Lecture 11 - AUD and other substances Flashcards
Where in HiTOP?
Disinhibited externalizing… substance abuse… substance-related disorders
History
“It is disgusting to notice the increase in the quantity of coffee used by
my subjects…. Everybody is using coffee; this must be prevented. His
Majesty was brought up on beer, and so were both his ancestors and
officers. Many battles have been fought and won by soldiers nourished
on beer, and the King does not believe that coffee-drinking soldiers can
be relied upon to endure hardships in case of another war.”
–Fredrick II of Prussia
Down the rapids of rum
If by Whiskey poem
The simpsons
Cocaine toothache drops
*DSM-I
* A symptom of “sociopathic personality disorder”
* Alcoholism and drug dependence
* No classes of drugs specified
* No specific criteria
*DSM-II
* Still a personality disorder
* Alcoholism and drug dependence
- Barbiturates, cannabis, cocaine, hallucinogens, opioids
* Some criteria specified
- “…the inability of the patient to go one day without drinking…”
- “…habitual use or a clear sense of need for the drug…”
*DSM-III (1980)
* “Substance use disorders” separated from personality
* Each class of substance recognized as a distinct disorder
* Sets of diagnostic criteria established
- Abuse vs. dependence
Causing social problems = abuse
Physiological tolerance and/or withdrawal problems = dependence
Substance Abuse
*A maladaptive pattern of substance use
leading to distress or impairment
*One or more of:
* Failure to fulfill role obligations
*Physically hazardous situations
* Legal problems (later removed)
*Social problems
Substance Dependence
*A maladaptive pattern of substance use
leading to distress or impairment
*Three or more of:
*Tolerance
*Withdrawal
*More than intended
* Failure to cut down
*Time spent
*Other activities given up
*Physical or psychological problems
(later added craving)
*DSM-III-R (1987), DSM-IV (1994), DSM-IV-TR (2000)
* Minor tweaks
* The word “addiction” doesn’t appear anywhere
*Implication: everyone who meets criteria
for dependence must also meet criteria
for abuse.
* Not the case!
*DSM-5
*No longer recognizes a distinction
between substance “abuse” and
“disorder.”
*Now a single disorder: e.g., alcohol use
disorder (AUD) with mild, moderate,
and severe sub-classifications.
Perspectives on Substance-Related Disorders
Five Main Categories of Substances
*Depressants… alcohol, sedatives…
*Stimulants… cocaine, nicotine, caffeine
*Opiates… heroin, morphine, codeine
*Hallucinogens… marihuana, lsd
*Other drugs of abuse… steroids, meds used in unintended ways
Non-Substance addictive Disorders
*In DSM-5, a change from
Substance Disorders to
“Substance-Related and
Addictive Disorders”
*Addictive disorders now
include Gambling Disorder–
only entry into new category of
behavioral addictions
*Hypothesized to be similar in
terms of clinical expression,
neural origins, comorbidity,
physiology, and treatment
* Internet gaming disorder
included in category for future
consideration
Drugs ranked by addictiveness:
nicotine
ice, glass
Crack
…
Diagnosing Substance Use Disorders
*Four general groupings of
indicators:
* Impairment of control
* Social Impairment
* Risky Use
* Pharmacological Dependence-
- Tolerance
- Withdrawal
Prevalence rates
Use of any illicit drug:
* 14% for 8th graders
* 27% for 10th graders
* 37% for 12th graders
* 35% for college students
* 34% for 19- to 28-year olds
Polysubstance Use Disorder
* Concurrent Dependence more
common than not
* 80% of problem drinkers also smoke
* 50% of cocaine users dependent on
alcohol
Even more difficult to treat
More severe
Interaction makes them more dangerous
More and more common among younger people
Prevalence: AUD
*50 % of adults over the age of 18 are
current “regular drinkers.”
*Lifetime prevalence:
*~ 13.2% for abuse
*~ 5% for dependence
*In men, rates have traditionally been
2-5 times higher
*In West, now less of a difference
between men and women
*Rates typically higher in White and Native
American/ First Nations populations
*Typically lower in Black and Hispanic
populations
*Can vary by study
East Asian and Jewish populations tend to
have lower rates
-ADH22
-Rates of abuse of other substances similar or
higher
*Approximately 35-40% also meet criteria for another
disorder
*Onset typically in late adolescence/ emerging
adulthood
-Median age of onset: 21
-Mean age of onset: 23
*Though more common in men, women deteriorate
more quickly
Gateway Theory
*Alcohol and marijuana are “gateways”
- Increase the likelihood of use of other drugs
*Doesn’t rule out general tendency towards
substance abuse
-Alcohol and marijuana are just easier to get
*Study: Mz and Dz twins.
-Minimal genetic effect (not much)
Not really true
People more likely to try one drug also more likely to try others (doesn’t have to do with the drug itself, but the person)
Maybe because of a social correlate rather than a property of the drug (smoke weed, hang out with people who do, those people also do other drugs, you try other drugs…)
Course/ risk: AUD
Heavy drinking associated with increased rates of:
*Vulnerability to injury
*Marital discord
* Intimate partner violence
* Illness (e.g., diabetes, cirrhosis of the liver)
*Neurocognitive impairments (e.g., brain shrinkage)… White matter decreases
*Decreased lifespan: As much as a 12-year decrease
*Suicide
*Dr. George Vaillant
*Study of 724 men, all originally recruited as healthy
controls for other studies during late 1930s and
early 1940s
*Of the 724, 181 (25%) eventually developed
substance use disorder.
*By age 70: ~ 50% of these had chronic course
*Between 25 and 30% had recovered
*10% had controlled drinking
*If abstinent for 5 years, unlikely to relapse
- Recent study from Witkiewitz and colleagues
- N= 694; 70% Male, 79.0% White
- Look at functioning 3, 7, and 9 years after treatment
- Identified four groups:
- (i) low‐functioning frequent heavy drinkers (13.9%)
- (ii) low‐functioning infrequent heavy drinkers (15.8%)
- (iii) high‐functioning heavy drinkers (19.4%)
- (iv) high‐functioning infrequent drinkers (50.9%)
- Looking at outcomes like hospitalizations, relationships, health, life
satisfaction, and other indices of functioning (e.g., employment)
Vulnerability Factors: AUD
*Early drinking (i.e. before the age of ~15)
*Family history of AUD
- Lifetime risk of AUD in relatives of AUD is 30% compared to 14% in
controls
-Relatives of AUD also had higher rate of abuse of multiple substances
-Higher rate of APD (8% vs 5%)
- Increased risk for almost all other psych disorders
-General liability for psychopathology?
-Slight inclination towards externalizing
Adoption Studies
* Individuals whose biological parent(s)
had AUD
*BUT adopted by non-AUD nonrelatives
*Look at frequency of AUD in these
individuals in adulthood
-Increased probability of AUD
-Suggests biological predisposition;
de-emphasize role of environment
-BUT: Biology ≠ Destiny
Twin Studies
Groups
*Group 1: Offspring of all twins (Mz and Dz) with dx of
AUD
-High genetic/ high environmental risk
-more likely to meet criteria than group 4
*Group 2: Offspring of Mz twins who do NOT meet
criteria for AUD but co-twin does
-High genetic risk, low environmental risk
-not more likely than group 4
*Group 3: Offspring of Dz twins who do NOT meet
criteria for AUD but co-twin does
-Moderate genetic risk, low environmental risk
-not more likely than group 4
*Group 4: Offspring of twins (Mz and Dz) who do not
meet criteria for AUD
-Low genetic risk, low environmental risk
-not likely to meet criteria (control)
Conclusions:
Genes matter, but environment matters quite a lot
Also genes are probabilistic, not deterministic
TOLERANCE
*If you have to drink more, then you’re slower to
recognize the effects
-Drink more
-Build up tolerance
-Drink more, spiral
*Sons of AUD fathers: balance and coordination after
drinking better than in sons of controls
*May start out less sensitive to the effects of alcohol
(subjective and physiological)
*Performance on lab tasks predictor of development of
AUD
Reinforcement and learning
- Alcohol dependence develops
through reinforcement - Positive reinforcement: It feels great
to BE drinking - Positive Affect Regulation Theory
- For many people, drinking increases
positive affect! - People feel more confident, happier
- Some evidence that people who are
high on reward-seeking or sensationseeking, more vulnerable to AUD
Catherine Fairbairn (UIUC)
*Why more prevalent in
males?
*Many men report that
majority of their bonding
w/ other males occurs in
the context of drinking
*Some evidence that the
effects of alcohol more
rewarding for males
*Why?
Effects of Alcohol on Social Smiling
*Test 720 participants (M & F)
*Both M & F show positive
effects of alcohol on mood
*Men experienced an increase in
reciprocal smiling
*The duration of men’s smiles
increased
*Making contagion more likely
*More interpersonally rewarding
for men
*Women in placebo group
shared same number of social
smiles
Negative Reinforcement
*For many, it feels bad to not drink
*Negative Affect Regulation Theory
- Self-medication theories of AUD
-Decreases anxiety, sadness, selfconsciousness
-Forget your worries
*Some evidence that people with
more trait negative affect (e.g.,
depression, anxiety) vulnerable to
AUD
*For many, both paths (positive and negative reinforcement) can
lead to increased alcohol
consumption
*“I could not live without
Champagne. In victory I
deserve it, in defeat I
need it.” Winston
Churchill, 1946
Neurobiology of addiction
The Mesocorticolimbic Pathway
Neurotransmission… dopamine
Shifts from reward to the cue
Craving for cue, when see cue start feeling that reward, anticipatory experience of the substance, and if you don’t receive it you get a crash in dopamine activity
(see study)
Craving associated with chronicity and severity of disorder
Physiological Effect of Alcohol
*Both a stimulant and a depressant
*While drinking: stimulant
-Drinkers report increasesin elation, excitement and
extroversion; decreases in fatigue, restlessness, depression and
tension
After drinking: depressant
-Decrease in vigor and an increase in fatigue, relaxation,
confusion, and depression
*Stimulation:
*Increases in Norepinephrine
*Increased Norepinephrine associated with
increased impulsivity
Alcohol affects Pre-Frontal
Cortex, hippocampus and cerebellum
(PFC)
GABA
*gamma-Aminobutyric acid
*Critical for reducing neuronal excitability throughout
the nervous system
*Acts at inhibitory synapses in the brain
*Inhibit DA neurons
*Where are these receptors found?
In prefrontal cortex (executive function), hippocampus (memory) and cerebellum (motor control)
Stimulants: Amphetamine Use Disorders
Effects of Amphetamines
* Produce elation, vigor, reduce fatigue (pleasure)
* Similar to the effects of adrenaline
* Followed by a “crash”
* Chronic use can lead to fatigue, sadness, intense anger
* Enhance release of dopamine and norepinephrine, while blocking reuptake
* Can cause psychotic symptoms
* High risk of dependency and withdrawal
* 6% of Canadians age 15+ report lifetime usage
* Methamphetamines—often amphetamine of choice for poorer people
Stimulants: Cocaine Use Disorders
Effects of Cocaine:
*Short lived sensations of elation, vigor, reduce fatigue
*Effects result from blocking the reuptake of dopamine
*Cocaine is highly addictive, but addiction develops slowly
(after 2 to 5 years)
*Withdrawal (boredom, tolerance, paranoia)
*Crack: crystallized form of cocaine that is smoked; acts faster
*Also more often consumed by poorer people
*Prevalence: about .7% past year (Cocaine OR Crack)
Opioids: An Overview
* Opiate – Natural chemical in opium
poppy
- narcotic effects (i.e., pain relief)
* Opioids – broader term that refers to a
class of natural & synthetic substances
with narcotic effects
* Activate endogenous opioid receptors
- Endorphins
* Morphine
- Too addictive
* Developed Heroin
Heroin:
*Low doses - euphoria, drowsiness, slurred speech,
memory impairment, & slowed breathing
*High can be sustained 4 to 6 hours
*High doses can result in death
*Withdrawal symptoms can be lasting (1 week) & severe
*Less than 1% of Canadians report ever having tried
heroin
-Prescription opioids more prevalent
-8% of adults use codeine, morphine, or Demerol
Opioids intense withdrawal
Tabacco, nicotine and caffeine also stimulants but classified differently in dsm5
Tend to pathologize and punish meth more severely (poorer people)
Treatment
AA, NA, CA, etc.
* “12 step programs”
* Preach total abstinence
* Faith in a higher power
* Hugely influential
* Limited research on effectiveness
* Potential problems with self-selection in studies
* BUT: Recent study: A.A. leads to increased rates and lengths of abstinence compared with
other common treatments. On other measures, like drinks per day, it performs as well as
approaches provided by individual therapists or doctors who don’t rely on A.A.’s peer connections.
* Key mechanisms:
- Social support
- Structure
*CBT for substance use
* Identify high-risk situations
- Environmental cues
- Affective triggers
- Distorted thoughts
* Emphasis on coping skills and relapse prevention
Pharmacological Treatment
*Agonist substitution
* Replace drug with a safer
substance
* e.g., methadone (for heroin), nicotine
gum/patch
Antagonists
* Blocks the positive effect of the
drug
* Doesn’t block withdrawal
symptoms
* Requires high degree of
motivation
*Aversive treatment
* Make the drug unpleasant
* risk of noncompliance
*Baclofen
*GABA agonist
*Suppression of craving; can be administered prior to
cessation
*Evidence that it is effective in very treatment-resistant AUD
*Also other SUDs
*Naltrexone
*Opioid antagonist
*Reduces both rewarding effects of alcohol and craving for it
*Meta-Analysis: Naltrexone reduced risk of heavy drinking to
83 percent of the risk in placebo group
*Gabapentin
*Increases GABA
*Administered following drinking cessation
*Reduces effects of withdrawal
*Can reduce relapse
*Disulfiram
*inhibits aldehyde dehydrogenase
*causes sweating, headache, dyspnea, lowered blood
pressure, flushing, sympathetic overactivity, palpitations,
nausea, and vomiting
*Pts must be sober
