PSYC 223 - Substance Use and Disorders (TWO)

3 constructs related to substance use

1. Consumption-based measures

2. Addiction (proxies of neurocogntiive and physiological changes)

3. Consequences of involvement

4 consumption-based measures of substance use

1. Frequency (timing)

2. Frequency of heaving drinking or heavy use

3. Quantity (amount)

4. Q-F (overall exposure)

3 consequences of involvement

1. Drug-related consequences/harm

2. Substance dependence syndrome

3. Substance use disorders

Substance use disorders are a product of what 3 aspects?

1. Abuse

2. Dependence

3. Craving

2 purposes of epidemiologic data

1. Framing the problem

2. Providing etiological clues

3 epidemiologic tools/surveys to assess alcohol use

1. Monitoring the Future (MTF, all drugs)

2. National Epidemiological Survey on Alcohol & Related Conditions (NESARC, alcohol)

3. National Survey on Drug Use & Health (NSUDH, all drugs)

Current trend in illicit drug use

Illicit drug use on the decline (except marijuana)

Current trend in cigarette smoking

Cigarette smoking shows markedly decline

Current trend in vaping among teens

Vaping declining among teens

Current trend in alcohol use

Alcohol use showing gradual decline

Current trend in binge drinking in teens

Binge drinking declining among teens

Current trend in high intensity drinking

High-intensity drinking is one the rise

Current trend in ecstasy, addrall, meth, and bath salts

Ecstasy, adderall, methamphetamine, bath salts are all on the decline

Trend in college vs. noncollege students with respect to high intensity and binge drinking

There is not a significant difference between non-college and college student (slightly higher levels of moderate/high intoxication in full-time college students)

Trend in lifetime use of illciit and licit drug use in 8th, 10th, and 12th graders

Lifetime use of licit and illicit drug use in 8th, 10th, and 12th graders has been on the decline

2 regions of the US where cannabis has been most legalized

1. Western states

2. Northeastern states

In what region of the US is cannabis legalization less common?

Southern states

Addiction

set of behaviors influenced by an external agent that leads to elements of impulsivity and compulsivity dysfunction marked by 3 domains

3 domains of addiction

1. Incentive salience

2. Negative emotionality

3. Cognitive control

Stage of addiction associated with incentive salience

Binge-intoxication stage (reward and incentive salience, habits)

Stage of addiction associated with negative emotionality

Withdrawal-negative affect (stress and negative emotional states, including but not limited to withdrawal)

Stage of addiction associated with cognitive control

Pre-occupation-anticipation (executive function)

4 brain regions associated with the binge-intoxication stage

1. Dorsal striatum

2. Nucleus accumbens

3. Globus pallidus

4. Thalamus

3 brain regions associated with withdrawal-negative affect stage

1. Cerebellum

2. BNST

3. Amygdala

4 brain regions associated with the pre-occupation stage

1. Prefrontal cortex

2. Orbitofrontal cortex

3. Hippocampus

4. Insula

2 key neurotransmitters involved in the binge-intoxication stage

1. Dopamine

2. Opioid peptides

6 key neurotransmitters involved in the withdrawal-negative affect stage

1. CRF

2. NE

3. ADH

4. Hypocretin (orexin)

5. Dynorphin

6. Neuroimmune

2 key neurotransmitters involved in the pre-occupation-anticipation stage

1. Glutamate

2. GABA

3 aspects of neuroadaptation

1. Neurocircuits

2. Synaptic systems

3. Molecules

What behavior often dominates in the early stages of addiction, and which often dominates in the later stages

• Early stages; Impulsivity

• Later stages: Impulsivity combined with compulsivity dominates in later stages

The transition from occasional drug use to addiction involves ____________________

neuroplasticity in the brain

How does the AMA characterize addiction?

• A: Inability to consistently abstain

• B: impairment in behavioral control

• C: craving, or increased “hunger” for drugs or rewarding experiences

• D: diminished recognition of significant problems with one’s behaviors and interpersonal relationship

• E: dysfunctional emotional response

How many stages of addiction are there?

4

Stage 1 of addiction

first encounter with the drug, and “rating” the experiences - the drug as a primary reward stimulus

Stage 2 of addiction

repeatedly taking the drug, with the reward effect becoming stronger and stronger (sensitization)

Stage 3 of addiction

associating the drug with environmental stimuli (secondary reward conditioning), the environmental stimuli can now induce craving

Stage 4 of addiction

“full blown” addiction - you live for the drug

4 steps of the continuum of addiction

1. Voluntary experimental or medicinal use

2. Repeated use to produce pleasure, alleviate stress, and/or alter or avoid reality

3. Use to avoid withdrawal and/or negative emotional states

4. Compulsive use, significant impairment in executive functioning

Diagnostic and Statistical Manual of Mental Disorders (DSM)

Reference book published by the APA that contains the classification of mental disorders and diagnostic criteria used by qualified mental health professionals and physicians to diagnose mental disorders

What happened in the 1840s in relation to the DSM?

the US government began collecting data on mental illness through a census that had 7 categories (established in 1880s)

7 categories of the 19th century mental illness census

1. Mania

2. Melancholia

3. Monomania

4. Paresis

5. Dementia

6. Dipsomania

7. Epilepsy

Mania category (mental illness census)

Delusions/dementia

Melancholia category (mental illness census)

Severe depression

Monomania category (mental illness census)

OCD

Paresis category (mental illness census)

Nerve damage

Dementia category (mental illness census)

Poor cognition

Dipsomania category (mental illness census)

Alcoholism

Epilepsy category (mental illness census)

Recurrent seizures

What happened in 1917 in relation to the DSM?

The Statistical Manual for the Use of Institutions for the Insane was created by the Committee on Statistics of the American Medico-Psychological Association (now APA) in collaboration with the National Commission on Mental Hygiene

How many groups of mental illnesses did the Statistical Manual for the Use of Institution for the Insane, and how many editions were published in a 25 year period?

Had 22 groups of mental illness with 10 editions being published in a 25 year period

DSM I perspective on substance use

DSM I primarily focused on alcohol due to the opium crisis (alcohol was an alternative)

DSM II perspective on substance use

DSM II considered it as a personality disorder

DSM III and III-R perspective on substance use

DSM III focused on psychosocial and pharmacological impairment rather than personality disorder

How long did DSM III-R and DSM-IV representations of alcohol use disorder persist?

DSM III-R and DSM-IV representations of alcohol use disorder persisted into the mid 2010s

DSM-5 perspective on substance use

DSM V extended beyond abuse and dependence and introduced substance use disorder

DSM-III and -IV abuse criteria (5)

1. Neglected major roles to use

2. Hazardous use

3. Legal problems

4. Social/interpersonal problems related to use

5. Criteria for alcohol dependence not met

DSM-IV dependence criteria (7)

1. Tolerance

2. Withdrawal

3. Using in larger amounts/over a longer time period than intended

4. Repeated attempts to quit/control use

5. Much time spent using

6. Activities given up to sue

7. Physical/psychological problems related to use

ICD-10 Drug Dependence Syndrome

a cluster of physiological, behavior, and cognitive phenomena in which the use of a substance takes on a much higher priority for an individual than other behaviors that once had greater value

How did the APA describe the edition’s changes made to substance use disorder and addiction?

The tolerance and withdrawal that previously defined dependence are actually very normal responses to prescribed medications that affect the CNS and do not necessary indicate the presence of an addiction

DSM-5 clinical criteria for substance use disorders

A problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:

11 symptoms outlined in the DSM-5 criteria for substance use disorders

1. Hazardous use

2. Social/interpersonal problems related to use

3. Neglected major roles to use

4. WIthdrawal

5. Tolerance

6. Used larger amounts/longer

7. Repeated attempts to quit/control use

8. Much time spent using

9. Physical/psychological problems related to use

10. Activities given up to use

11. Craving

Essential feature of substance use disorders outlined in the DSM-5

cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems

Important neurobiological characteristic of substance use disorders in the DSM-5

underlying change in brain circuits that may persist beyond detox, particularly in individuals with severe disorders

4 categories of substance use disorder symptoms in the DSM-5

1. Impaired control

2. Social impairment

3. Risky use

4. Pharmacological

4 impaired control symptoms of substance use disorder

1. Used larger amounts/longer

2. Repeated attempts to quit/control use

3. Much time spent using

4. Craving

3 social impairment symptoms of substance use disorder

1. Neglected major roles to use

2. Social/interpersonal problems related to use

3. Activities given up to use

2 risky use symptoms of substance use disorder

1. Hazardous use

2. Physical/psychological problem related to use

2 pharmacological symptoms of substance use disorder

1. Tolerance

2. Withdrawal

Tolerance is defined by either of the following 2 definitions:

1. A need for markedly increased amounts to achieve intoxication or desired effect

2. A markedly diminished effect with continued use of the same amount

Scoring DSM-5 Clinical Criteria for Substance Use Disorders

1. Mild: 2-3 symptoms

2. Moderate: 4-5 symptoms

3. Severe: 6+ symptoms

What does the ICD-11 posit in regards to substance use disorder?

ICD-11 posits that there is a spectrum of substance use and disorder in human society

Pyramid illustrated by ICD-11 (6 stages, from lowest to highest)

1. Zero use

2. Low risk use

3. Hazardous substance use

4. Episode of harmful substance use

5. Harmful pattern of substance use

6. Substance dependence

What does the ICD-11 pyramid of substance use and disorder inform?

WHO public health approach

ICD-11 Substance Dependence definition

disorder of regulation of substance use arising from repeated or continuous use of that substance and consisting of a strong internal drive to use that substance

ICD-11 Harmful Pattern of Use definition

sub-dependence diagnosis which is made on the basis of a repetitive pattern of substance use which has directly caused harm to the person or to someone els

ICD-11 Episode of Harmful Substance Use definition

episode of substance use that has caused harm to a person’s physical or mental health or has resulted in behavior leading to harm to others

ICD-11 Hazardous Substance Use Definition

pattern of substance use that is sufficient in frequency or quantity to increase appreciably the risk of harmful physical or mental health

ICD-11 Hazardous Substance Use Definition

Pattern of substance use that is sufficient in frequency or quantity to increase appreciably the risk of harmful physical or mental health consequences to the user or to others to an extent that warrants attention and advice from health professionals

In Hazardous Substance Use, the individual as not yet reached the level of __________________________________

having caused harm to physical or mental health of the user or others around the user

Fagerstrom Test for Nicotine Dependence

a standard instrument for assessing the intensity of physical addiction to nicotine

For what purpose is the Fagerstrom Test for Nicotine Dependence designed for?

Designed to provide an ordinal measure of nicotine dependence related to cigarette smoking

Content of the Fagerstrom Test for Nicotine Dependence

Contains 6 items that evaluate the quantity of cigarette consumption, the compulsion to use, and dependence

6 questions of the Fgaerstrom Test

1. How soon after you wake up do you smoke your first cigarette?

2. Do you find it difficult to refrain from smoking in places where it is forbidden?

3. Which cigarette would you hate most to give up?

4. How many cigarettes per day do you smoke?

5. Do you smoke more frequently during the first hours after waking than during the rest of the day?

6. Do you smoke when you are so ill that you are in bed most of the day?

Scoring of Fagerstrom test

• 0-2: very low dependence

• 3-4: low dependence

• 5: medium dependence

• 6-7: high dependence

• 8-10: very high dependence

FTND scores are highly correlated with what other score?

DSM severity score?

How effective are treatment services for substance abuse in America (in terms of outreach)?

Treatment services reach too few substance abusing Americans

______% of persons aged 12 or older needed treatment for an illicit drug or alcohol abuse problem in 2014

8.5

Only ______% of those who need treatment received it in 2014

18

Only ____% of those who needed treatment received treatment in a specialty treatment program

<10

Why are treatment services for substance abuse even worse among incarcerated indiviuduals?

Treatment is poor quality or is not well-suited to the needs of offenders and may not be effective at reducing drug use and criminal behavior

5 treatments for drug addiction

1. Behavioral counseling

2. Medication

3. Medication-assisted therapy

4. Evaluation and treatment for co-occurring mental health issues

5. Long-term follow-up

Behavioral counseling for drug addiction

in group or individual forms uses behavior therapy to limit or encourage abstinence - occurs in outpatient or inpatient settings

4 forms of behavioral counseling for drug addiction

1. CBT

2. Multidimensional family therapy

3. Motivational interviewing

4. Motivational incentives

Medication treatment for drug addiction

Under development

Medication-assisted therapy for drug addiction

medical devices and applications are used to treatment withdrawal symptoms (AKA detox) or deliver skills training

Purpose of long-term follow-up in drug addiction

Helps to prevent relapse

Gold standard addiction treatments

Combine therapies and other services to meet the needs of the individual patient

There are ongoing Clinical Trials for substance use disorder - what requirement must new methods fulfill?

New methods MUST perform better than existing care models