Substance Abuse & Dependence

1. Substance Abuse & Dependence Michael Wilson, PhD University of Illinois Department of Psychology and University of Illinois College of Medicine

2. A clinical vignette Approximately 2 days after admission to the hospital for a fractured hip, a 62 year-old male starts having an intense hand tremor, tachycardia, and sees spiders crawling on the walls. He also feels them crawling on his skin. Which of the following is the most likely cause? • Alcohol use • Alcohol withdrawal • Heroin use • Heroin withdrawal • Amphetamine use

3. Another clinical vignette A 22 year-old student tells the doctor that he has been using “speed” nightly. Which of the following complaints is the patient most likely to report? • Increased fatigue • Decreased pain threshold • Increased appetite • Decreased body weight • Decreased libido

4. Outline • What are drugs of abuse? • How to define abuse? • Overview of drugs of abuse • Effects of use & withdrawal • Focus on alcohol • Questions

5. Drug of Abuse (Psychoactive Substance) • Chemical substance that alters mood, changes perception, or changes brain functioning • Substances can range from legal (Nicotine) to prescription (Valium) to illegal (LSD) drugs • It is not unusual for people with substance abuse to use more than one drug (polysubstance abuse)

6. How to define abuse? • Thought question: how do we know when someone has a problem with drugs or alcohol? • Is it a mental illness? What is a mental illness? • Is it when they are acting abnormally? What is abnormal? • Is it simply the amount of substance being used?

7. Defining Abnormal Behavior: Group Activity • Purpose: to think critically about what is abnormal behavior in regards to drugs & alcohol • Write a definition of what it means to have a problem with intoxicating substances • Discuss your definition with your classmates

8. Defining Abnormal Behavior • Personal distress • subjective report of substance problems • Social impairment • violation of moral standards • observer discomfort • Statistical deviance • relative frequency of substance use • 54.9% of US adults reported 1 drink or more in last month (CDC 2002)

9. Definitions • Symptoms: thoughts, feelings, and behaviors that indicate a mental disorder • Syndrome: a group of symptoms that tend to co-occur and are assumed to have a common etiology • Additional Considerations • Duration • Impairment in important area of functioning (usually social or occupational)

10. What is abnormal behavior? • Abnormal behavior is a natural, fuzzy concept • Involves identifying certain symptoms or syndromes that co-occur with mental disorders • plus some sort of assessment of impairment • plus some sort of assessment of distress

11. What is the DSM? • The Diagnostic & Statistical manual is published by APA • lists criteria for mental disorders • includes description and research findings • now in fourth edition (text revised) • so referred to as DSM-IV-TR

13. Levels of Substance Use • Levels • Abstinence (personal, cultural, religious) • Experimentation • Social (just to get along with others) • Instrumental (using for serious reasons) • Addiction (out of control) • DSM-IV-TR has different categories of problems • No diagnosis • Intoxication • Abuse • Dependence • Withdrawal

14. Casual or “Recreational” Substance Use • Is this a problem? • Not usually for majority of users. Naïve users (especially young people) may unwittingly overdose or get into legal problems. • “Gateway” drugs may introduce drugs to individuals at risk of addiction. • Recreational use may also lower cultural barriers to substance abuse/addiction (seeing parents drink beer makes it easier for teenagers to try it themselves). • However, cultures that endorse “responsible” drinking & stigmatize drunkenness (e.g., Italian, French, or Jewish drinking of wine with dinner) can model low-risk behaviors for young people, perhaps lower incidence of addiction.

15. DSM-IV-TR Definition of Substance ABUSE Maladaptive pattern of substance use leading to distress, as manifested by one of the following, occurring within a 12-month period: • Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home. • Recurrent use in situations in which it is physically hazardous (ie, driving drunk). • Recurrent substance-related legal problems. • Continued substance use despite having persistent or recurrent social/interpersonal problems caused or exacerbated by the substance.

16. DSM-IV Substance DEPENDENCE A maladaptive pattern of substance use manifested by 3 or more of the following in a 12-month period: • tolerance – a need for increasing amounts of drug to get the desired effects • withdrawal – either characteristic withdrawal syndrome for a substance, or using a substance to avoid withdrawal symptoms (e.g., “hair of the dog…”) • increased use - the substance is taken in larger amounts or for longer periods than intended (e.g., a coke run that is only stopped when the money runs out) • loss of control - Persistent desire or unsuccessful attempts to cut back or control use

17. DEPENDENCE continued 5) Obsessing about using - Great deal of time is spent on obtaining the substance (e.g., finding the money, planning the buy), using the substance (e.g., drinking round the clock through a weekend), or on recovering from its effects (e.g., calling in sick because of a hangover). 6) Other parts of life become unimportant - Important activities are sacrificed to keep using (e.g., not going to your kid’s ball games; breaking dates; not completing assignments). 7) Use despite health effects – Substance use is continued despite knowledge of a physical or psychological problem caused or exacerbated by substance (e.g., continued drinking after a diagnosis of liver cirrhosis or a stomach ulcer).

18. Substance Intoxication • Development of a reversible substance-specific syndrome due to recent ingestion of or exposure to a substance. • Maladaptive behavioral or psychological changes due to effect of substance on CNS (belligerence, mood lability, impaired judgment, etc.). • Symptoms are not due to a general medical condition or another mental disorder.

19. Substance withdrawal • Development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy & prolonged. • Substance-specific syndrome causes significant distress or impairment in social, occupational, or other important areas of functioning. • Symptoms are not due to a general medical condition or another mental disorder.

20. Overview of drugs of abuse • Stimulants • Caffeine, nicotine, cocaine, amphetamines (crystal meth) • Euphoria (and addictive potential) comes from dopaminergic stimulation • Some stimulants have useful medical roles (e.g., Ritalin for treating ADHD, cocaine as topical anesthetic) • Activate sympathetic nervous system • cause mood elevation, tachycardia, dilated pupils, sweating, hyperthermia, alertness, insomnia, decreased appetite • withdrawal causes mood depression, lethargy, increased appetite

21. Stimulants • Caffeine • coffee ~125 mg/cup, tea ~65 mg/cup, cola ~40 mg/cup • most popular CNS stimulant • causes elevated levels of epi/norepi • has some medical use • combined with ergotamine is older tx for migraine

22. Stimulants • Nicotine • mimics the effects of Ach • causes increased heart rate, blood pressure, alertness • chronic users report pleasant effect • poisonous in large doses • in concentrated form, can be used as insecticide • 40-60mg believed to be fatal for humans if injected at once • Addictive potential believed to be great • Surgeon General Koop compared it to cocaine • smoking (but not nicotine) linked with many health problems

23. Stimulants • Cocaine • Interferes with dopamine reuptake from synapses (produces reward), NE reuptake from synapses (produces stimulation), serotonin reuptake • Estimated U.S. cocaine market = $35 billion in 2003, bigger than AT&T and Starbucks

24. Stimulants • Amphetamines • include methamphetamine, Ecstasy • cause release of NE & dopamine from synapses and prevent reuptake into synapses • medical uses include ADHD, narcolepsy

25. Sedatives & Hypnotics • Barbiturates, benzodiazepines, alcohol • Act mostly on GABA receptors, inhibit cortical function • low doses: disinhibition • high doses: inhibition of life functions • Withdrawal is notable as exactly opposite of intoxication • tachycardia, sweating, hypertension, irritability, anxiety, insomnia • Medical uses include insomnia or anxiety • if dose is decreased or missed, original symptoms can be intense

26. Hallucinogens • Marijuana, LSD, PCP • Cause mood elevation, altered perception, hyperthermia, sweating • Few if any withdrawal symptoms • if present, can be anxiety or mild depression • Most of these drugs relatively easy and cheap to manufacture • often not seen as a drug at all by users

27. Opiates • Heroin, opium, morphine, other prescription narcotics • Act directly on CNS • cause mood elevation, decreased anxiety, sedation, analgesia, respiratory depression, pupil constriction • heroin crosses the blood-brain barrier more easily, and so has rapid onset & addiction potential • Withdrawal is very unpleasant, but usually not medically dangerous • effects include mood depression, increased anxiety, flu-like symptoms, stomach cramps/diarrhea

28. Inhalants • Gasoline, paint, glue • Chemicals vary, but inhalants generally depress CNS • Causes decreased respiration and blood pressure • Users may report distortion in perceptions of time and space • May experience headaches, nausea, slurred speech, loss of motor coordination • Used mostly by young people • 15-20% of junior high students report use • highest incidence in 10-12 age range

29. Lifetime Prevalence: Drug Use and Dependence • Tobacco 75.6 24.1 31.9 • Alcohol 91.5 14.1 15.4 • Cannabis 46.3 4.2 9.1 • Cocaine 16.2 2.7 16.7 • Amphetamines 15.3 1.7 11.2 • Sedatives 12.7 1.2 9.2 • Hallucinogens 10.6 0.5 4.9 • Heroin 1.5 0.4 23.1 Proportion with Proportion with Dependence History of Use History of Among Users Dependence

30. Substance Use Among College Students (Shinew, 2005) • 84% drink alcohol • 65% started in high school • 22% use drugs • Marijuana (98%), ecstasy (28%), cocaine (12%) • Most college students agree or strongly agree that drinking is a leisure activity

31. Focus on alcohol: Alcohol retail sales (2002) Source: “Alcohol industry 101: It’s structure and organization” (AMA)

32. DSM-IV-TR definition of alcohol intoxication • Recent ingestion of ETOH. • Maladaptive behavioral or psychological changes such as inappropriate sexual or aggressive behavior, impaired judgment, impaired social/occupational functioning. • One or more of the following: slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention/memory, stupor/coma D. Symptoms not due to a medical condition or other mental disorder.

33. DSM-IV-TR definition of Alcohol Withdrawal • Cessation (or reduction) in alcohol use that has been heavy or prolonged. • Two or more developing within several hours to a few days after criterion A: autonomic hyperactivity (sweating, tachycardia), increased hand tremor, insomnia, nausea/vomiting, transient visual/tactile/auditory hallucinations, psychomotor agitation, anxiety, grand mal seizures C. Symptoms in criterion B cause distress or impairment in social/occupational or other important areas of functioning. D. Symptoms not due to a medical condition or another mental disorder.

34. Etiological Considerations • Not everyone who uses drugs or alcohol will move to the level of abuse or dependence • Biological, social, and psychological factors play a role in substance addictions

35. Etiology: Genes • Males: MZ = 56% DZ = 33% • Females: MZ = 30% DZ = 17% • MZ concordances > DZ concordances • Higher concordance rates in male twins reflect higher rates of alcoholism among men • Gender difference in alcoholism for MZ and DZ twins could be attributed to: • Lower physical tolerance for women • Negative social attitudes towards public intoxication for women

36. Etiology: Social factors • Culture or religion could influence how early someone is exposed to alcohol • as well as attitudes towards drinking • Initial experimentation more likely among the rebellious & extroverted • or if parents/peers model use • Unpleasant environment, low parental monitoring increase risk of use

37. The biopsychosocial model

38. A clinical vignette Approximately 2 days after admission to the hospital for a fractured hip, a 62 year-old male starts having an intense hand tremor, tachycardia, and sees spiders crawling on the walls. He also feels them crawling on his skin. Which of the following is the most likely cause? • Alcohol use • Alcohol withdrawal • Heroin use • Heroin withdrawal • Amphetamine use

39. Clinical vignette A 22 year-old student tells the doctor that he has been using “speed” nightly. Which of the following complaints is the patient most likely to report? • Increased fatigue • Decreased pain threshold • Increased appetite • Decreased body weight • Decreased libido

40. Readings • Read pages 73-85 in BRS: Behavioral Science, 4th edition