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Substance Use Disorders

Substance Use Disorders. How many people use mood-altering substances?. Harm can occur from use with or without a Substance Use Disorder. Saitz, NEJM 352:596, 2005. What is Abuse?.

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Substance Use Disorders

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  1. Substance Use Disorders

  2. How many people use mood-altering substances?

  3. Harm can occur from use with or without a Substance Use Disorder

  4. Saitz, NEJM 352:596, 2005

  5. What is Abuse? • DSM-IV: Maladaptive pattern of use leading to clinically significant impairment/distress as manifested by at least one of the following over 12 months • Recurrent use resulting in failure to fulfill major role obligations • Recurrent use in physically hazardous situations • Recurrent use-related legal problems • Continued use despite persistent social/interpersonal problems

  6. What is Dependence/Addiction? • DSM-IV • Maladaptive pattern of use leading to significant impairment/distress over a 12 month period with at least 3 of the following: • 1) Tolerance (consumption) [physical dependence] • 2) Withdrawal symptoms [physical dependence] • 3) Efforts to cut down or control use • 4) Great deal of time spent using/obtaining substance • 5) Important social, occupational, recreational functions given up because of the substance • 6) Continued use despite adverse consequences • 7) Substance often taken in larger amounts or longer than intended

  7. The Evolution of Addiction from Physical Dependence to Behavioral Compulsion • Physical dependence can be induced in any individual but does that in and of itself lead to addiction—NO • Chronic pain patients given opiates develop physical dependence but does not usually evolve into addiction and pts. frequently wish to get off opiates. • Is failure to develop physical dependence evidence of lack of addiction—NO • 1970s thought that cocaine was not significantly “addicting” because it did not produce traditional tolerance/withdrawal

  8. Compulsive Use—The Core Concept of Addiction • The drug becomes the primary motivating force—thought and actions directed towards obtaining and using the drug. • “When I wasn’t occupied with using the drug, I was preoccupied with it”

  9. Pathophysiology of Substance Use Disorders

  10. Positive Reinforcement—The Brain Reward SystemNegative Reinforcement-Protracted Withdrawal

  11. Neural Circuitry of Goal-Directed Behavior Kalivas and Volkow, Am J. Psych, 2005

  12. Effects of Cocaine on Dopamine Release in Nucleus Accumbens

  13. Alcohol Promotes Dopamine Release in the Nucleus Accumbens Boileau I, et al. Synapse 49:226, 2003

  14. Negative ReinforcementNeuroadaptation and the Neurobiology of Protracted Withdrawal

  15. Protracted Withdrawal • Concept that chronic alcohol dependence leads to brain alterations that may persist for months after consumption has stopped. • Stress Intolerance • Sleep disturbances • Irritability • Anxiety/restlessness • Reduced hedonic response

  16. Over time chronic drug use may lead to reductions in dopamine systems Volkow et al, Neurobiology of Learning and Memory, 78:610-624, 2002

  17. Sleep Recovery in AlcoholismDrummond et al, 1998 Normal mean

  18. Neurobiology of Protracted Withdrawal[see Koob G, Alcoholism: Clin Exp Res 27:232, 2003] • Impaired reinforcement systems • Dopamine/opioid systems impaired • An inability to experience the natural rewarding aspects of life • Increased activity of stress systems • Hyperactive brain stress hormone CRF • Irritability • Stress intolerance • Dysphoria • Sleep problems

  19. Compulsive Use—The Core Concept of Addiction • The drug becomes the primary motivating force—thought and actions directed towards obtaining and using the drug. • “When I wasn’t occupied with using the drug, I was preoccupied with it”

  20. Epidemiology of Substance Use Disorders • Lifetime Prevalence Alcohol Dependence • Men 5-10% +abuse (15%) • Women 2-3% +abuse (5%) • Lifetime Prevalence Drug Abuse/Dependence • Men 7% • Women 4%

  21. Understanding the transition from use to addiction • The disease concept of addiction as a biopsychosocial disease • Biological: Genetics, Developmental effects, Environmental effects (stress) • Psychological: Personality, Stress, Co-existing emotional problems • Cultural: Acceptance, legal sanctions, economics/taxation

  22. Genetics • “When a baby looks like its father that’s genetic; when it looks like its neighbor that’s environment”

  23. Population Based Twin Study of Alcoholism in Men and WomenKendler et al, 1992/99 Heritability 50-60%

  24. Population Based Twin Study of Drug Use, Abuse and Dependence in Men Kendler et al, 2000 Heritability 60-80%

  25. Risk of Alcoholism in Offspring • 4-10X risk if parent is alcoholic

  26. What is Inherited? • Alcoholism: Vulnerability Genes • NMDA subunits • GABA subunits • Dopamine receptors • Serotonin receptors/transporters • Alcoholism: Protective Genes • Alcohol dehydrogenase + aldehyde dehydrogenase

  27. Phenotypic markers of Risk for Alcoholism • Decreased sensitivity to alcohol prior to development of tolerance • Altered P300 potential—a measure of attending to and processing information

  28. Decreased Sensitivity to Alcohol in High-Risk Offspring

  29. Predictive Power of Decreased Sensitivity to Alcohol in Men with Alcoholic Fathers Schuckit et al, Am J Psych 151:184, 1994 Men followed up 10 years after study

  30. Psychological Factors • Is there an addictive personality? Probably not. Certain temperamental traits may predispose to alcohol problems including sensation seeking and low harm avoidance • Variety of mental illnesses associated with higher risks for alcoholism and drug abuse • Bipolar Disorder • Anxiety Disorders (social phobia, PTSD) • Antisocial Personality • Depression does not increase risk that much

  31. Frequency and Odds Ratios for AlcoholDependence in Various Psychiatric Disorders in a Community PopulationRegier et al, JAMA 21:264, 1990 50-70% of bipolar pts. presenting for treatment will have coexisting substance use disorder 14.7 4.6 3.8 3.3 1.6 1.6

  32. Cultural Factors • What is acceptable—for example in France and Italy regular drinking of wine culturally acceptable and occurs; in Scandinavian countries binge drinking of liquor more common. • Government, industry and social policies can affect rates of consumption and health consequences • Deaths from drunk driving have been reduced from 25,000 in mid 1980s to 16,653 in 2000

  33. The Transition Process from Use to Dependence • May be subtle, gradual, e.g. starting to drink in high-school, accelerating in college with DWI, black-outs and then progressing in adulthood to full blown dependence • May be rapid—development of full dependence on crack cocaine in weeks with serious social, legal, and medical consequences

  34. Treatment: Basic Principles

  35. Identification • History from patient • Drinking habits: how often, how much, most, problems? • Drugs: Using any, which ones, pattern, problems? • Contrary to popular belief many patients will discuss alcohol/drug use with a physician if questions are presented in an empathic manner • History from collateral (spouse, parent) • Questionnaires, e.g., CAGE, AUDIT, rarely used outside of research settings

  36. Identification • Physical Examination with suggestive findings • Laboratory Tests: GGT, AST, ALT; CDT; MCV • Blood Alcohol Level • .08 gms/dl legal intoxication • > .15 gms/dl highly suggestive of alcohol problem • Alcohol metabolized at .015 gms/dl/hour • Urine Toxicology, time positive post-use • Cocaine 2-3 days amphetamine 2 days • Cannabinoids 3 days 1X use, 27 days chronic use • Barbiturates 1-7 days depending on half-life • PCP 8 days Opiates 2-3 days

  37. Treatment: The Transition from Addiction to Long-Term Sobriety • 1) Detoxification—the “easy” step • 2) Acceptance of need for treatment and engagement in treatment process • 3) Maintenance of sobriety, change in life-style, physical and emotional recovery. • 4) Concept of harm reduction, goal of complete abstinence important but common outcome is reduced use and fewer consequences. • 5) Value in viewing addictive disorders as chronic diseases that wax and wane—like diabetes or hypertension.

  38. Treatment Outcomes from Project MATCHAbstinence Rates from Alcohol N=1,726

  39. Treatment Outcomes from Project MATCHReturn to Heavy Drinking N=1,726

  40. Detoxification • Alcohol: Indicated to prevent seizures/DTs that occur in 5% or so of withdrawing alcoholics. Benzodiazepines recommended. Thiamine required to prevent Korsakoff’s. • Benzo/barbiturate: BZs or Barbs may be used to prevent delirium, seizures. • Opiates: Methadone, buprenorphine or clonidine will reduce withdrawal sx., not life threatening. • Cocaine, Marijuana, Nicotine: Have withdrawal effects but not life-threatening and no specific treatment though nicotine patch will diminish sx.

  41. Forms of Treatment • Inpatient psychosocial treatment, “28 day” programs, usually have strong 12 Step foundation • Intensive outpatient, meet 4-6 X/week for 2-4 hours each visit, group and individual therapies, connected to 12 Step programs • Brief interventions may include 30 minute sessions total of 3-4 X over several months, usually targeted towards less dependent patients.

  42. Methods of Treatment • Motivational: Enhance patient’s motivation to change, increase confidence that he/she can change • Cognitive-Behavioral: Learn new skills to understand risk situations, learn refusal techniques, “urge surfing”, how to handle dysphoric states until they pass • Marital/Family Therapy: Important to engage famly

  43. Alcoholics Anonymous • Founded 1935 by Bill W. a stock-brocker • The heart of the suggested program of personal recovery is contained in Twelve Steps describing the experience of the earliest members of the Society: • 1. We admitted we were powerless over alcohol - that our lives had become unmanageable. • 2. Came to believe that a Power greater than ourselves could restore us to sanity. • 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. • 4. Made a searching and fearless moral inventory of ourselves. • 5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs. • 6. Were entirely ready to have God remove all these defects of character. • 7. Humbly asked Him to remove our shortcomings. • 8. Made a list of all persons we had harmed, and became willing to make amends to them all. • 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. • 10. Continued to take personal inventory and when we were wrong promptly admitted it. • 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, • praying only for knowledge of His will for us and the power to carry that out. • 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to • alcoholics and to practice these principles in all our affairs.

  44. Medication Management to Prevent Relapse • Alcohol • Disulfiram (Antabuse) produces nausea, weakness, vomiting, sweating, tachycardia, headache, drop in blood pressure when alcohol consumed. A psychological and a pharmacological deterrent. Evidence suggests limited overall efficacy but may be very useful for patients who wish to be “locked out” of drinking

  45. Percent Continuously Abstinent (12 months)Fuller et al, JAMA 256:1449, 1986 p=NS

  46. Reported Drinking Days (12 months)Fuller et al, 1986 p<.05

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