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MHD.Psych > Substance Use Disorders > Flashcards

Substance Use Disorders Flashcards

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1
Q

What are the C’s of Addiction?

A
  • Craving/Compulsion to seek and take
    • craving=cant stop thining about it/get it out of their mind; pt may not label it as craving
  • Use in spite of possible or actual Consequences
  • Loss of Control in limiting intake
  • (also Chronicity sometimes counted as C)
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2
Q

DSM-5

A
  • main changes from DSM-4:
      • abuse
    • +craving
    • -Legal problems
    • sum: substance use d/o
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3
Q

Addiction Cycle (3 stages)

A
  • useful for pharm and psychosocial tx
  • some tx can be used at diff levels-important to know which level you are trying to target
  • depression or hypomaniac will often resolve once withdrawal is over
  • three main steps
    • the list at each arrow stage=tx for that particular step
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4
Q

Animal Models of Addiction

A
  • study nature of addiction
  • examine underlying dz
  • test tx
  • conditioned place preference
  • condtioned place aversion
    • ex: hospital-no possitive association with it because thats where they fo through withdrawal
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5
Q

Animal-Bing, Intoxication

A
  • oral and iv drug self-administration
  • conditioned place preference
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6
Q

Animal-Withdrawal, Negative Affect

A
  • conditioned place aversion
  • anxiogenic responses
    • elevated plus maze
    • defensive burying
      • maze-enclosed spaces=less exposed, burying to avoid neg stimuli
    • negative motions-anxiety
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7
Q

Craving, Preoccupation, Anticipation

A
  • drug-induced reinstatement
  • stress-induced reinstatement
  • cue-induced reinstatement
    • ex: stopping by liquor store on way to groceries; need to avoid ppl, places, things (avoid trigger nouns)
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8
Q

“Addicted” animals

A
  • escalation in self-administration
  • withdrawal-induced drug taking
  • select lines of drug-preferring animals
  • drug taking in spite of consequences
  • relapse
  • **check feelings for pt, may not like them
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9
Q

What are the (4) models of addiction

A
  1. Moral model
  2. learning model
  3. self-medication model
  4. ***disease model
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10
Q

Moral Model of Addiction

A
  • only model for most of hx and still most pop
  • causes:
    • moral weakness/lack of willpower
  • tx: punishment or spiritual
  • GOOD: gives pt responsibility
  • BADL blaming pt
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11
Q

Learning Model of Addiction

A
  • thoughts lead to emotions which lead to behabiors
  • caused by learned maladaptive habits
  • treat:
    • learn triggers
    • learn new cognitions
    • learn new behaviors
      • stimulus control
      • response prevention
      • coping skills
  • CBT/relapse prevention employ this model in pt
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12
Q

Self-Medication Model of Addiction

A
  • physiological and cognitive
    • cognition may become distorderd
    • external locus of control-blame someone else for all their problems
      • takes it out of their hands
  • somtimes the drugs will actually make the mental illness worse
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13
Q

**Disease Model of Addiction**

A
  • caused by dz
  • important 3-step therapy:
    • pharmacotherapy
    • 12-step referral
    • psychosocial tx
  • genetics/environment
    • educate family members about exposure, etc
    • dont necessarily have that second step of psychological symptoms en route to substance use (unlike self-med model that has 3 steps)
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14
Q

ASAM definition of Addiction

A

Addiction is a primary, chronic dz of brain reward, motivation, memory and related circuitry.

Dysfxn in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.

This is reflected in an indiv pathologically pursuing reward and/or relief by substance use and other behaviors…”

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15
Q

Addiction as Chronic Disease

A
  • For some people best viewed as chronic, severe, recurrent disease
    • Like diabetes, HTN, asthma
    • Similarities
      • Behavioral factors associated with onset
      • Genetic influences
      • Rates of tx compliance (30-50%)
      • Rates of relapse (30-70%)
      • Worsening and potentially fatal if untx
  • Those in tx:
    • 20+ years
    • Brief episodes of tx and/or incarceration
    • Gradually longer periods of abstinence
      • **look at long-term sobriety
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16
Q

Substance Use Epidemiology

A
  • 8.7% used illicit drugs in past month (22 million)
  • 52% drank alcohol (133 million)
    • 23% binged (58 million)
    • 6.2% heavy alcohol use (16 million)
  • 26.5% population used tobacco (68.2 million) in 2011
    • Decrease from 30.4% in 2002

10,50,25,5,25,30

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17
Q

Definition of binge and heavy-drinking

A
  • Binge = 5+ drinks/day
  • Heavy drinking = 5+binges/month
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18
Q

Substance Dependence or Abuse in the past yr; ppl 12 and older

A
  • 20.6M total (~8%) [in 2011-last bar]
    • 14M alcohol (~5.4%)
    • 3.9M drugs (~1.5%)
    • 2.6M both (~1%)
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19
Q

Specific Illicit Drug Dependence or *ABUSE* in past yr, ppl 12 or older (2011)

A
  • when perscribed meds are abused they are not purchased from a dealer. often theyre real scripts stolen from a family/friend
  • note:sedatives=BX
  • look at the levels of MJ and pain relievers
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20
Q

Early onset impact

A
  • the earlier the exposure, the higher likelihood of alcohol disorder in adulthood
  • ***early onset of substance use is a MAJOR RF for subseqent onset of subtace use disorder
    • alcohol and MJ (in tne image)
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21
Q

What is the trend with opiod prescriptions

A
  • since the intro of OXYCONTIN in 1995 prescription rate have shot up
  • however, there is currently a shift of the pendulum to LESS opiates
22
Q

Are motor vehicles, poisoning, or drug poisoning (OD) responsible for more death rates?

A
  • drug poisoning (OD) and general poisoning have INCREASED
  • motor vehicle traffic has DECREASED
23
Q

Which of the major drug types has the most drug OD deaths?

A
  • unintentional, non-suicide: OPIODS
  • opiod sales, deaths, and tx admissions have all slteadily risen together
  • theres a positive correlatio with HIGH opiod dose and OD risk
24
Q

Tx

A
  • 21.6 million needed tx
    • ***2.3 million received
    • 19.3 million did not receive
  • 912,000- felt needed tx and did not make an effort
  • 281,000 made effort but failed
  • 95.3% ppl did not feel they needed tx
    • cuases: disorder thinking, unaware of tx or think tx will be detrimental/will feel worse without substances, not ready to stop using, no health coverage/cant afford cost
25
Q

TEDS-Tx Episode Data Set (TEDS)

A
  • admissions for substance abuse tx
  • licensed substance abuse tx facilities
  • 1.8 million admissions aged 12 and older in 2011
  • Primary substance:
    • 39% alcohol
    • 25% opioids (heroin-15, non-heroin 10)***
    • 18% cannabis
    • 8% cocaine
    • 6% amphetamine
    • 4% other
26
Q

co-occuring disorders

A
  • ***6.8 million pts with co-occuring disorders
  • more likely to see someone wiht a SUD and NO mental illness (than with)
27
Q

Mental Illness

A
  • **Schizophrenia
    • 50% have SUD
    • 70% have nicotine dependence
      • nicotine gives improvement in cognition; affect on nucleus succumbens (neg symptoms–decreased motivation, pleasure–can increase with smoking)
  • Affective Disorder
    • 32% have SUD
    • 56% of bipolar d/o patients have SUD
  • Anxiety Disorder
    • 36% have co-morbid SUD
    • PTSD strongly associated with SUD
      • 75% PTSD combat veterans have SUD
      • Women with SUD high risk for PTSD
      • smoking alleviates feelings and calm them down; hard to get them to stop due to reinforcement pattern
  • Personality Disorder
    • Antisocial PD: 74% lifetime Alcohol Use Disorder
    • Borderline PD have elevated risk for SUD
28
Q

What are the theoretical models for co-occuring disorders?

A
  • independent
  • common factor: shared vulnerabilities
  • secondary SUD: self-medication
  • secondary psychopathology: substance-induced
  • bi-directional
29
Q

Diagnostic Considerations

A
  • Problems (over/under/mis)
    • Overdiagnosis
    • Underdiagnosis
    • Misdiagnosis
  • Tips
    • Thorough psychiatric and substance use history
    • **Collateral information
      • will sometimes get completely different story from family
    • Symptoms during periods of prolonged abstinence
    • Overall longitudinal pattern (e.g. onset of psychotic symptoms at unusual age)
    • Urine toxicology
    • Serial assessments
    • FHx
30
Q

SBIRT-Tx

A
  • used in psych settings
  • Screening, Brief Intervention, Referral to Treatment (SBIRT)
  • Non-substance abuse tx setting (PCP office, ER, school, etc.)
  • Purposes
    • Reinforcement for non users/healthy users
    • Early intervention for risky substance use
    • Referral for more intensive tx for SUDs
  • Facts:
    • 38 million americans drink too much
    • 1 in 6 talk with HC provider about their drinking
    • alcohol screening and bried counseling can reduce the amt consumed on an occasion by 25% in those who drink too much
31
Q

Screening Component of SBIRT

A
  • Universal
  • 5-10 mins
  • Examples: CAGE, AUDIT (Alcohol Use Disorders Identification Test)
  • 5-20% typically have some level of misuse or a SUD (can be as high as 40% in some settings)
32
Q

Brief Intervention component of SBIRT

A
  • For those with risky behavior
  • 1 - 5 sessions
    • 5 mins – 1 hour
  • Educate and Increase motivation to reduce risky behavior
  • MD or allied health professional
  • Brief tx sometimes used (between brief intervention and referral to tx)
33
Q

What does drinking too much include?

A
  • # occasions
  • # drinks
  • pregnant
  • underage
34
Q

Referral to Tx component of SBIRT

A
  • Some SUD pts should be referred
  • Awareness of referral options is a major limitation
  • BI (brief intervention) can be motivation based to increase likelihood of following up with referral
35
Q

***Stages of Change***

A
  • level of motivation=number one predictor for how the pt will do
  • need to assess the right level in order to send them to the right level of tx
  • stages:
    • precontemplation
    • contemplation
    • preparation
    • action
    • maintenance
    • relapse
36
Q

What is the physicians job at each stage of change?

A
  • precontemplation-RAISE AWARENESS
  • contemplation-RESOLVE AMBIVALENCE
  • preparation-ID STRATEGIES AND EMPLOY
  • action-HELP CARRY OUT CHANGE
  • maintenance-DEVELOP NEW SKILLS TO MAINTAIN CHANGE
  • relapse
37
Q

Stages of Change-Precontemplation

A
  • Pt uninterested in change
  • Does not see major problem with use
  • Pros of chang outweighed by cons
  • Clinician task: get the patient to become interested and concerned about need for and possibility of change, RAISE AWARENESS
38
Q

Stages of Change-Contemplation

A
  • **goal is to get to this PRE-contemplation to actual contemplation
  • Pt now interested in change
  • Risk-reward analysis
  • Pros-Cons typically hang in the balance
  • RESOLVE AMBIVALENCE
39
Q

Stages of Change-Preparation

A
  • Pt creates a change plan (behavioral)
  • Increases commitment for implementing plan (cognitive-emotional)
  • IDENTIFY STRATEGIES AND EMPLOY
40
Q

Stages of Change-Action

A
  • Stopping problematic behavior
  • Establishing new pattern of abstinence or different behavior
  • 3-6 months
  • HELP CARRY OUT CHANGE
41
Q

Motivational Enhancement

A
  • Motivation
    • The probability that someone will enter into, continue, and adhere to a specific change strategy
    • Most not unmotivated to quit, just more motivated to continue
    • Encompasses internal urges, external pressures
    • The key to change
  • Task of clinician includes engendering motivation
    • Clinician style influences client motivation
    • Don’t dismiss unmotivated patients, Attempt to motivate
    • Stimulate movement through early stages of change
42
Q

Motivation Enhancement-engage pt in discussion of substance use and lifestyle using motivational enahcement techniques

A
  • REDS
    • Role with Resistance
    • Express Empathy
    • Develop Discrepancy
    • Support Self-efficacy
  • FRAMES Approach
    • Feedback on use
    • Responsibility on patient
    • Advice
    • Menu of options
    • Empathetic counseling
    • Self-efficacy
43
Q

What are 12 Step Programs

A
  • Alcoholics Anonymous, 2007
    • 50,000 groups in USA
    • 1,200,000 members in USA
    • 700,000 members outside of USA
  • AA members
    • 39% referred by health care professional
    • Sobriety
      • 26% less than 1 year
      • 38% 1-10 years
      • 36% greater than 10 years
  • Open meetings: anyone invited, including medical students
  • Closed meetings: only those concerned they may be an alcoholic
44
Q

What are the components of 12 Step and how does it work?

A
  • Components
    • Sponsorship
    • Meetings
    • Step-work
    • Commitments
    • Fellowship
  • How it works
    • Spiritual growth
    • Group adhesion
    • Peer support
    • Skills
    • Abstinence-based
  • Free
  • Long-term
  • 25-35% of pts who attend one AA meeting go on to active participation
  • Good evidence that those who engage in AA have better abstinence records than those with identical tx sans AA
  • May work best for people with severe disease
45
Q
A
46
Q

CBT

A
  • Disrupt learned association between drug-related cues or stimuli and drug use by understanding and changing these behavior patterns
  • In general:
  • Thoughts determine feelings and behavior
    • “I need a drink to relax”
    • “I can just have one hit”
  • Thoughts can be studied and modified
  • By modifying thoughts, can modify feelings and behavior
  • Recognition of situations most likely to use
    • Avoid those situations when appropriate: Stimuli Avoidance
    • When unable to avoid high risk situation, employ strategies to prevent use: Response Prevention
  • Functional analysis of drug use
    • Causes- emotional, social, cognitive, situational
    • Existing coping skills/strengths
    • Consequences of use
47
Q

Contingency Management

A
  • Controversial
  • Operant conditioning plays enormous role in genesis and maintenance of SUD
  • Reinforcing effects of drugs are immediate and reliable
  • Adverse consequences typically delayed, intermittent
  • Individuals with SUDs discount value of delayed consequences to a significantly greater extent than matched controls
  • Systematic application of reinforcing or punishing consequences in order to achieve therapeutic goals
  • Behavioral change using contingencies
    • ****Positive reinforcement- contingent on meeting therapeutic goal- e.g. monetary voucher for clean urine
    • **Negative reinforcement- removal/reduction of aversive event contingent on meeting therapeutic goal- e.g. regain custody of children after complete tx
    • Positive punishment- aversive event contingent on therapeutically undesirable response-
    • Negative punishment- removal of positive condition contingent on undesirable response
48
Q

How do you determine the level of care that is needed?

A
  • ASAM Placement Criteria: assess 6 areas
    • Acute intoxication/withdrawal potential
      • Detoxify
        • 90-95% chance of relapsing after detox-it is NOT tx
    • Medical conditions
    • Psychiatric or cognitive conditions
    • Motivation/Readiness to change
    • Potential for continued use, relapse
    • Recovery/living environment
  • Severity of illness, level of functioning
49
Q

Tx Settings-Detoxification

A
  • Detoxification
    • Alcohol, opioids: manage physiological withdrawal
    • Cocaine, stimulants, cannabis: experience substantial emotional and physiological sx; often require period of stabilization
    • “The easy pt”: unlikely to produce lasting recovery alone
    • One way to view is PRE-tx
50
Q

Tx Settings-Levels of Care

A
  • 0.5: Early intervention; explore, address problems
  • 1: Outpatient services
  • 2: Intensive outpatient services partial hospitalization programs
    • IOP 9-20 hours/week
    • PHP 20+ hours/week
  • 3: Residential or inpatient treatment
    • Intensive structure and services
    • Prevent imminent danger of negative consequences
  • 4: Medically managed intensive inpatient
    • focus on addiction treatment, but simultaneous medical care
51
Q

Take Home Points

A
  • New definitions and criteria for substance use disorders in DSM-V
  • Models of addiction focusing on the chronic disease model
  • SBIRT and its use in non-psychiatric settings
  • Motivational enhancement therapy and applications in non-psychiatric settings
  • Understanding diff levels of care and tx

MHD.Psych (9 decks)

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