Download Substance Use Disorders

The Spectrum of Use and the
Historical Context
Lecture 2
Chapter 1 & 2
Drugs Are Old
Drugs have been around since the dawn
of time… Probably
Coming on the Scene
•
•
•
•
•
•
•
•
•
Alcohol as early as 6400 years BC (Middle East)
Cannabis 3000 years BC (Middle East)
Opium 5000 BC (China)
Tobacco 100 BC (Mexico)
Coca 3000 BC
Cocaine Extracted 1855
Heroin 1874
MDMA (XTC) 1912
LSD 1938
Despite the Laws People Still Use
Does Use Mean Abuse?
The Spectrum of Use
•
•
•
•
Use – Periodic non-problematic use
Misuse – Periodic Use
Abuse – A pattern of misuse
Dependence – Compulsive problematic use
often with physiological dependence
Use
• Many drugs can be used relatively safely
• Most people who use drugs do not develop
problems, however this depends on the drug
• Drugs are used for many reasons
–
–
–
–
Social
Religious
Coping
Experimentation
Misuse
• Periodic circumscribed negative
consequences
– College students and alcohol
– “It only happened once.”
– Sometimes the consequences are catastrophic
DSM-IV Abuse
1. Failure to fulfill major role obligations
2. Use in hazardous situations
3. Legal Problems
4. Use despite problems
17
DSM-IV
Dependence
1. Tolerance
2. Withdrawal
3. Larger amounts/longer period than intended
4. Inability to, or persistent desire to, cut down
or control
5. A great deal of time spent obtaining, using, or
recovering
6. Important activities given up or reduced
7. Use despite problems caused or exacerbated by use
18
How Does One Move Through
the Spectrum?
Public Health Model
• Agent Factors – Properties of the drug or
substance
• Host Factors – Characteristics of the person
• Environment Factors – Context/Situation
Perspectives on SubstanceRelated
Disorders: An Overview (cont.)
• Five Main Categories of Substances
– Depressants – Result in behavioral sedation
– Stimulants – Increase alertness and elevate
mood
– Opiates – Primarily produce analgesia and
euphoria
– Hallucinogens – Alter sensory perception
– Other drugs of abuse – Include inhalants,
anabolic steroids, medications
The Depressants: Alcohol Use
Disorders
• Psychological and Physiological Effects of
Alcohol
– Central Nervous system depressant
– Affects several neurotransmitter systems
– Specific target is GABA
• Effects of Chronic Alcohol Use
– Alcohol intoxication & withdrawal
– Associated conditions – Dementia & Wernicke’s
disease
– Fetal alcohol syndrome
Alcohol: Some Facts and
Statistics
• In the United States
– Most adults view themselves light drinkers or
abstainers
– Over 50% of the U.S. (> 12 years age) report current
use
– 15 million Americans are alcohol dependent
– Rates are highest among Caucasian & Native
Americans
– Males use and abuse alcohol more than females
– Violence is associated with alcohol
– Alcohol alone does not cause aggression
Stimulants: An Overview
• Nature of Stimulants
– Most widely consumed drug in the United
States
– Such drugs increase alertness and increase
energy
– Examples include amphetamines, cocaine,
nicotine, and caffeine
•
Stimulants: Amphetamine Use
Disorders
Effects of Amphetamines
– Produce elation, vigor, reduce fatigue
– Effects are followed by extreme fatigue and depression
• DSM-IV-TR Criteria for Amphetamine Intoxication
• Ecstasy and Ice
– Produces effects similar to speed, but no “comedown”
– 2% of college students report using Ecstasy
– Both drugs can result in dependence
• Amphetamines stimulate CNS by
– Enhancing release of norepinephrine and dopamine
– Reuptake is subsequently blocked
Stimulants: Cocaine Use
Disorders
• Effects of Cocaine
– Short lived sensations of elation, vigor, reduce fatigue
– Blocks reuptake of dopamine
– Highly addictive, but addiction develops slowly
• DSM-IV-TR Criteria for Cocaine Intoxication and
Withdrawal
– Psychological symptoms
– Physiological symptoms
• Most Cycle Through Patterns of Tolerance and
Withdrawal
Opioids: An Overview
• The Nature of Opiates and Opioids
–
–
–
–
Opiate – Narcotic like chemical in the opium poppy
Opioids – Substances that produce narcotic effects
Often referred to as analgesics (i.e., help relieve pain)
Examples include heroin, opium, codeine, and
morphine
• Effects of Opioids
–
–
–
–
Activate body’s enkephalins and endorphins
Low doses – Euphoria, drowsiness, and slow breathing
High doses can be fatal
Withdrawal symptoms can be lasting and severe
Other Drugs of Abuse: Designer
• Designer Drugs Drugs
– Drugs produced by pharmaceutical companies for diseases
– Ecstasy, MDEA (“eve”), BDMPEA (“nexus”), ketamine
(“special K”) are examples
– All heighten auditory and visual perception (taste and
touch)
– Popular in nightclubs, raves, or large social gatherings
– All designer drugs can produce tolerance and dependence
Causes of Substance-Related
Disorders:
Family and Genetic Influences
• Results of Family, Twin, and Adoption
Studies
–
–
–
–
Substance abuse has a genetic component
Much of the focus has been on alcoholism
Genetic differences in alcohol metabolism
Multiple genes are involved in substance abuse
Causes of Substance-Related
Disorders:
Neurobiological Influences
• Results of Neurobiological Research
– Drugs affect the pleasure or reward centers in
the brain
– The pleasure center – Dopamine, midbrain,
frontal cortex
– GABA turns off reward-pleasure system
– Inhibition of neurotransmitters for anxiety /
negative affect
Causes of Substance-Related
Disorders:
Psychological Dimensions
• Role of Positive and Negative Reinforcement
– The self-medication and the tension reduction
hypotheses
– Substance abuse as a means to cope with negative
affect
• Opponent-Process Theory
– Why the crash after drug use fails to stop drug use
• Role of Expectancy Effects
– Expectancies influence drug use and relapse
Causes of Substance-Related
Disorders:
Social
and
Cultural
Dimensions
• Exposure to Drugs is a Prerequisite for Use of Drugs
– Media, family, peers
– Parents and the family appear critical
• Societal Views About Drug Abuse
– Sign of moral weakness – Failure of self-control
– Sign of a disease – Caused by underlying processes
• The Role of Cultural Factors
– Influence the manifestation of substance abuse
An Integrative Model of SubstanceRelated Disorders
• Exposure or Access to a Drug
– Is necessary, but not sufficient for abuse and addiction
• Drug Use Depends on Social and Cultural
Expectations
• Drugs Are Used Because of their Pleasurable
Effects
• Drugs Are Abused for Reasons that are More
Complex
– The premise of equifinality
– Stress may interact with psychological, genetic, social,
and learning factors
From A Psychological Standpoint
• Drug abuse and dependence are disorders of behavior
• Not only do each have health implications, abuse and
dependence have extreme psychosocial implications
• People make changes in their alcohol/drug abuse behavior
in the same way they make changes in all other behaviors
• Much alcohol and drug abuse/dependence is related to
psychopathology
• Most people stop on their own
Substance Abuse Treatment
• “Self-Help” (AA NA CA Rational Recovery)
• Psychosocial Interventions
• Medications
Self-Help 12 Step Fellowships
• Alcoholics Anonymous Narcotics Anonymous
– View of Problem: Spiritual disease
– Tools: 12 steps to recovery
– Mechanism: Powerful social support
– Issues: Effective for those who stick. Can be
difficult to stick
Psychosocial Interventions
• Behavioral and Cognitive Behavioral
– View of Problem: Behavioral disorder.
– Tools: Functional analysis, contingency management and
cognitive interventions as well as relapse prevention
– Mechanisms: Skills improvement, attitude change,
coping w/psychopathology
– Issues: Highly researched treatments. Very effective.
Not sure how they work actually.
Psychosocial Interventions
• Motivational Interviewing
– Alternative to confrontational approach
– Designed to move individual through stages of
change
– Brief (1-4 sessions)
– Effective as stand-alone and a booster to
treatment
Pharmacotherapy
• Alcohol Dependence
– Antabuse
– Naltrexone
• Drug Dependence
– Methadone & Naltrexone (Heroin)
– Antidepressants (Cocaine)
– Cocaine vaccine?????
•
•
•
•
•
•
•
•
Outcome
Abstinence vs. Harm Reduction
AA/NA, CBT, MI are all effective
Meds can be as well
Stage-matched interventions
The longer people stick the better they do
Most often takes multiple treatments
Social support after treatment is critical
Treatment works better than jail in the short and
long run