Substance Related and Addictive Disorders Flashcards
substance
- Any natural or synthesized product that has psychoactive properties.
- Acts primarily upon the central nervous system where it alters brain function. (crosses blood brain barrier)
- Acute/temporary changes in perceptions, thoughts, emotions, and behaviors.
Main Categories
!Depressants
! Stimulants
! Opioids
! Cannabis
! Hallucinogens
! Other drugs of abuse
Inhalants
Anabolic steroids
Medications
! Gambling disorder
-We look at "what things are being given up?"only behavioral disorder
gambling
Substance Use Disorders in the USA
About 9% of all teens and adults in the U.S. display
substance use disorders
• Lowest rate among Asian Americans (3.5%)
• White Americans, Hispanic Americans, and African
Americans display rates between 9-10%
• Only 11% receive treatment from a mental health
professional
Immigration Paradox
Immigrants to the United States, relative to the native born, are less likely to initiate and develop substance use disorders.
- -The paradox is that, despite having disproportionately lower income and education levels, immigrants are often healthier than their native-born counterparts.
- immigration is stressful & this not only exists in substance abuse disorder but can be seen across other health aspects
The Criteria (within 12-month period)
- Taking the substance in larger amounts or for longer than intended
- Wanting to cut down or stop using the substance but not managing to
- Spending a lot of time getting, using, or recovering from use of the substance
- Cravings and urges to use the substance
- Not managing to do what you should at work, home or school, because of substance use
- Continuing to use, even when it causes problems in relationships
- Giving up important social, occupational or recreational activities because of substance use
- Using substances again and again, even when it puts you in danger
- Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
- Tolerance
- Withdrawal
Severity
Depends on number of symptom criteria endorsed
Mild: 2-3 symptoms
Moderate: 4-5 symptoms
Severe: 6 or more symptoms
Addiction
you cannot be addicted to anything
-substance abuse can rob people of insight
#9» good example is depression
Tolerance
- Requires increasingly greater amounts of the drug
to experience same/desired effect.
OR - Markedly diminished effect with continued use of
same amount
Physiological reaction
-Examples»_space; cigarettes
Withdrawl
- Characteristic withdrawal syndrome for substance
- Same (or closely related) substance take to relieve
or avoid withdrawal
– Sometimes substance must be withdrawn gradually
– Symptoms tend to be the opposite of drug’s direct
effect on body
Specifiers
# In early remission: no criteria for > 3 months but 12 months (except craving) # In a controlled environment: access to substance restricted (ex. Jail)
Substance-Induced
" Intoxication " Withdrawal " Psychotic Disorder " Bipolar Disorder " Depressive Disorder " Anxiety Disorder " Sleep Disorder " Delirium " Neurocognitive " Sexual Dysfunction
DSM5 Criteria
Substance Use Disorder: addressed as a separate
use disorder (e.g., alcohol use disorder, stimulant
use disorder, etc.)
–Major change from DSM-IV to DSM5 was to remove
the criterion related to legal problems and to add
one related to substance craving
Depressants
Decrease CNS functioning
less neuronal firing (increases GABA and suppresses glutamate)
–Slurred speech, decreased motor functioning, memory impairments,
perceptual slowing, less inhibition
Alcohol use in the USA
24% of all people in the U.S. over the age of 11, most of them male,
binge-drink each month
• Nearly 7% of people over age the age of 11 binge-drink at least 5 times
each month
• Considered heavy drinkers, males outnumber females by more than 2:1
(around 8% to 4%)
-42% of college aged report binge drinking
Alcohol
•The first brain area affected is that which controls judgment and inhibition • Next affected are additional areas in the CNS, leaving the drinker even less able to make sound judgments, speak clearly, and remember well • Motor difficulties increase as drinking continues, and reaction times slow
Depressants: Alcohol
• The extent of the effect of alcohol is determined by
its concentration (proportion) in the blood
• A given amount of alcohol has a lesser effect on a
large person than on a small one
• Gender also affects blood alcohol concentration
• Women have less alcohol dehydrogenase, an enzyme
in the stomach that metabolizes alcohol before it
enters the blood
• Women become more intoxicated than men on equal
doses of alcohol
Difference in if you are a fast or slow metabolizer & big difference in gender
Slow metabolizer
for a certain substance is a protective factors
Asian countries
small alcohol abuse
except for South Korea b/c of culture
Alcohol Level of impairment
closely tied to the
concentration of ethyl alcohol in the blood:
–BAC = 0.06: Relaxation and comfort
– BAC = 0.09: Intoxication
–BAC > 0.55: Death
– Most people lose consciousness before they can drink this
much
Metabolic Tolerance
The liver reacts to greater
consumption of alcohol by producing more of the
enzyme (alcohol dehydrogenase) that metabolizes
alcohol. In chronic users, this can result in the
significantly faster metabolization of alcohol.
—-The increase in alcohol dehydrogenase (toxic) is one factor that leads to the destruction of the liver in chronic users.
Functional Tolerance
sway test standing on line
Mild alcohol withdrawal
occurs within 24 hours of last drink. tremulousness (shakes),
insomnia, anxiety, panic, twitching, sweating, raised blood pressure
and pulse, and stomach upset
(most people experience this)
moderate alcohol withdrawal
usually occurs 24-36 hours after the cessation of alcohol
intake. Intense anxiety, tremors, insomnia, seizures, hallucinations,
high blood pressure, racing pulse.
severe alcohol withdrawal
Delirium Tremens (D.T.s). More than 48 hours after a
cessation or decrease in alcohol consumption. Disorientation,
agitation, hallucinations, racing heart, rapid breathing, fever, irregular
heartbeat, blood pressure spikes, and intense sweating.
(had to be drunk for a very very long time)
Delirium Tremens
! Delirium, Hallucinations, Extreme, Fluctuations in Blood Pressure,
Grand mal seizures, Heart attacks!
Alcohol withdrawal
• When untreated about one person in five will die of
D.T.s. Some people refer to shakes as D.T.s but this
is inaccurate.
• Even mild or moderate withdrawal can be
dangerous for people with high blood pressure or
bad hearts.
• Withdrawal raises blood pressure ! danger of heart
attack or stroke. The longer and harder a person has
drunk alcohol–the more severe the withdrawal will be.
Alcohol subsiding
Nothing can lower BAC except time •The effects of alcohol subside only after alcohol is metabolized by the liver •The average rate of this metabolism is 25% of an ounce per hour •You can’t increase the speed of this process!
Alcohol culture
•People in countries who combine alcohol with meals (France) have lower alcohol-related substance disorders •Empty stomach results in rapid delivery of alcohol into blood stream. (more likely to black out) •Full stomach slows rate of absorption & more drinks needed to reach dangerous blood levels.
Passing out
•Colloquial term for syncope (loss of consciousness)
•Alcohol lowers blood pressure
•When sober, body constricts veins upon standing up
to increase blood pressure and prevent the person
from passing out as their blood falls due to gravity.
•After consuming 2-3 drinks, alcohol prevents the
blood vessels from constricting, and blood pressure
drops twice as much when the person stands up as it
would if they were sober.
Lose ability to compensate gag reflex while vomiting
Blacking out
Picture—
alcohol impacts the transfer from short term memory to long term memory
Blacking out once makes you more vulnerable to black out
black out a little or a lot
Hangover
• Vasopressin • Normally vasopressin repurposes water released by the kidneys back into the body. • Absence of vasopressin, that water is marked for the bladder and eliminated. • Alcohol also causes inflammation of the stomach lining, which can cause diarrhea -- another dehydrating condition. • Acetaldehyde toxicity
Sedative-Hypnotic Drugs
Sedative-hypnotic (anxiolytic) drugs produce
feelings of relaxation and drowsiness
• At low doses, they have a calming or sedative effect
• At high doses, they function as sleep inducers or
hypnotics
• Sedative-hypnotic drugs include barbituates and
benzodiazepines
Barbituates &
Benzodiazepines
•Barbituates (seconal, nembutal): sedative drugs prescribed for sleep (decrease in use post-1960)
•Benzos (valium, xanax, rohypnol): reduce anxiety
•less dangerous than barbituates but still carry significant addiction potential if used incorrectly.
•Intoxication symptoms similar to alcohol.
•High doses; diaphragm muscles relax so much that they
cause death by suffocation.
• OD on barbs common form of suicide
• Synergistic effect with alcohol
Barbituates
considered old school-easily overdosed & now used in lethal injections
intoxication agnosognia
lack of insight
Alcohol & Benzos
•Marilyn Monroe may have unintentionally killed herself with this combo • Heath Leger barbs, benzos, & pain killers • Whitney Houston xanax, cocaine • Medication “spellbinding:” individuals have no idea how badly they are being impaired
Benzodiazepine Withdrawal
• Overwhelming anxiety and panic, insomnia (far worse
than the individual has ever before experienced).
• Irritability ! uncontrollable anger & violence (at
extreme).
• Muscle spasms, painful feelings in the extremities,
painfully-heightened awareness of diminished mental
faculties, confusion, depression, suicidality, paranoia,
hallucinations
• Weeping, terror, negative looping thoughts (severe)
• Keep in mind CONTINUUM (mild, moderate, severe)
You have to wean off the benzos
Opioids
Pain relief, sedation,
euphoria, slowed breathing
opiate
any natural
chemical deriving from
opium poppy
opioid
all inclusive term for natural opiates, synthetic variations (heroin, methadone, oxycodone), & the comparable substances in brain
Morphius
God of Sleep
slow vs. fast delivery
fast= injecting, inhaling, snorting
slow= ingesting
the faster the delivery the more addictive
Opiods
•smoked, inhaled, injected by needle directly into the bloodstream (“mainlined”) ! Injection ! most common method of use • An injection quickly brings on a “rush”: a spasm of warmth and ecstasy •followed by several hours of pleasurable feelings (called a “high” or “nod”) I don't care feeling
tolerance for opiods
super rapid (vicadin)
dependence vs. addiction
dependence: withdrawal tolerance NOT behaviors
addiction: compulsive drug seeking behaviors-largely dictated by behaviors
Opioids create these effects by depressing the CNS..
• Opioids bind to the receptors in the brain that
ordinarily receive endorphins (NTs that naturally help
relieve pain and decrease emotional tension)
• When these sites receive opioids, they produce
pleasurable and calming feelings
• In addition to reducing pain and tension, opioids can
cause nausea, narrowing of the pupils, and
severe constipation
heroin makes you vomit
What are the dangers of opiod use?
• Once again, heroin provides a good example:
• The most immediate danger is overdose
• The drug closes down the respiratory center in the brain,
paralyzing breathing and causing death
• Death is particularly likely during sleep
• Ignorance of tolerance is also a problem (tolerance happends rapidly and decreases rapidly)
• People who resume use after having avoided it for some time
often make the fatal mistake of taking the same dose they had
built up to before
Pain killers in the USA
Since 1997, the number of Americans seeking treatment for
addiction to painkillers increased by 900%. this is an epidemic
Narcan
a nasal mist for opiate overdose reversal–now available in stores where no prescription is needed
the narcan occupies the receptor
Opioid Withdrawl
•restlessness, muscle and bone pain, insomnia, diarrhea and
vomiting, cold flashes with goose bumps(vasoconstriction) (“cold turkey”), and
kicking movements (“kicking the habit”).
• Severe craving can precipitate continued abuse and/or
relapse.
•Major withdrawal symptoms peak between 48 and 72 hours
after the last dose of the drug and typically subside after
about 1 week.
• Some individuals, however, may show persistent withdrawal
symptoms for months.
• Fatal in highly dependent & in poor health (somewhat rare)
Stimulants
(amphetamines, caffeine, nicotine, cocaine) • Cause increases in blood pressure, heart rate, and alertness • Cause rapid behavior and thinking • Alert/energetic ! crash (depressed/tired) • Long-haul truck drivers, pilots, some college students coffee 2nd most traded after oil
John oliver Tobacco Video
psychosocial factors that maintain addiction
Nicotine
• Cigarettes most popular nicotine-delivery device
•Nicotine addicts need nicotine to feel normal (report “stress
management”)
• Over 70% of people who smoke report wanting to quit
• Difficult due to withdrawal (depressed mood, irritability,
anger, anxiety, restlessness, difficulty concentrating)
•Only 7% who attempt to quit remain smoke-free after 1-year
Nicotine effects
•Reaches brain 7-19 seconds after inhaled • Smokers dose throughout the day to keep “steady state” in bloodstream & to avoid withdrawal • Complex bi-directional relationship between cigarette smoking & negative affect (anxiety, depression, irritability)
Tobacco industry is brilliant
Pay hollywood to not negatively depict cigarette smoking
smoke more, ^anxiety
smoke less, ^anxiety
Cocaine
•1885: Park, Davis, & Co manufactured coca &
cocaine in many forms: coca-leaf cigarettes, cigars,
inhalants, & crystals.
• Can’t afford those? Drink coca-cola! (until 1903)
• 1970’s -Replaced amphetamines as stimulant of
choice
• Increased alertness, euphoria, increase blood
pressure & pulse, insomnia, loss of appetite.
• Inhale (“snort”), smoked
• Short-lived (use repeatedly during binge) aka multiple times per hour
Stimulant: Cocaine
• Cocaine produces a euphoric rush of well-being
• It seems to work by
increasing dopamine at key receptors in the brain and overstimulating them
• Also appears to increase norepinephrine and
serotonin
Cocaine effects
•Cocaine-induced paranoia: > 2/3 of users will experience. •Smoked cocaine = “crack” • levels of dopamine in the brain take a long time to replenish themselves, and each hit taken in rapid succession leads to progressively less intense highs ** health effects can be worse due to adulterants (substances used to bulk up appearance/volume of drug)
What are the dangers of cocaine?
•Aside from its behavioral effects, cocaine poses
significant physical danger
•The greatest danger of use is the risk of overdose
•Excessive doses depress the brain’s respiratory function,
and stop breathing
• Cocaine use can also cause heart failure
• Pregnant women who use cocaine have an increased
likelihood of miscarriage and of having children with
abnormalities
Hallucinogens
• Change perception of world in terms of sights, sounds, feelings, taste, smells • Marijuana (some place in own category of “cannabis”), LSD, Psilocybin Mushrooms, Peyote (mescaline), Ayahuasca, DMT, STP • Psychological introspection that may lead to great elation, fear, or illumination -zero addiction potential -huge expectancy effect
Senses on hallucinogens
-sense of time is another sense
more than 5 senses
Hallucinogen effects
• Anxiety, depression, fear of losing one’s mind, paranoia, impaired judgment • subjective intensification of perceptions, depersonalization, derealization, hallucinations, synesthesia • Insight, religious/spiritual realizations
Cannabis
• Marijuana – most routinely used illegal (federal law) substance • impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal, increased appetite, dry mouth, tachycardia • Huge individual variation in reactions (sense of wellbeing to paranoia)
synesthesia
overlap of two senses like taste color or see sound
Smoked cannabis
! When smoked, cannabis produces a mixture of
hallucinogenic, depressant, and stimulant effects
! At low doses, the user feels joy and relaxation
! May become anxious, suspicious, or irritated
! This overall “high” is technically called cannabis intoxication
! At high doses, cannabis produces odd visual
experiences, changes in body image, and
hallucinations
! Most of the effects of cannabis last 2 to 6 hours
! Mood changes may continue longer
Cannabis uses and tolerance
! Tolerance? (heavy users report less euphoric high) ! Medicinal uses ! chemo-therapy induced nausea/ vomiting ! neuropathic pain from multiple sclerosis ! cancer pain ! seizures ! controversial
Cannabis withdrawal
>3 develop within approximately 1 week of cessation: ! Irritability, anger, or aggression ! Nervousness or anxiety ! Sleep difficulty (eg, insomnia, disturbing dreams) ! Decreased appetite or weight loss ! Restlessness ! Depressed mood ! At least one of the following physical symptoms causing significant discomfort: ! abdominal pain ! shakiness/tremors, sweating, ! fever, chills ! headache
Timing of Exposure
! With the brain developing into the mid-20s, young people who smoke early and often are more likely to have learning and mental health problems ! Moderate marijuana use by healthy adults seems to pose relatively minor risks
synergist effect:
one drug with similar action enhances another drug
entourage effect
different components hang out together & need to be present to have effect
cannabis has higher internal validity
infer causation
sleep drugs will stop working
What maintains problematic use?
- coping mechanism
- environment/exposure
- withdrawal
Etiology
• Multiple interacting factors influence using behavior and
loss of decisional flexibility
• Not all who become dependent experience it same way
or motivated by same factors
• Different factors may be more or less important at
different stages (drug initiation, maintenance, relapse)
Risk factors
-- People of any age, sex, or economic status --Higher risk if: Family history Male 3:1 Comorbid psychopathology (MDD, PTSD) Peer pressure Lack of family involvement Anxiety, depression, loneliness Highly addictive drug (heroin, cocaine)
Place preference?
Box of heroin, cocaine, etc.
nictotine: 93% will use next year after quitting
alcohol: serious health issues
heroin & meth have faster mechanism of action, more people like it
Pleasure Pathway
! All drugs work on this internal reward center ! Ventral Tegmental area (midbrain) ! Nucleus Accumbens ! Frontal Cortex ! Primarily dopaminesensitive neurons (other neurotransmitters important in reward, 5-HT, NE) ! Directly dopamine (cocaine) ! Indirectly via GABA inhibition (heroin)
Drugs of Abuse primarily exert effect on
Ventral Tegmental area
(midbrain) ! Nucleus
Accumbens ! Frontal
Cortex
impacts
cocaine impacts directly & heroin impacts indirectly
Learning and Physiological Basis for Dependence
•After using drugs or when stop – leads to a depleted
state resulting in dysphoria and/or cravings to use,
reinforcing the use of more drug.
• Response of brain cells is to downregulate receptors
and/or decrease production of neurotransmitters that
are in excess of normal levels.
Biological Influences
•Genes confer risk in a number of ways - influence
greater for transition from use to dependence
• Alcohol Dependence (AlcDep) in biological parents
strong predictor of AlcDep in adopted children
• AlcDep in adoptive parents not strongly related to
AlcDep in adoptees
•Concordance rate of alcohol dependence in identical
twins – 50-60%
• Sons of AlcDep parents may be more sensitive to
highs of drinking & less sensitive to lows (less
sensitive to alcohol (“low level of response”) = drink
more) Genes confer risk in a number of ways - influence
greater for transition from use to dependence
•Alcohol Dependence (AlcDep) in biological parents
strong predictor of AlcDep in adopted children
• AlcDep in adoptive parents not strongly related to
AlcDep in adoptees
•Concordance rate of alcohol dependence in identical
twins – 50-60%
• Sons of AlcDep parents may be more sensitive to
highs of drinking & less sensitive to lows (less
sensitive to alcohol (“low level of response”) = drink
more)
You can inherit
drug liking
drug effects/ speed of drug metabolism
the alcohol gene
•Genetic contribution involves multiple physiological pathways (drug metabolism, GABA, dopamine) •Genes that contribute to inefficient processing of alcohol metabolism >> protective factor (Asian & Jewish populations) •Genes that allow more rapid metabolism ! risk factor •Some genes influence reaction to specific drug
epigentic factors
• Cocaine abuse in a male rat rendered the next generation of animals resistant to the rewarding properties of the drug -- those offspring were less likely to take cocaine. •Sons, but not daughters, of male rats on cocaine were not only less likely to want the drug, but also resistant to effects of it.
Psychological influences
•Positive Reinforcement = pleasure! •Lab animals will self-administer same drugs as humans •Negative Reinforcement = stop feeling bad (even outside context of withdrawal) •Escape physical pain, stress, anxiety • Expectancy effect •Craving Knowledge is power to an extent --experience --effective escape mechanism
Sports as a protective factor(?)
sports are a protective factor in HS but risk in college “totally present”
Social Influences
Media may have greater role than peer influence on whether adolescents smoke cigarettes •2002: 74% of all US movies depicted smoking, including ¾ of films for youth •Tobacco manufacturers pay for exposure •Ex: Philip Morris & Lois Lane •Contracts with Hollywood to avoid negative portrayal of smoking
The Rational Choice of Addiction
Biggest problem is drug policy not drug addiction
Money vs. Drugs –>majority will pick money
Social Influences
• Lack of supervision • Cultural norms • Number of substance using friends • Peer pressure • Prescription drug abuse • sales of oxycodone increases 16-fold between 2000-1010 • 14,800 overdose deaths in 2008 alone • Protective: sports
Prescription Drug Abuse
• 2010: In USA, pharmacies dispensed 69 tons of oxycodone & 42 tons of hydrocodone • Enough to give 40 5-mg Percocets and 24 5-mg Vicodins to every person in the United States. • Misperceptions about safety (particularly in younger people) It is legal, safer, your dealer is your doctor
substance use disorder is predominantly defined by
behaviors
Drugs drugs
better to titrate down than titrate up
-use less when start high
Diathesis Stress model
How Are Substance Use
Disorders Treated?
• The value of treatment for substance use disorders can be difficult to determine • Different substance use disorders pose different problems • Many people with such disorders drop out of treatment early • Some people recover without any intervention at all • Different criteria are used by different clinical researchers
How to quit?
methedone
cold-turkey
rehab
AA meetings
Evidence based treatment?
the way we treat substance use disorder is nonmedical
Harm reduction approach
Mandated treatment works (license revoked after DUI)
Biological Treatments
• Agonist substitution: safer than drug abused (methadone = opiate agonist, nicotine replacement) >>Harm Reduction approach • Antagonist treatments: block effect of drug abused (naltrexone for heroin, alcohol) • Aversive treatment: disulfiram (antabuse for alcohol)
Methadone
controversial it has a street value can switch addictions taken daily good for communities treating community or the individual?
antabuse
makes you throw up
Antagoinist treatments
have to be motivated (Naltrexone)
Vaccines
• Theoretical basis: sequester the drug in the blood via antibodies •Drug of abuse is prevented from crossing the blood brain barrier
Psychosocial treatments
CBT
Behavioral couples therapy
motivational interviewing
AA/NA
CBT
what to do when craving hits, activity planning, avoiding drug cues, high risk situations, refusal skills (thoughts/ behaviors), relapse prevention (lapse vs. relapse) *Best data
Behavioral Couples Therapy
support around recovery,
communication, shared
rewarding activities
Motivational Interviewing
(helps with gaining insight &
willingness to change; taps into
core values facilitating change)
AA/NA
12-steps, avoid people/
places/things
Why do we need to hit rock bottom before getting treatment
nonmedical
Abstinence Violation Effect
relapse–>reinstate problematic use -had a slip up so will keep using & quit another time
lapse–> predictable using a drug that tried to quit
