Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD

1. Assessment and Treatment of Addictive BehaviorsCarl W. Lejuez, PhD Lecture 2 Alcohol & Smoking

2. Alcohol • Alcohol is a Central Nervous System depressant. • Exact mechanism of alcohol’s action are unknown • May be a GABA antagonist • Also effects dopamine in the nucleus accumbens • Why does it feel like a stimulant? • At low doses, alcohol relaxes the area of the cerebral cortex that inhibits the sub-cortical areas of the brain • Net effect: Lowered inhibitions, feelings of relaxation and increased social interactions • As BAC increases, sedative effects become more pronounced. • At lethal doses, the respiration centers in the medulla are shut down, and you stop breathing.

3. Alcohol How Alcohol Works in the Body • Alcohol is rapidly absorbed into the bloodstream from stomach, small intestine, and colon. • The drinker's blood alcohol concentration depends on: • the amount consumed in a given time • the drinker's size, sex, body build, and metabolism • the type and amount of food in the stomach (Once the alcohol has passed into the blood, however, no food or beverage can retard or interfere with its effects.)

4. Blood Alcohol Concentration Blood Alcohol Concentration/Blood Alcohol Level • The number of grams of alcohol in the blood relative to 100 milliliters of blood, expressed as a percentage • The higher the number, the more alcohol in your bloodstream. • To compute, you need to know your weight, the number of drinks, and the amount of time since your first drink Elimination of Alcohol • 5% is eliminated through the lungs • 95% is eliminated through the urine • Body breaks down about ½ ounce per hour (about 1 standard drink) per hour

5. Blood Alcohol Concentration

6. Blood Alcohol Concentration

7. Alcohol Abuse/Dependence • Lifetime Prevalence of DSM-IV disordersAlcohol Abuse 9.4% overall 12.5% of men 6.4% of womenAlcohol Dependence 14.1% overall 20.1% of men 8.2% of women

8. College Prevalence Rates 2001 CORE SurveyAverage Number of Drinks per WeekThe following tables give the average number of drinks per week . Male Female TotalFreshman 9.38     4.15 6.24Sophomore 9.93     4.43 6.62Junior 10.48     4.66 7.02Senior 10.46     4.65 7.07Total 9.874.376.58 Binge Drinking • Binge drinking is defined as five of more drinks in one sitting. • 49.7% of students in the sample engaged in binge drinking at least once during the two weeks prior to completing the Core survey.

9. Alcohol Use Screening Measures • Alcohol Use Disorders Identification Test (AUDIT) • Michigan Alcohol Screening Test (MAST)

10. Alcohol Consequences:Physical

11. Alcohol Withdrawal • Abstinence syndrome is MEDICALLY MORE SEVERE and more likely to cause death than narcotic withdrawal • In untreated advanced cases, mortality may be as high as one in seven • Recommended that initial period of detoxification (allowing the body to rid itself of alcohol) be carried out in an inpatient medical setting

12. Alcohol Withdrawal Timeline • Acute Stage: 3-5 days • Sub-Acute Stage: approximately 3 weeks • during this time, individual may still be experiencing measurable cognitive deficits • Chronic Stage: Up to one year • Slow, steady improvement in cognitive functioning.

13. Stages of Acute Withdrawal 1. Tremors, excessively rapid heartbeat, hypertension, heavy sweating, loss of appetite, insomnia 2. Hallucinations • auditory, visual, tactile, or a combination 3. Delusions, disorientation, delirium, sometimes intermittent in nature and usually followed by amnesia 4. Seizure activity & DTs

14. Long-term Effects 1 • Malnutrition: Because alcohol provides “empty” calories, many heavy drinkers do not eat well. This results in malnutrition • Malnutrition can result in tissue damage which is secondary to the alcohol consumption itself (not DIRECTLY caused by alcohol consumption). • It is difficult to separate the effects of alcohol exposure from those of malnutrition.

15. Long-term Effects 2 • Brain Damage: • Major damage is loss of brain tissue. • Ventricles in the brain become enlarged. • Fissures in the cortex are widened. • Probably due to direct effects of alcohol toxicity

16. Brain Damage (continued) • Alcohol dementia:global decline in intellect affecting Frontal area & memory

17. Brain Damage (continued) • Korsakoff’s Syndrome • Associated with a deficiency of thiamine (vitamine B1) and can sometimes be corrected nutritionally. • Symptoms include confusion, ataxia, (impaired coordination while walking) and abnormal eye movements. • Also, most Korsakoff’s patients also experience Korsakoff’s Psychosis (memory dysfunction, inability to remember recent events or to learn new information). • Also, confabulation (tends to be fantastic) • Abulia – blandness in affect and personality. Not much drive or motivation.

18. Long-term Effects 3 • Liver Disorders: • Fatty Liver. - Fatty acids (lipids) accumulate in the liver and are stored as small droplets in liver cells. This condition is known as alcohol-related FATTY LIVER. For most drinkers, not a serious problem • Sometimes droplets increase in size to the point where they rupture the cell membrane, causing death of the liver cells • Up to the point where liver cells die, a fatty liver is completely reversible and usually of minor medical concern.

19. Long-term Effects 4 • Liver Disorders continued: • Alcoholic Hepatitis • Serious disease that includes both inflammation and impairment of liver function. • MAYBE a connection to fatty liver? • Can get hepatitis even in the absence of fatty liver. • Probably due to toxic effects of alcohol on the liver.

20. Long-term Effects 5 • Liver Disorders continued: • Cirrhosis – related to high and prolonged alcohol consumption • Usually takes up to 10 years of steady heavy drinking (equivalent of a pint or more of whisky/day).

21. Long-term Effects 6 • Cirrhosis (continued) • Liver cells are replaced by fibrous tissues (collagen) which changes liver structure • changes decrease blood flow and, along with the loss of cells, result in a decreased liver functioning • When liver doesn’t function, fluid accumulates in the body, jaundice develops, other infections or cancers proliferate • Yellow skin (and in whites of eyes) is a sign that liver is not functioning properly and toxins are accumulating in the blood. • Cirrhosis is not reversible. Cessation of drinking can retard its development.

22. Alcohol Consequences:Psychological

23. Alcohol and Depression • Alcohol and depression are commonly co-morbid. • Among those with a history of Alcohol Dependence , lifetime rates of major depressive disorder [MDD] range from 24.3% for men to 48.5% for women (Kessler et al., 1997).

24. Alcohol and Depression 2 • Clinically significant levels of depressive symptoms in majority of patients entering treatment for an alcohol use disorder • Two explanations often have been offered for AUD and MDD • Alcoholic drinking may occur as a means of self-medication for underlying depression • Depression may result from the pharmacological effects of excessive alcohol use.

25. Alcohol and Depression 3 • Two Types of MDD associated with AUD • Schuckit (1983) • “independent” depression • "substance-induced" depression • The diagnostic distinction has potentially important clinical implications • Most depressive symptoms remit once abstinence from alcohol has been achieved • If primary depressive disorder, less rapid reductions in depressive symptoms after alcohol treatment than w/ substance-induced depression

26. Cigarette Smoking

27. Nicotine and Cigarettes • Nicotine is 1 of 4000 compounds released by the burning of cigarette tobacco. • Nicotine is the primary psychoactive ingredient in tobacco. • Nicotine accounts for the acute psychoactive effects of smoking and for the dependence on cigarettes. • The adverse, long-term cardiovascular, pulmonary, and carcinogenic effects of cigarettes are related to other compounds contained in the product • The delivery device (the tobacco cigarette) is responsible for much of its toxicity

28. Nicotine Dosage from Cigarettes • Most cigarettes contain between .5 and 2.0 mg of nicotine. • Only about 20% (.1 and .4 mg) is actually absorbed into the blood stream • One Pack Per Day: 2 to 8 mg of nicotine • Two Packs Per Day: 4 to 16 mg of nicotine • 60 mg of pure nicotine would be fatal

29. Nicotine and the CNS • Primarily an acetylcholine agonist • Also stimulates the release of dopamine in the nucleus accumbens, the same area of the brain responsible for the reinforcing properties of opiates, cocaine, and alcohol. • Nicotine “kick" caused in part by the stimulation of the adrenal glands and resulting discharge of epinephrine (adrenaline).

30. Nicotine and the CNS Nicotine is quickly absorbed and eliminated • Smoked nicotine reached the brain in 7 seconds, and “peak effects” are achieved before the smokers finishes the cigarette. • Nicotine half-life is about 2 hours

31. Physiological Effects of Nicotine Primary Effects of Nicotine • Increased HR, BP, and metabolism • Feelings of exhilaration and energy • Increased mental alertness and concentration • Increased task performance • Increased short-term memory • Decreased appetite • For some, increased relaxation (muscle relaxation, relief of withdrawal symptoms, increased concentration)

32. Nicotine Addiction Why is nicotine so addictive? • Rapid absorption and elimination • Indirect stimulation of dopamine system • Repetition (20 cigarettes, 200 puffs) • Environmental cues and easy access • Use can be used to Fight withdrawal

33. Nicotine Withdrawal Symptoms of Nicotine Withdrawal • Dysphoric or Depressed Mood • Insomnia • Irritability, Frustration, or Anger • Anxiety • Difficulty Concentrating • Restlessness • Decreased Heart Rate • Increased Appetite or Weight Gain Typical CoursePhysiological (physical) symptoms: begin almost immediately following last cigarette more severe symptoms begin at 6 hrs & peak at about 48 hrs symptoms begin to improve after 72 hrs minor symptoms may last up to 2-3 weeks Psychological withdrawal can last indefinitely

34. Smoking Consequences:Physical

35. Lung cancer • Symptoms include persistent cough, chest pain, hoarseness, pneumonia & bronchitis • Malignant tumor in the lungs invades and destroys lung tissue and can spread • Treatment may involve removal of affected area and sometimes the entire lung • The disease has usually spread by the time it is discovered, and the five-year-survival rate is only 13 percent

36. Bladder Cancer • Smoking is the greatest risk factor and smokers have more than double the risk of bladder cancer compared to nonsmokers • Symptoms are blood in the urine, pelvic pain and increased frequency of urination • Treatment involves surgery, chemotherapy and radiation. If the bladder must be removed, it is necessary to create an opening in the body through which urine can pass into a pouch. • If detected early, 5 yr survival rate is 91 percent.

37. Oral Cancer • Smoking cigars, cigarettes or pipes increases the risk for these cancers up to 60 percent by some estimates • Symptoms include a sore that bleeds easily and doesn't heal; a lump or thickening; a red or white patch that doesn't go away; difficulty in chewing, swallowing or moving the tongue and jaw • Radiation therapy and surgery are the main treatments for this cancer. In some cases, your voice box, the larynx, must be removed • Patient must use artificial voice aid in order to speak • Speech is most often a low, hoarse wound forced through a mechanical device inserted into the mouth or throat

38. Smoking Consequences 430,000 annual deaths are attributable to cigarette smoking Source: CDC, MMWR 1997; 46; 448-51

39. Smoking Consequences • Leading preventable cause of death/disability in US • 1/3 of cancer deaths are tobacco related • Lung cancer is almost 2x as common as breast cancer in women