Substance Abuse

1. Substance Abuse

2. Terms • Substance dependence- (Addiction older term replaced by substance dependence) more severe, refers to a pattern of repeated self-administration that often results intolerance. • Tolerance- (short def.) the need for increased amounts of the drug to achieve intoxication; withdrawal, unpleasant physical and psychological effects that the person experiences when they try to stop taking the drug. • Substance abuse- less severe pattern of drug use that is defined in terms of interference with the person’s ability to fulfill major role obligations at work or at home, the recurrent use of a drug in dangerous situations. and repeated legal difficulties associated with the drug use.

3. Terms (cont.) • Drug of Abuse-sometimes called psychoactive substances, are chemical substances that alter a person’s mood, level of perception or brain functioning. • CNS Depressants-depressants of the CNS that include alcohol, hypnotics, andanxiolytics. • CNS Stimulants-include illegal drugs such as amphetamine and cocaine as well as nicotine and caffeine. • Opiates-clinically used to decrease pain, can cause euphoria • Cannabinoids-marijuana produce euphoria and an altered sense of time.

4. Terms (cont) • Hallucinogens-euphoria and hallucinations from mild to very severe r. • Polysubstance Abuse- the observation that people with a substance abuse disorder frequently abuse several types of drugs. • Commonalities- Forms of abuse share many common elements. All forms of abuse represent an inherent conflict between immediate pleasure and longer term harmful consequences.

5. Typical Symptoms and Associated Features ` • Number of problems encountered as a consequence of the disorder. Loosely divided into two general areas: • Patterns of Consumption-to include psychological and physiological dependence. • Consequences following a prolonged pattern of abuse including social and occupational impairment, legal and financial difficulties and deteriorating medical conditions.

6. Symptoms & Associated Features • Dependence –people who state they are dependent on a drug often say they take the drug to control how they are feeling. (psychological) • Tolerance and Withdrawal- • Tolerance-process through which the nervous system becomes less sensitive to the effects of alcohol or any other drug of abuse. Three separate mechanisms for developing tolerance: Two are pharmacological and the third is behavioral • Metabolic Tolerance-develops when the liver produces more enzymes to break down the drug, therefore the drug is metabolized more quickly and larger doses are required to maintain the same level of the drug in the body. • Pharmacodynamic tolerance- receptors in the brain adapt to the continued presence of the drug and thereby down regulate (decrease)the number of receptors to that drug, reducing sensitivity to the drug. • Behavioral Conditioning Mechanisms- cues regularly associated with the administration or consumption of the drug begin to function as CS and elicit a CR that is in the opposite direction of the natural effect of the drug Compensatory response. Withdrawal- symptoms experienced when a person stops using a drug and are considerably different depending on the substances. Unpleasant reactions are most evident during withdrawal from alcohol, opioids and the general class of sedatives, hypnotics, and anxiolytics. Symptoms can include hand tremors, sweating, nausea, anxiety and insomnia, with more serious symptoms including convulsions, hallucinations and delirium.

7. . Common Drugs of Abuse • Alcohol- affects virtually every organ in the body. • Absorption- through membranes in the stomach, small intestine, and colon. Influenced by alcohol content( higher content faster absorption), volume and rate of consumption as well as presences of food in digestive system. • Metabolism-in the liver, rates of metabolism vary, but is somewhere around 1 0z of liquor or 12 ozs of beer per hour. • Short Term Effects—slowed reaction times and interference with driving times, slowed cognitive processes and slurred speech. Neurological and respiratory problems can occur a high blood alcohol levels of 400 mg per 100 ml. of blood • Consequences of Prolonged Use • Disruption of relationships with family and friends to include marital conflicts. • Interference with Job performance • Legal problems-DWI, as well as spousal or child abuse • Health related problems including deterioration of the liver, pancreas, gastrointestinal system, cardiovascular system, and endocrine system • Dementia-Korsakoff’s syndrome • Leads to enormous number of severe injuries, and premature deaths in every region of the world.

8. Nicotine • active ingredient in tobacco, almost never taken in pure form as it can be toxic. Can be inhaled or chewed, inhalation is the fasted route of administration as it results in highest concentration of nicotine carried directly from the lungs to the heart and then to the brain. • Short Term Effects- • Peripheral Nervous System-increased heart rate and blood pressure • CNS-affects several NT systems including, DA, NE and which causes both arousal and stimulation of pleasure via the mesolimbic pathway (reward pathway). Also effects serotonin, therefore having some anti-depressant effects. • Complex influence on subjective mood states as smokers report it helps them relax when in fact it is an arousing drug, however they could be relieving unpleasant withdrawal symptoms such as anxiety and mild tremors, drowsiness, lightheadedness, headache, and nausea. • Consequences of Prolonged abuse-One of the most harmful and deadly addicting drugs • Psychologically addictive-thought to be as difficult to quit smoking as it is to stop using heroin. • People who are attempting to quit experience very unpleasant symptoms such as insomnia, weigh gain, concentration difficulties, and erratic mood. • Increases risk of developing heart and lung disease and various types of cancer, especially lung. Women who smoke also have increased problems with fertility and give birth to low birth weight babies, as well as increased vulnerability to birth defects.

9. Amphetamine and Cocaine • Amphetamine-produced synthetically • Cocaine-naturally occurring stimulant drug that is extracted from the leaf of the coca plant • Short term effects –stimulants in general activate the sympathetic nervous system, thus increasing heart rate an dilating blood vessels . They also suppress appetite and prevent sleep • Induce positive mood states. • Low doses of amphetamine make people feel more confident, friendly and energetic higher doses cause euphoria. • Snorting or injecting cocaine extreme euphoria • Tolerance to Euphoric effects develops quickly and is followed several hours later by the onset of lethargy, and a mildly depressed, or irritable mood. • Consequences of Long Term Effects- High dose of both can lead to the onset of psychosis. The psychotic episode or syndrome, may appear in people with no prior history of mental disorder and usually disappears a few days after the drug has cleared the person’s system. Stimulants can also increase the severity of symptoms among people who had already developed some type of psychotic condition and can include both visual and auditory hallucinations as well as delusions of grandeur or persecution. • Disruption of occupational and social roles. • Compulsion to continue using cocaine can lead to physical exhaustion and financial ruin. • Cocaine dependent users must spend enormous amounts of money to support their habit which may result in loss of all assets or criminal activity. • Prolonged amphetamine use has been linked to violent behavior. • Withdrawal from stimulants is not severe, most common reaction is depression , and long term use can lead to profound depression or suicide on discontinuation.

10. Opiates • Drugs that have properties similar to opium, the natural source is the poppy flower and the main active ingredients are morphine and codeine. Opiates can be ingested orally, injected or inhaled. • Short-term effects-induce a state of dream-like euphoria which can be accompanied by an increased sensitivity in hearing and vision. However, the positive emotional effects do not last and are soon replaced by negative changes in mood and emotion. The opiates can also induce nausea, and vomiting as well as constricting of the pupils. • Consequences of Long Term Effects- Addiction at high doses causes chronic lethargy and loss of motivation to be productive. However people who have a low dose addiction can remain relatively healthy and function at work in spite of the addition. People who are addicted to opiates at any level become preoccupied with finding and using the drug in order to experience the rush and to avoid withdrawal symptoms.

11. Barbiturates and Benzodiazepenes • Tranquilizers-used to decrease anxiety or agitation. • Sedatives- more general term used for drugs that calm people and reduce excitement, ( other than the relief from anxiety) • Hypnotics-Help people to sleep • Short Term Effects- Sedatives and Hypnotics can lead to a state of intoxication that is identical to that associated with alcohol and is characterized by impaired judgment, slowness of speech, lack of coordination, a narrowed range of attention, and disinhibition of sexual and aggressive impulses. The benzodiazepines can sometimes lead to an increase in hostile and aggressive behavior referred to aggressive dyscontol. • Cosequences of Long Term Use and Abuse-discontinuance syndrome-symptoms experienced by people who abruptly stop taking high doses of benzo’s which can include a seizure and in some cases worsening of the original anxiety symptoms or development of new symptoms that are directly associated with drug withdrawal such as irritability, paranoia, sleep disturbance, agitation, muscle tension, restlessness, and perceptual disturbances.

12. Cannabis • Marijuana and hashish are derived from the hemp plant and the most common active ingredient is THC. • Short Term Effects-subjective effects almost always pleasant and refers to pervasive sense of well being. Laboratory research indicated that some people become anxious or paranoid. Temporal disintegration often accompanies cannabis intoxication which caused people to have trouble retaining and organizing information, even over relatively short periods of times. • Consequences of Prolonged Use and Abuse-Issues of addictive properties remain controversial. Tolerance effects in humans remain ambiguous with most evidence suggesting that people do not develop tolerance to THC unless exposed to high doses over an extended period of time. Withdrawal is also unlikely unless people have been exposed to continuous high doses of THC. These symptoms may include irritability, restlessness, and insomnia.

13. Hallucinogens and Related Drugs • cause people to experience hallucinations at relatively low doses. The molecular structure of many hallucinogens is similar to the molecular structure of various neurotransmitters such as serotonin and NE. • Short Term Effects- difficult to study as the effects are based primarily on subjective experience. Most hallucinogens are not particularly toxic as people do not die from taking an overdose of LSD, psilocybin or mescaline. However, high doses can lead to coma, convulsions, respiratory arrest and brain hemorrhage. Ecstasy can damage serotonin neurons on a permanent basis and has been associated with some deaths. • Consequences of Prolonged Use-Pattern of use is different than other drugs as they are most often used sporadically and on special occasions, with the exception of PCP. Tolerance develops quickly and if used daily their effect disappears after 2-3 days. Most people do not increase their usage of hallucinogens over time, and there seem to be no withdrawal symptoms associated with the hallucinogens. There have been cases where the use of the drugs has brought on persistent psychotic behavior, but it is thought the drug was a trigger for an already pre-existent condition. Flashbacks are also known to occur long after a person has used the drug at unpredictable intervals long after the drug has cleared the bodies system. There is currently no explanation for this phenomenon.

14. History of Legal and Illegal Substances • Drinking patterns vary widely from country to country and public attitudes have changed dramatically during the course of U.S. history. • In Colonial times, heavy drinking was an integral part of life, average amount of alcohol consumed per person in the 18th century was 4 gallons per year, compared to 2.5 gallons today. • Drunkenness was not considered to be either socially deviant or symptomatic of medical illness. • Temperance movement-early 19th century-based on moral and religious reasons and not medicine or science.

15. DSM IV-TR-Classification • Substance Dependence ( more severe) 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. 1. Tolerance as defined by either of the following: • A need for markedly increased amounts of the substance to achieve intoxication or desired effect. • Markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal as manifested by either of the following: • Characteristic withdrawal syndrome for the substance (criteria listed separately for specific substance) • Same substance is taken to relieve or avoid withdrawal symptoms. 3. The substance is often taken in larger amounts or over a longer period than it was intended. 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 5. A great deal of time is spend acquiring the substance or recovering from its effects. 6. Important social, occupational or recreational activities are given up or reduced because of substance use. 7. The substance use is continued despite knowledge or having a persistent or recurrent physical or psychological problem that is likely caused or exacerbated by the substance

16. DSM IV-TR-Classification • Substance Abuse- A maladaptive patter of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following occurring with a 12 month period. 1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. 2. Recurrent substance use in situations in which it is physically hazardous. 3. Recurrent substance related legal problems. 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. • Course and Outcome-Impossible to specify a typical course for substance dependence, especially alcoholism. Age of onset varies widely, ranging from childhood and early adolescence throughout the lifespan.

17. Epidemiology • Pattern of Abuse is regional-due to availability • Culture shapes people choice • Prevalence of Alcohol Use and Dependence • second most common type of mental disorder in the United States, second only to phobias. • most common forms of mental disorder among men with men outnumbering women at a ratio of 5 to 1.

18. Prevalence of Drug and Nicotine Dependence • The percentage of lifetime prevalence for nicotine dependence in the United States is 24% as compared to heroin-23%, cocaine-17% and alcohol-15%. • Declined since 1964 when the Surgeon General’s report found a definite link between smoking and cancer. • Among people age 18-25 smoking rates have increased in the past 8 years.

19. Etiology Three Basic Stages • Initiation and Continuation • Escalation and Transition to Abuse • Development of Tolerance and Withdrawal

20. Initiation and Continuation • Social Factors-cultures that actively prohibit or disapprove of drinking can decrease rates of substance abuse. • Biological-Initial response • negative physiological reactions • Positive reaction • Psychological- stress reduction and expectancy patterns

21. Escalation and Transition to Abuse • Social Factors- Development of drug dependence requires continued use and it is influenced by the person’s initial reaction to the drug. • Biological- Lifetime prevalence of alcoholism is three to five times higher among the parents, siblings, and children of people with alcoholism than the rate in the general population. Two main biological hypotheses. (DA & Serotonin) • Psychological-Interaction between environment and biological eventsTension Reduction hypothesis

22. Escalation and Transition to Abuse • Psychological- Progression of substance dependence involves the interaction between environmental and biological events as seen in the Tension Reduction hypothesis. • Expectations about Drug Effects • Expectancies from alcohol consumption

23. Hypothesis of Biological Factors • Dopamine Reward Pathway • Medial Forebrain Bundle • Mesolimbic DA pathway • Amphetamine and Cocaine-block the re-uptake of DA which accumulates in the synapse where it can further stimulate DA receptors. • Alcohol, opioids and nicotine ( indirect)-decreases the activity of the GABA neurons which normally inhibit DA neurons • Endorphins ( endogenenous opioidsnaturally synthesized in the brain, and closely related to morphine. • Serotonin Hypothesis

24. Serotonin Hypothesis • Alcohol does not bind to any specific receptor sites in the brain, however, it does alter the permeability of neuronal membranes. • The net result is a depression of the Central Nervous system. Initially, concentrations of NT such as DA and serotonin are increased. • If the person continues to drink over an extended period of time, the alcohol produces opposite effects of short term intoxication such as CNS excitation and the reversal of the ion channels. • Assumes that alcohol dependence is caused by a genetically determined deficiency.

25. 3. Development of Tolerance and Withdrawal • Social Factors • Psychological Factors • Biological Factors

26. Treatment • Goals of Treatment • Detoxification • Medication during Remission • Self-Help Groups • Cognitive Behavioral Therapy • Outcome Results and General Conclusions