Chapter 9 Drug Use and the Substance Use Disorders Defining Substance Use Disorders The importance of context in defining substance misuse Binge drinking - a dangerous practice of rapid alcohol consumption, defined as four or more drinks in a row for a woman or five or more drinks in a row for a man The continuum between normal and abnormal substance use (e.g. adaptive functioning, culture) Drugs can only simulate, either intensify or attenuate, naturally occurring processes in the body Agonists Antagonists Classifying Substance Use Disorders The ?Three C?s? of substance misuse Continued use despite negative consequences Compulsive use Loss of Control over use Classifying Substance Use Disorders: The DSM-IV-TR Categories Intoxication ? Reversible, non-dependent experience with a substance that causes impairment in mood, cognition, behavior, adaptive functioning Substance Abuse - The DSM-IV-TR diagnosis for substance use that has negative consequences. Deviation from social or medical patterns Substance Dependence - The DSM-IV-TR diagnosis for substance use that is compulsive, out of control, and has negative consequences, including psychological and physical (not always) dependence on the substance. Also known as Habituation, that is the craving for a substance to avoid a dysphoric state. Classifying Substance Use Disorders: The DSM-IV-TR Categories Tolerance The body?s adaptation to a substance as indicated by the need for increased amounts of the substance to achieve the desired effect or obtaining less effect in response to using the same amount over time Withdrawal Physical or psychological symptoms that occur when a specific substance use is decreased or stopped after using it for a certain period Defining Substance-Abuse Defining Substance-Dependence Classification Issues Polysubstance dependence - The misuse of three or more substances Dual diagnosis ? The coexistence of a substance use diagnosis and another Axis I or II diagnosis for a client Anti-Social PD Depression The advantages and limitations of the DSM-IV-TR diagnoses: Other Dx not appearing in the DSM system (sexual, internet) fig_09_01 Biological Half-Life of drugs (t˝) The duration of action of a drug is known as its half-life, or the time it takes for a substance (drug, radioactive nuclide, or other) to lose half of its pharmacologic, physiologic, or radiologic activity . This is the period of time required for the concentration or amount of drug in the body to be reduced by one-half (50%); For example, the time required for the body to eliminate 50% of the total amount of caffeine consumed when drinking a cup of coffee Commonly Abused Substances Depressants - substances that slow CNS functions: Alcohol Sedative-Hypnotics Opioids Commonly Abused Substances Depressants - Alcohol: Most commonly abused substance in the U.S. Biphasic response (initial stimulation and then depressant) Agonist ? Serotonin, DA, GABA, NE, Glutamate Decreased activity of neurological systems responsible for emotional and self-control (e.g. impulsivity, memory, balance, speech) Degree of intoxication ? amount consumed Metabolism of alcohol varies across age, gender, race Women < Men in alcohol dehydrogenase, thus twice more susceptible for intoxication Chronic misuse ? vitamin deficiency, Korsakoff?s syndrome, GI problems, Cirrhosis of the liver Fetal Alcohol Syndrome Commonly Abused Substances Alcohol ? Potent Teratogen ? Fetal Alcohol Syndrome Permanent birth defects that occurs in the offspring of women who drink alcohol during pregnancy. It is unknown whether amount, frequency or timing of alcohol consumption during pregnancy causes a difference in degree of damage done to the fetus Symptoms include mental retardation, growth impairment, birth defects (e.g. facial distortions) Commonly Abused Substances Depressants - Sedative-hypnotics: Sedatives - substances used to promote relaxation Hypnotics - substances used to promote sleep Barbiturates ? used to treat anxiety; dangerously addictive Benzodiazepines ? enhance GABA activity ? Anxiolytic Cross-tolerance - tolerance extending across drugs within a class Synergistic - the multiplication of effects when two or more drugs of the same class are taken together. Highly addictive; produce tolerance and withdrawal Flunitrazepan (Rohypnol) ? used as a ?date rape? drug (?roofies?) Commonly Abused Substances Depressants ? Opioids (?Narcotics?): Derivatives?natural and synthetic?of the opium poppy: Natural: Opium ? Morphine & Codeine (active ingredients) Semi-synthetic: Heroin, painkillers (Oxycodone) Synthetic: Methadone, Suboxone CNS depressants ? result in analgesia (pain relief), euphoria, and sedation Mimic effects of body?s endogenous opioids neurotransmitters (e.g., endorphins/enkephalins) Physical/psychological tolerance and cross-tolerance develop quickly Withdrawal is extremely uncomfortable; severe flu-like symptoms Commonly Abused Substances Stimulants - substances that increase CNS functions: Cocaine Amphetamines Nicotine Caffeine Enhance arousal, alertness, and energy Commonly Abused Substances Stimulants - Cocaine: Produced from the Coca leaves blocks reuptake of DA, NE, Serotonin leads to euphoria, confidence, energy, excitement short-lived, intense high; very reinforcing High danger of overdose; treatment is difficult Cocaine ? powder Crack - smoking cocaine Freebasing - inhaling the heated vapors of pure cocaine Commonly Abused Substances Stimulants - Amphetamines: Increase availability of NE, DA, Serotonin 1930s ? billed as ?wonder drugs?; used as ?pep pills? Used to enhance performance during WWII; U.S. government established stricter controls in the late 1940s/early 1950s Medical uses ? treatment for narcolepsy, ADHD, weight loss Potent high, unpleasant withdrawal effects (depression, decreased energy, increased appetite, irritability, cravings) ADHD medications ? Ritalin, Adderral, Concerta ? Paradoxical Effect Commonly Abused Substances Stimulants - Nicotine: Approximately 0.6?3.0% of dry weight of Tobacco Inhale, chewing, transdermal Highly addictive, toxic in large doses Nicotine ingested through smoking makes it the world?s deadliest drug Enhances vigilance & arousal, mood, relaxes muscles at high dose, reduces hunger, Acute tolerance, which also increases during the day as one smokes more (the 1st cigarette in the morning is the most potent) Highly reinforcing, unpleasant withdrawal effects (craving, depression, irritability, insomnia, restlessness, increased appetite, weight gain) Commonly Abused Substances Stimulants ? Caffeine: Oral, rapid distribution ? Peak blood levels ~1 hour Half-life 3-5 hours (drinking prior to sleeping); women taking oral contraceptives 5-10 hours pregnant women 9?11 hours; newborn baby may be as long as 30 hours Appears in many common foods, beverages, and medicines Highly reinforcing, physical/psychological dependence, tolerance/withdrawal Psychological: low dosage ? vigilance, alertness, mood elevation, mental clarity, concentration; large doses ? insomnia, tension, potential for panic attacks Physiological ? increases BP, respiration, headache relief, diuretic Links between caffeine intake and physical illnesses Caffeinism (Caffeine dependence syndrome) ? involves irritability, insomnia, nervousness, twitching, heart arrhythmias/palpitations, GI disturbances Commonly Abused Substances Hallucinogens LSD Psilocybin Peyote/Mescaline Also known as psychedelics, psychotomimetics, entheogens Produce hallucinations and delusions ? Psychotic-like symptoms Used for centuries; can be part of religious practices Commonly Abused Substances LSD (Acid): Chemical structure similar to serotonin; effects include perceptual changes, depersonalization, enhanced emotionality LSD doesn?t cause physical dependence, but it does cause tolerance, cross-tolerance, and psychotic symptoms. Psilocybin (mushrooms) Similar to LSD but less potent Chemical structure similar to serotonin Peyote/mescaline Causes hallucinatory experiences, euphoria Chemical structure is like NE & DA Tolerance occurs, but dependence and withdrawal are rare Commonly Abused Substances Other Substances: Marijuana Ecstasy PCP & Ketamine GHB Inhalants Anabolic Steroids Commonly Abused Substances Other Substances ? Marijuana Cannabis Sativa plant Most widely used illegal drug in the world; THC is the psychoactive ingredient Marijuana is rapidly absorbed (15 minutes), yet metabolizes slowly and has a long half-life; can be detected up to 30 days THC binds to cannabinoid receptors Common effects involve depressant, hallucinogenic, and stimulant properties;. Marijuana may have beneficial medicinal effects ? reduces nausea, stimulates appetite, decreases pain) ? 11 US states prescribe it Tolerance, withdrawal, and physical/psychological dependence can occur. Other Substances ? Marijuana Commonly Abused Substances Other Substances ? Ecstasy: MDMA ? chemical compound in Ecstasy; used legally until 1985. Effects include increased empathy, closeness, and connection with others; tolerance can occur. Ecstasy may cause permanent damage to serotonin neurons; Ecstasy-related deaths caused by hypothermia and dehydration. Commonly Abused Substances Other Substances PCP/Ketamine Originally developed as anesthetics. Causes bizarre & violent behavior; users are impervious to pain. Acute PCP intoxication can lead to psychosis. GHB Developed as an anesthetic; currently used as a bodybuilding drug and a club drug. Similar to a depressant and has synergistic effects with alcohol; A ?date rape? drug. Inhalants Involve a wide variety of chemicals, including solvents and medical drugs. Cause a variety of short-lived effects, yet toxic & can lead to permanent organ damage. Anabolic Steroids Resembling testosterone, abused in the service of enhancing athletic performance. Steroids do have legitimate medical use; Long-term ? health risks & withdrawal Sx. Explaining And Treating Substance Use Disorders Two major models to substance-abuse: The ?Moral Model? ? individuals are viewed: Bearing complete responsibility for their addiction Hedonistically-motivated; no regard for others? feelings Failing of willpower ? A sign of moral failing and essentially a sin Punishment through the legal system as the appropriate treatment ?Disease Model? The Individual is not held responsible for their illness Inherent predisposition with NO psychological factors involved Very prevalent today, especially in light of genetic research indicating genes play a role in one?s vulnerability. Eases shame & stigma, people more willing to seek help Explaining And Treating Substance Use Disorders Biological components Neurochemical ? ?Self-Medicating Hypothesis? people use substances to compensate for neurochemical deficiencies Virtually all drugs affect DA and activate the ?Reward Pathway? Repeated drug use ? normal Dopamine, Glutamate & other pleasure pathways? regulation are disrupted ? risk for development of an addictive cycle of drug craving particularly during times of stress Genetic factors ~50% of vulnerability to drug addiction is due to genetic factors Family studies ? alcoholism runs in families (genes? Environment?) Adoption studies ? heritability may be greater in males than females Twin studies ? high concordance rate between identical twins. Susceptibility to reinforcing effects of alcohol? sensitivity to alcohol? Explaining And Treating Substance Use Disorders Biological interventions Alcohol: Antabuse (Disulfiram); Benzodiazepines (ease withdrawal), SSRI?s, Opiate antagonists Opioids: (reduce cravings without typical ?high?) Naltroxene/opiate antagonists Substitution therapy (Methadone/Suboxone) Cocaine: Tricyclic/SSRI?s, DA antagonists, Opiate agonists/antagonists, anti-seizure; none very effective Nicotine: Aversive agents (e.g. cause bitter taste when smoking), Nicotine delivery systems (patch, gum), Buproprion (Wellbutrin/Zyban) Explaining And Treating Substance Use Disorders Behavioral Components Operant conditioning ? drug use is positively and negatively reinforcing (i.e., tension reduction motivation for substance misuse) Classical conditioning ? cues associated with drug use can become conditioned stimuli provoking cravings. Social learning (modeling) ? effects of family, peers, and media. Behavioral interventions Based on classical, operant, or modeling principles Relaxation techniques Covert sensitization (association of unpleasant consequences & drug-use Aversion therapies (e.g. antabuse ? associating drugs w/ aversive response) Contingency management ? rewarding healthy behaviors and punishing unhealthy behaviors Explaining And Treating Substance Use Disorders Cognitive Components Cognitions heavily involved in the subjective experience of drug effects. Expectations & beliefs about the effects of drugs often motivate their abuse Poor self-esteem and low self-efficacy expectations are risk factors for drug problems Emphasis on negative cognitive schemas and negative automatic thoughts. Cognitive interventions include cognitive restructuring. Cognitive interventions Cognitive restructuring Explaining And Treating Substance Use Disorders Family systems components Family characteristics: Denial, co-dependency, colluding and enabling a family member?s substance abuse Family as a system which is organized around a secret Family systems interventions Confronting family defenses, establishing appropriate roles and boundaries Effort NOT to focus on the identified patient, but rather on the entire family. Explaining And Treating Substance Use Disorders Psychodynamic Components: Psychodynamic model somewhat at odds with the disease model The symptom model: Substance-abuse as a symptom of underlying deficits and emotional difficulties (A defense mechanism) Current theories focus on relationships, attachments, self-esteem, and coping/defense strategies. ?Self-medication? - A way of numbing/avoiding painful emotions Alexithymia - Profound difficulty identifying and verbalizing feelings. Denial as a core defense mechanisms in abuse and dependence Psychodynamic interventions: Understanding the emotional purpose and role of substance abuse Develop better skills for dealing with troublesome emotions (emotional regulation); improve self-esteem, self-acceptance, ego skills and relationships Explaining And Treating Substance Use Disorders The Twelve-Step Approach Mutual support, empathy, and advice Alcoholics/Narcotics Anonymous AA NA The Twelve-Step approach Focuses on spirituality and adheres to the disease model. First-name only, sharing of experiences, encouragement, sponsor-based system, confrontation of denial
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