Lecture 9: Substance Use Disorders: Chapter 10 Flashcards
What is the most commonly used substance? And most commonly used drug?
Substance = alcohol
Drug = cannabis
What are 2 indications of tolerance?
- Larger doses of substance is needed to produce the desired effect
- Effect of drug are less if usual amount is taken
What are withdrawal symptoms?
Negative physical and psychological effects that develop when a person stops taking the substance or reduces the amount
What 2 types of reinforcement play a role in addiction? Explain
- Positive: rewarding, mood-enhancing effects of the drug
- Negative: reduces negative affect (self medication) and prevents withdrawal symptoms
What percentage of people in the Netherlands suffer from substance abuse at some point in their lives?
17%
(alcohol 12%, drugs 6%)
What are 3 reasons why we should understand addiction better?
- Very prevalent
- Destructive impact on individual’s well being and functioning
- Society as a whole pays a price for substance abuse
What are the 6 stages of the general developmental process of use to abuse?
- Positive attitude
- Experimentation
- Regular use
- Heavy use
- Substance abuse
- Maintenance
- Recovery/relapse
What is the relapse rate after treatment and recovery?
40-60%
What is the DSM definition of abuse?
Problematic pattern of substance use is required, leading to clinically significant limitations or suffering
What are the 11 characteristics of substance use disorder in the DSM? How many symptoms do you need to classify?
At least 2 of 11 features occuring within 1 year
- Taking substance in larger amounts or for longer than meant to
- Wanting to cut down or stop but not managing to
- Spending a lot of time on it
- Craving and urges
- Not able to do what you should in daily life because of substance use
- Continuing to use, even when it causes problems
- Giving up important activities because of substance use
- Using substances repeatedly despite danger
- Continuing to use despite knowing you have physical or psychological problems that are caused by it
- Tolerance: needing more
- Withdrawal symptoms, relieved by taking more substance
Why is gambling disorder part of the DSM of substance-related and addictive disorders?
Because there are similar biological and psychological foundations for it
What is the dominant idea for explaining the origin of the substance disorder?
Because of the addictive effect on the brain
What is delirium tremens (DTs)?
Withdrawal symptom of alcohol use disorder
Person becomes delirious and tremulous and has hallucinations that are mainly visual but also tactile
What does it mean that alcohol and nicotine are cross-tolerant?
Nicotine can induce tolerance for the rewarding effects of alcohol and vice versa
So consumption of both drugs may be increased to maintain their rewarding effects
What is the biological basis of cross tolerance of alcohol and nicotine?
Nicotine influences the way alcohol works in the brain’s dopamine pathways, associated with reward
In what population group is alcohol use disorder most prevalent?
College-age adults
What is the effect of alcohol on GABA receptors?
It stimulates these receptors, resulting in the experience of less tension
What is the effect of alcohol on serotonin and dopamine?
Increases these neurotransmitters, leading to pleasurable effects
What is the effect of alcohol on glutamate?
Inhibit glutamate receptors, which leads to cognitive effects, such as slowed thinking and memory loss
What is the impact of chronic alcohol abuse when getting older?
Deficiency of vitamin B, which causes severe loss of memory for recent and long term events
What is liver cirrhosis?
Liver cells become engorged with fat and protein, which impedes their functioning.
Some cells die and cause inflammation, with leads to scar tissue and obstruction of blood flow
What is the fetal alcohol syndrome (FAS)?
When pregnant woman has heavy alcohol consumption.
This leads to intellectual disability among children and growth anomalies
What is emphysema?
Consequences of long term cigarette smoing, such as cancers of larynx, pancreas, bladder and stomach - complications during pregnancy - cardiovascular disorders
What are the 3 most harmful components in burning tobacco?
- Nicotine
- Carbon monoxide
- Tar
Why do african american smokers get lung cancer more often than european americans?
They retain nicotine in their blood longer than european americans. So they metabolize it more slowly
What is environmental tobacco smoke (ETS)?
Secondhand smoke: there is a cause-effect relationship between ETS and cancer
What are 3 effects of environmental tobacco smoke (ETS)?
- Lung damage
- Babies of women exposed to secondhand smoke are more likely to be born prematurely and have birth defects
- Children of smokers are more likely to have asthma, bronchitis and inner-ear infections
What are 4 key findings in research on health effects of e-cigarettes?
- E-cigarettes are less toxic than traditional ones
- E-cigarettes can be helpful to stop smoking among adults
- Young people are more likely to transition to smoking cigarettes when using e-cigarettes
- Secondhand aerosols from e-cigarettes contain nicotine and other chemicals that impact others in the area
What is the difference between marijuana and hashish?
Marijuana: dried, crushed leaves of hemp plant
Hashish: stronger than marijuana, dryed resin of the tops of the cannabis plant
What is meant with decriminalization of marijuana?
Possessing a small amount often doesn’t lead to prosecution
In which areas of cognition does marijuana interfere with functioning? (5)
- Attention
- Planning
- Decision making
- Working memory
- Problem solving
What are long term consequences of marijuana abuse? For which age group is this most obvious?
Reduction in IQ, poorer working memory and processing
Most obvious in people who started using in adolescence
How does marijuana affect the brain?
- Affects receptors in hippocampus, leading to cognitive impairment in learning and memory
- Regular users have different patterns of connectivity between amygdala and frontal cortex when regulating negative emotions
What are 3 therapeutic effects of marijuana?
- Reduce nausea and loss of appetite in chemotherapy
- Alleviation of pain, spasms and glaucoma
- Relieve sleep disorders, social anxiety and dementia
What is the function of medical use of opioids?
Relieve pain
What are 4 common opioids?
Opium, morphine, heroin and codeine
What are 3 common chemicals in opioids?
- Hydrocodone
- Oxycodone
- Fentanyl
Describe the 2 waves of overdose deaths from opioids
1: driven by prescription of pain medication
2: driven by heroin abuse
Overdose deaths for all types of opioids continue to rise
How did pharmaceutical companies change practices to decrease addiction of opioids?
Develop opioids with coatings that weren’t easy to dissolve. This lead to less injection of these pills
How do opioids produce their effects in the body?
Opioids bind to opioid receptors throughout the brain. This links to the dopamine system and leads to pleasurable effects
What is dopesick? Describe the symptoms in 3 steps
Withdrawal from heroin.
1. Starting from 8 hours of the last injection. The symptoms are muscle pain, sneezing, sweating and becoming tearful
- Within 36 hours, symptoms are twitching, cramps, chills, rise in heart rate, unable to sleep, vomiting and diarrhea
- Symptoms last for 72 hours and then diminisch gradually over a 5-10 day period
What is the name of the opioids that the body naturally produces?
Endorphins and enkephalins
What are stimulants?
Drugs that act on the brain and sympathetic nervous system to increase alertness and motor activity
What are examples of common stimulants?
Amphetamines, cocaine, caffeine
How do amphetamines work in the brain?
They cause the release of norepinephrine and dopamine and block the reuptake of these neurotransmitters. In this way, they highten wakefulness, quicken heart rate and give a feeling of euphoria, energy and self-confidence
What are symptoms in heavy amphetamine users?
Suspicion, hostility, agitated, confused, sleepy and sometimes dangerous to others
What can you say about the tolerance of amphetamines?
Tolerance develops rapidly, namely after 6 days of repeated use
What is the difference in use in gender between amphetamines and methamphetamines?
Amp: equally used by male/female
Meth: more used by male
What are the effects of methamphetamine on the brain?
- Damage dopamine/serotonin systems (striatum)
- Reductions in brain volume in frontotemporal regions (insula) –> poor decision making
- Damage to hippocampus –> poor memory
What is crystal meth?
The purest form of methamphetamine
What is a difficulty in researching studies on drugs?
It’s very hard to find users who have only used that particular drug of interest and not other drugs as well (alcohol, cocaine, nicotine etc.)
Where does cocaine come from?
Leaves of the coca shrub
What is crack?
A rock-crystal form that is heated, melted and smoked. It’s a form of cocaine
How does cocaine work in the brain?
It blocks the reuptake of dopamine, so the dopamine left in the synapse facilitates neural transmission. This causes pleasure, self confidence and stamina
What is a consequence of chronic cocaine use?
Heightened irritability, impaired social relationships, paranoid thinking, disturbances in eating and sleeping
What does it mean when you say cocaine is a vasoconstrictor?
Cocaine causes narrowing of blood vessels. People taking overdoses often suffer from a heart attack or stroke.
What are cognitive effects of heavy cocaine use?
Difficulty paying attention and remembering
What is the relation between prenatal development and maternal cocaine use? What are the consequences for the child (2)?
Maternal cocaine use leads to less blood flow to the fetus, leading to less development of the fetus.
- Eventually the child has less gray matter volume, especially in regions for cognitive control and emotion regulation
- More substance abuse in these adolescents
What are hallucinogens?
It refers to the main effect of these drugs: hallucinations
E.g. LSD, psilocybin and mescaline
How do hallucinogens work in the brain?
They affect the serotonin system, leading to hallucinations, altered sense of time and mood swings
What is a therapeutic effect of LSD?
Reduce anxiety in people diagnosed with life-threatening illnesses
What is a hallucinogen persisting perception disorder?
It involves flashbacks and other perceptual symptoms that occurred during hallucinogen use, even if the drug is no longer used
What 2 drugs are mixed in ecstasy/mdma?
Hallucinogens and amphetamines
How does ecstasy work in the brain?
It contributes to the release and reuptake of serotonin
What is PCP (phencyclidine)? How does it work in the brain?
It’s a hallucinogen, which causes serious negative reactions (paranoia, violence).
It affects multiple neurotransmitters
What is the consequence of chronic PCP use?
Neuropsychological deficits
What is the general disease model of addiction?
It describes that there are premorbid differences between addicted and non-addicted people, meaning some people can’t use substances in a non-addictive way
What is the main idea of the learning model of addiction?
Addiction is seen as a maladaptive learned behavior that has to be unlearned with behavioral interventions
What is the biopsychosocial model of addiction?
The idea that a mixture of biological, psychological and social factors contribute to the addiction. It’s a holistic perspective
What is the difference between the brain disease model and the biopsychosocial model?
Not that different, but brain disease model has the emphasis on the neurobiological part of addiction
What is the main idea of the brain disease model?
Addiction is a complex, chronic, relapsing brain disease with a genetic and neurobiological basis. It’s characterised by compulsive drug seeking and use despite harmful consequences
Explain the brain disease model in 4 steps
- Interaction between genes (genetics, gender) and environment (home, child abuse, parent’s use, community attitudes, low school performance)
- Drug use (route of administration, effect, availability, cost)
- Brain mechanisms
- Addiction
What are 2 prominant criticisms on the brain disease model?
- It’s possible to say no to drugs, so it’s not purely a brain disease
- Addicts are not blameless victims of a terrible illness they have no control over
What is the heritability of drug and alcohol use disorders?
40-60%
Why are alcohol problems in certain ethnic groups, such as Asians, lower?
They have an inherited physiological deficiency in the enzymes in alcohol metabolism (ADH). They experience unpleasant effects from small quantities of alcohol (flushing), which may protect them from becoming alcoholic
What is a genetic factor in nicotine addiction?
The presence of a gene that metabolizes nicotine. People who process nicotine more quickly, smoke more per day. This relates to a higher activity of that gene
What is the dopamine vulnerability model?
The idea that problems in the dopamine system increase vulnerability of some people to becoming dependent on a substance
What is the toxic effect model?
The idea that problems in the dopamine system are the consequence of taking substances
Is there more evidence for the vulnerability model or the toxic effect model?
Both are equally supported by science, so it’s difficult to make the distinction
What type of learning is involved in craving? How does it work?
Pavlovian learning/classical conditioning: stimuli can become associated with alcohol and drugs. Stimuli can be certain environments or people. These stimuli are triggers of craving
What are the 2 types of stimuli that trigger craving?
- External: places, things, people
- Internal: anxiety, stress, depression
What is the incentive-sensitization theory?
The idea that repeated drug use sensitizes the brain, increasing the ability of drugs and stimuli associated with drugs to elevate dopamine activity
This leads to increased wanting of the drug, while liking stays the same or even decreases
The transition from liking to wanting is accomplished by the drug’s effects on the dopamine pathways
What are good predictors of drinking behavior in research?
Self-reports of wanting and liking of the specific substance
What is delay discounting? How is this in people who are dependent on drugs or alcohol?
The extent to which people opt for smaller immediate reward instead of waiting for larger delayed rewards
This is higher in people with substance dependence
How does delay discounting work in the brain?
Brain regions compete when someone is presented with a decision about whether to take a drug or think about a larger reward in the future
Valuing delayed reward = PFC
Valuing immediate reward = amygdala and nucleus accumbens activity
What is the difference between known risks or ambiguous risks? Give an example of each
Known: if I take this drug, I know I’ll be late for work
Ambiguous: if I take this drug, I might get caught by my boss
What does a low tolerance for ambiguous risk and an average to high tolerance for known risks predict in opioid abuse disorder?
These people were more likely to relapse after treatment
How does risky decision making work in the brain?
It’s associated with activation in the orbitofrontal cortex, parietal corex and ACC
What are 3 types of psychological influences that may contribute to the etiology of substance use disorders?
- Emotion regulation
- Expectations and beliefs about the drug prevalence and health risks
- Personality traits
Which type of learning is involved in habits?
Instrumental learning/operant conditioning
How does instrumental/operant conditioning work in creating habits? Describe in 4 steps
- Repeated performance of a behavior in the presence of certain stimuli can strenghten stimulus-response (SR) habits
- Rewards reinforce SR learning
- Drugs may reinforce habits more powerfully than natural rewards
- Once formed, habits are automatically triggered by stimuli, independent of one’s motivation for the outcome
What stages in the developmental process of substance abuse disorder fit with:
Craving (2)
Habit (2)
Compulsive drug seeking (3)?
Craving: positive attitude, experimentation
Habit: regular use, heavy use
Compulsive drug seeking: substance abuse, maintenance, recovery/relapse
Substance abuse is marked by cognitive dysfunction. Which 3 aspects are important? Are they a consequence or a vulnerability factor?
- Impaired response inhibition
- Steeper delay discounting
- Risky decision making
They can be a consequence of the neurotoxic effects (especially on PFC), but they can also be a vulnerability factor in developing an addiction
What is the double trouble / disrupted dual processes model?
Bottom up processes: craving and habits are going up
Top down processes: cognitive control functions are decreasing
So this combination can give rise to truly compulsive drug seeking
What are 5 sociodemographic risk factors associated with greater substance abuse?
- Gender: male
- Young age
- Living alone
- Being unemployed
- Very high degree of urbanization
What are 2 risk factors for SUD concerning personality?
- Sensation seeking (desire for arousal and positive affect)
- Low impulse control
What are 2 cultural risk factors for developing SUD?
- Drug availability
- Advertising and media
What are 4 family and peer related risk factors for developing SUD?
- Substance abuse by caregivers
- Marital discord or other problems in the family
- Lack of parental monitoring
- Lack of parental support
- Social influences by peers
In what phase of your life are peers a great risk factor for developing SUD?
In adolescence
What is the difference between the self-medication hypothesis and the high-risk hypothesis?
Self medication: mental disorder leads to substance abuse
High-risk: substance use leads to mental disorder
What are common comorbid disorders with SUD?
Depression, PTSD, ADHD, bipolar disorder, borderline and anti-social personality disorder
For who does substance use spiral out of control?
There is nothing that can predict whether someone will develop a SUD
More risk factors: more chance SUD
More protective factors: more resilience against SUD
Why might expectations play a role in potential substance abuse? What is some evidence on this?
People may drink not because it reduces negative emotion, but because they expect it to do so
–> People who expect alcohol to reduce stress are more likely to be frequent users
What is the aim of CBT in SUD?
Breaking through a pattern of problematic substance use (reducing or quitting)
What are 6 steps in CBT for SUD?
- Enhancing motivation for treatment
- Self-control measures and contingency management
- Functional analysis
- Dealing with craving
- Prevention of relapse
- Declining/refusing substances
How do you enhance motivation for treatment in SUD?
Collaborative, goal-oriented conversation with attention to change language. You want to elicit and explore a person’s reasons for change in an atmosphere of acceptance
Make a cost/benefit balance (disadvantages of use, benefits of decreasing/stopping use)
Withdrawal symptoms are not the main cause of relapse in addiction. What are the 2 main causes?
- External stimuli (places, people)
- Internal stimuli (stress, anxiety)
What are some self-control measures? (2)
- Stimulus control
- Stimulus-response prevention
What is stimulus control?
Avoiding risk situations and triggers
What is stimulus-response prevention? Give an example
Linking risk situations with an alternative behavior, preferably one with the same function.
E.g. relaxation –> mindfulness
What is contingency management?
Reinforcing desirable behavior, such as abstinence, attendence and positive activities
What are 2 strategies to deal with cravings?
- Seek distraction or social support when craving
- Urge surfing: ride the craving out, like a surfer riding a wave
What are the 4 stages of urge surfing?
- Trigger: craving is triggered
- Rise: craving increases
- Peak: craving is most powerful
- Fall: craving fades away
Why can a relapse be dangerous for falling back into SUD?
A slip after abstinence may cause a person to feel guilt, shame and self doubt. This increases the risk of a full-blown relapse
What are 2 strategies to prevent a slip from turning into a relapse?
- See relapse as part of the recovery process
- Perform a task that is effortful/unpleasant but that makes you feel better in the end (cleaning the curtains)
What are 3 types of medication used for SUD treatment?
- Aversion drugs: nausea and vomiting if substance is used
- Anti craving drugs
- Detoxification and/or maintenance drugs
What is the alcoholics anonymous group?
The largest self-help group, where regular meetings are held with other addicts to provide support. The goal is complete abstinence
What is Community Reinforcement and Family Training (CRAFT)?
Evidence-based treatment based on CBT.
It aims to help relatives to adjust their behavior in order to motivate the patient to recover from their addiction. It improves quality of life of close relatives
What are 2 important aspects of CRAFT treatment for the relationship between addict and relative?
- Not enabling and reinforcing unwanted behavior: allow negative reinforcement to take place
- Positive reinforcement ofdesirable behavior
What is controlled drinking?
Treatment approach from guided self-change. The basic assuption is that people can have more control over their drinking than they believe. Heightened awareness of costs of drinking and benefits of cutting down can help
What is nicotine replacement therapy?
It substitutes a different delivery system for nicotine (e.g. gum) to allay cravings
What is the central theme in treating drug use disorders (opioids, cocaine)?
Detoxification and withdrawal from the drug –> cravings for the substance often remains after the substance has been removed in detoxification
What are 5 features of self-help residential programs?
- Separation of people from previous social contacts
- Comprehensive environment without drugs
- Presence of role models
- Direct confrontation in group therapy (accept responsibility for their problems and habits)
- Respectful setting, no stigma
What is the difference between opioid substitutes and opioid antagonists?
Substitutes: chemically similar to opioids and lessen cravings
Antagonists: prevent user from experiencing the high
What is MAT?
Medication assisted treatment: effective for treating opioid use disorders (e.g. opioid substitutes or opioid antagonists)
What is methadone treatment?
Going to a drug-treatment clinic and swallowing the drug in the presence of a staff member in combination with a supportive social interaction
What is methadone?
A drug similar to morphine. It doesn’t provide a high and is less sedative. It’s part of treating heroin or morphin addiction
Why do many people drop out of methadone programs?
Side effects: insomnia, constipation, sweating and big stigma
