Substance Use Disorders

Todd Kashdan, Ph.D

Gerstein and Harwood (1990)

0 5 10 15 20 25 30 35

Productivity Losses

Crime Victim Losses

Law Enforcement

Economic Productivity Losses

Drug Prevention and Treatment

Drug-Related AIDS

33.35.5

12.8

17.6

1.7

1

In Billions

Economic Costs of Substance Abuse

Total Costs: $71.9 Billion

Prevalence of drug use

What makes marijuana the most

frequently used illicit drug among

people aged 12 and older?

Terminology

Psychoactive Substance: ingested to alter mood, behavior or both to become intoxicated/high

Use vs. Intoxication

Tolerance vs. Withdrawal

Profiles of DSM‐IV and DSM‐5 Alcohol Use Disorders

Alcoholism: Clinical and Experimental Researchpages E305-E313, 13 SEP 2012 DOI: 10.1111/j.1530-0277.2012.01930.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.2012.01930.x/full#acer1930-fig-0001

Etiology of Dependence

Developmental Framework

Initiation and continuation

Escalation and transition to abuse

Development of tolerance and withdrawal

Types of commonly abused substances:

Depressants: Behavioral Sedation Alcohol, Sedatives, Anxiolytic substances

Stimulants: Increases alertness and elevates mood Coffee, nicotine, cocaine, amphetamines

Opiates: Pain relief and euphoria, numbing effect Heroin, morphine, codeine, opium

Hallucinogens: Alter sensory perception Marijuana, LSD

Licit vs. Illicit drugs Nicotine, Alcohol, Caffeine (Available without

prescription ) Anxiolytic Drugs such as Benzodiazepines

(Valium and Xanax) and Certain opiates (e.g. morphine and methadone) (Available with a prescription from a physician)

Stimulants (e.g., cocaine, amphetamines) Opiates (e.g., heroin) Hallucinogens (e.g., LSD)

Cannabis (e.g., marijuana and hashish

Leg

al

Illeg

al

Why are Some Addictive Drugs Illegal?

Depressants

Depressants Primarily decrease CNS system activity. Reduces physiological arousal Most likely to produce physical dependence,

tolerance, and withdrawal

Ex: Alcohol, anxiolytic drugs, sedatives

Depressants - Sedative Drugs Barbiturates: sedatives that act on GABA

system in a manor similar to alcohol Ex: Amobarbital, Pentobarbital, and Secobarbital

Benzodiazepines: sedatives that can be responsibly and effectively used for the short-term Ex: Valium, Xanax, and Halcion

Impairment due to Sedatives overall sedation Tolerance potential for overdose Death Withdrawal symptoms (similar to alcohol) Common users:

59 % Women Anglo Greater education

Depressant - Alcohol

Alcohol - CNS depressant

initial effect may be to stimulate, but its a physiological and psychological depressant.

Changes in mood and social behavior, judgment, and motor coordination. (cerebellum)

Depressant - AlcoholWithdrawal: Hand tremors, anxiety, nausea etc. Extreme cases: Delirium Tremens

Associated Brain Conditions: Dementia

ETOH appears to damage neural connections vs. neurons

Liver disease, Fetal Alcohol Syndrome

Drinking Practices

Binge Drinking – Consuming 5 or more drinks in one sitting, for women, reduced to 4 (2 hours)

Note: does not refer to a bender that is a period of two or more days of sustained heavy drinking.

Examples? Experiences?

Stories?

o“A” Students have ~ 3 drinks a week;

o“D” and “F” students ~ 11 drinks a week.

Lifetime Prevalence of Alcoholism (ECA)

14% (combining abuse and dependence)

Men > women with chronic alcohol problems

12-month point prevalence rates for alcohol dependence 11 % men 4% women

Psychological Models of ETOH

1. Expectancy Theory: predicting positive reinforcement.

Negative expectancies?

Common Alcohol Expectations

transforms experiences in positive way (“make future seem brighter”)

enhances social and physical pleasure enhances sexual performance increases power and aggression reduces tension increases social assertiveness

Alcohol Expectancies

Social learning in youth

Predicts future drinking behavior

Positive expectancies > negative expectancies

Psychological Models of ETOH cont.

2. Tension Reduction Theories

Drinking to cope

Stress Response Dampening

Primary effects are physiological Self-regulation is dependent on person x situation

Note:

Drinking to cope or reduce tension is a

?

Predictor of AUDs than Drinking for Positive Affect

Deception in ExpectanciesAbsolut® Memory Distortions N = 148 “Tonic” or “Tonic & Vodka” groups

Observations?

Results?

Biological Factors Initial physiological reactions affect early

drinking experiences. Some people are unable to tolerate even small amounts of alcohol

Aldehyde Dehydrogenase (ALDH-I & ALDH II) breaks down alcohol.

Asians, Asian-Americans and ALDH-I Result: “flush”, palpitations, muscle weakness,

and illness

Twin Studies

When proband has AUD in treatment (Heath and Martin,

1997)

M:     MZ = 56%    DZ = 33% W:  MZ = 30%    DZ = 17%

Higher concordance rates in male twins reflect higher rates of alcoholism in men

2/3 of variance due to genetic factors

Adoption Studies

Proband had biological parent with AUD

Proband adopted away at an early age and raised by adoptive parents

Method allows separation of G and E effects

Cultural Factors

What factors contribute to countries having greater tolerance levels compared

to others?

What do you think would

happen if you got pulled

over in Pakistan or

Saudi Arabia and you had a

0.08 BAC limit?

How do you interpret the data,

what do you notice first?

© 2014, 2012, 2010 by Pearson Education, Inc. All rights reserved.

Social Factors and Alcoholism

Experimentation with drugs most likely to occur among adolescents whose peers and parents model or encourage it.

Parents more important for alcohol

Peers more important for marijuana and other drugs

Social Factors and Alcoholism

Modeling Adoption studies?

How do parents influence children’s drinking? By influencing attitudes and expectations By providing access and monitoring use less

closely By creating a negative emotional climate

Back to initial slide…

Significant reduction in substance abuse at age 26.

What role incompatibilities may be a cause of this reduction?

Alcohol is the most widely used and socially accepted

drug.

Stimulants

Stimulants Stimulant – Promotes alert and active

state as well as elevates mood.

Examples:

Caffeine Cigarettes Cocaine (crack) Amphetamines

Stimulants : Caffeine most widely used and socially accepted drug.

75 % of caffeine ingested through coffee

Average American drinks – 2 cups per day; Cup of coffee has about 100 mgs of caffeine

Caffeine stimulates CNS increasing levels of dopamine, norepinephrine, and serotonin.

Stimulants : Caffeine

Symptoms include: Restlessness, nervousness, excitement, insomnia, flushed face, frequent urination, stomach upset, muscle twitching, rambling flow of thought or speech, rapid heartbeat, periods of inexhaustibility, psychomotor agitation.

Withdrawal Symptoms: (Provisional diagnosis in DSM-IV) marked fatigue or drowsiness, marked anxiety or depression, nausea or vomiting

Can you get a DSM diagnosis from drinking too much coffee? Yes! – “Caffeine Intoxication”

Over 250 mg/day (~ 2 cups) Symptoms: Restlessness, nervousness, excitement,

flush, GI disturbance, etc.

Over 1 gm/ day (~8 cups) Symptoms: Can get arrhythmia, agitation, rambling

speech

Over 10 gm/ day (~80 cups) Symptoms : Seizures, death

Stimulants : Nicotine Nicotine creates high levels of addiction (≥

cocaine, heorin)

≥ 90 % of smokers want to quite, but < 10% who try are actually successful Ex: Distress tolerance study

Produces significant physical problems (long-term)

In DSM – no abuse, only dependence and withdrawal.

Impact of smoking

25% of Americans Smoke (was 42% in the 60’s) No decline among college age (33% smoke)

Nicotine takes 7 – 19 seconds to reach the brain Increase alertnessor relaxation Linked with negative affect

Relapsers indicate negative mood as cause

http://www.youtube.com/watch?v=WI25DmCoWvI

Stimulant : Cocaine Derived from the leaves of the coca plant In small amounts produces behavioral or

psychological changes:

Increases alertness Increases blood pressure and pulse Produces euphoria Causes insomnia and loss of appetite

Stimulant : Cocaine cont.

Upon entering the brain, cocaine molecules block the reuptake of dopamine. This causes repeated stimulation of the next neuron.

Withdrawal produces feelings of apathy and boredom.

Cocaine vs. Crack

Hallucinogens

Hallucinogens

Altered sensory perceptions including: Delusions, paranoia, hallucinations

Examples: Cannabis (marijuana, hashish) Hallucinogens (LSD, peyote, mescaline,

psilocybin)

Hallucinogen : Marijuana

Active chemical- tetrahydrocannabinol (THC) Most regularly used illegal substance Evidence for Tolerance is mixed Withdrawal sxs

E.g., irritability, anger, depressed mood, headaches, restlessness, lack of appetite, & craving

Marijuana and Functional Impairment

Persistent memory loss, impairment of attention, learning skills, and motor movement

AddictionPhysical health problemsMedicinal purposesWithdrawal symptoms

© 2014, 2012, 2010 by Pearson Education, Inc. All rights reserved.

Epidemiology of Marijuana

Most frequently used (14.8 million users)

More common among males (8.3%)

versus females (4.3%)

-Average age of first use 18

-Men greater risk

-Prevalence of use stable from 1991 to 2002

-Abuse and dependence has increased

Why do you believe males are more likely to use

marijuana than females?

© 2014, 2012, 2010 by Pearson Education, Inc. All rights reserved.

Study: Marijuana Use and Panic

Treatment of Substance-Abuse and Dependence: Therapy

CBT-Avoidance of stimulus (fellow drug users, drug paraphernalia)

-Relapse prevention (identify antecedents and consequences of drug use, and develop ways to reduce the risk of future use)

Motivation enhancement therapyBehavioral therapiesTwelve-step approaches

© 2014, 2012, 2010 by Pearson Education, Inc. All rights reserved.

Treatment of Substance Use Disorder: Biological Treatments

Detoxification

Nicotine replacement therapyAntagonist treatmentsAversive treatmentsVaccines

© 2014, 2012, 2010 by Pearson Education, Inc. All rights reserved.

Controlled Drinking?

the evidence1. Mark and Linda Sobell

conducted a research study on controlled drinking with people who were alcoholics receiving both behavioral treatment and learning skills.

Fact: findings suited to individuals with less severe drinking problems, reviewed as harm reduction; however, it may be best to allow client to choose.

Evidence: Although abstinence is still for some the only treatment option, researchers hope to provide alternatives.

© 2014, 2012, 2010 by Pearson Education, Inc. All rights reserved.