli was pointing left or right - The amount of time it takes for them to do this is "go reaction time" 500ml second - Approximately 20% of the trials there is an auditory prompt, a bell ringing, for the person not to press the button. The computer moves the stimulus at different times to find that point when the individual can be correct and inhibiting their response 50% of the time. - The latency from the appearance from the stimulus to that time where the person is correct 50% of the time and the "go" reaction time is called the stop-signal reaction time. It is a measure of how long someone needs before someone can stop, motor response inhibition

Gambling Disorder (4)

Characterized by persistent and recurrent maladaptive patterns of gambling behavior, leading to impaired functioning 1) Associated with higher risk of bankruptcy, divorce, and incarceration, and reduced quality of life 2) Males are more likely to report strategic types of gambling (blackjack or poker) where as females tend to undertake non-strategic forms (slot machines or bingo) 3) Advertisements represent a common trigger for gambling urges across genders, while feeling bored and lonely is a common trigger in women 4) *The only behavioral addiction recognized by DSM, allows insurance to cover treatment and for research of treatment* Also known as pathological gambling

What is addiction?

Chronic and relapsing brain/psychological disorder marked by continued use of alcohol or drugs despite consequences (*This is the hallmark of addiction*)

Strength of Evidence (4) and Criteria of Causal Impact on Outcomes (5)

Clinical evidence is concerned with cause and effect Evidence: 1) Clinical observation 2) *Controlled experimentation is the gold standard for obtaining stronger evidence* (THE MORE CONTROLLED TRIALS, THE STRONGER THE STRENGTH OF TREATMENT) 3) Efficacy - controlled trials (assessment all protocol based, therapy sessions are designed to reach a specific goal, adherence monitoring; provides useful data) 4) Effectiveness - real world trial Criteria used to determine causal impact of an intervention on an outcome: 1) Strength of association 2) Temporality (causal chain in what comes first - treatment first, outcome later) 3) Specificity 4) Consistency (replicated findings) 5) Plausibility (does it makes sense)

What behavioral interventions for addiction is predicated on operant conditioning models?

Contingency Management: delivering a reinforcer or abstinence

Biological Model of Addiction: *Psychostimulant Theory* (2)

Contributed to the understanding of addiction in the brain *Recognized the common neurobiological denominator across drugs of abuse is the increase in dopamine release in the mesolimbic dopamine pathway* 1) This process is responsible for reward and for motivating behavior for survival (they share the same brain structures) 2) Subsequent theories focused on how repeated drug administration gives rise to neuroadaptations

D2 Receptor Availability is correlated to stopping ability

D2-type receptor deficit in stimulant users and low D2 receptor binding is negatively correlated with impulsivity - Methamphetamine users have a deficit in stop signal reaction time (need more time to stop) - Lower dopamine, have longer stop signal reaction Disproportionate effect on D2- type receptors: a large loss of D2 receptors in Meth users, shows an imbalance between the direct and indirect pathway - Enhancing activity-dependent signaling through D2 receptors may be a useful approach for treating meth dependence - Exercise training increases striatal D2 receptors over the education group

Marijuana: *Pharmacological treatments* (4)

Despite demand for cannabis treatment, there are no FDA-approved pharmacotherapies for CUD (someone people use off label drugs) - Medications investigated: 1) Cannabinoid substitues such as dronabinol and nabilone 2) N-acetylcysteine (NAC) an antioxydant 3) Oxytocin 4) Gabapentin

Challenges in implementing ESTs (3)

Distinction between efficacy studies and effective studies ESTs can be challenging to implement in the real world due to: 1) Ingrained clinical habits of practitioners 2) Training in new strategies with large caseload of practitioners 3) Clinician's views that research does not address questions relevant to them Psychopharmacology and psychosocial treatments are often tested separately in trials (COMBINE study is an exception)

Social Models of Addiction: *Classes of Social Influence and Mechanisms* (2)

During adolescence and young adulthood, parental influences and peer affiliations are particularly powerful 1) *Parental influences*: structure and warmth are protective (protects individuals against misuse or dangers), *harsh parenting is a risk factor* 2) *Peer influences*: Overt offers, modeling, social norms Beyond adolescence addiction can occur in couples/dyads with more negative consequences including intimate partner violence

Etiology of Addiction

Etiology = *The study of causation* A good addiction model must synthesize pharmacological, experiential, cultural, situational and personality components in a fluid description of addiction motivation (Peele & Alexander) - A foundation in the causal models of addiction provides a scientifically-minded clinician with a framework for approaching treatment - Theories do not provide a simple answer to why a given patient developed their presenting problems, but go deeper than symptoms to articulate the important process and mechanisms that are operative - These theories are from empirical observation/testing: theoretically-informed treatment is one key aspect of evidence-based treatment (can inform practice)

Effects of Alcohol in the fetus

Fetal Alcohol syndrome (FAS) is a major cause of birth defects worldwide. Fetal Alcohol Spectrum Disorder (FASD) includes both FAS and FAE. 1) In the US, 3-4 children are born with FAS each day 2) Signs of FAS include: facial features, sometimes missing fingers, toes, or kidneys, a small brain, low IQ, shortened life span 3) The teratologic causes FASD include reduced blood flow in the fetus, a toxic effect of acetaldehyde, and alcohol-induced increases in prostaglands (chemicals released during tissue damage) Alcohol use during pregnancy is considered the number one preventable cause of developmental disability

Allostasis Theory: *George Koob's Three Stages of Addiction* (3)

George Koob suggested a progression from impulsive to compulsive disorder with a *shift* from positive reinforcement to negative reinforcement (*Hallmark of disorder*) 1) *Preoccupation/anticipation*: anxious about where and when the next hit is 2) *Binge/intoxication*: finally get ahold and binge 3) *Withdrawal/negative affect*: Non-drug state/anxiety then the cycle starts again When you take a drug, there is a spike in mood because of the high (positive reinforcement - A process). After the drug wears off, mood dips and the person wants to get back to "normal" or homeostasis (negative reinforcement - B process)

FDA Approved Pharmacological Interventions for Alcohol: *Acamprosate*

Glutameteric Antagonist: Reestablish glutamatergic tone that is disrupted by chronic alcohol use The hypothesized mechanism of action of acamprosate is to reduce protracted withdrawal symptoms, such as sleep difficulty and anxiety during abstinence

Marijuana Withdrawal (7)

Happens within a week of stopping or reducing heavy, prolonged use 1) Irritability, anger or aggression 2) Nervousness or anxiety 3) Sleep difficulty 4) Decreased appetite or weight loss 5) Restlessness 6) Depressed mood 7) Physical symptoms causing discomfort

Diagnosis of Addiction

Having *DSM-5* (2013) gives us a universal definition of disorders, which help with giving health codes for treatments when sending referrals and also identifying disorders in general *No more alcohol abuse and dependence in DSM-5* - it is now categorized as a *single substance use disorder* -This is the hallmark of transition from DSM-4 to 5 -Measured as mild, moderate, or severe

Heritability Definitions and Estimates for Substance Use Disorders

Heritability is the extent to which genetic individual differences contribute to individual differences in observed behavior Statistical Definition: heritability is the proportion of phenotypic variance attributable to genetics (other proportion is called environmentability, the contribution of environmental factors that play a role in a disorder) Heritability estimates for the following substance use disorders: Alcohol use disorder: 58% (to genetic factors) Cannabis use disorder: 71% Cocaine use disorder: 70% Nicotine dependence: 73%

Behavioral Interventions for Addiction: *Cognitive Behavioral Therapy*

Including relapse prevention, are grounded in social learning theories (skill building) and principles of operant conditioning The defining features are: 1) Emphasis on functional analysis and skill training (identify triggers and teach skills to cope with them) 2) Skills training involves teaching patients: recognize situations or states in which they are more vulnerable, avoid high risk situations when possible, use a range of behavioral and cognitive strategies to cope effectively with high risk situations

Addiction: Innate Tolerance

Individuals who can "drink other under the table" have a HIGHER risk of developing alcohol use disorder These people have "innate tolerance" they can drink more before they feel effects, thus they expose themselves to more alcohol and then later experience more of the negative effects

Genetic Linkage Studies

Linked analysis consist of examining family pedigrees of affected individuals (i.e., probands) in order to find chromosomal regions that tend to be shared among affected relatives but not among unaffected relatives (good for single-gene and mendelian genes, but not complex genes) -Linkage analysis finds genetic locations in the chromosomes by showing that a genetic marker of known genetic location tends to be transmitted along with the disease within families (can identify causal genes) - The transmission of the marker among affected relatives needs to be significantly greater than the transmission of the marker that is expected by chance - In genetics research "LOD scores" are commonly used as a quantitative index of linkage such that high scores indicated greater evidence of linkage. The classical critical LOD score is 3 or higher

Addiction: *Translational Model*

Look at other factors that are easier to keep track of and we can see how it can relate to the behavioral disorder that is being displayed

National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III) and its conclusion

Looks at representative U.S. populations (36k individuals) 12 months vs. lifetime prevalence for criteria of alcohol use disorder *Conclusion*: Alcohol use disorder defined by DSM-5 criteria is a highly prevalent, highly co-morbid, disabling disorder that often goes untreated in the U.S.

What do you need for motivational interviewing (MI)?

Need motivation and skill to succeed; people always remain ambivalent

What is the emphasis of The Pathology of Motivation and Choice Theory?

Neuroadaptation is the concept that the brain is changed, at a cellular or molecular level, in response to experience with a drug and that those changes correspond with progression of drug-induced behavioral changes

Pharmacological Treatments: *Stimulants and Cannabis*

No FDA approved medications

Correlates of Alcohol Use Disorder

Only 19.8% (1/5) of respondents with lifetime AUD were ever treated (formal treatment) AUD is associated with: 1) *Other substance use disorders*: most likely co-occurrence 2) Major depressive disorder 3) Bipolar 1 disorder 4) Antisocial and borderline personality disorders 5) Anxiety disorders

Treatment for Gambling Disorder

Only about 6% seek treatment Psychosocial Interventions include: CBT, Family therapy, cue-exposure, MI, and Gamblers anonymous Pharmacological treatment include: Opioid antagonists (naltrexone - some benefit), N-acetylcytesine (NAC) - a dietary supplement thought to modulate glutamate, which faciliate top-down regulation of behavior; SSRIs, antidepressants, lithium, antipsychotics Comorbidity is a significant factor

Social Models of Addiction: *Social Networks Model*

Perspective that proposes that individuals self-selected into networks that are populated with people exhibiting similar levels of substance use (or lack thereof) - "Birds of a feather flock together" - Social networks analysis - *Change in social networks during treatment can support recovery (Ex:AA)*

Philosophy of Addiction Treatment: *Public health level & Medication development perspective*

Philosophy of treatment often determines the level of support for harm reduction, abstinence only models, the use of medications, and level of 12-step involvement (*how agencies consider treatment determines the level of support they have for different kinds of treatment*) At the public health level, the philosophy of treatment is manifested in the availability of treatments for addiction, which includes those who do not have insurance (hard reduction treatments) From a medication development perspective, more is better because more options can be tried until one is found that works best

Psychological (5) and Social (3) Models of Addiction

Psychological Models of Addiction: 1) Reinforcement-based approach 2) Variability in drug effects 3) Cognitive processes 4) Personality factors 5) Developmental Psychopathology Social Models of Addiction: 1) Social Networks 2) Social influences and mechanisms 3) Sociocultural influences

CNS Stimulants: *Psychological Treatments* (5)

Psychological interventions are the primary method for treating psychostimulant use disorder (PUD) given the dearth of effect pharmacological treatments (no medication) *Gold standard outcome assessment is urine toxicology* - ask for repeated tests 1) *Contingency Management* (EBI): good outcomes during active treatment but not sustained beyond the end of CM delivery 2) *Cognitive Behavioral Therapy* (EBI): not widely implemented because clinicians not trained to deliver CBT for stimulant use disorder, but has better treatment outcomes 3) *Computer-based CBT* (CBT4CBT): all assessed online, designed to overcome barriers of delivering manualized CBT, 70-83% completion rates, cost effective and reliable treatment option 4) *Gay-Specific CBT* (GCBT): MSM have higher prevalence of psychostimulant use (3x more than gen. pop.); has good outcomes for stimulant use but also for reducing risky sexual behaviors 5) *Matrix Models*: goal is to build a more personalized treatment option for PUD; integrates CBT, 12-step, and family education (16-week, intensive program) Barriers to delivering evidence-based therapies: Lack of training and active dissemination of EBTs

CNS Stimulants: Methamphetamine (MA)

SYNTHETIC - duration of high is longer than other amphetamines (8-10 hours) and cheaper, which is the reason for transition from cocaine to meth in 90s Became an epidemic in the late 1990s, particularly in certain regions of the country, including southern California; Extensive MA research at UCLA; *Most effective psychotherapy for methamphetamine dependence is contingency management (CM)* 1) Cognitive deficits are associated with MA use and impact treatment outcomes (patients seem disoriented and might have more problems with cognitions, diminished cognitive capacity) 2) MA abuse may be particularly high among MSM (MA facilitates sexual encounters that are more risky, causing the spread of disease like HIV) 3) MA is often studied in the context of HIV prevention for its involvement in unprotected sex

CNS Stimulants: Amphetamines (4)

Several drugs in the amphetamine class, including: 1) Dextroamphetamine (Dexedrine) 2) Methamphetamine (MA)(Desoxyn) - synthetic 3) Methyphenidate (Ritalin) 4) Mixtures (adderall) All have diversion potential (can crush or snort prescription drug and use for non-therapeutic purposes), or abuse liability - Amphetamines have biobehavioral actions similar to cocaine but with a longer duration of action - These drugs cause the release of DA from the nerve cell with additional but lesser effects on norepinephrine and serotonin0

Severity Specifier

Severity is specified based on the number of criteria met: *Mild*: meet 2-3 symptoms *Moderate*: meet 4-5 symptoms *Severe*: 6 or more symptoms *ICD-10* (International classification of diseases) *classification is also used internationally*; an alternative model for diagnosing mental and physical conditions

How does California compare to the rest of the US in terms of smoking prevalence?

Smoking is less prevalent in California - they are ahead of the tobacco regulation and smoking prevalence Tobacco related disease research program funds research int he state to address the burden of smoking in our communities

Social Models of Addiction: *Sociocultural influences* (4)

Social influences on addiction include higher-order factors within society and culture: 1) Religion 2) Economic conditions 3) Public policy (taxation, legal age, density of outlets) 4) Cost of care and access to evidence-based intervention is also a sociocultural factor

Developing Novel Behavioral Treatments: Stage Model of Behavioral Treatment Development (3)

Stage 1: *Pilot/feasibility testing*: deliver treatment, open label, see how people engage Stage 2: *Efficacy testing*: compare active treatment to control treatment and see if there are any benefits Stage 3: *Transportability and Dissemination*: if there are significant benefits, do large scale testing

Biological Model Addiction: *Pathology of Motivation and Choice Theory* and it's three stages of addiction (3)

States that dopamine and endogenous opioids are central for acute reward and initiation of addiction (starting point of addiction driven by reward) 1) Acute drug effects 2) Transition from recreational use to repetitive use 3) *End-stage addiction*: characterized by an overwhelming desire to use the drug, diminished ability to control drug-seeking, and reduced pleasure from everyday rewards - *Neuroplasticity on excitatory neurotransmission reduces the capacity of prefrontal cortex to initiate behaviors in response to biological rewards and to exercise control over drug seeking* - End-stage addiction results from cellular adaptations in the anterior cingulate and the orbitofrontal glutamatergic projections to the nucleus accumbens - Cellular adaptations in the prefrontal glutamatergic pathway of the accumbens promote compulsive drug seeking - Vulnerability to relapse is caused by long-lasting changes in brain function as a result of repeated drug use, genetics, and environmental contributions to learning - Emphasizes the idea that GLU projections from the prefrontal cortex to the NAcc makeup the final common pathway for eliciting drug-seeking behavior

Genetics of Addiction

The "Big Picture" Genetics is only a part that we look at for the development of addiction - There's also physiological (alcohol metabolism, craving, reward, tolerance, withdrawal) and behavioral (personality/temperament, externalizing/internalizing disorders) factors that are considered in the development of addiction - Addiction is a disorder of *complex* genetics; twin studies can help estimate heritability

Epidemiology

The branch of medicine that deals with the incidence, distribution, and possible control of diseases and other factors relating to health (prevalence, trends, correlates) -Tracks occurrences of diseases

Criteria for Gambling Disorder (4)

The criteria set are different from SUD with a total of 9 symptoms described: 1) Functional impairment 2) urges to cravings 3) Prooccupation 4) failed attempts to stop gambling ..... Mild GD = 4-5 criteria met Moderate GD = 6-7 criteria Severe = 8-9 criteria met Past year prevalence is .2-.3%, and lifetime is .4-1% - Lifetime prevalence is higher for males than females

Heritability of Alcoholism

The heritability estimates for alcoholism range between 40-60% of the variance. Specifically, on average, 40-60% of the risk for developing alcoholism is attributed to genetics - Heritability is a population genetics concept (estimating the risk for the population)

Evidence-Based Practice in Psychology

The integration of the best available research with clinical expertise in the context of patient characteristics, cultures, and preferences - How to move from theoretical study to meeting with someone and identifying a treatment based on research evidence - Be flexible with a science mind

Basics of Brain Science: The Nervous System

The nervous system is the body's control and communication network: 1) Sensory functions 2) Integrative functions 3) Motor functions The nervous system is divided into: 1) The Central Nervous System (CNS) - brain and spinal cord 2) The Peripheral Nervous System (PNS) - all other nerve element Alcohol and drugs alter the working of the human nervous system, including changes at the cellular level in how cells communicate with one another

Levels of Response to Alcohol

The self-rating of the effects of alcohol (SRE) is a measure of one's level of response to alcohol (the first 5 times of drinking alcohol) - Individuals who need more drinks to reach certain levels of intoxication (low responders) were shown to be at a higher risk for developing alcohol problems in their lifetime - Level of response to alcohol is a heritable construct - Candidate genes in the GABA receptor may underlie the expression of this endophenotype for alcoholism (predisposes individuals to a differential response to alcohol)

CNS Stimulants: *Pharmacological Treatments*

There are no FDA approved medications for treating stimulant use disorder Several medications have been tested: - Monoamine modulators (burpropion, modefinil) - Antipsychotics - Antidepressants - GABA agonists (Baclofen, Gabapentin) Bupropion, riperidone, topiramate show some promise

Evidence-Based Treatment: *Evidence-based practices (EBP)* and *Empirically Supported Treatments (EST)*

These are terms used to describe both general practices and specific treatments that have been tested under rigorous research conditions Evaluate goal and the strength of its evidence: important as healthcare providers in order to effectively order and deliver treatment in community settings

Psychological Model of Addiction: *Cognitive Processes* (2)

These models emphasize the role of mental or information processing mechanisms 1) *Expectancies* = cognitive templates - Positive expectancies can drive behavior (ex: liquid confidence = positive cognition) - Expectancies can account for placebo effects (and influence behavioral effects) - Expectancies do no necessarily reflect direct pharmacological effects 2) *Motives* are also cognitive determinant of substance use - Motives reflect the reasons that a person reports why he/she uses the drug (ex: pain management and social enhancement) - Typically assessed in self-report format Expectancies and motives can be though of as an explicit reflective cognitive processes or declarative "top-down" process in which the individual reports introspectively available cognitions about the drug (ex: smokers pay more attention to things relating to smoking) - An important complement are implicit automatic cognitive processes, or unconscious "bottom-up" processes that reflect the salience of drugs (cognitive bias)

What are some things to consider when treating with Alcohol Use Disorder?

When working with pharmaco-therapy, the worry is about *adherence*

Hangovers and Shakes (2)

Withdrawal occurs when alcohol is removed from the cells causing them to return to normalcy. This attempt of the body to produce normalcy often leads to over-stimulation of hyperactivity known as withdrawal (achy, uncomfortable, anxious) 1) Cessation of long-term heavy drinking can lead to the shakes, delirium, and even seizures 2) Hangover symptoms include increased gastric acid, early morning awakening, pounding heart, headache, dehydration, and electrolyte imbalance There are several types of tolerance: Behavioral, metabolic (liver), functional (cellular, tissue, brain) The best measure to prevent hangover is to drink in a manner that does not allow the BAC to rise above ~0.05% in an episode