Substance-Related and Addictive Disorders

How do substances differ?

• Pharmacological mechanisms by which each class of drugs produces reward

• Experience of intoxication

• Experience of withdrawal

• Addictive potential

What do all substances have in common?

Direct activation of brain reward system, influencing behaviour reinforcement and memory production

Produce pleasure/a “high”

Intense activation of reward system, such that normal activities may be neglected

Direct activation from drugs of abuse can lead to individuals being unable to achieve reward system activation through adaptive behaviours

How are other behaviours similar to drugs of abuse?

Behaviours including gambling can also activate similar reward systems

What behavioural addictions are under review?

Internet gaming

Sex addiction

Shopping addiction

Exercise addiction

How is substance dependence/addiction conceptualised and used today?

Defined by tolerance and withdrawal, or drug-seeking behaviour

Used to be a classification/diagnosis, still utilised clinically if not an official dx

Threshold of 2+ symptoms interfering with life/well-being still utilised under SUD

What is drug tolerance?

Needing more to get the same effect, or reduced effects from the same amount

What is drug withdrawal?

The physical response when substance is discontinued after regular use

What are substance-induced disorders?

Intoxication

Withdrawal

Substance/medication-induced mental disorders

• Psychotic

• Bipolar and related

• Depressive

• Anxiety

• OC and related

• Sleep disorders

• Sexual dysfunctions

• Delirium

• Neurocognitive

What is [Substance] Use Disorder in the DSM-5?

Note: this criteria consistent across substances

Pattern of substance use leading to significant impairment and distress

Symptoms (2+ w/in year)

1. Impaired control (NOTE: not symptom itself but description of the following)

   1. Taking more of the substance than intended

   2. Desire to cut down use

   3. Excessive time spent using/acquiring/recovering

   4. Craving for the substance

2. Social impairment

   1. Role disruption (work, parental duties)

   2. Interpersonal problems

   3. Reduction of important activities

3. Risky use

   1. Use in physically hazardous situations (e.g., driving)

   2. Keep using despite causing physical or psychological problems

4. Pharmacological criteria

   1. Tolerance

   2. Withdrawal

How might tolerance vary? What are other things to note about tolerance?

Across individuals, substances, CNS effects

Requires laboratory tests

Different from initial sensitivity

NOT required to diagnose SUD

When does withdrawal occur? What is more likely to happen as a result?

When blood or tissue concentrations of a substance decline after prolonged heavy substance use

After withdrawal, likely to consume substance to relieve symptoms (past history associated with more severe clinical course)

How do tolerance and withdrawal relate to SUD diagnosis?

Neither are necessary to diagnose SUD (despite being criteria), and SUD is not diagnosed if only tolerance and withdrawal occur during medical treatment

How has substance use-related disorders changed from DSM-IV to DSM-5?

Used to be 2 categories (abuse and dependence). Now, all combined to create Substance Use Disorders.

Removed legal problems as it is racially/minority discrimination motivated rather than actually related to abuse

Introduced craving

What are the types of Substance-Related Disorders in the DSM-5?

Substance intoxication (from diff types of substances)

Substance use disorder (““)

Withdrawal (““)

(Substance)-Induced mental disorders

What are the 5 main categories of substances?

Depressants

• Behavioural sedation

• Alcohol (own category), sedative, anxiolytic (same category)

Stimulants

• Increase alertness and elevate mood

• Cocaine, nicotine, caffeine (note: caffeine under separate DSM category than stimulant related), amphetamine-type substances

Opiates

• Analgesia and euphoria

• Heroin, morphine, codeine

Hallucinogens

• Alter sensory perception

• Cannabis (own category), LSD and psilocybin

Other drugs of abuse

• Inhalants, anabolic steroids, medications

What are psychological and physiological effects of alcohol?

CNS depressant influencing several neurotransmitter systems, specifically GABA and increasing inhibitory effects which makes neural cells worse at firiing

Depresses inhibitions

Intimate partner violence, risky sexual behaviour, + undermining sexual consent

What is the dx criteria for alcohol use disorder?

Problematic pattern of alcohol use leading to significant impairment or distress, 2+ of following over a year:

1. Larger amounts or over longer period than intended

2. Persistent desire or unsuccessful efforts to cut down or control alcohol use

3. A great deal of time spent in activities necessary to obtain, use, or recover from alcohol

4. Craving or strong desire to use

5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home

6. Continued use despite persistent or recurrent social or interpersonal problems

7. IMportant social, occupational, or recreational activities given up or reduced

8. Recurrent alcohol use in situations in which it is physically hazardhouse

9. Alcohol use is continued despite knowledge of having a recurrent physical/psychological problem likely caused/worsened by alcohol

10. Tolerance

11. Withdrawal

What are prevalence estimates of alcohol?

Most adults are light drinkers or abstainers, with ~50% of Americans drinking.

Around one quarter or Americans have had 5+ drinks on one occasion in the past month

How does alcohol use relate to diagnosis, life events, and gender?

Typically a secondary diagnosis to other disorders, such as mood and anxiety

• Typically mood/anxiety disorders precede development of SUDs, with S-induced disorders low

Linkages found between stressful life events and AAD, providing support for stress-reduction model

Men have higher prevalence (though gap is closing) and higher rates of death

What are key facts about drinking alcohol in NZ?

Men 2x likely as women to be hazardous drinkers

1 in 2 Maori men who drink and 1 in 3 Maori women who drink are hazardous drinkers

2 in 5 young adults drink hazardously

AKA: Men, Maori, younger = higher risk of hazardous drinking

Pasifika and Asian men and women least likely to drink alcohol but hazardous drinking is high among Pasifika who do drink

How does comorbidity relate to substance use?

Very high lifetime comorbidity (74%)

• Increases with different types of substances

• MDE 34%, Social anxiety 31%, PTSD 31%, SZD 47%

• Comorbidity decreases treatment response

37% of those with AUD will meet criteria for another mental disorder

What are the most common mental disorders that are co-morbid with AUD?

Mood disorders (both unipolar and bipolar)

• Depressive symptoms often result from intoxication or withdrawal

Anxiety disorders (PTS, panic disorder, social anxiety disorder)

Personality disorder (Antisocial, borderline)

Psychosis/Szd

Poly-substance use

Substance-induced disorders

Neurocognitive impairment

ADHD/conduct disorder

Eating disorders

What is the progression of alcohol related disorders?

20% able to stop drinking on their own

Dependence usually develops over time, but course may be variable

Starting drinking at age 11 or earlier at higher risk for chronic or severe disorders

• Parental factors + disadvantage

Alcohol and violence

• Does not cause but may increase likelihood of impulsive behaviour

Unplanned and unprotected sex

• STIs, unplanned pregnancy

What is diagnostic criteria for alcohol intoxication?

A. Recent ingestion (duh)

B. Clinically significant problematic behavioural or psychological changes

C. One (or more) of the following signs or symptoms during or shortly after use

• Slurred speech

• Incoordination

• Unsteady gait

• Nystagmus

• Impairment in attention or memory

• Stupor or coma

Not attributable to another medical condition or substance

What is a sign on withdrawal of chronic alcohol use?

Delirium tremens - hallucinations and tremors

What is diagnostic criteria for Alcohol withdrawal?

A. Cessation or reduction of heavy, prolonged alcohol use

B. 2+ of the following, developing shortly after ceasing alcohol use

1. Autonomic hyperactivity (sweating, tachycardia)

2. Increased hand tremor

3. Insomnia

4. Nausea or vomiting

5. Transient visual, tactile, or auditory hallucinations or illusions

6. Psychomotor agitation

7. Anxiety

8. Generalised tonic-clonic seizures

C. Clinically sig. distress or impairment

D. Not attributable to other condition or substance

What is Fetal alcohol syndrome?

Problems from alcohol use during pregnancy

Impaired fetal growth, cognitive difficulties, behavioural problems, and emotional lability

DIstinctive characteristics

• Low nasal bridge

• Short nose

• Flat philtrum between nose and upper lip

• Small head circumference

• Small eye openings

• Skinfolds in corners of the eyes

• Small midface

• Thin upper lip

How is alcohol related to dementia?

Wernicke-Korsakoff disorder (confusion, lack of coordination, impaired speech)

Thiamine/B1 deficiency due to poor intake and metabolization

How may assessment be used with regards to substance use problems?

Screening, diagnosis, development of treatment goals, plan, and assessment of treatment outcome

What are some quick screeners for alcohol use disorder?

CAGE-AID - cut down, annoyed, guilty, eye-opener

AUDIT

Addiction Severity Index (ASI)

How is most information obtained for Alcohol use/substance use?

Retrospective self-reports/clinical interview

• Self-reported use prone to inaccuracy - utilise overlapping info from other sources such as tests, collateral, and reports

• Alcohol-related negative consequences

What should we also assess for when assessing alcohol?

Organic brain dysfunction

Social needs

Medical status

Other psychopathology

How might one conduct a functional analysis for alcohol/substance use?

ABCs

Development of alternative cognitive and behavioural skills to reduce risk of future use

Identifying high-risk situations

• Trigger

• Thoughts during situation

• Feelings/emotions experienced in response to trigger, thoughts

• S.U. behaviour

• Positive and negative consequences

  • Acknowledge and distinguish between the short-term immediate positives and larger magnitude, longer term negatives

• Behavioural chain

What are family and genetic influences of substance use?

Increased genetic risk for AUD

40-70% of risk variance explained by genetic influences

Increased risk in biologically close relatives (3-4)

Genetic risk for tolerance, craving

Shared patterns of alcohol use in twins even across separate environments

Magnitude varies over development

• Negligible during early adolescence, increases over time, stabilises around 35-40

Much of focus of genetic studies has been on alcohol-related problems

• Legality, gender differences, high rates of dependence

Multiple genes involved

Common genetic influences across substances with some susbtance-specific genetic factors

How do gene-environment interactions relate to alcohol use disorder (+ other substances)?

Early life stress → alterations in stress circuitry → risk for substance use

GABRA2 gene associated with heroin, cocaine for individuals with severe childhood maltreatment

7R+/DRD4 Dopamine receptor gene and attachment history predict cannabis use in young adulthood

How do drugs affect pleasure pathways of the brain?

Reinforcing properties of substances

Particularly dopaminergic system in mesocorticolimbic areas

Prolonged alcohol use increases brain’s sensitivity to alcohol related dopamine release

• Other activities become less reinforcing

• Learn drinking = best dopamine way

• Leads to preference of drinking over other activities

How does chronic alcohol use affect brain’s reactivity to stress?

HPA Axis effect on behavioural, emotional, and physiological stress responses

Animal models show that rats with elevated HPA axis reactivity to stress show greater self-administration of addictive substances

Alcohol increases CRF (which stimulates release of cortisol) → more reactive to stress

Epidemiological studies show evidence for the role of elevated stress (early life stress, trauma, accumulated adversity) on development and maintenance of substance use and substance use disorders

Lower levels of self-control may be predisposed to develop substance use disorders

How does sex relate to SUD and neurobiological influences?

Women are:

• less likely to have a SUD

• Later age at onset

• Become dependent quicker and face more severe consequences over shorter time periods

• Pathway to SUD often relationship-based (intimate partners)

• Greater barriers to accessing treatment due to child-rearing

How does sexual orienation relate to SUDs?

Minority sexual orientations at greater risk

May relate to discrimination, stigma-related social stressors, and social influence of peers

How does ethnicity relate to neurobiological influences of SUD?

Asian ethnicities: low/absent levels of liver enzyme alcohol dehydrogenase → drink less, lower risk

Native Americans: don’t become intoxicated as quickly → drink more, higher risk

What does Alexander’s Rat Park Research indicate?

Rats housed alone (isolated, impoverished) rather than the Rat Park (other rats, games, stimulation), consumed up to 20x more morphine than those in the Rat Park

While biology and hormones are important, we need to consider how trauma, loneliness, lack of purpose, and difficult life circumstances drive use and addiction

How does learning relate to use disorders?

Reinforcement - initially seeking high (positive), then later seeking escape from withdrawal (negative)

Social learning one of the best predictors of substance use

• Attitudes, factors, relapse, exposure

Parental factors

• Abuse or are dependent, modelling, reduced monitoring, discipline, stability, and attachments

How might substance abuse be a means to cope with negative affect?

Tension reduction

Self-medication

Escapism

Modelling of alcohol to cope with stress

Severe and recurrent family conflict and other adversity factors

Ineffective coping skills

What are cognitive factors in substance use?

Role of expectancy effects/anticipation of positive effects

Expectancy of not coping without use

What is the opponent process theory?

Drugs themselves easiest way to alleviate withdrawal

SUDs come from emotional pairing of pleasure and emotional symptoms of withdrawal

At beginning of drug or substance use, high levels of pleasure and low levels of withdrawal

How do substance-related disorders relate to social and cultural dimensions?

Exposure through media, family, peers, influences exposure

Drug abuse seen as a sign of moral weakness rather than a disease/caused by some underlying process

Cultural factors - some expect heavy drinking and may influence behaviour due to what the substance is thought to do

What is an integrative model of substance-related disorders?

Exposure or access to a drug is necessary but not sufficient

Drug use also depends on:

• Social and cultural expectations

• Positive and negative reinforcement

• Genetic predisposition and biological factors

• Psychosocial factors

How does the diathesis-stress model relate to alcohol/substance use?

Diathesis (mechanisms) = susceptibility; condition that makes someone vulnerable to developing a problem or disorder

Stressor (precipitant) activates the diathesis

So, someone may have a genetic vulnerability (diathesis) that may or may not lead to development depending on a stressor/precipitant

What are the two parts of Beck, Wright, Newman, & Liese’s Cognitive Developmental Model for drug use?

Developmental (how it got started) and maintanence (how it keeps going)

What is the developmental aspect of Beck, Wright, Newman, and Liese’s Cognitive Development Model?

Early life experiences

Schemas and beliefs

Exposure to drugs

Drug related beliefs

Continued use

What early life experiences contribute to the development of schemas and beliefs in Beck, Wright, Newman, and Liese’s Cognitive Development Model?

Parental disharmony

Abuse

Loss of a parent

Culture and social acceptance of substance use

Parents with substance misuse

What schemas and beliefs are a part of the development portion of Beck, Wright, Newman, and Liese’s Cognitive Development Model?

Not good enough

Don’t belong

Unworthy

I’m a failure

Cultural acceptance of substance use

Acceptance of OTC drug use

How does exposure to drugs influence development of addiction in Beck, Wright, Newman, and Liese’s Cognitive Development Model??

Exposure to parental substance use and self-experimentation with substances

What are potential drug related beliefs in Beck, Wright, Newman, and Liese’s Cognitive Development Model?

I’ll meet cool people if I drink/use

Drinking is cool

Drinking makes me feel confident

What is the maintenance model of Beck, Wright, Newman, and Liese’s Cognitive Development Model?

Closed loop

Activating stimuli → D-R beliefs activated → automatic thoughts → urges/cravings → facilitating beliefs → focus on instrumental strategies → continued use/relapse

What are activating stimuli in the maintenance part of Beck, Wright, Newman, and Liese’s Cognitive Development Model?

Internal and external cues - anxiety, low mood, interpersonal conflict, other users