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Causes and Treatment of Substance Use Disorders

Causes and Treatment of Substance Use Disorders. Chapter 11. The Spectrum of Use. Use – Noncompulsive and nonconsequential use Misuse – Periodic negative consueqnces Abuse – A pattern of misuse Dependence – Compulisve use with significant consequences often w/physiological dependence .

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Causes and Treatment of Substance Use Disorders

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  1. Causes and Treatment of Substance Use Disorders Chapter 11

  2. The Spectrum of Use • Use – Noncompulsive and nonconsequential use • Misuse – Periodic negative consueqnces • Abuse – A pattern of misuse • Dependence – Compulisve use with significant consequences often w/physiological dependence

  3. Moving Through the Spectrum • Depends on numerous issues • The drug itself (The Agent) • The person (The Host) • The person’s environment (The Environment) • With some drugs it is difficult to maintain the line between use, misuse, abuse and dependence

  4. DSM – IV CriteriaSubstance Abuse • A maladaptive pattern of substance use occurring within a 12 month period • Impairment/Distress • One of the following • Failure to fulfill major role obligation • Use in physically hazardous situations • Recurrent legal problems • Continued use despite recurrent psychosocial problems

  5. DSM-IV Substance Dependence • A maladaptive pattern of substance use occurring within a 12 month period • Three of the following: • Tolerance (increased drinking to achieve same effect) • Withdrawal • Drinking more than intended • Unsuccessful attempts to cut down on use • Excessive time related to obtaining, using and or recovering from • Impaired social or work activities due to alcohol • Use despite physical or psychological consequences

  6. Causes - Multidimensional • Abuse/Dependence is an interaction between • Pharmacological • Biological/Genetic • Psychological/Behavioral • Social/Environmental

  7. Pharmacologic • Drugs differ in terms of the potential for physiological addiction. • Nicotine – High • Heroin – High • Cocaine – High • Alcohol – Moderate • Marijuana – Low • Hallucinogens - Low

  8. Biologic/Genetic • Substance Abuse and Dependence runs in families. • Diathesis for certain types of alcohol dependence. Mechanism seems to tolerance • Diathesis for other drugs is less clear. Probably through a temperamental characteristic, psychopathology and/or dopamine NT system sensitivity

  9. Psychological/Behavioral • Alcohol/Drug use is functional and is reinforcing. Use is subject to the laws of behavioral reinforcement (positive and negative). • Self-regulation/Coping • Certain personality characteristics are predictive.

  10. Social/Environmental • Certain developmental insults • Access • Social norms • Using peers

  11. Substance Abuse Treatment • Three main philosophies/modalities • Mutual-help • Psychosocial • Pharmacological • In the past there has been much conflict between these philosophies. Not so much now.

  12. Mutual Help Philosophy • Twelve Step Fellowship • Alcoholics Anonymous • Narcotics Anonymous • Spiritual Disease Model • Mechanisms • Acceptance of loss of control and higher power • Working the steps • Most probably powerful social support and behavioral management

  13. Psychosocial Treatment • Psychological Treatments • Motivational Interviewing/MET • Empathy • Rolling with resistance • Develop Discrepancy • Community Reinforcement Approach • Rearrange reinforcement contingencies • CBT • Skills training and cognitive restructuring • Psychotherapy and Educational alone are ineffective

  14. Project MATCH • Mulitsite clinical trial of psychosocial treatments • Three alcohol dependence treatments treatments • MET • CBT • 12 Step Facilitation • Results • TSF marginally better. AA meetings • MET as good over time with less treatment. Better for those high in anger • Behavioral treatments work

  15. Pharmacotherapy • Alcohol • Antabuse – Become ill if one drinks • Naltrexone – Opiate antagonist • Heroin/Opiates • Methadone – An agonist. Opiate replacement • Buprinorphine – A partial agonist. • Naltrexone – Blocks opiate action • Cocaine • Haven’t found one yet • Overall not many meds work. Compliance is the ultimate issue.

  16. Treatment Integration • Combine treatment philosophies/modalities • Motivation Enhancement • Increase readiness • CRA/CBT • Active treatment • Rearrange reinforcement structure • Teach coping skills • Address psychopathology • Pharmacotherapy • Mutual-help groups • Social Support • Maintenance

  17. Project COMBINE • Multisite clinical trial addressing the combination of drugs and psychosocial treatments • Acamprosate (a benzo) and/or Naltrexone • Medication management or Psychosocial Treatment • Psychosocial Treatment is a combo of MET and CRA

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