9. Substance-related disorders Flashcards
how many Australians use substances daily?
4/10 Australians daily smokers, risky drinkers, or used illicit drugs in last 12 months
percentage of Risky alcohol use in Australians > 14 years
18% drinking > 2 SD / day
percentage of Tobacco use in Australians > 14 years
12% daily smokers
percentage of Cannabis use in Australians > 14 years
10.4% national average (use in last 12 months)
Most common illicit drug (36% of drug users report cannabis use)
percentage of Metham use in Australians > 14 years in last 12 months
Ice (80% pure metham) Speed (10-20% pure) 1.4% national average (last 12 months) 6.3% ever used Drops in NSW Higher rates in WA (2.7%), Tasmania (2.1%) and SA (1.9%)
percentage of Ecstacy use in Australians > 14 years in last 12 months
2% national average
percentage of Pain killers / opiate misuse (excl OTC) use in Australians > 14 years in last 12 months
4.8% opioids
Over the counter / prescribed codeine products most commonly misused.
Pharmas second most commonly misused illicit
drug
Highest users in their 20s and 40s
public perception of illicit drug use according to the NDSHS
Public perception – treatment/education program best for all drugs except cannabis (warning)
Most people support harm reduction for injectors
Great majority of people support medicinal cannabis (87%)
One third Australians support cannabis legalisation
Low risk drinking
– 2SDs/5 days per week, 4 SDS on a single occasion increases risk of injury
At what age does alcohol have bad affects?
under 15s, no alcohol, delay as long as possible after 15
Tobacco, alcohol and illicit drugs as a killer
Tobacco still the biggest killer (18000K per year), followed by alcohol (6000K per year), followed by illicit drugs (1800 per year))
Drug use in disadvantaged communities
2.7x smoking
1.7x alcohol abstinence
Less cocaine/ecstasy (1.2% compared to 3%)
Drug use in unemployed people
1.8x smoking
1.5x cannabis
3.1x meth/amphetamine
Drug use in Homosexual or bisexial people
5.8x use of ecstasy and meth/amphetamine
Drug use in people living in urban and regional regions
Smoking under 10% in inner city areas, around 20% in regional areas
What are the basic criteria of substance use disorder
impaired control (craving, larger amounts than intended, persistent desire to cut down, excessive time to obtain)
social impairment (failure to fulfil obligations, continued use despite problems)
risky use (use in hazardous situations)
tolerance/withdrawal
Number of symptoms present determines severity
Severity of of substance use disorder
Number of symptoms present determines severity
2-3 mild
4-5 moderate
6+ severe
Key feature of presentation: Ambivalence
Tolerance of drugs
Milder symptom, somewhat normative, varies greatly over comparatively few years
Withdrawal
Rare for adolescents
Confused with hangover
Normative aspects may mean..?
over-diagnosis -
stigmatisation
useful assessment measures of substance use disorder
Screening – AUDIT, Fagerstrom
Patterns, context, baseline - Timeline follow-back
Motivational factors - Expectancies/efficacy
What items are involved in an AUDIT as a measure of SUD
Hazardous alcohol use (3 items) Dependence symptoms (3 items) Harmful alcohol use (4 items: guilt/blackouts/injuries/others concerned about drinking) Scores and treatment (tentative) - 8-15: brief advice/education - 16-19 brief counselling and monitoring - 20+ further diagnosis
Timeline follow back as a measure for SUD
1-3 months (up to yesterday), marked in standard days, mark in personal holidays special events, best estimate, something written in each box
Last drink? How much? Where were you?
Max drink? When? (How much)? Where were you?
Least amount? When? Where were you?
Abstinence days? Where were you?
Then work back from today..
Work around anchors
Expectancies of alcohol according to the alcohol expectancy questionnaire and the drinking expectancy profile?
(Young & Knight, 1991)
- Transforms experience
- Enhances social/physical pleasure
- Sexual experience and performance
- Power and aggression
- Social assertiveness
- Reduces tension
What are the expectancies of alcohol according to the Negative alcohol expectancy questionnaire?
(McMahon & Jones, 1993)
- same day
- next day
- long term
Expectancies of cannabis according to the Marijuana Effect Expectancy Questionnaire - brief
(Torrealday et al., 2008)
- Cognitive and behavioural impairment (heavily weighted negative)
- Relaxation and tension reduction (heavily weighted positive)
- Social and sexual facilitation (very heavily weighted positive)
- Perceptual and cognitive enhancement (very heavily weighted)
- Global negative effect (heavily weighted negative expectancy)
- Craving and physical effects (modestly weighted negative)
Tobacco expectancies according to Smoking abstinence (Abrams et al., 2011; 28 items four scales)
- Negative mood (“I would feel agitated”)
- Somatic symptoms (“my hands would shake”)
- Feeling physically awful (“I would feel like I’m going to die”)
- Feeling calm
Efficacy and drug use
Situational confidence/drug use control self-efficacy Common high risk situations: - interpersonal conflict - negative emotional states - testing personal control - feeling urges or temptations
Cannabis products - contents of the cannabis leaf
Cannabinoids – some 80 chemicals in the cannabis sativa plant
Cannabidiol – 40% of cannabis extracts – has antipsychotic effects (for anxiety, bipolar managing seizures)
Delta-9-tetrahydrocannabinol (THC) – major active ingredient (euphoria, pain relief)
Cannabis products - contents of cannabis candies, cookies and infusions
More ED admissions
Child poisoning
Cannabis concentrates
70% - 90% THC Content
Vapourisers and e-cigarettes
Adverse acute effects of cannabis according to early research
Anxiety, dysphoria, paranoia (especially when naive users)
Attention and memory impairment
Psychomotor impairment
Risk of psychotic symptoms, partic where family history of psychosis
Increased risk of low birthweight babies when used during pregnancy
Cannabis as a cause of car accidents
Cannabis impairs reaction time, information processing, attention and tracking, motor performance, and tracking behaviour
Often not clear whether cannabis impairment present at time of accident
More recently – cannabis doubles – triples risk of crashes (Gerberich et al)
High but not as high as alcohol, where 6-15 higher risk of crash
Fatalities of cannabis?
Fatal overdose – very unlikely – still holds
Case reports of cardiovascular fatalities in otherwise healthy men
Neurological impacts of cannabis
Imaging studies show Reduced activity in brain regions related to memory and attention (hippocampus, prefrontal cortex, cerebellum)
Cannabis and its association with other drug use
More likely to use other drugs, particularly when start cannabis
at a young age. Why? Exposure through suppliers
Early users use cannabis because of other issues (e.g., sensation
seeking)
Cannabis increases propensity to use other illicit drug use (Gateway
theory)
.
Cannabis as a reverse gateway
Cannabis use increases tobacco use
Cannabis dependence
Impaired control Difficulties ceasing use despite harms 1-2% adults affected in past year 4-8% adults in their lifetime Among those who have ever used, 9% report lifetime risk of dependence (compared to 32% for nicotine)
cognitive impairment as a result of chronic cannabis use
Few studies control for intellectual functioning before cannabis use
Available studies indicate frequent long term cannabis use produces unique negative impairments
Verbal learning, memory, attention
Unclear whether the brain fully recovers – probably not
Some evidence that effects significant for adolescents, but not for adults
Cannabis withdrawal according to the DSM 5
Anxiety / Irritability / agitation
Insomnia
Mood swings / tremor / nausea / anorexia
Poor concentration / headache
Perspiration / cravings
Unlike alcohol withdrawal, THC rarely requires in-patient care
Use diazepam, sometimes anti-psychotics
What is the medicinal cannabis?
Sativex®
Sativex®
Only medicinal cannabis product registered by the
TGA
Can be prescribed without state approval if you are
a patient class subscriber, or GPs can apply to DG
Health
Price set by overseas suppliers
How is Sativex® accessible?
Authorised Prescriber Scheme
Special Access Scheme (severe illnesses)
Clinical trials
CBT as treatment for cannabis dependence
Coping with relapse vulnerabilities
Building social/group support for change
Motivational interviewing (client centred, reflective)
Goal setting (3-4 prioritised problems)
Resource identification
Clear plan with specified steps
Progress measures – diverse, use of cannabinoid-positive urine testing
Steinberg et al: Marijuana Treatment Program as treatment for cannabis dependence
Included a case management module – addressing any issue affecting durability (relationship problems, housing, employment/financial, psychiatric, transportational, parenting/medical)
Case manager a mentor/guide
Analglesics - opioids
(e.g., Morphine, codeine, fentanyl, oxycodone)
Very common treatment
Effective in the treatment of acute pain
Not recommended as a long term treatment for chronic non-cancer pain
Safety and efficacy concerns (State health departments in Australia)
Short acting opioids more dangerous than longer acting ones
Opioid use in Australia
In Australia, there has been a 600% increase in opioid prescriptions in the last 10 years
Side effects of opioid use
Side effects – lots, constipation, decreased alertness, disassociation. However, side effects are manageable most of the time
Risks of dependence of opioids compared to other substances
High risk of dependence, particularly in those with Hx of dependence on a substance
Motivational interviewing
- A conversation about change
- Foster internal confrontation
- Bring together uncomfortable realities with empathy
- Roll with resistance
- Look for change statements
- Strengths-based – support efficacy
What is a behavioural indicator of motivational change?
Do i have a problem? –> What can i do?
Acceptance and commitment therapy
‘Feeling good’ versus living a rich and meaningful life
What is happiness in Acceptance and commitment therapy?
Happiness (pleasure, gratification elation) is
- not normal but we crave and strive for it
- Great but doesn’t last
- Pursuing it is unsatisfying
- THIS IS THE TRAP
what is a rich and meaningful life in acceptance and commitment therapy?
- Take action based on what we consider valuable and meaningful
- When we know what we stand for
- Not fleeting, sometimes uncomfortable
How is pain seen in acceptance and commitment therapy?
- ‘Life involves pain – cannot be avoided but we FIGHT IT,
ARGUE, TAKE DRUGS TO STOP IT - We all struggle with being fused to our thoughts
Psychological flexibility in acceptance and commitment therapy
- being present here and now
- Being fully aware
- Choosing actions that are guided by your values
- Moving towards what is important
How does ACT allow us to live meaningfully?
Drains the power of chronic and overwhelming
troublesome thoughts and frees us to live meaningfully. Can change your life’s trajectory
Troublesome/uncomfortable thoughts
> Most people have them.. Called stories, that run all the time
They expand [+++++, xxxxxx, no subtraction]
Same old stories running and rerunning – self concept
–Ï am hopeless
- I am unlikeable
-I am a fraud
How does CBT overcome troublesome/uncomfortable thoughts?
seeks to challenge írrational’ thoughts,
How does ACT overcome troublesome/uncomfortable thoughts?
thoughts are only a problem if you fuse with them
Defusing as a treatment of addiction
- Wisdom traditions, not problem solving traditions
- Endless ways of creating distance from thoughts
- Ten deep breaths > Slow > Focus on air moment, chest, shoulders > Empty your lungs, breath in > If a thought comes by, acknowledge it, then turn back to your breath - Name your stories > The ‘I can’t do this’ story.. > Don’t have to challenge, or push away - Let it come and go then do things you value.
- I’m having the thought that….
Delusion as treatment for addiction
Not a control strategy – if its an attempt to change, avoid, get rid
of.. Its not defusion
Is an acceptance strategy
Can stop struggling with troublesome thoughts (the happiness trap), struggling takes you away from what you value.
What happens with the struggle switch is on?
‘should have.. Could have…. This must…. This has to be… this can’t…’
troublesome feelings snowball – anxiety causes anger..
Acting inconsistent with values - alcohol/drugs to distract…
What happens when the struggle switch is off?
- Anxiety comes, rises, goes..
- Observe, don’t waste time and energy struggling
Urges as a treatment for addiction
Seem overwhelming, rate them (scale 0-10)
Urges like waves that one can learn to surf
What are urges to like?
- Body scanning: What do they feel like from head to toe?
Where are they located?
Awareness of them, rate them (scale 0-10)
Acknowledge them – I’m having the urge to… My brain is
telling me to..
Breathe into it, make room for it, observe it crest and fall..
Response: Can act or not act.. If act, will I be acting like the
person I want to be?
Take action
Does ACT work?
Lee et al. (2015). An initial meta-analysis of Acceptance and
Commitment Therapy for treating substance use disorders. Drug
and Alcohol Dependence. Meta-analysis of 10 trials of ACT compared to CBT,
pharmacotherapy, 12-step, treatment as usual. Small to medium effect size favouring ACT. Promising approach to the addictions
