Week 12 - Substance-related and Addictive Disorders

Substances and Addictive Disorders (SUADs):

A psychoactive substance is defined as anything that changes neurological functioning

Psychoactive substances are divided into:

  • Depressants

  • Stimulants

  • Hallucinogens

However this is a simplistic view of their properties

e.g. cocaine “stimulates” by depressing inhibition

OR cannabis has multiple active compounds, and despite THC being the main focus as a depressant, it can have multiple effects

Caffeine is most common stimulant, with a half life of 5 hours. Negative effects occur at 400-500 mg, and causes alertness, loss of sustained attention, increased anxiety, potential stomach discomfort

Alcohol is most common depressant, where 77% of Australians say they have used recently, heavy single-occasion usage prominent, but this decreases with age

28% say they have 2 drinks regularly, up to 4 (this can be a health risk)

Problematic drinking is high, but decreasing over time

Young people abstain for longe periods now than before

Other substances are less common, such as tobacco and especially illicit drugs, alongside misused medications, and usage rates are either stable or reducing

In fact in America pharmaceutical opioids were likely in recent studies to be involved in opioid deaths than heroin

Substance risk assessment:

Based of factors such as:

  • Rates of usage

  • Effects of substance/s

  • Social responses

Significant health impacts prevalent from drug use, with 20k Australian deaths being attributed in 2017.

Tobacco responsible for 9.3% of disease burden in 2015, especially from chronic respiratory and cancer related complications

Alcohol responsible for 4.5% burden, with it actually being leading risk factor for men aged 25-44 in 2015

Illicit drugs caused 2.7% of disease burden in 2015

Specific health effects of alcohol:

  • Liver issues such a fatty liver, fibrosis, cirrhosis, liver failiure

  • Pancreatitis (from high single-occasion consumption especially)

  • Cancers of gastrointestinal tract, kidneys, breast

  • Cardiovascular issues

  • Sleep disorders

  • Sexual dysfunction

  • Weakened immune systems, longer recover times from injury

  • Neurological/neurocognitive issues

  • Foetal alcohol syndrome

Other damaging implications:

  • Financial

  • Use of machinery while intoxicated

  • Interpersonal injuries from lack of inhibition while drunk

  • Occupational accidents

  • Exacerbate and are often co-morbid with other mental health concerns

  • Obesity

DSM-5 describes problematic substance use as causing

  • Physical dependence, with tolerance present without functional harm, and withdrawal being severe/harmful

  • hazardous/risky use

  • harmful use: hazardous use with risks now understood

  • Addiction (much broader concept than drug use however)

Prior conceptualisation in DSM-5 separated substance usage problems into “substance dependence” and “substance abuse”, with dependence being more severe form

Current DSM-5 sees reclassification into Substance related and addictive disorders, with a SUD (substance use disorder) first being identified, then severity specified

Gambling disorder added to this section

Substance Use Disorder Criteria Abbreviated:

2/11 possible features in 12-month period, such as:

-Problems with control

  • larger amounts or longer periods of consuming

  • persistent desire or unsuccessful attempts to control

  • craving/strong desire or urge

-Priority

  • substantial time spent obtaining, using, recovering

  • failure to fulfil major role obligations

  • important activities given up or reduced

-Continued use despite concerns

  • use despite interpersonal problems

  • recurrent use when physically hazardous

  • use despite knowledge that a physical or psychological problem is caused or exacerbated by it

-Physical Dependance

  • Tolerance

  • Withdrawal

Alcohol withdrawal criteria:

  • Nausea

  • Autonomic hyperactivity

  • Hand tremor

  • Insomnia

  • Transient visual, tactile or auditory hallucinations

  • Psychomotor agitation

  • Anxiety

  • Seizures

Occurring after heaving drinking , distress or impairment, no other attributions seen

OR

Another closely related substance, such as benzodiazepines, used to relieve or avoid withdrawal

Severe Alcohol Withdrawal:

  • Typically begins 8 hours after last drink, peak is 72 hours, with reduced symptoms 5-7 days

  • Occurs in phases

  • Grand mal seizures (described by sudden loss of consciousness and violent muscle contractions) occurring 12-48 hours after last drink

  • Potentially fatal (1-4%)

  • For safety, may involve hospitalisation/institutionalisation

Severe withdrawal symptoms can be life threatening and can peak and fluctuate at different times

Non-substance related addictions:

Controversial, many parallels with control, craving, priority, continued behaviour despite problem

Sometimes has similar phenomena with withdrawal and tolerance (gambling)

Can also parallel with other disorder types, including impulse control problems

Gambling Disorder criteria abbreviated:

Criterion A: Persistent and recurring maladaptive gambling behaviour, indicated by 4 or more symptoms being present over 12 month period

Criterion B: gambling behaviour is not better explained by a manic episode

Important to specify if:

  • Episodic

  • Persistent

  • In-early remission

  • Sustained remission

  • Specify current severity: 4-5 mild, 6-7 moderate, 8-9 severe

Internet Gambling Disorder almost added to DSM-5, but did not show enough evidence in literature to differentiate from others. It is still in the conditions for further study section.

Gaming Disorder recognised by ICD-11, codifying it a a medical illness. Requirements slightly different from DSM-5 requirements, with DSM invoking physiological components as well

Aetiology:

Substance use is common, and not everyone has addiction, so what causes addiction?

Biological factors:

  • addictive properties by solidifying neural reward networks

  • genetics, via inherited predispostion for alcohol dependence

Psychological factors:

  • Expectations about drugs effects

  • role models/learning (particularly in children observing parents behaviours)

Social

  • Availability, cultural/religious norms

Integrated biopsychosocial explanations:

Epigenetic factors / genetic predisposition +/- utero exposure to alcohol +/- neurodevelopmental and neurocognitive effects

Initial exposure: influenced by availability, norms, safety appraisal, reactions of others. Physiological effects, liking/disliking “intoxication”. Psychological inputs such as self awareness, self medication, stress reduction/avoidance

If early exposure is positive, continued use is prone to rewarding effect to influence it

Treatments:

Self help with 12 step program, strengths include:

  • long term support group

  • public commitment

  • day-at-a-time focus

  • admission of wrongs and compensation for others who have been affected

  • ways back after falter

Limitations

  • admitting powerlessness addresses excessive self-efficacy- but may undermine it

  • permanent label elicits continued vigilance-but maintains self definition (addicted) May this continued focus trigger lapses

  • Some reject spiritual aspects

Motivational Interviewing: Counselling approach to support readiness for change; can be used early on and in combination with other features

Detox/Medication: withdrawal management through aversive conditioning, reward blockers, anticonvulsants

Community reinforcement: creates a context that stimulates and rewards change in behaviour from addictive tendencies. Through creating opportunities for employment, non-using social groups

Contingency management: rewards for clean tests, other activity, but behaviour stops once reward stops. Need lasting benefit from short-term compliance, such as skills that don’t go away

Planning and preparing for re-treatment is key as relapse is very common

Other cognitive behavioural techniques:

  • Identify, plan for high risk situations

  • Establish pleasurable, routine non-drug activities

Cognitive therapy or mindfulness:

  • for low self efficacy

  • distress, guilt, shame

  • overly positive expectancies

  • craving “urge surfing”

Couple therapies: improving interpersonal relationships can lead to lessened psychological negative effects that people may be “escaping”

Social/community programs raising awareness

Effectiveness of treatments:

  1. General trends show that some of the most effective “treatments” are good brief interventions. For people who already have skills, they may just need help applying them

  2. Large scale trials find that few differences in impact from 12 step/AA programs, adding psychological treatment to medication helps improve effects.

  3. Success varies based on special groups/circumstances

Special groups:

Adapting programs for groups and individuals is important to address the specific sociopolitical situations of certain groups,

such as Culturally and Linguistically Diverse (CALD) people, Indigenous populations, Poly-substance users, younger people, older people, Homeless people, people with Trauma-history, People with Brain injuries, and people with comorbidities

Prevention of Substance Disorders:

Policy distinctions:

  • Supply control through quality control, prohibition vs legalisation

  • Harm minimisation: Information and empowerment to reduce risk/harm e.g. pill testing - usually combined with advice, link to treatment, Decriminalisation

  • Combined strategies, e.g. prohibition and decriminalisation, but must consider what is supply is illegal then its prone to criminal link and lacks quality control, and is there a maximum amount we should consider? is this arbitrary?

  • Marketing from legalisation can increase use and harm