suds

Substance-related and addictive disorders

What is a substance

• Any natural or synthesized product that has psychoactive effects on one's perceptions, thoughts, and behaviour, can be considered this

Diagnosis and assessment

• 9 DSM-5 categories of disorders

  • Alcohol

  • Caffeine

  • Cannabis

  • Inhalant

  • Opioid 

  • sedative/hypnotic/anxiolytic

  • Stimulant

  • Tobacco

  • Other

Substance Use Disorder (SUD)

• Impairment of control: inability to control use

• Social impairment: impairment in your work, academically, social life

• Risky use: using in situations where it might be dangerous while driving, pool, heavy machinery

• Pharmacological dependence (tolerance; withdrawal)

2+ following symptoms occurring within 12 months 

1. Taken in larger amounts than intended: 3 drinks, have 1 more, continue

2. Persistent desire/unsuccessful efforts to reduce/stop: reflect a desire to want to stop, but not being able to 

3. Great time spent using, recovering, or obtaining: long hangovers, time spent drinking

4. Craving

5. Failure to fulfill social/personal/professional obligations: not showing up to class instead

6. Continued use despite soc/interpersonal problems caused by substance: problems with family and friends

7. Social/occupational/personal activities given up to use: used to enjoy doing, instead of spending time using

8. Recurrent use in hazardous situations: drinking or being high and driving

9. Recurrent use despite psych/phys problems: if you have MDD but still use or use it to cope, but it makes it worse

10. Tolerance

11. Withdrawal

Substance-induced disorders

Intoxication:

• Behavioural or physiological changes that occur as a direct result of using

• Acute state that can change over time

• If someone comes into treatment and they are demonstrated changes from a substance

Withdrawal:

• Physical and behavioural symptoms when people have been using substances for a prolonged time stop their use

Substance/medication-induced:

• You can have depression directly caused by using substance

• If you’re able to directly link psychopathology to a substance, you can label it as substance-induced depression, psychosis, mania, etc.

Substances

• Depressants

  • Result in behavioural sedation or relaxation

  • Alcohol, benzos

• Stimulants

  • Cause one to be more activated or alert

  • Coke, nicotine, caffeine

• Hallucinogens (shrooms, LSD, PCP)

  • Change sensory processing

  • Produce hallucination, paranoia, 

• Opioids (pain pills, morphine, heroin, fent)

  • Reduce pain and euphoric feeling

• Other

  • Inhalant or over-the-counter medications

Alcohol

• World’s #1 psychoactive substance

• The most widely used substance in the world

• 7,000 BC China

• Binds to GABA and glutamate receptors, slowed down and reflects this as the depressant

• Intoxication

• Low doses: self-confidence, relaxation, slight euphoria, disinhibition 

• High doses: fatigue, lethargy, discoordination, blackout, impaired respiration, death

• Hangovers

  • Appear after a bout of heavy drinking when the drinker’s blood alcohol concentration (BAC) returns to 0.00g/dl

  • Hangovers occur when there's no more alcohol in your system

  • headache, fatigue, dehydration, anxiety, low mood, agitation

  • Causes = dehydration, sleep deprivation, cytokines (inflammatory makers)

• Hangovers vs withdrawal

  • Within a few hours: tremulousness (shakes), weakness, cramps, perspiration, nausea, headache

  • 12hr-3days: convulsive seizures

  • 12hr-3days: delirium tremens (“DTs)=hallucinations, delusions, fever, perspiration, irregular heartbeat

  • These stages of withdrawal can be fatal for people, this is why cold turkey is dangerous

  • Treatment is giving an alcohol detox regimen and other depressants that mimic

• Biphasic effect

  • Initially stimulating effects

  • Sedating effects as blood alcohol levels decrease

  • People’s responses to the effects of alcohol based on their drinking status and curve

  • The BAES is the alcohol effects scale, where people are asked when they’re drinking how happy they are, agitated, etc.

  • The red line is the alcohol line trigger (who drink a lot, HD)

  • The blue line is low drinkers (LD)

  • Energized, happy, excited

  • People in the HD group are in general feeling more stimulation and less sedation from alcohol across time compared to LD

  • As LD drinks, they have smaller stimulation and higher sedation, but there is a clear difference

  • The way people respond to alcohol as more stimulating with more positive effects and also less sedating effects are at high risk for AUD

  • When you drink and you feel happier, more confident, and by the end of the night you start to get more sedated 

Alcohol drinking

• Prevalence

  • Drinking

    • ~80% Canadians drinks

    • 81% of men, 73% of women

  • Alcohol use disorder (AUD)

    • 18.1% lifetime; 3.2% past year

    • 4.7% for men vs. 1.7% for women

• High-risk drinking

  • Split it up based on women and men

  • Women: more than 2 drinks in a day, more than 10 in a week

  • Men: more than 15 in a week

• Hazardous drinking/ binge drinking (level 1)

  • Women: 4 drinks in one sitting

  • Men: 5 drinks in one sitting

• Extreme binge drinking

  • Drinking more than that

  • Women: more than 8 in a sitting

  • Men: more than 10 in a sitting

• Significant risk for developing AUD

• Benefits?

  • Moderate use can decrease heart disease, stroke and diabetes

• Risks

  • Cirrhosis of the liver

  • Cancers

  • Fetal alcohol syndrome

  • Alcohol-relate dementia

Opioids

• Poppy plant

  • Opium:

    • First cultivated in lower Mesopotamia in 3400 BC

  • Morphine:

    • Germany 1803

  • Heroin (~10x more potent than morphine):

    • Production began 1895

    • Replacement for those struggling with morphine addiction

  • Fentanyl (~50-100x more potent than morphine):

    • Discovered in 1960s

• Primarily bind to opioid receptors 

• Intoxication

  • Euphoria, relaxation, dulled senses

  • Side effects: itchiness, impaired respiration, nausea, vomiting

• Withdrawal

  • “Worst flu of your life”

    • Pain sensitivity, cold sweats, dysphoria, vomiting, cramping, diarrhea

    • Typically non-fatal

• Prevalence

  • Opioids = 13% (2% non-medical)

    • 13.9% women vs. 12.1% men

• Heroin = < 1%

  • Typically, more use among men (particularly injection use)

• Benefits?

  • Very effective as pain relievers

  • Post-surgery helps minimize pain and is often used for patients dealing with cancer/end-of-life

  • Helps them feel better and not have as much pain

• Risks

  • High addiction potential

    • When you do use them, due to the euphoric feeling, changes in the brain, have the potential for misuse

  • Overdose

  • Liver failure

  • Blood-borne illnesses

    • Due to unsafe injections (unclean needles)

Cannabis

• First documented use as a medicine by the Chinese in 2027 BC

• Cannabinoid receptors

• Intoxication

  • Mild changes in perception, euphoria, analgesia (pain reduction)

  • Hallucinations, panic, anxiety, paranoia

• Withdrawal

  • Irritability

  • Disruption of appetite and sleep

  • 36% lifetime prevalence

• Risks

  • Deficits in working and short-term memory

  • Amotiavtional syndrome

  • Evidence of associations with psychotic episodes (~2%)

• Benefits

  • Glaucoma

  • Anti-nausea

  • Epilepsy (emerging)

  • Most everything else is anecdotal 

Models of addiction

• Biopsychosocial model

  • The difference between substances and SUDs, you need to have access to the substance to become addicted

  • One of the only forms of psychopathology that is truly preventable

  • If you don't use the substance, you’ll never get addicted

  • Biological factors (genetic vulnerability, enjoyment of how you feel) 

  • Environmental factors (peer group, family that uses, or opposite)

  • A lot of different risk factors and processes that contribute to SUDs

Treatments for substance use disorders

Biological

• Alcohol

  • Benzos (withdrawal)

  • Naltrexone (opioid antagonist, alcohol is less rewarding)

  • Antabuse (blocks metabolism of acetaldehyde, taken before drinking and leads to immediate hangover/sickness – think conditioning)

• Opiates

  • Naloxone (opioid receptor antagonist, reverse an overdose)

  • Methadone (opioid agonist, mimics effects and given to someone who has a heroin addiction and helps reduce craving to prevent withdrawals)

  • Buprenorphine/naloxone (similar to methadone, reducing craving a withdrawal, doesn’t allow you to get high when you use heroin, another harm reduction approach)

Psychological/behavioural treatments

• 12-step/AA

  • use a disease model and sees alcohol as a disease and the user is powerless over this disease

  • The person has to maintain abstinence

  • Peer-lead, folks who have had AUD and are sponsors, but have recovered

  • Works for a lot of people, but not a lot of testing of these programs

• CBT

  • Individuals would identify thoughts and triggers associated with substance use and try to develop skills to manage substance use

  • Trying to understand what the patterns of use are, contributing to use, underlying causal or maintaining factors

  • Trying to create better strategies for stopping

• Contingency management

  • Typically conducted in in-patient or other treatment settings

  • Tokens, monetary rewards when people aren’t using

  • Set up contracts and  behavioural charts with individuals and they get rewarded for not using

  • The problem is that they are hard to implement and not always practical 

  • Out-patient settings with no rewards can be seen as less effective

• Motivational interviewing

  • Non-judgmental approach

  • Illicit their reasoning to stop using

  • Help patient identify what is beneficial about their use

  • What’s getting in the way of things they are wanting to do 

  • Helping patients motivate themselves to change

  • Once motivated, you can integrate it with problem-solving (like CBT)

Goals of treatments

• Abstinence

  • No substance use

  • Helpful for some individuals who find any amount is a big trigger

  • Abstinence violation effect: attributes the cause of a lapse or slip to themselves, you may feel guilty, and then that can become a bigger relapse

• Moderation

  • Goal benign that you are going to accept that they will not stop completely

  • Develop a plan for how the person can use occasionally and in a controlled way

  • Sometimes this can be a good model for those who can’t see themselves using it or it is not an option

• Harm reduction

  • Accepting the person is going to continue using

  • The goal is not to stop use, but when using to be safe

  • I.e. safe injection sites, instead of streets or work, clean needles