Substance Use Disorder

Understanding Addiction

  • Addiction: A strong physical or psychological need or urge to do something or use a substance, where control is lost. It's considered a complex brain disease manifested by compulsive substance use despite harmful consequences.

Core Concepts:

  • Reward: Humans are driven to pursue known rewards. Substances hijack the brain's reward pathways.

  • Tolerance: Needing more of the substance to achieve the desired effect, or getting a reduced effect from the same amount.

  • Dependence: Reaching a state where functioning without the substance feels impossible.

  • Withdrawal: Experiencing unpleasant physical and psychological symptoms when substance use is abruptly stopped or reduced.

  • Cycle: Tolerance can lead to taking increasingly larger amounts to achieve the initial pleasure.

Study Pointers:

  • Understand these four core concepts (Reward, Tolerance, Dependence, Withdrawal) as fundamental to addiction.

  • Recognize addiction as a brain disease involving compulsive behavior despite negative outcomes.

Substance-Related Disorders: Overview

  • These disorders are divided into two main groups:

    1. Substance-Use Disorders (SUDs): Characterized by a persistent pattern of substance use leading to impairment or distress, despite negative consequences. Includes tolerance, withdrawal, and continued use despite harm.

    2. Substance-Induced Disorders: Psychiatric conditions arising directly from substance use or withdrawal. Manifest as intoxication, withdrawal, or other mental disorders (like depression, anxiety, psychosis).

Study Pointer:

  • Clearly differentiate between using a substance despite problems (SUD) and problems caused by the substance's effects (Substance-Induced).

Substance-Use Disorder (SUD)

  • Definition: A cluster of cognitive, behavioral, and physiological symptoms indicating continued substance use despite significant substance-related problems.

Diagnostic Criteria (General Themes - need at least two within 12 months):

  • Impaired Control: Taking larger amounts/longer than intended; persistent desire or unsuccessful efforts to cut down; spending excessive time obtaining/using/recovering; craving.

  • Social Impairment: Failure to fulfill major role obligations (work, school, home); continued use despite social/interpersonal problems; giving up important activities.

  • Risky Use: Recurrent use in physically hazardous situations; continued use despite knowing it causes/worsens physical or psychological problems.

  • Pharmacological Criteria: Tolerance; Withdrawal.

    • Explanation: "Pharmacological" refers to the effects of the drug on the body.

  • Severity: Based on the number of symptoms present:

    • Mild: 2-3 symptoms.

    • Moderate: 4-5 symptoms.

    • Severe: 6 or more symptoms.

Study Pointers:

  • Group the 11 criteria into the four themes (Impaired Control, Social Impairment, Risky Use, Pharmacological) to help remember them.

  • Note that tolerance and withdrawal are not required for a diagnosis but are indicators.

Substance-Induced Disorders

1. Substance Intoxication:

  • Definition: Development of a reversible, substance-specific syndrome due to recent ingestion. Involves clinically significant problematic behavioral or psychological changes attributable to the substance's physiological effects on the CNS. Accompanied by substance-specific signs/symptoms. Not due to another medical condition or better explained by another mental disorder.

  • Common in individuals with or without an SUD.

  • Does not apply to tobacco.

2. Substance Withdrawal:

  • Definition: Development of a substance-specific problematic behavioral change (with physiological and cognitive concomitants) due to cessation or reduction in heavy, prolonged use. Causes significant distress or impairment. Not due to another medical condition or better explained by another mental disorder.

  • Usually, but not always, associated with an SUD.

  • Withdrawal symptoms during appropriate medical use of prescribed medications are not counted towards an SUD diagnosis.

3. Substance/Medication-Induced Mental Disorders:

  • Definition: A clinically significant presentation of symptoms characteristic of a mental disorder (e.g., psychosis, depression, anxiety) that predominates the clinical picture. There must be evidence (history, exam, labs) that symptoms developed during or soon after intoxication or withdrawal from a substance/medication capable of producing those symptoms.

  • Can occur with substances of abuse or prescribed/over-the-counter medications taken at suggested doses.

  • Examples: Sedating drugs (alcohol, sedatives) can cause depressive disorders during intoxication and anxiety during withdrawal. Stimulating drugs (amphetamines, cocaine) can cause psychotic and anxiety disorders during intoxication and depressive episodes during withdrawal.

Study Pointers:

  • Understand the specific definitions and criteria for intoxication and withdrawal.

  • Know that other mental disorders can be directly induced by substance use or withdrawal.

  • Note the exclusion criteria (not due to other medical conditions, etc.).

10 Substance Classes Covered by DSM-5 Criteria

  1. Alcohol

  2. Caffeine

  3. Cannabis

  4. Hallucinogens (including Phencyclidine - PCP)

  5. Inhalants

  6. Opioids

  7. Sedatives, Hypnotics, or Anxiolytics

  8. Stimulants

  9. Tobacco

  10. Other (or Unknown) Substances

Specific Substance Classes: Key Points from PPT

Alcohol:

  • Examples: Beer, wine.

  • Withdrawal: Develops after 4-12 hours, can be unpleasant, potentially triggering reuse. Seizures can occur.

  • Risks: Adolescents vulnerable to brain damage (learning, memory, decision making).

Caffeine:

  • Examples: Coffee, tea, soft drinks, energy drinks, chocolate, weight loss aids.

  • Intoxication: Higher doses lead to muscle twitching, rambling thoughts/speech.

  • Withdrawal: Headache, fatigue, irritability, difficulty concentrating.

Cannabis (Marijuana):

  • Intoxication: "High," euphoria, inappropriate laughter, grandiosity, sedation, lethargy. Distorted sensory perceptions, time passing slowly.

Hallucinogens (Phencyclidine - PCP):

  • Examples: PCP ("angel dust"), ketamine, dizocilpine. Dissociative hallucinogen. Smoked, oral, snorted, injected. Ketamine used for depression.

Inhalants:

  • Examples: Gases from glues, fuel, paint (volatile hydrocarbons).

  • Intoxication: Immediate upon inhalation.

  • Risks: Unconsciousness, anoxia (lack of oxygen), death. Lingering odors, peri-nasal rash may suggest use.

Opioids:

  • Examples: Heroin (illegal), medically prescribed pain relievers.

  • Function: Relieve pain, induce euphoria.

  • Intoxication: Initial euphoria followed by apathy, dysphoria, psychomotor agitation, impaired judgment.

Sedatives, Hypnotics, or Anxiolytics:

  • Examples: Sleeping medications, anti-anxiety medications. Act as brain depressants.

  • Intoxication: Inappropriate sexual/aggressive behavior, mood fluctuation, impaired judgment, slurred speech, falls.

  • Note: Tolerance/withdrawal from appropriate medical use does not meet criteria for SUD. Often prescribed to alleviate effects of other SUDs.

Stimulants:

  • Examples: Amphetamines (cocaine, crack, methamphetamine).

  • Function: Stimulate CNS, produce sympathomimetic effects. Prescribed for obesity, ADHD, narcolepsy.

  • SUD: Can develop within one week of use onset.

  • Risks: Panic attacks, paranoid psychosis, heart attacks.

Tobacco:

  • SUD: Occurs in those who smoke daily.

  • Withdrawal: Strong cravings occur if smoking ceases for several hours.

Study Pointers for Substance Classes:

  • For each class, know common examples, key intoxication/withdrawal features, and specific risks mentioned.

  • Pay attention to notes distinguishing medical use from SUD (e.g., Sedatives, Opioids).

Gambling Disorder

  • Considered an addictive disorder (behavioral addiction).

  • Definition: Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress.

  • Key Features: Involves risking something of value for hopes of greater value; "chasing one's losses" (urgent need to gamble more to undo losses); cognitive distortions (denial, superstitions, sense of power over chance, overconfidence).

  • Onset: Early expression more common in young men (18-21); youth often start gambling with family/friends.

  • Diagnostic Criteria (Summarized): Need 4 or more in a 12-month period: Need to gamble with increasing money; restless/irritable when trying to cut down; repeated unsuccessful efforts to control/stop; preoccupied with gambling; gambles when distressed; chases losses; lies to conceal involvement; jeopardized/lost relationships/jobs/opportunities; relies on others for money due to gambling.

  • Exclusion: Behavior not better explained by a manic episode.

  • Specifiers:

    • Episodic vs. Persistent.

    • In Early Remission (3-12 months symptom-free) vs. In Sustained Remission (>12 months symptom-free).

    • Severity: Mild (4-5 criteria), Moderate (6-7), Severe (8-9).

Study Pointers for Gambling Disorder:

  • Recognize this as the primary behavioral addiction currently in the DSM SUD chapter.

  • Focus on the concepts of "chasing losses" and cognitive distortions.

  • Learn the criteria themes (similar structure to SUDs: preoccupation, loss of control, negative consequences).

Epidemiology (Profile of Drug Abusers, Philippines 2023 Data)

  • Age: Median 35 years.

  • Sex: Male:Female ratio 12:1.

  • Civil Status: Mostly Single (52.07%).

  • Employment: Mostly Employed (57.09%).

  • Education: Highest group at High School Level (26.96%).

  • Income: Average family income ~Php 13,201.

  • Residence: Mostly Urban (NCR 26.11%).

  • Duration: >6 years.

  • Pattern: Mostly Mono drug use (one drug).

  • Primary Drugs: Methamphetamine (Shabu), Cannabis (Marijuana), Cocaine.

Study Pointer:

  • Note the key demographic features and substances most commonly abused according to this specific dataset.

Etiology (Causes of SUDs)

Biological Dimensions:

  • Genetic/Familial: SUDs run in families; shared genetic risk factors across substances.

  • Neurobiological: Substances hijack the brain's pleasure/reward pathway (mesolimbic dopaminergic system ); all addictive drugs increase dopamine activity; other neurotransmitters involved (serotonin, norepinephrine, etc.).

    • Explanation: The "mesolimbic dopaminergic system" is a key brain circuit involved in motivation, reward, and pleasure, heavily implicated in addiction.

  • Physiological Reactivity: Some individuals (e.g., sons of alcoholics) may have lower sensitivity to negative effects (e.g., of alcohol), increasing risk.

  • Self-Medication: Using substances to cope with symptoms of other mental disorders (ADHD, anxiety, depression); treating the underlying disorder can reduce SUD risk.

  • Psychological Dimensions:

    • Positive Reinforcement: Using substances for pleasurable effects (euphoria, relaxation). Social context can enhance reinforcement. External rewards can also influence use.

    • Negative Reinforcement: Using substances to escape or reduce unpleasant feelings (stress, pain, negative emotions). Concepts include:

      • Tension-Reduction Hypothesis: Consuming to alleviate anxiety/stress.

      • Self-Medication Theory: Coping with difficult emotions/conditions.

      • Negative Affect Regulation: Using substances to manage negative emotions.

  • Cognitive Dimensions:

    • Expectancy Effect: Beliefs/expectations about drug effects influence behavior. Positive expectancies predict future use. Formed via modeling, peers, media.

    • Cravings and Cue Reactivity: Intense urges (cravings) triggered by drug-related cues, emotions, small doses (priming), environmental stimuli. Craving management is key for relapse prevention.

      • Explanation: "Cue reactivity" refers to the physiological and subjective reactions (like cravings) that occur when exposed to stimuli previously associated with substance use. "Relapse" is returning to substance use after a period of abstinence.

  • Social Dimensions:

    • Initial Exposure: Friends, family, media, advertising play a role. Media/advertising can be influential.

    • Family/Parental Influence: Drug-using parents increase risk; poor monitoring/supervision linked to drug-using peers. Family history of SUD predicts early use.

    • Peer Influence/Social Learning: Mimicking peer behavior; normalization of use.

    • Cycle in Dysfunctional Environments: Normalization leads to adoption of behaviors; cycle across generations. Emphasizes need for early intervention.

  • Cultural Dimensions:

    • Acculturation & Identity: Adjusting to a new culture can be protective or a stressor. Cultural concepts (machismo, marianismo, spirituality, tiu lien - loss of face) influence use.

      • Explanation: "Acculturation" is the process of adapting to a new culture. Machismo (emphasis on masculinity) and marianismo (emphasis on traditional femininity) are concepts often discussed in Hispanic/Latinx cultures. Tiu lien (losing face) is important in many East Asian cultures.

    • Cultural Framing: Whether use is seen as dysfunction or accepted behavior varies culturally; shapes rates, approaches to addiction/treatment.

Study Pointers for Etiology:

  • Adopt an integrated perspective – biological, psychological, social, and cultural factors all interact.

  • Understand the difference between positive and negative reinforcement in maintaining substance use.

  • Recognize the power of expectancies and cravings/cues.

  • Consider the influence of family, peers, and broader cultural context.

Treatment Approaches

Cognitive-Behavioral Therapy (CBT):

  • Cognitive Therapy: Challenges and changes irrational thoughts about substance use and related situations; addresses psychological dependence.

  • Behavioral Therapy: Changes maladaptive learning patterns/behaviors. Examples:

    • Skills Training: Understanding triggers (antecedents) and consequences; recognizing high-risk situations.

    • Self-Monitoring: Recording substance use, situations, and emotions leading to urges.

Family and Marital Therapy:

  • Multidimensional Family Therapy (MDFT): 12-week program focusing on adolescent-parent bond, negotiation/problem-solving skills, supervision, correcting school problems. Goal: Foster environment preventing relapse, reduce enabling/"codependence".

Group Therapy:

  • Meeting with a therapist to reduce substance use. Practices: education, commitment to change, enhancing social support, recognizing cues, restructuring lifestyles, identifying coping strategies.

Self-Help Groups:

  • Peers meet for mutual support and encourage abstinence. Usually led by peers, not professionals (cost-effective).

  • Example: Alcoholics Anonymous (AA): Relies on Twelve Steps/Traditions, guidance from a sponsor. Philosophy: Alcoholism is a disease controlled only by complete abstinence.

Study Pointers for Treatment:

  • Understand the goals and techniques of CBT (both cognitive and behavioral components).

  • Recognize the importance of involving family systems (MDFT).

  • Differentiate between therapist-led group therapy and peer-led self-help groups like AA.

  • Note the abstinence-based philosophy common in self-help models like AA.