Session-11 Substance Disorders

Question 1

How is DSM-IV-TR: “Substance” defined?

Answer 1

Drug of abuse, medication, or toxin

Question 2

What are the DSM-IV-TR Substance Classes?

Answer 2

1. Alcohol
2. Amphetamine
3. Caffeine
4. cannabis
5. Cocaine
6. Hallucinogins
7. Inhalants
8. Nicotine
9. Opiods
10. Phencyclidine
11. Sedatives, Hypnotics or Anxiolytics
12. Polysubstance
13. Other.
    See pp. 193 (Table 1): diagnoses associated with each class of substances

Question 3

What are the 4 Major Categories of Substance Use Diagnoses in DSM-IV-TR?

Answer 3

1. substance intoxication
2. substance abuse
3. substance dependence
4. substance withdrawal

Question 4

What is #1 Substance intoxication?

Answer 4

effects of ingestion of the substance (reversible substance-specific syndrome due to recent ingestion of/exposure to a substance; clinically significant maladaptive behavioral or psychological changes due to effects of the substance; sxs not due to GMC or better accounted for by another disorder).

Question 5

What is #2 Substance abuse?

Answer 5

repeated negative consequences (legal, social, occupational, etc.) resulting from a maladaptive pattern of substance use.

Question 6

What is #3 Substance dependence?

Answer 6

cognitive, behavioral, and physiological symptoms that indicate that the person continues use of the substance in spite of negative consequences related to the substance; will see tolerance, withdrawal, and compulsive drug use.

“…maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:” (APA, 2000)

• Tolerance
• Withdrawal
• Substance taken in larger amounts or over longer period than intended
• Unsuccessful efforts to cut down or control use
• Great deal of time spent obtaining, using or recovering from effects
• Social, occupational or recreational activities given up because of use
• Use is continued despite knowledge of a persistent psychological or physical problem likely to have been caused or exacerbated by substance use

Question 7

What is #4 Substance withdrawal?

Answer 7

cognitive, behavioral and physiological changes after cessation of prolonged use (development of a substance-specific syndrome due to cessation of/reduction in substance use; causes clinically significant distress or impairment in functioning; sxs not due to GMC and not better accounted for by another mental disorder).

Question 8

DSM-IV-TR: What is diagnostic criteria for Alcohol Intoxication?

Answer 8

A. Recent ingestion of alcohol.

B. Clinically significant maladaptive, behavioral or psychological changes that developed during, or shortly after alcohol ingestion

C. One or more of the following symptoms

• Slurred speech
• Incoordination
• Unsteady gait
• Nystagmus
• Impairment in attention or memory
• Stupor or coma

D. Symptoms not due to GMC and not better accounted by another mental disorder.

Question 9

DSM-IV-TR: What is diagnostic criteria for Alcohol Withdrawal?

Answer 9

A. Cessation or reduction of alcohol use that has been heavy and prolonged.

B. Two or more of the following developing after criterion A:
Alcohol withdrawal (2 or more)
-Autonomic hyperactivity
-Increased hand tremor
-Insomnia
-Nausea or vomiting
-Transient visual, tactile or auditory hallucinations
-Psychomotor agitation
-Anxiety
-Grand mal seizures

C. Symps. Cause clinically sig. distress or impairment.

D. symps. Not due to GMC and not better accounted by another mental disorder.

Specify if: with Perceptual disturbances (hallucinations with intact reality testing or aud/vis/tactile illusions occur without delirium). Intact reality testing—knowledge that hallucination caused by substance and not representing external reality.

Question 10

What are issues related to Alcohol?

Answer 10

Alcohol intoxications sometimes associated with blackout (no memory of what happened when drinking).

Alcohol related disorders are associated with increase in risk of accidents, violence and suicide.

Long-term use associated with liver function problems.

One of the leading cause of birth defects when a pregnant woman drinks-Fetal Alcohol Syndrome babies.

Clinically comorbid with other mental disorders.

Question 11

What are Differential Issues Re: the Continuum of Substance Abuse-Dependence Disorders?

Answer 11

Course of pathology often entails substance abuse evolving into substance dependence, with long periods of dependence followed by sporadic periods of sobriety and remission/relapse.

Differential considerations re: substance abuse vs. dependence: typically involves an evaluation of factors such as tolerance, time spent on the substance, social relationships around the substance, other activities given up, and continued use (these are “habitual” indicators, i.e., dependence vs. abuse).

Question 12

What are DSM-IV-TR Substance Dependence Specifiers?

Answer 12

The DSM notes two specifiers (p. 195):

(1) With Physiological Dependence (evidence of tolerance and withdrawal)
(2) Without Physiological Dependence (no evidence of tolerance and withdrawal; instead, compulsivity).

Tolerance = need for greatly increased amounts of the substance to achieve either the desired effect or intoxication.

Withdrawal = physiological and behavioral changes that occur in the central nervous system when blood and tissue concentrations of the substance of choice decline after prolonged consistent use of the substance.

Question 13

What is beyond the DSM Substance Dependence Specifiers?

Answer 13

Beyond the DSM Substance Dependence specifiers, note that there is physiological (see tolerance and withdrawal) and psychological (compulsive use) dependence

Question 14

What is physiological dependence?

Answer 14

Physiological dependence is an indication of a more severe clinical course including earlier onset, higher levels of intake, and more problems overall related to the substance use

note: Yet, research has found that psychological dependence is harder to break than physiological dependence

Question 15

What are DSM-IV-TR course specifiers for abuse or dependence?

Answer 15

See p. 195-197; apply these only after criteria for Abuse or Dependence have not been met for at least 1 month:

• Early Full Remission
• Early Partial Remission
• Sustained Full Remission
• Sustained Partial Remission

Question 16

DSM-IV-TR: when do course specifiers for abuse or dependence not apply?

Answer 16

Previous course specifiers do not apply if the individual is on agonist therapy or in a controlled environment; in these situations, use specifiers (see p. 197):

• On Agonist Therapy (i.e., methadone) or Partial Agonist or Agonist/Antagonist
• In a Controlled Environment

Question 17

What is an agonist?

Answer 17

An agonist is an agent that binds to a receptor and activates that receptor in order to elicit an effect (typically transmitting a signal to the inside of the cell, either by opening a channel to allow ions to flow in/out, or changing the receptor’s shape to cause a cascade of intracellular events to occur).

Drugs that are agonists essentially mimicthe action of the endogenous (naturally occurring) neurotransmitters, typically with the sameor a stronger affinity than the neurotransmitter itself

Question 18

What is an antagonist?

Answer 18

Anantagonistis an agent that binds to a receptor but does not elicit the response that the neurotransmitter or an agonist would cause.

The antagonist blocks the receptor and prevents activation by neurotransmitters or other drugs.

Question 19

What is “the opiate agonist morphine”?

Answer 19

When morphine enters the brain, it binds to opiate receptors and activates them. This binding is what produces the effects of Morphine.

In the case of a Morphine overdose, where a hospital is concerned that the high dose of morphine may be dangerous (depressing breathing and heartrate), they may administer Naloxone (an opiate antagonist). The Naloxone finds its way to your opiate receptors and “competes” with Morphine for binding of the receptors.BecauseNaloxone has a higher affinity for the receptors than Morphine, the Naloxone will generally win out, replacing much of the Morphine at the receptor sites.

Within 1-3 minutes of a sufficient Naloxone injection (2-4mg), a patient who has overdosed on Morphine will generally wake up, usually quite agitated. If given to an otherwise “normal” person (not in the midst of an overdose) who happens to be addicted to an opioidor opiate, Naloxonecan immediately precipitate withdrawal symptoms (Nausea, vomiting, hallucinations, disorientation, excretion, tremors, convulsions, agitation, anxiety and so forth).

Question 20

What are the three traditional types of pharmacotherapy for opiod addiction?

Answer 20

1. agonist treatment (methadone and buphrenorphine)
2. antagonist treatment (naltrexone)
3. the use of these and other agents (clonidine) that are medically supervised to help withdrawal (detoxication) from opiods as a means of entry into treatment

Question 21

What is #1: Agonist Treatment (Methadone Pharmacotherapy)?

Answer 21

Agonist Pharmacotherapy
Methadone is the most commonly used medication for opioid addiction treatment in the United States.

Methadone suppresses opioid withdrawal, blocks the effects of other opioids, and decreases craving for opioids.

Question 22

How is substitution therapy defined (opiate agonist methadone)?

Answer 22

Substitution therapy is defined as the administration under medical supervision of a prescribed psychoactive substance–pharmacologically related to the one producing dependence – to people with substancedependence, for achieving defined treatment aims (usually improved health and well-being). Substitution therapy is widely used in the management of opioid dependence and is often referred to as“opioid substitution treatment,” “opioid replacement therapy”, or “opioid pharmacotherapy”.

Question 23

What agents are suitable for substitution therapy (opiate agonist methadone)?

Answer 23

Agents suitable for substitution therapy of opioid dependence are those with some opioid properties, sothat they have the capacity to prevent the emergence of withdrawal symptoms and reduce craving.At the same time they diminish the effects of heroin or other opioid drugs becausethey bind to opioid receptors in the brain.

In general, it is desirable for opioid substitution drugs to have a longer duration of action than the drug they are replacing so as to delay the emergence of withdrawal and reduce the frequency of administration. As a result there is less disruption of normal life activities from the need to obtain and administer drugs, thereby facilitating rehabilitation efforts.

Question 24

What is #1: Agonist Treatment (Suboxone Pharmacotherapy)?

Answer 24

Another Opioid agonist used for pharmacotherapyis buprenorphine (Suboxone);

Buprenorphine has undergone extensive clinical testing for treatment of opioid dependence and is becoming the medication used in the management of opioid dependence,not only in specialized clinics, but also in primary health care.

Question 25

What is buprenorphine (suboxone pharmacotherapy)?

Answer 25

Its pharmacological properties and resultant clinical characteristics – especially its relativelylong duration of action and high safety profile– appear certain to ensure buprenorphine an important place in the overall treatment of opioid dependence.

Pharmacologically, buprenorphine is a partial agonist at the mu receptor and a weak antagonist at the kappa receptor. Because it binds tightly to, and dissociates slowly from these receptors, buprenorphine exhibits an agonist ‘ceiling effect’, most noticeably in its respiratory depression effect, which accords the medication a high degree of clinical safety. Its tight binding with slow dissociation from receptors also provides a blockade for the effects of subsequently-administered agonists, precipitates withdrawal in patients maintained on a sufficient dose of full agonist, and provides prolonged duration of action with poor reversibility by naloxone.

Question 26

What has research demonstrated about buprenorphine (suboxone pharmacotherapy)?

Answer 26

Further research has demonstrated buprenorphine’s limited levels of reinforcing efficacy in comparison to opioids, and established its ability to suppress heroin self-administration in opioid-dependent primates and humans.

The formulation containing both buprenorphine and the opioid antagonist naloxone has been introduced for maintenance therapy of opioid dependence.

Adding naloxone to buprenorphine aims at reducing a risk of diversion and injecting use of prescribed buprenorphine.

Question 27

Do opiod addicts relapse (suboxone pharmacotherapy)?

Answer 27

Unfortunately, the majority of individuals addicted to opioids relapse to opioid use after withdrawal, regardless of the withdrawal method used.

Too often, physicians and facilities use dose-reduction and withdrawal in isolation without adequate arrangements for the appropriate treatment and support services that decrease the likelihood of relapse and that are usually necessary for long-term recovery.

Question 28

What is #2: Antagonist Pharmacotherapy?

Answer 28

Naltrexone is an opioid antagonist that blocks the effects of heroin and most other opioids.

It does not have addictive properties or produce physical dependence, and tolerance does not develop. It has a long half -life, and its therapeutic effects can last up to 3 days. It also decreases the likelihood of alcohol relapse when used to treat alcohol dependence.

From a purely pharmacological point of view, naltrexone would appear to have the properties of a useful medication for the treatment of opioid addiction.Its usefulness in the treatment of opioid addiction, however, has been limited because of certain disadvantages.

Question 29

What are disadvantages to naltrexone (antagonist pharmacotherapy)?

Answer 29

First, many addicted patients are not interested in taking naltrexone because, unlike methadone, it has no opioid agonist effects; patients continue to experience cravings and are thereby not motivated to maintain adherence to the medication regimen.

Second, a patient addicted to opioids must be fully withdrawn for up to 2 weeks from all opioids before beginning naltrexone treatment.

Unfortunately, during this withdrawal period, many patients relapse to use of opioids and are unable to start on naltrexone. Furthermore, once patients have started on naltrexone, it may increase the risk for overdose death if relapse does occur.

Question 30

What is #3 Medical Detoxification?

Answer 30

An addiction to drugs or alcohol represents a habit that is almost impossible to break without help, and for many years individuals who have been addicted have been heading to rehabilitation facilities to help get into a state of recovery.

In recent years, there has also been an emergence of medical detoxificationopportunities, and this is a method of ridding one’s self of a chemical dependence through the use of certain medication.

Question 31

What is the three step process for Medical Detoxification?

Answer 31

Doctors often rely on a three-step process for drug detoxification created by The United States Department of Health and Human Services:

• Evaluation: Doctors will first test a patient to see what types of drugs might be in their system.
• Stabilization: Detoxification will commence through medication or the natural means of time.
• Treatment: Once a person is free of toxins, he or she will be recommended for further treatment.

Question 32

What is the outpatient method in Medical Detoxification?

Answer 32

One option for an individual seeking medical detoxification is an outpatient method where the detox might be performed in a doctor’s office, after which standard follow-ups would occur. This method usually carries the most controversy with it since a person isn’t under the constant care of a medical professional, and must go into the doctor’s office of his own volition.

One of the issues that some recently addicted people experience with this method is the formation of an addiction to the other drugs taken during the detoxification process. For example, methadone treatments used during heroin detoxification do carry the risk of addiction, and a person will still experience lengthy withdrawal symptoms during this type of medical detoxification.

Question 33

What is the inpatient style of Medical detoxification?

Answer 33

An inpatient style of detoxification requires the individual to remain in a treatment or medical facility for the entirety of the detoxification process.

The type of detox process undertaken might be a rapid detox, after which enrollment in a treatment facility would be the best course of action. In some cases, an inpatient detoxification may be performed more quickly due to the constant presence of medical personnel during the detox process.

Alternatively, traditional medical detoxification that might take much longer would also require a stay within the medical facility until the patient’s system was free of drugs and withdrawal symptoms. Traditional treatment time frames for slow medical detox might be anywhere from six days to two weeks.

Question 34

What is “ultra rapid” of Medical Detoxification?

Answer 34

Recently, a particularly fast method of detoxification called “ultra rapid” has come into existence, and this means that someone might have all the drugs in their body removed in just a few hours and have no withdrawal symptoms. There have been studies by different groups, such as a group from Australia that suggested rapid detoxification was an effective way of starting an addict onto the road to recovery.

Rapid detox is a method sometimes utilized to reduce the number of days or weeks a person will have to suffer through withdrawal symptoms. But the process does come with certain risks, and unfortunately, the rising popularity of this method has caused some difficulties in certain patients exiting the detoxification process in a healthy way.

Question 35

What are examples of medically supervised withdrawal detoxification from opiods?

Answer 35

Medically supervised withdrawal (detoxification) from opioids is an initial component of certain treatment programs but, by itself, does not constitute treatment of addiction.

A variety of agents and methods are available for medically supervised withdrawal from opioids.

These include methadone dose-reduction, the use of clonidine and other alpha-adrenergic agonists to suppress withdrawal signs and symptoms, and rapid detoxification procedures (e.g., with a combination of naltrexone or naloxone and clonidine and, more recently, buprenorphine).

Each of these methods has strengths and weaknesses. When used properly, various pharmacological agents can produce safe and less uncomfortable opioid withdrawal. As a result of the increasing purity of street heroin, however, physicians are reporting more difficulty managing patients with the use of clonidine and other alpha-adrenergic agonists during withdrawal.

Question 36

What are three aspects to understanding addiction?

Answer 36

Genetic
-Significant variability across studies regarding the respective contributions of genes and environment

Behavioral

• Positive reinforcement
• Negative reinforcement

Cultural
-Variability in prevalence of alcoholism across cultures

Question 37

What is the disease model of addiction?

Answer 37

The latest version of modern medicine puts a high emphasis on scientific scrutiny and proven treatments, the disease model of addiction. This means that measurable outcomes and visible, testable ideas are valued more than “common sense” solutions. In this picture, the disease model of addictionmeets many of the criteria.

Question 38

Disease model of addiction: What does thinking of addiction as an illness mean?

Answer 38

Thinking of addiction as an illness, rather than a character flaw or amoral failing means scientists can look for underlyingbiologicaland psychological factors. The search is augmented by advances in medical imaging and DNA techniques. We now have images of the differences between an addicted brain and a non-addicted brain. We also have some hints at just what genetic factors come into play.

Question 39

Disease model of addiction: What does it mean that a strict disease model of addiction suffers from granularity?

Answer 39

A strict disease model of addiction suffers from granularity. In other words, while there are pictures of the biology behind addiction, these aren’t fine-grained and specific. Rather, they are too foggy to make the kind of predictions that would completely validate a disease model of addiction. In scientific circles, it’s the ability to predict who will or will not become addicted that proves the point.

Question 40

Disease model of addiction: What is the hope to understand addiction as a disease process…?

Answer 40

The hope, of course, is to understand addiction as a disease process well enough to intervene. This may or may not be possible.

Certainly, although much is known about cancer and diabetes, it is still not possible to keep them from arising. None of this means advances in treatment haven’t come by illuminating the sites where drugs bind or how the brain changes with substance abuse.

It only means that to win against competing models, the disease model of addiction has to produce an answer.

Question 41

Disease model of addiction: what do critics argue?

Answer 41

Critics argue that the disease model of addiction suffers in being too narrow. At times it seems like a willingness to ignore much in the hope of finding a pill that will “cure” addiction. They point out that addiction is clearly not just a genetic vulnerability, but has social and psychological elements. Furthermore, it may be that addiction is too complex and too much a matter of individual traits to pin down under one clear category.

note:
Meanwhile, the search for clear causes that can be “fixed” continues.

On the positive side, shifting addiction into a disease model of addiction helps dispel the shame that often comes with being identified as an addict. After all, if it is a disease, it’s not due to being a bad person or immoral. That’s a step in the right direction.

Question 42

DSM-5 changed the name of “substance classes” to?

Answer 42

Recall changes of this diagnostic category to “Substance-Related and Addictive Disorders”

Question 43

What are the DSM 5: Substance Disorders: 3 Major Groups?

Answer 43

1. Substance Use Disorders
2. Substance-Induced Disorders
   Substance intoxication and withdrawal
   Substance/medication induced mental disorders (e.g. substance-induced depressive disorder)
3. Nonsubstance-Use Related Disorders (e.g., Gambling Disorder)

Question 44

What are the DSM-5: Classes of Substances?

Answer 44

1. Alcohol
2. Caffeine
3. Cannabis
4. Hallucinogens
5. Inhalants
6. Opioids
7. Sedatives, hypnotics and anxiolytics
8. Stimulants
9. Tobacco
10. Other (or unknown)

Question 45

What is the DSM-5: Substance Use Disorders: General Definition (see pp. 483-484)?

Answer 45

• cluster of cognitive, behavioral and physiological symptoms indicating that person continues using substance despite significant substance related problems.
• behavioral manifestations re: relapse/cravings

Question 46

What is the DSM-5: Substance Use Disorders: Specific Criteria?

Answer 46

Criterion 1: taking larger amt of substances or taking them over longer time period than originally intended.
Criterion2: desire to cut down but multiple unsuccessful attempts to cut down or discontinue use.
Criterion 3: great deal of time obtaining, using or recovering from substance use.
Criterion 4: Craving at any time, particularly in environment where drug was previously used.
Criterion 5: use related to failure to fulfill major role demands.
Criterion 6: using despite social and interpersonal problems caused by or exacerbated by use.
Criterion 7: important social, occupational or recreational activities reduced because of use
Criterion 8: recurrent use even when it is physically hazardous
Criterion 9: using despite knowledge that physical or psychological problem related to use. Key-failure to abstain despite difficulty it is creating etc.

Pharmacological criteria related to using:
Criterion10:Tolerance
Criterion 11: Withdrawal

Question 47

What are DSM-5: Substance Use Disorders: Specifiers for Severity and Course (p. 484)?

Answer 47

Mild: 2-3 symptoms
Moderate: 4-5 symptoms
Severe: 6 or more

Course

• In early remission
• In sustained remission
• On maintenance therapy
• In a controlled environment

Question 48

What is DSM-5 Substance Induced Disorders: Intoxication and Withdrawal?

Answer 48

Intoxication: Development of reversible substance specific syndrome related to recent ingestion of substance.
Not tobacco.

Withdrawal: lead to reuse

Question 49

What is criteria for Substance/Medication-Induced Mental Disorders (pp. 487-490)?

Answer 49

A. Clinical sig. symptom profile of a mental disorder
B. History, physical exam or lab work indicate BOTH:
-Dx. Develop within one month of substance intoxication or withdrawal or taking med.
-Substance/med capable of producing mental dx.
C. Not accounted by independent mental disorder
-not apply to substance induced neurocognitive disorders (e.g. inhalant induced neurocog. Dx) or hallucinogen persisting perception disorder which continue after stopping intox. Or withdrawal.
D. Not occur exclusively during delirium
E. Clinically sig. distress or disability

Question 50

What are DSM-5 Alcohol-Related Disorders?

Answer 50

1. Alcohol use disorders
2. Alcohol Intoxication
3. Alcohol withdrawal
4. Other alcohol induced disorders
5. Unspecified alcohol related disorder

Question 51

What are DSM-5 Caffeine Related Disorders?

Answer 51

1. caffeine Intox.
2. cafeeine withdrawal
3. Other caffeine induced disorders
4. Unspecified caffeine Related disorders

Question 52

What are DSM-5 Tobacco Related Disorders?

Answer 52

Tobacoo Use disorder
Tob. Withdrawal
Other Tob. Induced disorders
UnspecifiedTobacco related disorder

Question 53

What is the diagnostic criteria for DSM-5 Gambling Disorder?

Answer 53

A. Pervasive gambling behavior associated with distress and disability. 4 or more of the following in a twelve month period

1. needs to gamble with increasing amounts of money in order to achieve the desired excitement
2. restless or irritable when attempting to cut down or stop
3. multiple unsuccessful efforts to reduce or stop
4. pervasive preoccupation with gambling
5. often gables when feeling distressed
6. after losing money gambling, comes back next day to get even
7. lies to cover up extent of gambling
8. Jeopardized or lost a sig. relationship, job etc. because eof gambling
9. relies on others toprovide money to relieve desperate financial situations caused by gabling

B. Gambling not better accounted by manic episode

Question 54

What are DSM-5 Gambling Disorder: Specifiers?

Answer 54

Specify if:

• Episodic- symptoms subside between points of gambling
• Persistent-continuous symptoms for multiple years

Specify if:

• in early remission- no symptoms for at least 3 months but not 12 months
• in sustained remission-no criteria for a period of 12 months

Specify if:

• Mild: 4-5 criteria met.
• Moderate: 6-7 criteria met
• Severe: 8-9 criteria met

Question 55

What are DSM-5:Conditions for Further Study?

Answer 55

Internet gaming disorder

Caffeine use disorder

Neurobehavioral disorder associated with pre-natal alcohol exposure