Substance-related and addictive disorders​

Substance Use Disorders

The person has a problematic pattern of substance use leading to clinically significant impairment and distress

Substance-Induced Disorders

• The person experiences psychological or behavioural symptoms that are caused by the direct physiological effects of the substance on the person’s nervous system​

• Substance Intoxication​

• Substance Withdrawal​

• Substance/Medication induced Mental Disorders​

Key Characteristics of SUD

• Underlying change in user’s neurological circuitry​

• Brain reward circuits ​

• Brain threat/stress circuits​

• Cognitive control system ​

​

• Increased vulnerability to repeated relapse​

• Especially when exposed to substance use-related cues​

• Increased negative emotional reactivity when attempting to refrain from using the substance​

• Change NS functions (significant impact on brain reward system (dopaminergic system)​

• Brain threat (GABA)/stress circuits ​

  • Neuroadaptive changes: increased vulnerability to relapse​

Substance Classes

• Alcohol​

• Caffeine (2nd most traded)​

• Cannabis​

• Hallucinogens​

• Classic hallucinogens (e.g., LSD,​ psilocybin, mescaline)​

• Dissociative drugs (e.g. phencyclidine,​ ketamine)​

• Inhalants (e.g., solvents, gases, ​aerosol spray) ​

• Gambling​

• Opioids (e.g., heroin, synthetic opioids (fentanyl), pain killers (oxycodone (Percocet), hydrocodone (Vicodin), morphine)​

• Sedatives, hypnotics, and anxiolytics​

• Stimulants (e.g., cocaine, crack cocaine, methamphetamine, ecstasy, concerta (Tx for ADHD)​

• Tobacco​

• Other​

DSM-5-TR Substance Use Disorder Criteria​

Criteria Groupings | Criteria (Need 2 or More of 11)

Impaired Control

1. The individual may take the substance in larger amounts or over a longer period than was originally intended.

2. The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful attempts to decrease or discontinue use.

3. The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects.

4. Craving with intense desire for the drug.

Social Impairment

5. Recurrent substance misuse may result in a failure to fulfill major role obligations at work, school, or home.

6. The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

7. Important social, occupational, or recreational activities may be given up or reduced because of substance use. The individual may withdraw from family activities and hobbies in order to use the substance.

Risky Use

8. This may take the form of recurrent substance use in situations where it is physically hazardous.

9. The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

Pharmacological

10. Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed.

11. Withdrawal is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance.

A biopsychosocial perspective​

• Symptoms: a combination of acquired habits on genetic, social, pharmacological and behavioural factors​

• Addiction: It involves physiological changes as a result of the interaction between environmental stressors and individual factors. ​

• Societal norms and definitions of SUDS are intertwined. ​

  • Stigma​

  • Punishments ​

• “Normal drinking merges imperceptibly with pathological drinking. Culture and idiosyncratic viewpoints will always determine where the line is drawn”. Vaillant, 1990.​

• Depending on the definition (i.e., disease), medicalized approached become central to treatment.​

Epidemiology: Prevalence​

• Lifetime prevalence of alcohol use disorder alone is 10.3%​

• Rates higher for males than females ​

  • gap closes in uni

• Peak age onset: late adolescence /early 20s ​

• Among university students​

• 21-31% have an alcohol use disorder​

• 14% have nicotine dependence​

• 5% have problems with other drugs ​

• Trauma history is associated with increased risk of SUDS, especially women​

• Over past decade 18% ↑ in marijuana use disorder (in US where marijuana is illegal) ​

• Prescription opioid use disorder ↑ exponentially in the last five years​

• People who start at earlier age (<15 y.o.) are more likely to develop a SUD​

• Many people do not seek treatment because of stigma​

SUDs-Severity and Course Specifier​

• Severity occurs on a continuum​

  • Mild: 2-3 symptoms ​

  • Moderate: 4-5 symptoms​

  • Severe: 6 or more symptoms​

• Course of disorder specified as​

  • in early remission: started or is continuing to reduce​

  • in sustained remission​: sober for certain amount of time​

  • on maintenance therapy: continuing treatment (reducing)​

  • in a controlled environment: inpatient setting​

Identifying Alcohol Use Disorder​

• 3 goals: ​

  • 1. are the symptoms due to alcohol use?​

  • 2. how severe are the symptoms?​

    • Primary care physician and psychiatrist would recommend treatments​

    • Clinicians need to be non judgemental​

  • 3. Any comorbid/concurrent disorders?​

• Be non-judgmental​

• Non-threatening questions: Do you enjoy a drink now and then? Have you felt you should cut down on your drinking? Have people annoyed you by getting on your case about your drinking? Have you ever felt bad/guilty about your drinking? Have you ever needed to take a drink first thing in the morning? Do you have a drinking problem?​

Neurobiology of addiction​

• What are the specific brain circuits that mediate the transition from controlled substance use to chronic addiction?​

  • Dopamine system​

  • Opioid peptide​

  • GABA​

  • Serotonin pathways​

  • (1) reward, located in the nucleus accumbens and the ventral pallidum; ​

  • (2) motivation/drive, located in the orbitofrontal cortex and the subcallosal cortex; ​

  • (3) memory and learning, located in the amygdala and the hippocampus; and ​

  • (4) control, located in the prefrontal cortex and the anterior cingulate gyrus​

• Genetic influences: Twin studies. 50 % -60 % heritability for alcohol dependence​

• Family environment influences: parental monitoring and youth behavioural problems​

Health risks associated​ with unhealthy levels of alcohol use​

• Alcohol use is a leading risk factor for disease burden worldwide (Global Burden of Disease Study 2016)​

• Accounts for 10% of global deaths among populations 15-49 years ​

• Associated complications: ​

  • Liver disease​

  • Cardiovascular disease (hypertension, cardiomyopathy)​

  • Gastritis, esophagitis​

  • Bone marrow suppression, chronic infectious diseases​

  • Peripheral neuropathy​

  • Pneumonia​

  • Several types of cancer​

  • Communicable diseases (e.g., sexually transmitted diseases)​

  • Psychiatric conditions (anxiety, depression, etc.)​

  • Major risk factor for trauma and violence​

  • Withdrawal can be fatal (e.g., delirium tremens)​

Canada’s guidance on alcohol and health​

• There is a continuum of risk associated with weekly alcohol use where the risk of harm is:​

  • 0 drinks per week — Not drinking has benefits, such as better health, and better sleep.​

  • 2 standard drinks or less per week — You are likely to avoid alcohol-related consequences for yourself or others at this level.​

  • 3–6 standard drinks per week — Your risk of developing several types of cancer, including breast and colon cancer, increases at this level.​

  • 7 standard drinks or more per week — Your risk of heart disease or stroke increases significantly at this level.​

  • Each additional standard drink radically increases the risk of alcohol-related consequences.​

• Consuming more than 2 standard drinks per occasion is associated with an increased risk of harms to self and others, including injuries and violence.​

• When pregnant or trying to get pregnant, there is no known safe amount of alcohol use.​

• When breastfeeding, not drinking alcohol is safest.​

• No matter where you are on the continuum, for your health, less alcohol is better.​

Cannabis and Risk for Psychotic Disorders​

• Cannabis confers a twofold risk of later schizophrenia or schizophreniform disorder among psychologically vulnerable adolescents​

• The youngest cannabis users are at greatest risk​

• Mechanism by which cannabis increases risk for psychotic illness is not clear​

Substance Intoxication​

• Reversible substance-specific syndrome due to recent ingestion of a substance ​

• Behavioral/psychological changes due to effects on CNS developing after ingestion:​

  • ex. Disturbances of perception, wakefulness, attention, thinking, judgement, psychomotor behavior and interpersonal behavior​

• Not due to another medical condition or mental disorder​

• Does not apply to tobacco​

Substance Withdrawal​

• Substance-specific syndrome problematic behavioral change due to stopping or reducing prolonged use​

• Physiological & cognitive components​

• Significant distress in social, occupational or other important areas of functioning​

• Not due to another medical condition or mental disorder​

• physical response to substance that can occur after the extended and consistent use for alcohol withdrawal symptoms​

• psychomotor agitation, delirium stramma. So what that means is Shaking, hallucinations, and it can lead to heart attacks or stroke, chest pain, sweating, confusion, blood pressure increases and seizures. And it can be a medical emergency with very high m​

Specific Populations: Gender​

• Onset of SUDs tends to be later in life for females, but​

  • Women become dependent at a quicker rate ​

• Pathway to substance use is often relationship based​

  • More likely to initiate and continue use in the context of an intimate partner relationship​

  • Following treatment, use is more likely to be influenced by partner’s continued use​

• Women face unique barriers to treatment engagement ​

  • limited access to child care services​

  • society’s more punitive attitude towards women​

• Women are more likely to complete treatment than men​

• Males diagnosed at higher rates to SUD​

• Habit forming takes a while to become diagnosable conditions, they tend to appear later on life​

• Women: more severe in shorter times​

  • Often relationship based (introduced by partners)​

  • Less lieklty to seek treatment due to stigma (due to dependents in their care)​

  • More likely to complete rtreamtent​

• Men: society more linient on SU​

  • More likely to stope treatment early​

​

Course and Prognosis​

• Many people stop using without treatment​

  • For others, recovery is difficult ​

• High treatment drop-out & relapse rates​

  • 90% of heroin- and cocaine dependent users experience at least one relapse within 4 years of treatment​

  • Most initiate 3-4 episodes of treatment over multiple years before achieving abstinence (Hser et al, 1998)​

• SUDs are considered chronic illnesses​

  • A continuum of care can improve outcome​

• By 12th grade, 50% half used at least one illicit substances​

• Most don’t progress to dependence​

• A lot stop using without treatment​

• SUD considered chronic illnesses​

  • Treatment compliance is not any diff to any chronic condition (diabetes, etc.)​

• There s a continuum of care and impairment of symptoms​

  • In order to be successful, it needs ot meet the individuals need​

• What is highly predictive of the success of treatment is a thorough examination of the social environment, the working environment, the familiar environment. Past history. Positive factors, supporting factors, coping strategies, et cetera. So it's not just that this works and then you have to, you just apply the treatment without taking into effect.​

​

Stats on SUDs

• 40% of hospital admission are associated with alcohol or drug use ​

• Accounts for 25% of all hospital deaths​

• Intoxication is associated with ​

  • 50% of all MVA​

  • 67% of all domestic violence cases ​

  • 40-50% of all murders, assaults and rapes​

• 60 specific medical conditions are alcohol related​

• 1% of babies suffer from fetal alcohol spectrum disorders​

• Opioid withdrawal in newborns has ↑ exponentially in the 5 years​

• Smoking is the most preventable cause of disease & death in North America​

• Huge societal and financial toll (particularly alcohol)​

• Alcohol increases the risk for developing mental and behavioral disorder, liver cirrhosis. So again, other types of chronic illnesses that do not really fit the category of alcohol. Cancer, cardiovascular disease, especially accidents​

• Alcohol: huge toll on medical system (25% deaths in hospital)​

• Smoking decreased in north America, but increased worldwide​

• Vaping has increased​

  • Chronic side effects

Risk Factors for SUDs​

• Family history: genetics (contribute to 50% of risk)​

• Gene-Environment Interactions​

  • GABRA2 gene (gamma aminobutyric neurotransmitter system) associated with heroin and cocaine use in individuals with severe childhood maltreatment (e.g., Enoche et al. 2010)​

  • DRD4-7R gene (dopamine neurotransmitter system) and avoidant and anxious attachment predicts cannabis use in young adults (Olsson et al., 2011)​

• Early exposure to substance use​

• Certain personality traits: Negative Emotionality and low Constraint (e.g., impulsive, risk taking) at age 17 predicts alcohol, nicotine and illicit drug use disorders by age 20 (Elkin et al., 2006)​

• Conduct disorder and callous-unemotional traits in youth​

• Other psychological disorders ​

Environmental Risk Factors for SUDs​

• Stress, poverty, discrimination & other stigma-related social stressors​

• Environments where there is easy access to substances and normative attitudes towards substance use​

  • Environments with alternative behavioural choices​

    • Vietnam veterans​

• Social/Cultural Factors​

  • Cultural variation in substance use ​

  • In areas where cocaine and heroin are grown, abuse is miniscule in comparison to North American and European societies ​

  • Religious beliefs and practices are protective ​

• Some addictions can dissolve if radical changes in environment were done (radical context change)​

• one of the or many of the factors that maintain or contribute to the chronicity of substance use disorder is that the environment continues to have many of the similar stressors, many of the similar cues, and many of the similar reminders of trauma or triggers That were there before the person started to use substances.​

Stages of Interventions for SUDs​

• Primary prevention​

• Early Intervention​

• Treatment​

  • Outpatient​

  • Day Treatment​

  • Residential ​

  • Inpatient​

• Recovery and Support

Treatment of Concurrent Disorders​

• Integrated:​

  • Gold standard​

  • Tx SUD and MH problem at same time & place​

• Parallel:​

  • Tx of SUD and MH problem at same time but by different providers​

• Sequential:​

  • Treat SUD or MH problem first and then the other ​

  • Least advantage​

  • Bounce back and forth​

Pharmacotherapy​

• Based on principles of counterconditioning (for alcohol)​

  • Disulfiram​

    • Enhances sensitivity to alcohol​

    • Mixed effectiveness-unless it’s supervised.​

    • Blocks oxidation of alcohol, person immediately feel sick or ill​

    • Need patient to adhere to medication taking​

    • Mixed results​

  • Naltrexone​

    • Reduces cravings​

    • Effective for heavy drinking​

    • reduce cravings for alcohol​

    • quite affective inreducing heavy dirnking​

    • Block pleasure producing effects ​

    • Not as effective in earlier stages of consumptions​

  • Acamprosate​

    • Reduces cravings by blocking glutamate receptor​

    • Reduce reward​

  • SSRIs​

    • Reduce frequency of drinking​

    • Help people feel less depressed​

  • Opiate use disorder​

    • Methadone​

    • LAAM​

    • Naltrexone​

Psychosocial Interventions for SUDs​

• Wide range of interventions are effective ​

  • Many are based on social learning theory ​

  • Develop skills and self-efficacy to avoid using the substance, to cope with cravings, or to achieve or maintain moderate consumption​

• Interventions with the strongest evidence include Motivational Enhancement Therapy & various behavioural interventions (Martin & Rehm, 2012)​

  • CBT​

  • Behaviour Self-control Training ​

  • Behaviour Contracting ​

  • Feedback informed treatment (FIT) ​

  • Social Skills Training ​

• Treatment matching may be important​

  • Adhere to treatment protocol​

• Strongest evidence for SUD is Motivational Enhancement Therapy​

  • Very effective​

  • Good for other addictions​

• Predictive success​

  • Match the treatment with what the person presents with

Components of Motivational Interviewing​

• Feedback

  • The client is provided constructive, nonconfrontational feedback regarding personal risk in impairment secondary to their pattern of substance use.

• Responsibility

  • Responsibility for change is clearly and explicitly placed on the client, respecting the client's right to make decisions for himself/herself. The intention is to empower and motivate client investment in change.

• Advice

  • In a nonjudgmental manner, the clinician recommends the client reduce or stop substance use. This is done either through suggestion or education (explaining information).

• Options

  • Offering clients a menu of options regarding change strategies, treatment goals, or types of services helps decrease dropout rates, reduces resistance to treatment, and increases overall treatment effectiveness.

• Empathetic Counseling

  • Display of therapist’s characteristics such as warmth, respect, caring, commitment, and active interest engages the client and increases motivation to change. Particularly effective with clients who appear angry, resistant, or defensive.

• Self-efficacy

  • Optimistic empowerment is engendered in the client to encourage change.

Other treatment considerations

• General “talk therapy” is not helpful- intervention needs to target SUD behaviours​

• Confrontation does not work​

  • Predicts treatment drop-out and relapse​

• Self-Help Recovery Groups (e.g., Alcoholics Anonymous; Narcotics Anonymous, twelve step facilitation (TSF)) can be an important part of treatment for some people​