Substance Abuse Disorder Flashcards
substance abuse trends in the western cape
- patients under 20 yrs, drug of choice are cannabis, tik and alcohol
- > 20% of admissions are for persons under the age of 20 (has gone up from 5% in 1996)
- black africans proportionally underrepresented in treatment facilities across the country
Cannabis/marijuana
-dagga, green, hash, joint, dope, weed, herb, pot
appearance:
- dried plants or resinous dark brown blocks
-smoked in a joint when rolled in tobacco
-smoked in water pipes
-usually sold in a ‘stop’, 1g rolled in newspaper or in a plastic bank packet (‘bankie’)
-often smoked with mandrax as a ‘white pipe’
-can be eaten or drunk
-known as gateway drug
Mandrax street name
-Street names
Titanic, buttons, mandrakes, mandies, mz, whites, germans,
Mandrax appearance
Tablets ranging in size from a usual small tablet to the size of a dog pellet, and ranging in colour from white to pink, blue, speckled etc.
Mandrax withdrawal
Headaches, stomach cramps, anxiety, insomnia, irritability
Cannabis withdrawal
Irritability, sleep difficulty, anxiety, depressed mood
Heroin street names
H, smack, china white, brown, brown sugar, junk, gear, skag
Heroin appearance
Powder ranging in colour from white to brown
Heroin withdrawals
Sweating, nausea, vomiting, tremors, yawning, stomach cramps, diarrhoea
LSD streetnames
acid, A, candy, trips, papers, liquid, sugar cubes, star tab, smarties, strawberries, sunshine
LSD appearance
- White powder, liquid, tablet.
- Liquid sometimes injected into blotting paper
LSD withdrawal
- few, if any
- users can experience flashbacks days, months or years later
Ecstasy streetnames
E, pills, ickies, love drug etc.
Ecstasy withdrawal
Aches and pains, depression,
paranoia, anxiety, insomnia
Ecstasy active ingredient
MDMA
Ecstasy effect
Feeling of tranquility, increased confidence, feeling ‘at one’ with the world and other people. Dance and rave parties.
Cocaine/crack streetnames
powder: coke, charlie, snow, schnaff
crack: rocks, klippe
Cocaine/crack appearance
- Cocaine usually comes as a white powder.
- Rocks (crack) vary in size but are a soapy like substance usually about half the size of a pinkie fingernail.
Cocaine/crack withdrawal
Fatigue, depressed mood, paranoia, irritability, nausea and vomiting spells, insomnia, cravings
Tik streetnames
-speed, ice, choef, straws, lolly
Tik appearance
oudourless, crystal like substance
Tik withdrawal
Nausea, depressed mood, aggression, fatigue, anxiety, cravings, stomach cramps, back pain, drowsiness, increased appetite
Inhalants/solvents appearance
Glue, petrol, cleaning fluids, nail polish remover, paint thinners, aerosols.
inhalants/solvents withdrawal
Insomnia, headaches,
irritability, anxiety,
hallucinations
What is a drug?
any substance (other than food) that alters mood, behaviour, cognition, perception of consciousness
4 cultural categories of substances
- celebrated (alcohol/caffeine)
- tolerated (nicotine)
- instrumental (over the counter, prescription)
- prohibited
5 physiological categories
- CNS depressants
- CNS stimulants
- Opioids
- Hallucinogens and phencyclidine (PCP)
- cannabis
CNS depressant examples
alcohol
benzodiazepines
inhalents
CNS stimulants examples
cocaine
tik
nicotine
caffeine
Opioids examples
heroin
codeine
morphine
methadone
Substance-induced disorders
- intoxication
- withdrawal
Substance use disorder
‘substance use’ is preferred due to imprecise nature and negative connotation of ‘addiction’
Addiction definition
the user’s body require a drug to feel ‘normal’
psychological dependence definiton
the user has altered their lifestyle in order to secure continuous access to the drug
craving definition
the strong subjective sense of an addict to use a drug
DSM IV definition of substance abuse
‘A maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use of the substance’
DSM IV definition of substance dependence
‘A cluster of cognitive, behavioural and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems’
substance use disorders
- Involves all 10 classes, except caffeine
- Cluster of cognitive, behavioral and physiological symptoms
- Substance use continues despite significant substance-related problems
- Underlying change in brain circuitry beyond detoxification
- Diagnosis is based on a pathological pattern of behaviours related to substance use
Criterion A for substance use disorder
Problematic pattern of substance use, occurring over 12/12 period, leading to clinically significant impairment or distress, with ≥ 2 SX:
- Impaired control
- Social impairment
- Risky use
- Pharmacological criteria
Impaired control
- Substance is used in larger amounts or over a longer period than was originally intended
- Persistent desire to cut down or regulate substance use and multiple unsuccessful efforts to decrease or discontinue use
- Spend a great deal of time obtaining the substance, using the substance, or recovering from its effects
- An intense desire or urge for the drug (i.e. craving) that may occur at any time but is more likely when in an environment where the drug previously was obtained or used
Social impairment
- Recurrent substance use results in a failure to fulfill major role obligations at work, school, or home
- Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
- Important social, occupational, or recreational activities are given up or reduced because of substance use
Risky use
- Recurrent substance use in situations in which it is physically hazardous
- Consistent substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
Pharmacological criteria
- A markedly increased dose of the substance is required to achieve the desired effect or a markedly reduced effect occurs when the usual dose is consumed (tolerance)
- A withdrawal syndrome occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance
Comorbitity
- Strong associations with lifetime mood (i.e. bipolar & depressive) and anxiety d/o’s
- Causality can be bidirectional
- However, the majority view is that psychiatric d/o precedes substance use d/o
- Substance use d/o’s develop out of maladaptive attempts at self-medication
What is a hazardous drinker?
- male: 5 or more standard drinks on a typical drinking day
- female: 3 or more standard drinks
Alcohol use disorder: physiological effects
- ethyl alcohol is absorbed into the bloodstream via the lining of the stomach and intestine and then reaches the CNS
- it influences the receptors associated with the GABA neurotransmitter, leading to talkativeness, confidence and happiness
- as more alcohol is absorbed, the drinker’s judgement, speech, memory, mood and motor abilities are affected
- effects are biphasic
- stimulant effect is counterbalanced by depressant effect
what is the intoxicating ingredient in alcohol?
ethyl alcohol
long term effects of heavy drinkers
- Delirium tremens (DTs, hallucinations, shaking, muslce tremors)
- hypertension
- heart failure
- ulcers
- cancer
- cirrhosis of the liver
- brain damage
- Korsakoff’s syndrome (dementia, memory disorders)
- Foetal alcohol syndrome
Alcohol use disorder: treatment
- self help groups
- motivational-enhancement therapy (MET)
- Social behaviour and network therapy (SBNT)
- Pharmacotherapy
Self-help groups (Alcoholics Anonymous)
- long-term abstinence in 25% of participants
- decreased consumption in 78% of participants
Motivational-enhancement therapy (MET)
- Client carries the responsibility for change
- Feedback on effects of drinking
- Explore benefits of abstinence
- Successful, cost-effective
- 50% report decreased drinking & related problems
Social behaviour and network therapy (SBNT)
- developing positive social network
- similar success rates to MET
Pharmacotherapy
- block alcohol-brain interactions (naltrexone)
- antabuse (disulfiram)
active agent in tobacco and effects
nicotine
- acts as stimulant by increasing blood pressure and heart rate
- also has a relaxing effect by reducing stress levels, anxiety and anger
2nd most widely used legal drug after alcohol, killing up to half of its users
tobacco
Associated features of tobacco use disorder
- Smoking within 30 minutes of waking
- Smoking daily
- Smoking more cigarettes per day
- Waking at night to smoke
first time tobacco users
- may experience nausea and dizziness
- These effects weaken as tolerance builds
tobacco withdrawal syndrome
Dysphoric mood, insomnia, irritability, anxiety, concentration difficulties, restlessness, increased appetite
why is tobacco use disorder difficult to treat?
- Withdrawal symptoms are constant when not smoking
- Smoking can become a form of coping with any negative mood
Tobacco use disorder treatments
Nicotine replacement therapy Bupropion Aversion therapy Cognitive-behaviour therapy (CBT) Hypnotherapy Acupuncture
Nicotine replacement therapy
- Skin patches, chewing gum, lozenges, inhalers, nasal sprays
- Significantly more effective than placebo
- 17% of NRT users have abstained for 12 months following prescription
Bupropion
- Mild antidepressant
- Acts on brain pathways associated with dependence and withdrawal
- 19% have abstained for 12 months following prescription
Aversion therapy
for tobacco use
- Replace pleasant feelings of smoking a cigarette with negative consequences
- One form is rapid smoking (puff every 4-5 seconds)
- Reduces craving, but has limited success controlling actual smoking behaviour
Cognitive-behaviour therapy (CBT) for tobacco use
- Depression and negative mood associated with failure to quit
- CBT helps smokers develop strategies for coping with negative mood states
Hypnotherapy
for tobacco use
- Some evidence of efficacy relative to waiting list and no treatment controls
- Little systematic evidence that it is more effective than placebo
Acupuncture for tobacco use
- Some evidence of efficacy compared to control groups
- Much evidence is anecdotal
Cannabis effects
- is a sedative/depressant because of its relaxing effects
- But it also has mild hallucinogenic and stimulant effects (agitation and paranoia).
- Its medicinal effects have also led to the formation of powerful lobbies for its legalization.
risk factors for developing cannabis dependence
- Early age of onset (i.e. first use)
- Tobacco smoking
- Regularity of cannabis use
- Impulsiveness and mood unpredictability
- Diagnosis of conduct d/o and other emotional d/o’s in childhood
- Dependence on alcohol and other drugs
Cannabis comorbidity
- Anxiety and panic disorders
- MDD
- Increased suicide risk
- Schizophrenia
Cognitive deficits (while intoxicated) cannabis
- Deficits in reaction time
- Decreased attention span
- Decreased verbal ability
- Loss of short-term memory
- Impaired driving
Cognitive deficits (long-term) cannabis
-Very little evidence for permanent neuropsychological deficits
-Regular, heavy cannabis use is associated with:
–A syndrome of underachievement
–Lower educational achievement / income
-Use during school/college years impairs academic performance and therefore career prospects
-BUT: heavy cannabis use is also associated with deprivation and poor educational opportunities
-Amotivational syndrome:
Apathy, loss of ambition, difficulty concentrating
caffeine benefits
- Increased alertness, attention, & cognitive function
- Elevated mood, fewer depressive symptoms, lower risk of suicide
high doses of caffeine
- psychotic and manic symptoms, while anxiety symptoms are common
- Individuals with panic d/o and social phobia are particularly vulnerable to the anxiety-generating effects of caffeine
explaining substance use disorders (3 areas)
- developmental
- neurological
- behavioural
Developmental stage 1: experimentation
- availability
- legality
- cost - familial factors
- regular use among family members
- Extreme poverty in the childhood home
- Marital / legal problems in the household
- Serious psychiatric illness in the household
- Childhood neglect and abuse - peer group influences:
- conforming to group norms
- in-group favouritism
- cementing friendship (smoking)
- Substance use determines membership of social groups - media influences
- exposure to advertising
Developmental stage 2: regular use
- Mood-altering effects
- A range of drugs “activate the natural reward pathways in the brain by converging on a common circuitry in the limbic system”
- Drug use is reinforced by the associated pleasurable feelings
- Craving can occur in the presence of drug-related cues - Self-medication
- Regular use can result from attempting to mitigate the distress associated with psychiatric d/o’s
- But the self-medication account has poor predictive ability
- -People living with anxiety do not prefer alcohol over amphetamines
- -People with ADHD do not prefer amphetamines over alcohol - Long-term expectations and beliefs
- Regular use can result from expectations that substance use will have positive effects
- Regular use can also result from beliefs that the use of a given substance is harmless - Cultural variables
- E.g. alcohol consumption differs greatly across countries
developmental Stage 3:abuse and dependence
- genetic predisposition
- cognitive deficits
- Concurrent psychiatric diagnoses:
- Comorbid psychiatric problems appear to play an important role “for both transition from first use to regular use, and from regular use to abuse and dependence” - Poverty
- There is evidence that first use increases in probability if one lives in or near an economically poor neighbourhood
- Conditions of unemployment, lack of recreation, poor educational opportunities create a perfect storm for the descent into abuse and dependence
genetic predisposition
- Heritability is around 0.46 for substance use disorders generally
- As high as 0.78 for alcohol and nicotine dependence
- Concordance rates for alcohol abuse of 54% (MZ twins) and 28% (DZ twins)
- Genes can interact with environmental factors like stress (diathesis-stress model)
- There may be a more general gene-environment interaction
- -E.g. living in environment with large numbers of young people
- Genetic factors can also influence tolerance levels to drugs such as alcohol
- Many individuals with alcohol use disorder appear to have inherited a strong tolerance for alcohol
- Certain genes (e.g. ALDH2) appear to influence sensitivity to alcohol
- -Many Asians have a variant form of ALDH2 that slows alcohol metabolism
- -This may explain why Asians develop alcohol use disorders at only half the rate of non-Asians
Cognitive deficits
- Many abusers often exhibit lower IQ, lower educational achievement, and motivational deficits
- These factors suggest that abusers may lack the coping skills to pull them out of the downward spiral into abuse and depedence
- However, these deficits may be caused by regular substance use
treatment challenges
- Physical effects of dependence
- Probability of comorbid disorders
- High rates of relapse
Treatment is typically multifaceted:
- Detoxification
- Psychotherapy / counselling
- Groupwork
- Skills training
- Family psychoeducation
treatment: Community based programs
- Alcoholics Anonymous
- Support group for individuals wanting to abstain - Drug prevention schemes
- Used with young people to prevent first drug use
- Peer-pressure resistance training
- Combating media advertising
- Peer leadership
- Change erroneous beliefs about drugs - Residential treatment
- Controlled environment for detox and longer term support
Treatment: behaviour therapies
- aversion therapy
- contingency management therapy
- controlled drinking
Aversion therapy
- behaviour therapy
- Pair the drug with another drug that causes unpleasant effects
- Covert sensitisation (a variant of aversion therapy)
- Limited evidence for efficacy of aversion therapy
Contingency management therapy
- behaviour therapy
- Contingency management therapy
- Identifying triggers (stimulus control)
- Giving rewards (for not using)
- Becoming more aware of when and how frequently drugs are used
- Setting attainable goals (non-abstinence goals)
Controlled drinking
- behaviour therapy
- Emphasis is on controlled use, not abstinence
- Based on assumption that alcohol is unavoidable
- Teaching control improves self-esteem, sense of responsibility
Cognitive behaviour therapies
- CBT
-Address dysfunctional beliefs about relapse
-‘Abstinence violation’ beliefs lead to full relapse
-Best employed in cases of comorbidity - MET
Motivational Enhancement Therapy
-Manage stressful emotional states and their contributory factors
-Negative mood management, work-related skills, problem-solving skills, communication skills etc.
Both forms are especially effective when combined with family therapy
Family and couple therapy
- Helps family members understand reasons for substance use
- Helps them provide support during and after treatment
Biological treatments: Detoxification
Supervised cessation of substance use that uses drugs in a controlled manner to combat withdrawal symptoms
Biological treatments: Antabuse / Disulfiram
Affects metabolism of alcohol resulting in nausea / vomiting
Biological treatments: Naltrexone, naxolone, and buprenorfine
- Can treat alcohol, cocaine and opioid dependence
- They inhibit the release of endorphins in the brain
Biological treatments: Drug maintenance therapies
Treating severe d/o’s by substituting drug of choice with a less harmful one (e.g. methadone instead of heroin)
