Detailed Notes about Substance Use and Addictive Disorders (SUD)

Substance Use and Addictive Disorders

• Psychoactive substance: Any substance other than food that affects our bodies or minds, including alcohol, tobacco, and caffeine.
• Acts on the central nervous system, affecting thought, emotions, and behavior.
• Substance intoxication: Cluster of changes in behavior, emotion, or thought caused by substances (DSM-5).
• Substance use disorder (SUD): Maladaptive behavior patterns and reactions caused by repeated substance use.
• The term “substance” includes alcohol, tobacco, and caffeine.

Types of Psychoactive substances

• CNS depressants:
  • Alcohol
  • Antianxiety medications or Benzodiazepines (e.g., Xanax, Ativan)
  • Hypnotics (sleep medications – e.g., Halcion, Lunesta, Ambien)
  • Barbiturates or sedatives (amobarbital, phenobarbital, Seconol)
    • Alcohol and barbiturates combined have synergistic effects, becoming 4x more powerful than when used individually.
• Cannabis: marijuana; hashish; butane hash oil or BHO
• Opioids or narcotic analgesics:
  • Prescription painkillers (e.g., Fentanyl, Oxycontin, Vicadin)
  • Opium, morphine, fentanyl, heroin
  • Addictive drugs with pain-relieving and sleep-inducing properties.
    • Morphine, codeine, and heroin are derived from the juice of the poppy plant.
    • Fentanyl (80-100x stronger than morphine), Demerol, Percodan, and Darvon are synthetic drugs with opiate-like effects.

More Types of Psychoactive Substances

• CNS stimulants: nicotine; caffeine; amphetamine & methamphetamine; cocaine
• Hallucinogens: LSD; PCP; mescaline (peyote); mushrooms
• Solvents: aerosol sprays (e.g., Dust-Off, Reddi-Whip & hairspray); glue; paint thinner
  • “Huffing” is the term used to inhale solvents.
  • Difluoroethane (in canned air cleaners like Dust-Off) promotes GABA activity, similar to alcohol.
  • NIDA (2015): 10% of US persons aged 12+ had misused inhalant products to get high.

Substance Use Disorders (SUD)

• Maladaptive pattern of substance use leading to significant impairment or distress.
• Presence of at least 2 of the following symptoms within a 1-year period:
  • Substance taken in larger amounts or over a longer period than intended.
  • Unsuccessful efforts or persistent desire to reduce or control substance use.
  • Much time spent trying to obtain, use, or recover from the effects of substance use.
  • Failure to fulfill major role obligations at work, school, or home due to repeated substance use.
  • Continued use despite persistent social or interpersonal problems caused by it.
  • Cessation or reduction of important activities because of substance use.
  • Continuing to use substance in situations in which use poses physical risks.
  • Continuing to use substance despite awareness that it is causing or worsening a physical or psychological problem.
  • Craving for substance.
  • Tolerance effects.
  • Withdrawal reactions.

SUD Ethnicity & Treatment (Tx) Statistics

• American Indians/Indigenous peoples have the highest rate of substance use disorders in the United States (11.6 %), while Asian Americans have the lowest (3.8 %).
• Non-​Hispanic white Americans, Hispanic/Latine Americans, and African Americans have rates between 7 and 8.2 % (NSDUH, 2016; SAMHSA, 2017).
• A study of undergraduate college students (McCabe et al., 2007) found that whites and Latines were more likely to have issues surrounding drug abuse than their Asian and African American counterparts.
• 13% of SUD persons seek treatment. However, rates vary by substance: 54.9% of those with heroin addictions sought treatment in 2017.
• Only 18 % of all those with substance use disorders receive treatment from a mental health professional.

SUD Risk Factors

• US is a drug(-loving) culture
• Being male
• Family history of substance abuse
• Age 16-25 at greatest risk for abusing alcohol and other drugs
• Elderly at greatest risk for abusing prescription drugs and OTC medications
• Ethnicity: American Indian/Indigenous Americans are at most risk; Asian Americans at least risk
• Less education
• Poverty
• Incarceration
• Unemployment - almost twice as many people who are unemployed struggle with addiction than those who are fulltime workers (CNN Money, 2013); around 17 percent of the unemployed vs. 9 percent of the employed population struggled with a substance use disorder in 2012.

Route of Administration Table

• Route of administration – how a drug is ingested; the more efficient routes lead to greater likelihood of addiction and binge use.
• Injection
• Snorting
• Inhaling/smoking
• Oral ingestion
• Other: Under tongue; inserted anally; inserted vaginally; eyedrops

SUD Statistics

• 48.5 million Americans aged 12+ (16.7%) met criteria for a substance use disorder or SUD in the past year.
• 28.9 million or 10.2% of Americans 12+ had an alcohol use disorder (AUD) in the past year.
• 27.2 million or 9.7% of Americans 12+ struggled with a (non-alcohol) substance use disorder in the past year.
• 7.5 million or 2.7% of Americans 12+ struggled with co-morbid alcohol and drug use disorders or polysubstance use disorders (PUD).
• 20.4 million (7.9%) American adults suffered from both a mental illness and a SUD aka as dual diagnoses or co-occurring disorders in the past year.
• Among adults 18+ yrs, 24.5% or 61.2 million people had either a mental illness or a SUD in the past year.
• 20+% of those with mental illness(es) meet criteria for SUD(s).
• Over half of all American adults have a family history of problem drinking or alcohol addiction.
• An estimated 88,000 people die from alcohol-related causes annually.
• 50+% of the homeless suffer from SUD and 30+% suffer from severe mental illness (SMI).
• Drug abuse and addiction costs total more than 740 billion annually in lost workplace productivity, healthcare expenses, and crime-related costs.

SUD Statistics

• Drug related fatalities have increased for 15 successive years and have doubled in the past decade.
• Drug overdoses are now the number one cause of accidental deaths, overtaking motor vehicle accidents.
• According to the Centers for Disease Control (CDC), opiates are responsible for 7 out of 10 overdose deaths in the United States
• Between 2000-2020, the number of overdose deaths involving opioids (including prescription opiates and illegal opiates like heroin and illicitly manufactured fentanyl) increased 400%.

SUD - Alcohol Statistics

• 88,000 Americans die from alcohol use every year.
• Worldwide, 3+ million people die from alcohol abuse, alcoholism, and alcohol use disorder (AUD) each year, which accounts for 6% of global deaths.
• Alcohol alone is involved in more than 1/3rd of all suicides, homicides, rapes, assaults, and accidental deaths.
• Men are 2x as likely as women to suffer from AUD and 3x as likely as women to die due to alcohol abuse.
• 32% of young adults reported binge drinking (5+ drinks in a row in past 2 weeks) in 2021. High-intensity drinking (10+ drinks in a row in past 2 weeks): 13% - highest level since 2005 (11%).
• Over 50% of the population has had exposure to alcoholism in the family.

SUD & the Criminal Justice System

• About half of the population of American prisons and jails suffers from addiction.
• 80% of offenders abuse drugs or alcohol.
• Approximately 60% of individuals arrested for most types of crimes test positive for illegal drugs at arrest.
• NIH (2013):
  • About 45% of inmates in local jails and state prisons suffered from both substance addiction and mental illness.
  • In addition, about 75% of inmates with a mental illness also met criteria for substance abuse.
• Providing treatment is cost-effective, saving between 2 and $6 for every $1 spent on it, which in part reflects reductions in criminal behavior and re-incarceration.
• Longitudinal studies show that treatment begun in the criminal justice system and continued in the community garners lasting reductions in criminal activity and drug abuse.

SUD & COVID-19

• CDC: 08/15/20
  • 13.3% of survey respondents reported starting or increasing substance abuse (including drugs and alcohol)
• Between March 13 and May 30, 2020:
  • 32% increase for nonprescribed fentanyl
  • 20% increase for methamphetamine
  • 12.5% increase for heroin
  • 10% increase for cocaine
  • 18% increase in suspected drug overdoses
• NCDAS*: 04/30/22
  • 60% of people increased their alcohol consumption during COVID-19 lockdowns.
• AMA: 10/31/20
  • More than 40 states reported increases in opioid- and other drug- related mortality and abuse rates since the start of COVID-19 mandates.

U.S. Substance Use DOs & COVID-19

• NIDA (National Institute on Drug Abuse): 10/5/20
  • Those with substance use disorders (SUDs) are at greater risk of contracting COVID-19 and suffering more adverse health outcomes.
  • 7.5 million patients in the sample who had ever had any SUD (lifetime SUD) were 1.5 times more likely than the rest to have a COVID-19 diagnosis. Those with an opioid use disorder (OUD) were 2.4 times more likely to have COVID- 19 than those without, followed by people with cocaine use disorder (1.6 times), alcohol use disorder (1.4 times), and tobacco use disorder (smoking or vaping; 1.3 times).
  • Patients with lifetime SUD diagnoses also experienced more severe outcomes from COVID-19 than others, including hospitalization (41% versus 30%) and death (9.6% versus 6.6%).
  • 13 percent of African Americans in the sample with both lifetime SUD and COVID-19 died, versus 8.6 percent of Caucasians with both diagnoses.
  • Among other reasons, chronic substance use weakens the body and increases infection vulnerability. For ex., opioids compromise breathing and can lead to reduced blood oxygen or hypoxemia, which in turn can impact cardiac and pulmonary functioning.
  • Due to stigma and other barriers, people with SUDs are less likely to seek medical treatment and when they do, may receive substandard care or be rejected for care.

Substance Use Disorders

• Withdrawal – negative physical and psychological effects as a result of cessation of drug use or taking a reduced amount of the drug. Not all drugs lead to withdrawal; for example, cannabis (pot; hash), hallucinogens (LSD; PCP) do not lead to withdrawal.
• Tolerance – needing larger doses of a drug to achieve the desired effect or the effects of the drug are markedly less if the usual amount is taken. Not all drugs lead to tolerance.
• Polysubstance Use Disorder: More than 1 substance abused at the same time
• Dual Diagnosis: SUD and other mental illness; SUD and mood disorders or schizophrenia are highly comorbid

Cross tolerance

• Cross-tolerance
  • Sometimes two or more drugs are so similar in their actions on the brain and body that as people build a tolerance for one drug, they are simultaneously developing a tolerance for the other drug (even if they have never taken it).
  • Users who display this cross-tolerance can reduce the symptoms of withdrawal from one drug by taking the other.
  • Example: Alcohol and benzodiazepines are similar enough that drinking alcohol may help withdrawal from benzodiazepines (anti-anxiety meds).

Synergistic Effects

• Synergistic effects
  • When different drugs are in the body at the same time, they may multiply, or potentiate, each other's effects.
  • This combined impact is called a synergistic effect and is often greater than the sum of the effects of each drug taken alone.
  • One kind of synergistic effect occurs when two or more drugs have similar actions.
    • Example: Alcohol, barbiturates, benzodiazepines, and opioids
      • All depressants, these drugs may severely depress the CNS when mixed, leading to “accidental OD” and death.
  • A different kind of synergistic effect results when drugs have opposite (antagonistic) effects.
    • Example: Stimulants like cocaine mixed with depressants like barbiturates or alcohol
      • Individuals may build up lethal levels of the drugs because of metabolic issues (stimulants impede the liver's processing of barbiturates and alcohol).

Dependence Rates by Substance

• Nicotine: 32%
• Heroin: 24%
• Cocaine: 15%
• Alcohol: 15%
• Marijuana: 9%
• Hallucinogens: <10%

SUD Causes

• Genetics: Genetics, including the impact of one’s environment on gene expression, account for about 40% to 60% of a person’s risk of addiction. Abnormal genes, such as the abnormal D2 receptor gene, may cause dysfunction in the brain reward circuit à SUD.
• Brain reward circuit and dopamine activity: dysfunction in the brain reward circuit (prefrontal cortex, nucleus accumbens, and ventral tegmental area, plus the striatum, hippocampus, and hypothalamus) is thought to increase risk of SUD.
• Dopamine plays a primary role in the brain reward circuit and drugs like cocaine and amphetamines directly increase dopamine activity, while alcohol, opioids, and marijuana indirectly stimulate dopamine binding.
• Reward deficiency syndrome – brain reward circuit is not sufficiently activated by external events so the individual is reward or pleasure deficient. Alcohol and drugs stimulate the reward circuit à SUD.

SUD Causes

• Environmental factors include a chaotic home environment and abuse, parent’s drug use and attitude toward drugs, peer influences, community attitudes toward drugs, and poor academic achievement.
• Teenagers and people with mental health disorders are at greater risk for drug use and addiction than other populations.
• Cognitive behavioral model’s tension reduction hypothesis – people learn that using alcohol or drugs lowers distress (operant conditioning) leading to an increase in substance use when tense (“self- medicating”).

SUD Causes - More

• Developmental psychopathology view
• Substance use disorders
  • Genetically inherited predisposition
  • Externalizing or internalizing temperament
  • Numerous stressors throughout childhood (ACES)
  • Inadequate parenting, such as lack of nurturance
  • Rewarding substance use experiences
  • Relationships with peers who use drugs

Depressants

• Slow the activity of the central nervous system (CNS)
• Reduce tension and inhibitions
• May interfere with judgment, motor activity, and concentration
• Most widely used depressants*
  • Alcohol
  • Anxiolytics (benzodiazepines)
  • Cannabis
  • Sedative-hypnotic drugs (barbiturates)
  • Opioids/opiates (heroin, fentanyl, oxycontin)
• Cannabis/marijuana has depressant properties but also has stimulant, analgesic, and hallucinogenic effects as well.

Depressants - Opioids

• Opioids
  • Include natural (opium, heroin, morphine, codeine) and synthetic (fentanyl, oxycodone, methadone) compounds
  • Known collectively as “narcotics”
  • By 1917, opium-derived drugs were deemed addictive and illegal
  • Each drug has a different strength, speed of action, and tolerance level
  • Most are smoked, inhaled, snorted, injected (skin-pop or mainline), or swallowed
• Cause CNS depression; drugs attach to endorphin-related brain receptors

Endorphins

• Endorphins are also known as endogenous (natural) opioids; these are biochemicals produced in the brain, types of neurotransmitters, that help relieve pain and reduce emotional tension. They are our natural pain relievers.
• The good feeling after working out is due to the release and actions of endorphins.
• Opiates bind to endorphin receptors.

Depressants - Opioids Continued

• Injection seems to be the most common method of use, although other techniques have been increasing in recent years.
• An injection quickly brings on a “rush”—a spasm of warmth and ecstasy that is sometimes compared with orgasm.
• This spasm is followed by several hours of pleasurable feelings (called a “high” or “nod”).
• Opioids create these effects by depressing the CNS.
• Opioids bind to the receptors in the brain that ordinarily receive endorphins (NTs that naturally help relieve pain and decrease emotional tension).
• When these sites receive opioids, they produce pleasurable and calming feelings, just as endorphins do.
• In addition to reducing pain and tension, opioids can cause nausea, narrowing of the pupils, and constipation.

Depressants - Heroin

• Heroin
  • After just a few weeks, users may become caught in a pattern of abuse (and often dependence)
  • Tolerance for the drug quickly builds and withdrawal occurs when drug ingestion stops
  • Early withdrawal symptoms include anxiety and restlessness; later symptoms include twitching, aches, fever, vomiting, diarrhea, and weight loss from dehydration
  • Increased doses are required to avoid withdrawal

Depressants - Opioids

• 3.8% or over 10 million adults in the US abuse opioids each year
• 80 percent are addicted to pain relievers; 20 percent are addicted to heroin
• 224 deaths/day from opioid OD in US
• Mortality rate is 63 percent higher than in a non-addicted person when untreated
• The International Narcotics Control Board reported that in 2015, Americans represented about 99.7% of the world's hydrocodone (Vicodin) consumption. Where do people obtain pain killers for nonmedical use?

Depressants - Opioids - Danger

• Most immediate danger is overdose
  • Ignorance of tolerance
  • Getting impure drugs
  • Infection from dirty needles and other equipment
• Costs of opioid addiction in the US
  • The CDC estimates that the total