Week 12 Substance Abuse Flashcards
What is the global problem of psychoactive drug use?
8.9% of total burden of disease comes from the use of psychoactive substances
4.1% from Tobacco
4% from Alcohol
0.8% from illicit drugs
Cost to the Australian economy $24.5billion /year
There is a long history of drug use in human society. How long have substances been used by people?
Alcohol - 12,000 years
Coco - thousands of years
Cannabis - 10,000+ years
Opium - 6,200+ years
*Only Inuit Eskimos have no record of traditional drug use
*Most, if not all, societies integrate drug use into accepted, sometimes ritualistic, cultural patterns of behaviour, & every-day social interaction
What are some of the historical limits to the extent of drug use?
- Prior to the advent of global trade, simple geography limited the use of many drugs
- Cultural norms and taboos (often associated with mysticism and ‘rites of passage’)
- Extraction, preservation, and synthesis of active substance
When was drug use expanded?
Colonialism and global trade:
- Cash crops (e.g. opium, tobacco)
- Opium wars
- Scientific advances:
- Extraction and purification of active ingredients (e.g. cocaine, morphine)
- Synthesising new substances (e.g. heroin)
What has been the reaction to widespread use of substances?
*Widespread intoxication clashed with modern industry’s need for a disciplined, productive work force.
- Xenophobia and moral panics:
- Demonisation of Chinese opium dens in US West, Australia
- Association of “marihuana” with illegal Mexican immigrants
- Social movements: temperance
- Legislative control, prohibition
Some people kept using substances anyway, what happened here?
Concept of “addiction” emerged:
- Substance abuse as a “disease”
- Efforts to define, treat
What is the medical model of substance abuse?
- Drug dependence is seen as chronic and relapsing sickness or disease
- Removes responsibility from abuser - not weak-willed, is sick
- Widely accepted, though support for a discrete “disease” category from scientific, clinical, and sociological research is inconsistent at best.
What is the DSM definition of abuse?
A maladaptive pattern of excessive use leading to interpersonal, legal, behavioural, or occupational problems
What is the DSM definition of dependence?
compulsive pattern of chronic use, leading to loss of control over use, pathological valuation of substance use over other activities, and physiological adaptation to the substance
What is the DSM criteria for substance abuse?
Any one of the following symptoms occurring repeatedly within a 12-month period:
- Recurrent substance use resulting in a failure to fulfil major obligations (e.g. repeated absence from work or school, or poor performance, neglect of children, etc.)
- Recurrent use in situations where it may be physically hazardous (e.g. driving)
- Recurrent substance-related legal problems.
- Continued use despite recurrent interpersonal problems (e.g. fights or arguments either caused by intoxication or about person’s excessive use)
What is the DSM criteria for Substance Dependence?
Any 3 or more of the following symptoms occurring within a 12-month period:
- Frequently using more of the substance, or using for longer periods of time, than intended
- Persistent desire, or repeated unsuccessful efforts, to cut down or cease.
- Large proportion of one’s time spent obtaining, using, and/or recovering from effects of substance.
- Important social, recreational, or occupational activities given up or reduced because of substance use
- Substance use continued despite knowledge of physical or psychological health problems caused by substance
- Tolerance (needing more of substance than previously to achieve same effects and/or diminished effects from using previously “effective” amount)
- Withdrawal symptoms when substance use reduced or ceased (symptoms depend on type of substance)
What are the main differences between DSM-IV and DSM-5?
“Substance use disorder”, with no distinction between “abuse” and “dependence”:
- All 11 criteria pooled together
- “legal problems” criterion removed, but “cravings” added.
Severity defined by number of symptoms:
- Mild: 2-3 symptoms
- Moderate: 4-5 symptoms
- Severe: 6 or more symptoms
What is the ICD-10 criteria for Substance Dependence?
Substance dependence diagnosis requires at least 3 of following criteria:
- Strong desire or compulsion to use
- Difficulties controlling onset, termination, or level of use
- Withdrawal syndrome when use reduced or ceased
- Tolerance
- Increasing neglect of alternative pleasures or interests because of use or because of increased amount of time necessary to obtain substance or to recover from its effects
- Persisting with use despite experiencing harmful consequences (physical or mental health; cognitive impairment) and being aware that these were being caused or exacerbated by substance use.
What is the Fagerstrom Test for Nicotine Dependence (FTND)?
A questionnaire which scores a patient’s level of nicotine dependence:
- How soon after waking do you have your first cigarette?
- Do you find it difficult to keep from smoking in places where smoking is forbidden (cinema, church, library)?
- Which cigarette would you hate to give up?
- How many cigarettes do you smoke per day?
- Do you smoke more during the 1st hours after waking than during the rest of the day?
- Do you smoke if you are so ill you are in bed most of the day?
What is the scoring system for the Fagerstrom Test for Nicotine Dependence (FTND)?
0-2 = very low dependence 3-4 = low dependence 5 = moderate dependence 6-7 = High dependence 8+ = very high dependence
What are some of the problems with defining and measuring “addiction” found by Davies and Baker (1987)?
- 2 questionnaires administered in random order to 20 heroin users:
- One administered by university professor
- One administered by a local, well-known heroin user
To the professor, participants consistently reported: *More frequent use *More problems associated with use *Higher levels of dependence To their peers, less so
What are some of the effects of labelling on self-report measures found by McAllister & Davies (1991)?
Interviews with smokers on two occasions
- At first interview, all smokers categorised as “problem smokers”.
- After first interview, randomly split into two groups – LIGHT and HEAVY smokers.
- Group designation clearly printed at top of each page at follow-up questionnaire
- ‘Heavy’ smokers reported increases in problem smoking and tobacco dependence no matter how much they actually smoked
What is the biopsychosocial model of substance abuse, also referred to as the ‘drug, set and setting’ model (Zinberg, 1986)?
Drug effects are an interaction of:
- The substance
- type of drug, dose, purity, adulterants
- The user
- physiological and psychological state
- The context
- social and physical context
Tell me more about the ‘set’ from the biopsychosocial model of substance abuse, also referred to as the ‘drug, set and setting’ model (Zinberg, 1986)?
The ‘set’ refers to
- Physiological:
- age, body weight, sex
- genetics
- circadian rhythms, health
- Psychological:
- Mood
- Beliefs regarding drug usage and its consequences (usage is inversely proportional to perceived harm)
- personality traits
Tell me more about the ‘setting’ from the biopsychosocial model of substance abuse, also referred to as the ‘drug, set and setting’ model (Zinberg, 1986)?
The ‘setting’ refers to:
Physical Environment: effects in hospital vs. at a party
*Social Environment: stress of modern society
*Cultural norms: religious taboos; parents attitude; condoned use of certain drugs; social support and sanctions for appropriate and inappropriate behaviour
*Peer behaviour: compare our behaviour with others, learn rules and rituals
Peer-group identificationMedia’s portrayal of drug use/ advertising
*Popular culture
Tell me more about the ‘drug’ from the biopsychosocial model of substance abuse, also referred to as the ‘drug, set and setting’ model (Zinberg, 1986)?
The ‘drug’ refers to:
- Route of administration
- Type of drug:
- CNS depressants:
- GABAergic drugs (alcohol, benzodiazepines, GHB)
- Opioids (heroin, morphine, codeine, oxycodone)
- CNS stimulants:
- Cocaine, amphetamine, methamphetamine, cathinones (MDPV, mephedrone, “bath salts”)
- nicotine
- caffeine
- “Hallucinogens”: Psychedelics, Dissociatives
- Mixed effects: cannabinoids, “empathogens” (e.g. MDMA), solvents/hydrocarbon inhalants
What do we know about the interactions alcohol (AKA Ethyl Alcohol, Ethanol) has on the body?
*Agonist at GABAa benzodiazepine receptor sites
Alcohol inhibits:
-ion channels (sodium, calcium, potassium) that facilitate excitatory neurotransmission
-glutamate receptors (AMPA, kainate, and, at high doses, NMDA)
-adenosine reuptake
- Various other actions, e.g. at some serotonergic and cholinergic receptor sites
- The blood alcohol concentration (BAC) is determined by:
- Concentration of alcohol in drink, rate of drinking
- Presence of food in stomach
- Body size
- Sex
What do we know about the effects low doses of alcohol (AKA Ethyl Alcohol, Ethanol) has on the body?
Low doses (below 0.1% BAC):
- Disinhibition (consequences are specific to person and surroundings; relaxed, euphoric, withdrawn or aggressive)
- Expectancy effects (only with low doses)
- Increased talkativeness, sociability
- Impaired judgment, attention, self-control, information processing, reaction time
- Impaired muscle coordination
- Increased heart rate, reduced body temperature
- Increased urination
- Sleepiness (hypnotic agent)
What do we know about the effects high doses of alcohol (AKA Ethyl Alcohol, Ethanol) has on the body?
High doses: blood alcohol content (BAC) > 0.15%:
- disorientation, confusion, slurred speech,
- blurred vision, poor muscle control
- if new drinker → nausea/vomit,
- decreased testosterone (and sexual response),
BAC > 0.3:
*stupor, sleep, unconsciousness, coma, death
What do we know about the effects chronic heavy alcohol consumption on the body?
Central Nervous System:
- Peripheral Neuropathy
- Alcoholic Dementia
- Wernicke-Korsakoff’s syndrome
Cardiovascular:
- Hypertension, *Strokes, *Cardiomyopathy
- Arrythmias
Reproductive:
- impaired sexual desire or arousal
- Impotence or testicular atrophy (men)
Other effects:
- Haematological- Macrocytic Anaemia
- Musculoskeletal- Myopathy with Chronic weakness
- Endocrine
- Dermatological
What are the other effects of chronic heavy drinking?
Gastrointestinal:
- Oesophagitis, *Gastritis, *Peptic ulcer disease
- Malabsorption, *Gastric cancers
Pancreas:
*Pancreatitis- Acute & Chronic, *Cancer
Liver:
*Fatty liver changes – Reversible, *Alcoholic hepatitis - (i.e., damaged hepatocytes).
-Cessation likely to lead to recovery.
Cirrhosis – Liver cells die and are replaced by fibrous scar tissue
Hepatocellular Carcinoma
What is Wernicke-Korsakoff’s syndrome?
A brain disorder involving loss of specific brain functions caused by a thiamine (vitamin B1) deficiency .
- Generally attributed to malnutrition. Symptoms may be exacerbated by alcohol withdrawal.
- The syndrome is actually a spectrum, including two separate sets of symptoms.
- Wernicke’s encephalopathy involves damage to multiple nerves in both the central and peripheral nervous systems.
- Korsakoff syndrome involves impairment of memory out of proportion to problems with other cognitive functions due to damage to areas of the brain involved with memory.
What are the symptoms of Wernicke-Korsakoff’s syndrome?
Vision changes (including double vision, eye movement abnormalities, eyelid drooping)
- Loss of muscle co-ordination
- Unsteady, uncoordinated walking
- Loss of memory, can be profound
- Inability to form new memories
- Confabulation (making up stories to fill lapses in memory of events; often not conscious of this)
- Hallucinations
What are the symptoms & implications for brain damage caused by alcohol?
Excessive consumption of alcohol leads to damage to myelinated neurons (white matter).
- Women show a greater sensitivity to alcohol neurotoxicity than do men.
- Cigarette smoking can exacerbate alcohol-induced damage
- Increased brain volume and improved cognitive function with several months or years abstinence
What are the symptoms & implications for alcohol withdrawal?
- Autonomic hyperactivity (sweating, racing heart)
- Shaking hands
- Nausea
- CNS excitability:
- Anxiety, agitation
- Seizures in severe cases (can be life-threatening)
- Delirium Tremens (DT’s):
- profound confusion, delusional states, fluctuating consciousness, hallucinations
*Treated with other CNS depressants such as benzodiazepines
What are the guidelines for drinking for daily & weekly drinking for Men & Women?
Low risk Males:
daily up to 6, no more than 3 days/week; 28/week
Low risk Females:
Daily up to 4, no more than 3 days/week; 14/week
Risky Males:
Daily 7-10 on any day; 29-42/week
Risky Females:
Daily 5-6 on any day; 15-28/week
High Risk Males:
Daily 11+ on any day; 43+/week
High Risk Females:
Daily 7+ on any day; 29+/week
Which drugs are Benzodiazepines?
- Diazepam (valium, valpam)
- Alprazolam (xanax)
- Clonazepam (klonipin, rivotril)
- Nitrazepam (mogadon)
- Oxazepam (serapax, murelax)
- Flunitrazepam (Rohypnol)
- Temazepam (normison, temaze)
- Lorazepam (Ativan)
- Triazolam (halcion)
- Chlordiazepoxide (Librium)
- Midazolam
What are Benzodiazepines?
- Agonists of the benzodiazepine site on the GABAA receptor
- Increase ability of GABA to activate GABAA receptor, enhances inhibitory neurotransmission
- “Z drugs” have different chemical structure, but similar pharmacological activity:
- Zolpidem (stilnox)
- Zopiclone (imovane)
How are Benzodiazepines used?
Replaced more dangerous barbiturates for most clinical applications during 1960s-70s
- Anxiolytic: stop panic attacks
- Anticonvulsant: control of seizures
- Hypnotic: insomnia
- Muscle relaxant
- Occasionally used in anaesthesia
- Reduce alcohol and opioid withdrawal symptoms
*Rapid, high tolerance should limit long-term medical use, but often doesn’t
What are some of the acute effects of Benzodiazepines?
- Relaxation, loss of inhibition, euphoria
- Sedation, lack of muscular coordination
- Cognitive impairment
- Amnesia
- Enhances effects of alcohol, opiates
- Overdose: respiratory depression, coma, cardiac arrest
What are some of the chronic effects of Benzodiazepines?
- Cognitive impairment
- Extreme tolerance
- Paradoxical effects, e.g. increased anxiety
- Withdrawal:
- Similar to alcohol withdrawal syndrome
- Extremely dangerous and prolonged:
- Acute symptoms last up to 2 months
- Residual symptoms can last 6-36 months
- Re-emergence of severe withdrawal after single use many months after cessation
What is Nicotine?
Primary psychoactive ingredient in tobacco: accounts for the acute pharmacological effects of tobacco and the subsequent dependence on cigarettes.
•Numerous chemicals in tobacco smoke. Nicotine has some harmful effects, but most harmful effects of tobacco smoking are due to other chemicals.
•Agonist at nicotinic acetylcholine receptors
•Effects in central and peripheral nervous systems, heart, and cardiovascular system
•Brain areas activated by nicotine include:
• Locus coeruleus (behavioural arousal and vigilance)
• Frontal lobes and cingulate gyrus (cognition, working-memory, attention, motivation, mood, and emotion)
What are the behavioural, cognitive, & Psychological effects of Nicotine use?
- Increased concentration
- Improved working memory
- Improved performance in vigilance and rapid information processing tasks
- Relaxation
- Dizziness (in non-tolerant smokers)
Smokers unconsciously self-titrate to optimize nicotine levels and keep them at steady-state.
What are the consequences of tobacco use with regard it’s toxicity?
- Smoking is the leading preventable cause of death, illness and disability: causes 4.3 million deaths annually.
- It is the tar in tobacco that leads to much of the long-term toxicity
- Lung cancer, non-cancerous lung diseases, cancers of other body organs, heart and cardiovascular diseases.
- It is estimated that 14 min of life is lost for every cigarette smoked
- One in every six people who try smoking will eventually die of a smoking-related illness.
- Serious health risks associated with passive smoking
- Increased risk of spontaneous abortion, stillbirth, preterm delivery, retarded intrauterine growth and early postpartum death when mothers smoke.
What are the consequences of tobacco use with regard dependence on nicotine?
- Smoking does not appear to lead to nicotine tolerance (except for tolerance to dizziness/nausea/vomiting)
- However, clear physiological and psychological dependence does develop
- Withdrawal is characterized by:
- severe craving for nicotine
- irritability, anxiety, anger, restlessness, impatience
- difficulty in concentrating
- increased appetite, weight gain
- insomnia
