Download Causes and Treatment of Substance Use Disorders

Causes and Treatment of
Substance Use Disorders
Chapter 11
The Spectrum of Use
• Use – Noncompulsive and
nonconsequential use
• Misuse – Periodic negative consueqnces
• Abuse – A pattern of misuse
• Dependence – Compulisve use with
significant consequences often
w/physiological dependence
Moving Through the Spectrum
• Depends on numerous issues
– The drug itself (The Agent)
– The person (The Host)
– The person’s environment (The Environment)
• With some drugs it is difficult to maintain
the line between use, misuse, abuse and
dependence
DSM – IV Criteria
Substance Abuse
• A maladaptive pattern of substance use
occurring within a 12 month period
– Impairment/Distress
– One of the following
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Failure to fulfill major role obligation
Use in physically hazardous situations
Recurrent legal problems
Continued use despite recurrent psychosocial
problems
DSM-IV Substance Dependence
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A maladaptive pattern of substance use
occurring within a 12 month period
Three of the following:
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Tolerance (increased drinking to achieve same
effect)
Withdrawal
Drinking more than intended
Unsuccessful attempts to cut down on use
Excessive time related to obtaining, using and or
recovering from
Impaired social or work activities due to alcohol
Use despite physical or psychological
consequences
Causes - Multidimensional
• Abuse/Dependence is an interaction
between
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Pharmacological
Biological/Genetic
Psychological/Behavioral
Social/Environmental
Pharmacologic
• Drugs differ in terms of the potential for
physiological addiction.
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Nicotine – High
Heroin – High
Cocaine – High
Alcohol – Moderate
Marijuana – Low
Hallucinogens - Low
Biologic/Genetic
• Substance Abuse and Dependence runs in
families.
– Diathesis for certain types of alcohol
dependence. Mechanism seems to tolerance
– Diathesis for other drugs is less clear. Probably
through a temperamental characteristic,
psychopathology and/or dopamine NT system
sensitivity
Psychological/Behavioral
• Alcohol/Drug use is functional and is
reinforcing. Use is subject to the laws of
behavioral reinforcement (positive and
negative).
• Self-regulation/Coping
• Certain personality characteristics are
predictive.
Social/Environmental
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Certain developmental insults
Access
Social norms
Using peers
Substance Abuse Treatment
• Three main philosophies/modalities
– Mutual-help
– Psychosocial
– Pharmacological
• In the past there has been much conflict
between these philosophies. Not so much
now.
Mutual Help Philosophy
• Twelve Step Fellowship
– Alcoholics Anonymous
– Narcotics Anonymous
• Spiritual Disease Model
• Mechanisms
– Acceptance of loss of control and higher power
– Working the steps
– Most probably powerful social support and behavioral
management
Psychosocial Treatment
• Psychological Treatments
– Motivational Interviewing/MET
• Empathy
• Rolling with resistance
• Develop Discrepancy
– Community Reinforcement Approach
• Rearrange reinforcement contingencies
– CBT
• Skills training and cognitive restructuring
• Psychotherapy and Educational alone are
ineffective
Project MATCH
• Mulitsite clinical trial of psychosocial treatments
• Three alcohol dependence treatments treatments
– MET
– CBT
– 12 Step Facilitation
• Results
– TSF marginally better. AA meetings
– MET as good over time with less treatment. Better for
those high in anger
– Behavioral treatments work
Pharmacotherapy
• Alcohol
– Antabuse – Become ill if one drinks
– Naltrexone – Opiate antagonist
• Heroin/Opiates
– Methadone – An agonist. Opiate replacement
– Buprinorphine – A partial agonist.
– Naltrexone – Blocks opiate action
• Cocaine
– Haven’t found one yet
• Overall not many meds work. Compliance is the
ultimate issue.
Treatment Integration
• Combine treatment philosophies/modalities
– Motivation Enhancement
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Increase readiness
CRA/CBT
Active treatment
Rearrange reinforcement structure
Teach coping skills
Address psychopathology
– Pharmacotherapy
– Mutual-help groups
• Social Support
• Maintenance
Project COMBINE
• Multisite clinical trial addressing the
combination of drugs and psychosocial
treatments
– Acamprosate (a benzo) and/or Naltrexone
– Medication management or Psychosocial
Treatment
• Psychosocial Treatment is a combo of MET and
CRA