Substance-Related Disorders

Substance-Related Disorders

Diagnosis of Substance Use Disorders

Substance use disorder: when an individual uses more of the substance than they originally intended to and continue to use that substance despite experiencing significant adverse consequences. There are two types of dependence:

• Physical dependence involves changes in normal bodily functions—the user will experience withdrawal from the drug upon cessation of use. 

• Psychological dependence is an emotional, rather than physical, need for the drug and the drug is used to relieve psychological distress. 

• Tolerance is linked to physiological dependence, and it occurs when a person requires more and more drug to achieve effects previously experienced at lower doses. 

• Withdrawal includes a variety of negative symptoms experienced when drug use is discontinued.

Alcohol Use: Prevalence

• 30% of Americans meet DSM criteria for AUD in their lifetime

• 27% report binge drinking monthly

• High association with accidents, suicide, homicide

• Life expectancy: ~12 years shorter for people with alcohol dependence

Alcohol Use: Common Misconceptions

• Alcohol is a stimulant” →  Actually a depressant

• “Coffee sobers you up” →  Doesn’t affect intoxication

• “Withdrawal from heroin is worse” → Alcohol withdrawal can be more dangerous

Effects of Alcohol on the Brain

• Low doses: activates dopamine in the mesolimbic pathway → pleasure

• High doses: inhibits glutamate → poor judgment, lowered self-control

• Can lead to brain shrinkage, impaired memory, and decision-making deficits

Alcohol Short-Term & Long-Term Consequences

Short-Term:

• Hangover (fatigue, nausea, anxiety)

• Blackouts, risky behavior

Long-Term:

• Liver cirrhosis (15–30% of heavy drinkers)

• Malnutrition and gastrointestinal problems

• Cognitive decline and brain damage

Fetal Alcohol Syndrome (FAS)

• Caused by alcohol consumption during pregnancy

• Leads to: growth deficiencies, facial abnormalities, intellectual disability

• CDC: “No safe amount of alcohol during pregnancy”

DSM-5 Criteria for Alcohol Use Disorder

(2+ of the following within 12 months)

• Craving, unsuccessful attempts to cut down, role failures, tolerance, withdrawal, etc.

• Severity: Mild (2–3), Moderate (4–5), Severe (6+ symptoms)

Alcohol Use: Biological & Genetics

Biological Causal Factors

• Pleasure Pathway  (mesocorticolimbic pathway aka MCLP): Alcohol stimulates dopamine release

Genetic Vulnerability:

• Having 1 alcoholic parent ↑ AUD risk significantly

• Adoption studies support genetic influence

• Alcohol flush reaction common in Asians → potential protective factor

Alcohol Use: Psychosocial Causal Factors

• Poor parental modeling and lack of monitoring

• Psychological vulnerability: antisocial personality, depression, trauma history

• Stress & Tension-Reduction Hypothesis: alcohol used to self-soothe

• Expectancy Theory: beliefs that alcohol enhances social success, relaxation, and improved mood

Alcohol Use: Progression & Course

 Early use → tolerance → dependence

• Can begin in childhood or later life

• Withdrawal symptoms include tremors, hallucinations, confusion (delirium tremens)

• Chronic use → brain and liver damage, memory disorders (e.g., Korsakoff’s)

Alcohol Use: Alcohol Amnestic Disorder 

(Korsakoff’s Syndrome)

• Severe memory issues and confabulation

• Due to thiamine (vitamin B1) deficiency

• Can be reversed early with thiamine; may become irreversible if untreated

Interpersonal Influences on Alcohol Abuse

Marital and Intimate Relationships

• Excessive drinking can be reinforced within intimate relationships.

• Spouses or close partners may unknowingly enable or promote alcohol use.

• Relationship crisis (e.g., marital conflict) often trigger increases in drinking.

• Family Dynamics:

  • Family factors (e.g., poor supervision, marital conflict, lack of cohesiveness) are linked to later alcohol use disorders.

College Binge Drinking & Sociocultural Factors

• Approximately 80% of college students drink; half engage in binge drinking.

• Binge drinking is associated with academic problems, and in some tragic cases, fatalities.

  • Examples: Incidents of alcohol poisoning among college students.

Reasons for Binge Drinking:

• Expression of independence from parental influence.

• Peer pressure, situational influences, and gender role expectations.

• Beliefs about alcohol’s ability to enhance celebrations and social interactions.

Cultural Attitudes:

• Religious and cultural values (e.g., in Muslim, Mormon, and orthodox Jewish communities) limit alcohol use.

• In contrast, European cultures often show higher rates of alcohol consumption.

Treatment of Alcohol-Related Disorders – Overview

Challenges in Treatment:

• Many alcohol abusers are in denial; treatment is often sought only after “hitting bottom.”

• Less than one-third of individuals with alcohol use disorders receive treatment.

Multidisciplinary Approach:

• Combining medical, psychological, and environmental interventions is most effective.

• Treatment goals include detoxification, behavioral change, and social reintegration.

Traditional vs. Controlled

 Drinking Approaches:

• Traditional programs emphasize complete abstinence.

• Some interventions (e.g., Brief Motivational Intervention, self-control training) aim at moderated or controlled drinking.

Medical & Pharmacological Treatments

Detoxification:

• Initial focus on eliminating alcohol and managing withdrawal symptoms.

• Use of benzodiazepines (e.g., Valium, diazepam) to reduce withdrawal risks (seizures, delirium).

Medications:

• Antabuse (Disulfiram): Creates an aversive reaction if alcohol is consumed.

• Naltrexone: Blocks alcohol’s pleasure-producing effects.

• Acamprosate: Properties still under study; helps reduce heavy drinking.

Psychological & Behavioral Treatments

Individual and Group Therapy:

Individual and Group Therapy:

• Cognitive-behavioral therapy (CBT) focuses on developing coping and stress-management skills.

• Group therapy helps confront denial and facilitates learning through shared experiences.

Brief Interventions:

• Brief Motivational Intervention (BMI): A short session that enhances self-regulation and readiness to change.

• Computer-based self-control training programs have shown promise in reducing problem drinking.

Family Involvement:

• Family counseling (e.g., Al-Anon) addresses relational dynamics and provides mutual support.

Relapse Prevention Strategies

Relapse as a Treatment Focus:

• Relapse is common

• Interventions teach clients to identify and manage high-risk situations (e.g., parties, sports events).

Cognitive-Behavioral Approaches:

• Planned relapse strategies help maintain confidence and prevent complete loss of self-efficacy.

• Involvement of family members in relapse prevention can enhance long-term outcomes.

Abstinence Violation Effect:

• Minor transgressions may lead to feelings of failure, increasing the risk of full relapse.

• Emphasizes the need for continuous self-monitoring and support.

Controlled Drinking vs. Abstinence Debate

• Abstinence Approach: Emphasizes total cessation of alcohol use; favored by many self-help groups like AA.

• Controlled Drinking Approach: Suggests some individuals (often with less severe problems) can learn to moderate their intake.

• Research Findings:

  1. Studies indicate a minority of subjects maintain controlled drinking post-treatment.

  2. Ongoing debate among professionals regarding which approach yields better long-term results.

Alcoholics Anonymous (AA) & Self-Help Models

Pharmacological Options:

• Founded in 1935; uses a 12-step program and emphasizes lifelong abstinence.

• AA provides social support through group meetings, testimonials, and mutual help.

Strengths & Limitations:

• AA helps reduce personal responsibility by framing alcohol use disorder as a chronic condition.

• Outcome studies are mixed due to methodological challenges; however, AA participation is associated with decreased drinking in both short- and long-term follow-up.

Opiate Abuse – An Introduction

Common Opiates:

• Include opium, morphine, codeine, heroin, and methadone.

Historical Context:

• Opium has been used for centuries; morphine was widely used during the Civil War.

• Heroin was developed from morphine and quickly became more potent and addictive.

Methods of Administration:

• Opiates can be smoked, snorted, or injected (mainlining and skin popping).

• Immediate Effects:

  • Users experience a rapid, intense “rush” (often compared to a sexual orgasm) followed by several hours of a “high” and subsequent negative phases.

Biological Effects & Withdrawal from Opiates

• Continued use (approximately 30 days) leads to physical dependence.

  1. Tolerance increases over time; larger amounts are needed for the same effect.

• Withdrawal Symptoms:

  1. Can include runny nose, sweating, nausea, tremors, insomnia, and, in severe cases, delirium and cardiovascular collapse.

  2. Withdrawal symptoms generally peak within 3–4 days and subside by days 7–8.

• Social and Health Impacts:

  1. Opiate addiction often leads to criminal behaviors and serious health issues (e.g., hepatitis from unsterile injection practices).

Causal Factors & Neural Bases of Addiction

Causal Factors in Opiate Abuse:

• Genetic predispositions, environmental influences, and personal maladjustment all contribute.

• Many begin using opiates for the pleasurable “high” and due to ease of access and lower cost.

Neural Bases for Addiction:

• Opiate Receptors: Opiates bind to receptors that regulate pleasure, pain, and breathing.

• Dopamine Reward Pathway: Addiction is linked to dysfunction in the dopamine system—from the ventral tegmental area to the nucleus accumbens.

• Reward Deficiency Syndrome: Individuals with genetic variations may find natural rewards less satisfying, predisposing them to seek external stimulation via drugs.

• Other neurotransmitter systems (e.g., the opioid system) play key roles in the “liking” aspect of drug use.