Addiction-Medicine: An Overview

Ramkumar G. S. MD

Dept. of Psychiatry.

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Over view of presentation

Why do people take drugs and why some of them become addicted?

Neurobiological understanding of addiction. Alcohol Use Disorder. Treatment processes in deaddiction care/

drugs used/psychotherapy.

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Why use drugs?

Is it simply a search for fun?

Image courtesy: Google images

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Why use drugs?

many people also take drugs to feel comfortably numb.

Feel pleasantly drowsy. Feel full of energy and confidence. As a self administered medicine for negative

emotional states, aversive states like drug withdrawal

Feel normal Peer pressure

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Why use drugs?

Individual development (Thrill seeking predispositions, impulsive temperament)

Social background. Unidentified disorders of mood. Unopposed and chronic stress responses. Genetic predisposition.

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Why use drugs?

In a “Drug using career” different motivations may become dominant at different point of time.

Different perspectives – molecular, genetic, pharmacological, psychological, Social.

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Alcoholism

Substance use. Problematic use. Substance misuse. Abuse. Harmful use. Addiction

Dependence Spectrum

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Addiction/Dependence

PHYSICAL vs Psychological Dependence

Conditioning to Pathological neuroadaptation…..

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Neurobiology of addiction.Reward circuitry

Neurotransmitters involved Dopamine, Endogenous opoids

+ve reinforcement, compulsive drug seeking behaviour

Pleasure seeking

Neuroadaptive process… an altered biological homeostasis

Involvement of stress hormones like NYP and CRP

-ve reinforcement, craving, tolerance, salience in drug usage

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Neuroadaptation (+ve reinforcement) in Chronic alcohol use

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Mu opoid receptor

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Neuroadaptation (-ve reinforcement) in Chronic alcohol use

CRF/Glutamate tone is upregulated

NYP/GABA is down regulated.

Alcohol is neuro inhibitory/depressant/ anxiolyticGlutamate is excitatoryGABA is inhibitoryCRF stress promotingNYP stress reducing

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Changing pattern of motivation in a “drug using career”

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AUD

Heterogenous disorder eg. Type 1 and 2 Course: remission and relapse. Disease management approach rather than

the cure approach in acute illness. Chronic illness needing long term long

intensity treatment with brief high intensity treatment for relapse and on the front end of the abstience process.

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Treatment approach

Detoxification Pharmacological detoxification treatment.

Psychological Treatment.

Pharmacology for reversing pathological neuroadaptation.

Maintenance treatment

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Containing the withdrawal response by detoxification Withdrawal symptoms arise

when alcohol is being used regularly and withdrawn rapidly.

Excitatory glutamatergic tone. Delerium tremens Treatment is via sedation with

adequate dosage of benzodiazepines, Thiamine supplementation.

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Reversing pathological neuroadaptation. With appropriate help, withdrawing from

alcohol is not the dependent drinkers’s main difficulty.

The main difficulty is avoiding relapse into further problematic drinking or dependence.

Differentiation of physical vs psychological dependence as therapeutic implications.

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Drugs.

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Psychological therapy

Motivational enhancement therapy.(MET) 12 Step facilitation program/ AA group. Relapse prevention. Craving management. Cognitive Behavioural therapy ( dealing with

high risk situation, contingency management, community reinforcement techniques)

Social skills training, Behavioural contracting, Behavioral Family therapy.

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MET (stages of changer model- Miller)

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Off label drugs in AUD

Topiramate Buspirone Fluoxetine Ondansetron Baclofen

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Summary. Addiction which sets in because of the conditioning

effects of the self reinforcing reward sensations associated with substance use.

It is maintained by the underlying neuro-adaptive process that sets in.

There are biological, psychological and social vulnerabilities that directly influence it in addition to the environment.

Effective treatment takes on a bio-psycho-social-spiritual approach.

Matching treatment to the person.

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Sources:

Oxford textbook of Psychiatry. Medscape Psychiatry, July 22,2014, What is

Addiction? by Denck E Vergne MD Psychiatric Times, Nov 2, 2012, Advances

and challenges in treating alcohol dependence by Hellen M Pattinatti PhD

Other internet resources.