Download 18 Wilson substance abuse 2006

Substance Abuse &
Dependence
Michael Wilson, PhD
University of Illinois Department of Psychology
and
University of Illinois College of Medicine
A clinical vignette
Approximately 2 days after admission to the hospital for a
fractured hip, a 62 year-old male starts having an intense
hand tremor, tachycardia, and sees spiders crawling on the
walls. He also feels them crawling on his skin. Which of the
following is the most likely cause?
A.
B.
C.
D.
E.
Alcohol use
Alcohol withdrawal
Heroin use
Heroin withdrawal
Amphetamine use
Another clinical vignette
A 22 year-old student tells the doctor that he has
been using “speed” nightly. Which of the following
complaints is the patient most likely to report?
A.
B.
C.
D.
E.
Increased fatigue
Decreased pain threshold
Increased appetite
Decreased body weight
Decreased libido
Outline
• What are drugs of abuse?
• How to define abuse?
• Overview of drugs of abuse
– Effects of use & withdrawal
• Focus on alcohol
• Questions
Drug of Abuse
(Psychoactive Substance)
• Chemical substance that alters mood,
changes perception, or changes brain
functioning
• Substances can range from legal
(Nicotine) to prescription (Valium) to illegal
(LSD) drugs
It is not unusual for
people with substance
abuse to use more
than one drug
(polysubstance abuse)

How to define abuse?
• Thought question: how do we know when
someone has a problem with drugs or
alcohol?
– Is it a mental illness? What is a mental
illness?
– Is it when they are acting abnormally? What is
abnormal?
– Is it simply the amount of substance being
used?
Defining Abnormal Behavior:
Group Activity
• Purpose: to think critically about what is
abnormal behavior in regards to drugs &
alcohol
• Write a definition of what it means to have
a problem with intoxicating substances
• Discuss your definition with your
classmates
Defining Abnormal Behavior
• Personal distress
– subjective report of substance problems
• Social impairment
– violation of moral standards
– observer discomfort
• Statistical deviance
– relative frequency of substance use
– 54.9% of US adults reported 1 drink or more in last
month (CDC 2002)
Definitions
• Symptoms: thoughts, feelings, and behaviors that
indicate a mental disorder
• Syndrome: a group of symptoms that tend to
co-occur and are assumed to have a common
etiology
• Additional Considerations
– Duration
– Impairment in important area of functioning (usually social or
occupational)
What is abnormal behavior?
• Abnormal behavior is a natural, fuzzy
concept
• Involves identifying certain symptoms or
syndromes that co-occur with mental
disorders
– plus some sort of assessment of impairment
– plus some sort of assessment of distress
What is the DSM?
• The Diagnostic & Statistical manual is
published by APA
– lists criteria for mental disorders
– includes description and research findings
– now in fourth edition (text revised)
– so referred to as DSM-IV-TR
Levels of Substance Use
• Levels
–
–
–
–
–
Abstinence (personal, cultural, religious)
Experimentation
Social (just to get along with others)
Instrumental (using for serious reasons)
Addiction (out of control)
• DSM-IV-TR has different categories of problems
–
–
–
–
–
No diagnosis
Intoxication
Abuse
Dependence
Withdrawal
Casual or “Recreational”
Substance Use
• Is this a problem?
– Not usually for majority of users. Naïve users (especially
young people) may unwittingly overdose or get into legal
problems.
– “Gateway” drugs may introduce drugs to individuals at risk of
addiction.
– Recreational use may also lower cultural barriers to substance
abuse/addiction (seeing parents drink beer makes it easier for
teenagers to try it themselves).
– However, cultures that endorse “responsible” drinking &
stigmatize drunkenness (e.g., Italian, French, or Jewish
drinking of wine with dinner) can model low-risk behaviors for
young people, perhaps lower incidence of addiction.
DSM-IV-TR Definition of
Substance ABUSE
Maladaptive pattern of substance use leading to distress,
as manifested by one of the following, occurring
within a 12-month period:
1)
2)
3)
4)
Recurrent use resulting in a failure to fulfill major role
obligations at work, school, or home.
Recurrent use in situations in which it is physically
hazardous (ie, driving drunk).
Recurrent substance-related legal problems.
Continued substance use despite having persistent or
recurrent social/interpersonal problems caused or
exacerbated by the substance.
DSM-IV Substance DEPENDENCE
A maladaptive pattern of substance use manifested by 3 or
more of the following in a 12-month period:
1)
2)
3)
4)
tolerance – a need for increasing amounts of drug to get the
desired effects
withdrawal – either characteristic withdrawal syndrome for a
substance, or using a substance to avoid withdrawal symptoms
(e.g., “hair of the dog…”)
increased use - the substance is taken in larger amounts or for
longer periods than intended (e.g., a coke run that is only
stopped when the money runs out)
loss of control - Persistent desire or unsuccessful attempts to
cut back or control use
DEPENDENCE continued
5) Obsessing about using - Great deal of time is spent on
obtaining the substance (e.g., finding the money, planning the
buy), using the substance (e.g., drinking round the clock
through a weekend), or on recovering from its effects (e.g.,
calling in sick because of a hangover).
6) Other parts of life become unimportant - Important activities
are sacrificed to keep using (e.g., not going to your kid’s ball
games; breaking dates; not completing assignments).
7) Use despite health effects – Substance use is continued
despite knowledge of a physical or psychological problem
caused or exacerbated by substance (e.g., continued drinking
after a diagnosis of liver cirrhosis or a stomach ulcer).
Substance Intoxication
A.
B.
C.
Development of a reversible substance-specific
syndrome due to recent ingestion of or exposure to a
substance.
Maladaptive behavioral or psychological changes due
to effect of substance on CNS (belligerence, mood
lability, impaired judgment, etc.).
Symptoms are not due to a general medical condition
or another mental disorder.
Substance withdrawal
A. Development of a substance-specific
syndrome due to the cessation of (or reduction
in) substance use that has been heavy &
prolonged.
B. Substance-specific syndrome causes
significant distress or impairment in social,
occupational, or other important areas of
functioning.
C. Symptoms are not due to a general medical
condition or another mental disorder.
Overview of drugs of abuse
• Stimulants
– Caffeine, nicotine, cocaine, amphetamines (crystal
meth)
– Euphoria (and addictive potential) comes from
dopaminergic stimulation
– Some stimulants have useful medical roles (e.g., Ritalin
for treating ADHD, cocaine as topical anesthetic)
– Activate sympathetic nervous system
• cause mood elevation, tachycardia, dilated pupils,
sweating, hyperthermia, alertness, insomnia,
decreased appetite
• withdrawal causes mood depression, lethargy,
increased appetite
Stimulants
• Caffeine
– coffee ~125 mg/cup, tea ~65 mg/cup, cola
~40 mg/cup
– most popular CNS stimulant
• causes elevated levels of epi/norepi
– has some medical use
• combined with ergotamine is older tx for migraine
Stimulants
• Nicotine
– mimics the effects of Ach
• causes increased heart rate, blood pressure, alertness
• chronic users report pleasant effect
– poisonous in large doses
• in concentrated form, can be used as insecticide
• 40-60mg believed to be fatal for humans if injected at once
– Addictive potential believed to be great
• Surgeon General Koop compared it to cocaine
– smoking (but not nicotine) linked with many health
problems
Stimulants
• Cocaine
– Interferes with dopamine reuptake from
synapses (produces reward), NE reuptake
from synapses (produces stimulation),
serotonin reuptake
– Estimated U.S. cocaine market = $35 billion in
2003, bigger than AT&T and Starbucks
Stimulants
• Amphetamines
– include methamphetamine, Ecstasy
– cause release of NE & dopamine from
synapses and prevent reuptake into synapses
– medical uses include ADHD, narcolepsy
Sedatives & Hypnotics
• Barbiturates, benzodiazepines, alcohol
– Act mostly on GABA receptors, inhibit cortical
function
• low doses: disinhibition
• high doses: inhibition of life functions
– Withdrawal is notable as exactly opposite of
intoxication
• tachycardia, sweating, hypertension, irritability,
anxiety, insomnia
– Medical uses include insomnia or anxiety
• if dose is decreased or missed, original symptoms
can be intense
Hallucinogens
• Marijuana, LSD, PCP
– Cause mood elevation, altered perception,
hyperthermia, sweating
– Few if any withdrawal symptoms
• if present, can be anxiety or mild depression
– Most of these drugs relatively easy and cheap to
manufacture
• often not seen as a drug at all by users
Opiates
• Heroin, opium, morphine, other prescription
narcotics
– Act directly on CNS
• cause mood elevation, decreased anxiety, sedation, analgesia,
respiratory depression, pupil constriction
• heroin crosses the blood-brain barrier more easily, and so has
rapid onset & addiction potential
– Withdrawal is very unpleasant, but usually not medically
dangerous
• effects include mood depression, increased anxiety, flu-like
symptoms, stomach cramps/diarrhea
Inhalants
• Gasoline, paint, glue
– Chemicals vary, but inhalants generally depress CNS
• Causes decreased respiration and blood pressure
• Users may report distortion in perceptions of time and space
• May experience headaches, nausea, slurred speech, loss of
motor coordination
– Used mostly by young people
• 15-20% of junior high students report use
• highest incidence in 10-12 age range
Lifetime Prevalence: Drug Use and
Dependence
Proportion with
History of Use
•
•
•
•
•
•
•
•
Tobacco
Alcohol
Cannabis
Cocaine
Amphetamines
Sedatives
Hallucinogens
Heroin
75.6
91.5
46.3
16.2
15.3
12.7
10.6
1.5
Proportion with
History of
Dependence
24.1
14.1
4.2
2.7
1.7
1.2
0.5
0.4
Dependence
Among Users
31.9
15.4
9.1
16.7
11.2
9.2
4.9
23.1
Substance Use Among College
Students (Shinew, 2005)
• 84% drink alcohol
– 65% started in high school
• 22% use drugs
– Marijuana (98%), ecstasy (28%), cocaine
(12%)
• Most college students agree or strongly
agree that drinking is a leisure activity
Focus on alcohol: Alcohol retail
sales (2002)
DSM-IV-TR definition of alcohol
intoxication
A.
B.
C.
Recent ingestion of ETOH.
Maladaptive behavioral or psychological changes such
as inappropriate sexual or aggressive behavior,
impaired judgment, impaired social/occupational
functioning.
One or more of the following:
slurred speech, incoordination, unsteady gait, nystagmus,
impairment in attention/memory, stupor/coma
D.
Symptoms not due to a medical condition or other
mental disorder.
DSM-IV-TR definition of
Alcohol Withdrawal
A.
B.
Cessation (or reduction) in alcohol use that has been
heavy or prolonged.
Two or more developing within several hours to a few
days after criterion A:
autonomic hyperactivity (sweating, tachycardia), increased
hand tremor, insomnia, nausea/vomiting, transient
visual/tactile/auditory hallucinations, psychomotor agitation,
anxiety, grand mal seizures
C. Symptoms in criterion B cause distress or impairment in
social/occupational or other important areas of
functioning.
D. Symptoms not due to a medical condition or another
mental disorder.
Etiological Considerations
• Not everyone who uses drugs or alcohol will
move to the level of abuse or dependence
• Biological, social, and psychological factors play a
role in substance addictions
Etiology: Genes
• Males:
MZ = 56%
• Females: MZ = 30%
DZ = 33%
DZ = 17%
 MZ concordances > DZ concordances
 Higher concordance rates in male twins reflect higher rates
of alcoholism among men
• Gender difference in alcoholism for MZ and DZ twins
could be attributed to:
– Lower physical tolerance for women
– Negative social attitudes towards public intoxication for
women
Etiology: Social factors
• Culture or religion could influence how early
someone is exposed to alcohol
– as well as attitudes towards drinking
• Initial experimentation more likely among the
rebellious & extroverted
– or if parents/peers model use
• Unpleasant environment, low parental monitoring
increase risk of use
The biopsychosocial model
A clinical vignette
Approximately 2 days after admission to the hospital for a
fractured hip, a 62 year-old male starts having an intense
hand tremor, tachycardia, and sees spiders crawling on the
walls. He also feels them crawling on his skin. Which of the
following is the most likely cause?
A.
B.
C.
D.
E.
Alcohol use
Alcohol withdrawal
Heroin use
Heroin withdrawal
Amphetamine use
Clinical vignette
A 22 year-old student tells the doctor that he has
been using “speed” nightly. Which of the
following complaints is the patient most likely
to report?
A.
B.
C.
D.
E.
Increased fatigue
Decreased pain threshold
Increased appetite
Decreased body weight
Decreased libido
Readings
• Read pages 73-85 in BRS: Behavioral
Science, 4th edition