Substance Use Disorders

1. Substance Use Disorders Theodore M. Godlaski

2. biomedical psychological behavioral social spiritual Elevated liver tests, tenderness in lower abdomen, hypertension, hyperlipidemia, bruising, peripheral neuropathy, chronic headaches, probable sleep apnea, poor muscle tone, erectile dysfunction, rapid pulse, pulmonary edema, multiple recent upper respiratory infections Impaired self-esteem, labile mood, irritability, anger over job conflicts, feeling of guilt, anhedonia, occasional sense of futility and apathy, belief that children and spouse hate him, occasional thoughts of suicide. Drinks increasing amounts of alcohol daily, agitation alternating with lethargy, elicits arguments with spouse and children, occasional angry outbursts at home and work, frequently absent or tardy at work, multiple unsuccessful efforts to change drinking behavior refuses to have contact with former friends and extended family Significant marital and family conflict, neglectful and possibly abusive parenting, serious financial problems, social isolation, withdrawal from healthy recreational activities, serious conflict with co-workers and supervisor at work Sense of futility and hopelessness, near despair, feelings of abandonment, inability to express acceptance for self or others, pervasive sense of guilt and resentment, increasing hatred and hostility toward those he sees as different than himself, guarded and angry unwillingness to know or be known. Biopsychosocial and Spiritualview of alcohol dependence

3. Biomedical observer Boundary of The phenomenon Psychological observer Social observer Spiritual observer Behavioral observer

11. Synthetic Rewards • The use of specific substances can be highly rewarding. • In some individuals use of such substances can lead to uncontrolled use, displacement of more normal activity, and continued use despite painful and even life threatening consequences.

12. Nesler, E & Melenka, R. (2004) The addicted brain. Scientific American, March: 78-85

13. Nesler, E & Melenka, R. (2004) The addicted brain. Scientific American, March: 78-85

15. Epidemiology • Rates vary depending on the population studied and the measurement. • The one thing that seems certain is that lifetime prevalence rates in the United States are very high. • Additionally, rates for men are significantly higher than for women.

16. Male Lifetime Female Lifetime Total Lifetime Alcohol Abuse 12.5% 6.4% 9.4% Alcohol Dependence 20.1 8.2% 14.1% Drug Abuse 5.4% 3.5% 4.4% Drug Dependence 9.2% 5.9% 7.5% Any Substance Use Disorder 35.4% 17.9% 26.6% Lifetime Prevalence of Substance Use Disorders,National Comorbidity Survey Kessler, McGonagle, et al. (1994). Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States. Arch of Gen Psychiatry, 51:8.

17. Substance Abuse/Dependence Lifetime Prevalence Any drug 6.2% Cannabis 4.4% Stimulants 1.7% Sedatives 1.2% Opioids 0.7% Hallucinogens 0.4% Cocaine 0.2% Alcohol 13.8% Tobacco 36% Lifetime Prevalence of Substance Use Disorders (1980-1984),Epidemiologic Catchment Area Study Kandel (1992). Epidemiological trends and implications for understanding the nature of addiction. In O’Brien & Jaffe. Research Publications: Association for Research in Nervous and Mental disease, vol. 70, p. 23. N.Y.:Raven.

18. Distal Antecedents Peer group Family interactions Parental sub. use Immediate Antecedents Laws Social pressures Availability demographics Adverse Consequences Toxic effect Psychosocial Dysfunction Organic damage Avoidance learning social tolerance Disposition to use Drug use Neuro- adaptive state Distal Antecedents Early learning Drug experience Genitics Developmental events Immediate Antecedents Mood states Self-efficacy expectations withdrawal Reinforcing Consequences Mood enhancement Psychosocial facilitation Approach learning individual WHO schematic model of drug use and dependence

19. Comorbidity • Substance Use Disorders are often found together with other Axis I and Axis II Disorders: • Anxiety Disorders • Mood Disorders • PTSD • Antisocial Personality Disorder

20. Comorbid Disorder Alcohol Abuse Alcohol Dependence National Comorbidity Survey 1–year rate (%) Odds ratio 1–year rate (%) Odds ratio Mood disorders 12.3 1.1 29.2 3.6 Major depressive disorder 11.3 1.1 27.9 3.9 Bipolar disorder 0.3 0.7 1.9 6.3 Anxiety disorders 29.1 1.7 36.9 2.6 GAD 1.4 0.4 11.6 4.6 Panic disorder 1.3 0.5 3.9 1.7 PTSD 5.6 1.5 7.7 2.2* Kessler, McGonagle, et al. (1994). Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States. Arch of Gen Psychiatry, 51:8.

21. Prevalence of Other Disorders in Individuals Diagnosed as Having Drug Abuse or Dependence Kandel, D.B. (1992) Epidemiological trends and implications for the understanding of addiction. In Addiction Studies, P. O’Brian & J. Jaffe (Eds.). Research Publication, New York: Vol 70, p23.

22. Criteria for Substance Dependence • A 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.

23. (1) tolerance, as defined by either of the following: • (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect • (b) markedly diminished effect with continued use of the same amount of the substance.

24. Tolerance • With opioids and stimulants dramatic (10x) tolerance can develop. • With other drugs like alcohol, sedatives, and benzodiazapines tolerance is significant but not as dramatic. • With some drugs like PCP, hallucinogens, and possibly marijuana there may be little to no identifiable tolerance. • The picture can be further clouded if a person is using drugs of unknown purity and concentration.

25. Tolerance • The initial tolerance to a drug and the rates at which tolerance develops can vary greatly from one individual to another. • In general, the higher the initial tolerance the greater the likelihood of later problems because of potential for exposure to larger doses. • Aging and tissue damage from toxic drugs can lead to an eventual reversal of tolerance.

26. (2) withdrawal, as manifested by either of the following: • the characteristic withdrawal syndrome for the substance • the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms

27. General Criteria for Substance Withdrawal • The development of a substance specific syndrome due to cessation of (or reduction in) substance use that has been heavy and prolonged. • The substance specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

28. Alcohol, Sedative, Hypnotic, or Anxiolytic Withdrawal • Two or more of the following: • autonomic hyperactivity (e.g. sweating or pulse rate >100) • increased hand tremor • insomnia • nausea or vomiting • transient visual, tactile, or auditory hallucinations or illusions • psychomotor agitation • anxiety • grand mal seizures

29. Amphetamine or Cocaine Withdrawal • Dysphoric mood and two (or more) of the following physiological changes: • fatigue • vivid, unpleasant dreams • insomnia or hypersomnia • increased appetite • psychomotor retardation or agitation

30. Nicotine Withdrawal • Four (or more) of the following: • dysphoric or depressed mood • insomnia • irritability, frustration, or anger • anxiety • difficulty concentrating

31. Opioid Withdrawal • Three (or more) of the following: • dysphoric mood • nausea or vomiting • muscle aches • tearing or runny nose • dilated pupils, goose flesh, or sweating • diarrhea • yawning • fever • insomnia

32. Other Drugs • There is no clearly defined withdrawal syndrome for the following: • Cannabis • Phencyclidine • Inhalants • Hallucinogens

33. Specifiers • With Physiologic Dependence • if either tolerance or withdrawal are present • Without Physiologic Dependence • if neither tolerance nor withdrawal are present

34. (3) the substance is often taken in larger amounts or over a longer period of time than was intended. • The underlying concept here is that the drug use is no long fully under the conscious control of the individual. • Determining how “often” is “often enough” is not specified.

35. (4) there is a persistent desire or unsuccessful efforts to cut down or control substance use. • The underlying concept here is that the drug use is no long fully under the conscious control of the individual. • This criteria can manifest as thoughts or wishes to stop, cutback, control, or do something about drug use or as actual unsuccessful attempts to do so.

36. (5) a great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long distances), use the substance (e.g. chain smoking), or recover from its effects • The underlying concept is that the drug use assumes a very high priority in the life of the individual and all that surrounds the drug use is valued above other things. • It seems legitimate to include resources other than time. • “a great deal” is not specified.

37. (6) important social, occupational, or recreational activities are given up or reduced because of substance use • The underlying concept is that the drug use assumes a very high priority in the life of the individual and all that surrounds the drug use is valued above other things. • There can be a problem here because for some, social and recreational activities include heavy use of substances and substance use itself can be seen as a form of recreation.

38. Likewise, there can be difficulty applying this criterion to specific groups of individuals who do not fit a mainstream cultural norm. • Individuals who are chronically unemployed, work part-time irregular hours, or have been disabled for some time may not identify any occupational problems related to substance use.

39. (7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been cause or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption) • The critical issue is that the individual not only have physical or psychological problems but know that they are caused or worsened by substance use.

40. Alcohol Related Physical Problems • liver disease or jaundice • stomach disease or vomiting blood • tingling or numbness in the hands or feet • memory problems • pancreatitis • any other physical illness that could be made worse by drinking Robins, L., Cottler, B., Bucholz, K., Compton, W., North, C., & Rourke, K. (1999) Diagnostic Interview Schedule, St. Louis, MO, Washington University School of Medicine.

41. Alcohol Related Psychological Problems • feeling uninterested in things • feeling depressed • feeling suspicious of others or paranoid • believing things that were not true • any other emotional problems that that could be made worse by drinking Robins, L., Cottler, B., Bucholz, K., Compton, W., North, C., & Rourke, K. (1999) Diagnostic Interview Schedule, St. Louis, MO, Washington University School of Medicine.

42. Drug Related Physical Problems • losing a lot of weight • numbness in hands or feet • seizures • persistent cough • eye problems • an injury or burn • heart pounding • sexual difficulties • overdose • infections • problems with veins • any other physical problems that is worsened by drug use. Robins, L., Cottler, B., Bucholz, K., Compton, W., North, C., & Rourke, K. (1999) Diagnostic Interview Schedule, St. Louis, MO, Washington University School of Medicine.

43. Drug Related Psychological Problems • depressed or uninterested in things • paranoid or suspicious • confused • anxious • irritable or angry • keyed up or overactive • seeing, hearing, smelling, or feeling things that weren’t there • laughing or crying for no reason • jumpy or easily startled • reckless or fearless • memory problems • flashbacks Robins, L., Cottler, B., Bucholz, K., Compton, W., North, C., & Rourke, K. (1999) Diagnostic Interview Schedule, St. Louis, MO, Washington University School of Medicine.

44. A Concern About Polysubstance Use • Although there is a unitary set of criteria for substance dependence and abuse, diagnosis is still tied to individual drugs. • If an individual is using multiple drugs with some frequency, how can the specific effects of each be identified? • In such cases Polysubstance Dependence is used when an individual is using at least three categories of drugs and none predominates.

45. Course Specifiers • Early Full Remission: for at least 1 month, but less than 12 months, no criteria of dependence or abuse are met. 1 month dependence 0-11 months

46. Course Specifiers • Early Partial Remission: for at least 1 month, but less than 12 months, one or more criteria for dependence or abuse are met but not the full criteria for dependence. I month dependence 0-11 months

47. Course Specifiers • Sustained Full Remission: none of the criteria for dependence or abuse have been met for 12 month or longer. 11 months dependence 12+ months

48. Course Specifiers • Sustained Partial Remission: the full criteria for dependence have not been met for 12 months or longer, but one or more criteria for dependence or abuse have been met. 11 months dependence 12 + months

49. Course Specifiers • On Agonist Therapy: individual on prescribed agonist medication and no criteria for dependence or abuse have been met for 30 days. Also applies to those treated with agonist/antagonist drugs. • In a Controlled Environment: individual in environment where access to alcohol and drugs restricted and no criteria for dependence or abuse have been met for 30 days.

50. Compulsion and Craving • Although not included in the DSM-IV Criteria, compulsion and craving is mentioned in the text and has long been associated with Substance Dependence. • Compulsion seems to manifest as a preoccupation with substance use and a powerful and overwhelming drive to use a substance; • Craving as strong, dominantly physical, desire to use a substance even against a persons conscious judgement. • It is valuable to assess compulsion and craving since they effect the individuals ability to recover.