Substance Use and Addiction Disorders

I. Classification of Substance-Related Disorders

Substance-related disorders fall into two major categories:

1. Substance Use Disorders (Addiction)

2. Substance-Induced Disorders

   • Intoxication

   • Withdrawal

   • Psychosis

   • Depression

   • Bipolar Disorder

   • Anxiety Disorders

   • Sexual Dysfunction

   • Sleep Disorders

Mood-altering substances are prevalent in society, often socially acceptable, and commonly used by many adults in moderation.

II. Classes of Psychoactive Substances

1. Alcohol

2. Caffeine

3. Cannabis

4. Hallucinogens

5. Inhalants

6. Opioids

7. Sedatives/Hypnotics

8. Stimulants

9. Tobacco

III. Foundational Issues

• Alcohol is often seen as a social lubricant.

• Drug use, however, is associated with severe risks and consequences.

• Substance use disorders contribute to more deaths, illnesses, and disabilities than any other preventable health condition (SAMHSA).

• Recognized as a national epidemic, substance abuse is linked to an alarming number of deaths.

Notable Celebrities Who Died Due to Substance Use

• Heath Ledger

• Jimi Hendrix

• Anna Nicole Smith

• Whitney Houston

• Elvis Presley

• River Phoenix

• Chris Farley

IV. Basic Facts About Addiction

• Addiction is treatable, not curable.

• An addict is always recovering, never fully recovered.

• Without treatment, most addicts eventually die.

• Anyone can become an addict.

V. Predisposing Factors for Addiction

1. Biological Factors

• Genetics: A hereditary component is particularly noted in alcoholism.

• Biochemical: Alcohol may trigger pleasurable sensations in the brain, reinforcing addiction.

2. Psychological Factors

• Developmental Influences: Early childhood experiences and trauma can contribute.

• Punitive Superego: Fixation at the oral stage of psychosexual development.

• Self-Medication: Using substances to cope with panic, anger, depression, or alexithymia (inability to recognize one’s emotions).

• Personality Traits:

  • Risk-taking behaviors

  • Difficulty communicating

  • Inability to relax

• Cognitive Distortions:

  • Denial – refusing to acknowledge the problem

  • Projection – blaming others for substance use

  • Rationalization – justifying substance use

3. Social Factors

• Social Learning: Parental modeling of substance use increases risk in children.

• Peer Influence: Substance use is often reinforced within peer groups.

• Conditioning: Positive reinforcement from pleasurable effects encourages continued use.

• Cultural and Ethnic Influences: Some cultures and social norms may promote or discourage substance use.

VI. Why Do Individuals Seek Treatment?

1. They are facing negative consequences and risk significant losses (health, relationships, jobs, legal issues).

2. They want to reduce their substance use but may not have a full commitment to quitting.

3. They need temporary relief (e.g., avoiding financial trouble or threats from drug dealers).

Progression of Alcohol Use Disorder (Phases)

Phase I: Early Use

• Used as stress relief.

• Tolerance develops (need for increasing amounts to achieve the same effect).

Phase II: Problematic Use

• Blackouts (memory loss from drinking).

• Alcohol becomes necessary to function in daily life.

• Secret drinking begins.

• Preoccupation with the next drink.

• Guilt, denial, and rationalization of drinking behavior.

Phase III: Dependence

• Loss of control over alcohol consumption.

• Physiological dependence (body requires alcohol to function).

• Life problems worsen (job loss, relationship issues).

• Moral decay (dishonesty, irresponsibility).

• Increased anger and aggression.

• Alcohol becomes the "great reliever" (relied on for emotional escape).

Phase IV: Chronic Stage

• Drinking > Sobriety (intoxicated more than sober).

• Feelings of helplessness and self-pity.

• Suicidal ideation (SI) may occur.

• Physical deterioration (malnutrition, organ damage).

• High risk for Delirium Tremens (DTs)—a severe withdrawal complication.

Effects of Alcohol on the Body

Psychological & Behavioral Effects

• Gradual personality changes:

  • Low self-esteem

  • Feelings of failure & inadequacy

  • Guilt, shame, loneliness, and despair

• Sexual dysfunction (libido may increase or decrease).

Physical Effects

Alcohol Screening Tools

CAGE Questionnaire

A simple screening tool to assess alcohol dependence:

1. Cut Down – Have you ever felt the need to cut down on your drinking?

2. Annoyed – Have people annoyed you by criticizing your drinking?

3. Guilty – Have you ever felt guilty about your drinking?

4. Eye Opener – Have you ever needed a drink first thing in the morning to steady your nerves?

👉 Two or more “yes” responses suggest possible alcohol dependence.

CIWA (Clinical Institute Withdrawal Assessment)

• Used to assess alcohol withdrawal severity.

• Evaluates symptoms like:

  • Tremors

  • Sweating

  • Nausea

  • Anxiety

  • Hallucinations

  • Seizure risk

Alcohol Withdrawal Timeline

Delirium Tremens (DTs)

• Most serious and potentially fatal withdrawal syndrome

• Symptoms:

  • Severe agitation, tremors, disorientation

  • Persistent hallucinations (visual, auditory, tactile)

  • Large increases in HR, BP (hypertension, tachycardia)

Pharmacotherapy for Alcoholism

Alcohol Deterrence

• Disulfiram (Antabuse) – causes unpleasant reactions if alcohol is consumed.

  • Ensure:

    • No alcohol for at least 12 hours before starting disulfiram.

    • Avoid alcohol for up to 2 weeks after discontinuation.

    • Hidden alcohol sources (e.g., mouthwash, aftershave, rubbing alcohol) must be avoided.

Alcohol Withdrawal Treatment

1. Benzodiazepines

   • Chlordiazepoxide (Librium), Oxazepam (Serax), Lorazepam (Ativan), Diazepam (Valium)

   • Reduces withdrawal symptoms and seizure risk

2. Anticonvulsants

   • Carbamazepine (Tegretol), Valproic Acid (Depakote), Phenobarbital (Luminal), Gabapentin (Neurontin)

   • Used to prevent withdrawal seizures

3. Multivitamin Therapy

   • Corrects nutritional deficiencies common in alcoholism.

4. Thiamine (Vitamin B1) Supplementation

   • Prevents Wernicke’s encephalopathy, a serious neurological disorder.

Staying Sober

Daily Sobriety Disciplines

• Friends – Change social circles to avoid alcohol-related triggers.

• Meetings – Attend 90 meetings in 90 days (Alcoholics Anonymous - AA).

• Work Habits – Change daily routines to avoid temptation.

• Sponsor – Get a sober mentor for accountability.

Alcoholics Anonymous (AA)

• 12-Step Program for maintaining sobriety.

• First 4 Steps:

  1. Admit powerlessness over alcohol; life has become unmanageable.

  2. Believe in a Higher Power to restore sanity.

  3. Turn life over to a Higher Power.

  4. Conduct a fearless moral inventory of oneself.

Family Issues in Alcoholism

Key Terms

• Enabling – Covering up for the alcoholic's actions, removing consequences.

• Codependency – A person becomes addicted to helping the alcoholic.

• Examples of enabling behavior:

  • Making excuses for drinking.

  • Paying bills, bailing out of jail.

  • Rationalizing irresponsible behavior.

  • Cleaning up their messes.

Important Terms & Concepts

Dependence & Tolerance

• Physical Dependence

  • Need for increasing amounts to produce the desired effect.

  • Withdrawal symptoms occur when alcohol is stopped.

• Psychological Dependence

  • Cravings and desire to use alcohol to feel good or function normally.

• Tolerance

  • Larger doses required for the same effect.

  • Diminished effect over time with the same amount of alcohol.

Alcohol Intoxication

• Blood Alcohol Level (BAL):

  • 100-200 mg/dL → Signs of intoxication.

  • 400-700 mg/dL → Can be fatal.

Alcohol Withdrawal

• Symptoms occur within 4 – 72 hours after stopping alcohol.

• Severe withdrawal + malnutrition = risk for Delirium Tremens (DTs).

Defense Mechanisms in Alcoholism

Stimulant (Cocaine) Withdrawal

Signs & Symptoms

• Pupil Changes – Dilated pupils (under influence).

• Sleep Patterns –

  • Insomnia while using → Hypersomnia (excessive sleep) in withdrawal.

• Cravings – Strong urge to use again.

• Mood Swings – Dysphoria (distress) → Euphoria (pleasure).

• Increased Appetite – Common withdrawal symptom.

• Psychomotor Changes:

  • Agitation (restlessness, pacing)

  • Psychomotor Retardation (slowed thoughts and movements)

Opioid/Heroin Withdrawal

Signs & Symptoms

• Pupil changes → Small, constricted pupils (miosis) when under the influence.

• Cravings → Strong urge to use again.

• Mood changes → Dysphoria (distress, anxiety) → Euphoria (pleasure, relief).

• Excessive bodily fluids → Sweating, tearing (lacrimation), runny nose (rhinorrhea).

• Gastrointestinal (GI) symptoms → Diarrhea, stomach pain, nausea, vomiting (N/V).

• Vital Signs Changes → Tachycardia (increased HR), hypertension.

• Withdrawal timeline →

  • Begins 6-12 hours after the last dose.

  • Lasts 1-7 days depending on severity and opioid type.

Opioid/Heroin Withdrawal Treatment

1. Methadone

• Suppresses withdrawal symptoms if started on Day 1.

• Gradual tapering helps prevent withdrawal symptoms.

2. Narcotic Antagonists (Reversal Agents)

• Naloxone (Narcan)

  • Reverses opioid overdose (respiratory depression, coma).

  • Short-acting, may require repeated doses.

• Naltrexone (ReVia)

  • Blocks opioid effects to prevent relapse.

  • Used in long-term maintenance therapy.

• Nalmefene (Revex)

  • Similar to Naloxone, but longer duration of action.

Other Street Drugs & Their Effects