Chapter Twelve: Substance Use and Addictive Disorders (copy)

• Drug: Any substance other than food that affects our bodies or minds
  • Also called a substance
• Substance Intoxication: When substances cause temporary changes in behavior, emotion, or thought
• Alcohol Intoxication: A temporary state of poor judgment, mood changes, irritability, slurred speech, and poor coordination
• Hallucinogen Intoxication / Hallucinosis: Perceptual distortions and hallucinations
• Substance Use Disorders: Patterns of maladaptive behaviors and reactions brought about by the repeated use of substances
  • Crave a particular substance and rely on it excessively
  • Results in
  • Damage to their family and social relationships
  • Poor functioning at work
  • Danger to themselves or others
  • Become physically dependent on the substance
• Tolerance: A person needs increasing doses of the substance to produce the desired effect
• Withdrawal: Unpleasant and sometimes dangerous symptoms that occur when the person suddenly stops taking or cuts back on the substance
• 7.8 % of all teens and adults in the US have a substance use disorder

Depressants

• Depressants: Substances that slow the activity of the central nervous system

Alcohol

• 2 billion people worldwide consume alcohol
• Binge Drinking Episode: When people consume five or more drinks on a single occasion
• Heavy drinkers: People who binge drink at least five times a month
• Ethyl Alcohol: A chemical that is quickly absorbed into the blood through the lining of the stomach and the intestine
  • Carried into the central nervous system
  • Acts to depress (slow) functioning by binding to various neurons
  • Depresses the areas of the brain that control judgment and inhibition
    • People become looser, more talkative, and more friendly
    • Feel relaxed, confident, and happy
  • Slows down additional areas in the central nervous system
  • Less able to make sound judgments
  • Speech becomes less careful and less coherent
  • Memory becomes weaker
  • Motor difficulties increase
  • Reaction times slow
• When alcohol binds to receptors on GABA neurons, it helps GABA to shut down the neurons, helping to relax the drinker
• Concentration
  • A given amount of alcohol has less effect on a large person than on a small one
  • Women have less of the stomach enzyme that breaks down alcohol
  • 0.06 percent of blood volume - person feels relaxed and comfortable
  • 0.09 percent - drinker becomes intoxicated
  • 0.55 percent - drinker will likely die
• Most of the alcohol is broken down (metabolized) by the liver into carbon dioxide and water, which can be exhaled and excreted
• Alcohol Use Disorder / Alcoholism
  • Clinical Picture
  • Those with alcohol use disorder drink large amounts regularly and rely on it to enable them to do things that would otherwise make them anxious
  • Drinking interferes with their social behavior and ability to think and work
  • Impairments in memory, speed of thinking, attention skills, and balance patterns of alcoholism vary
  • Tolerance and Withdrawal
  • As their bodies build up a tolerance for alcohol, they need to drink larger amounts to feel the effects
  • They have withdrawal symptoms when they stop drinking (within hours)
  • Small percentage of ppl with alcohol use disorder go through this withdrawal reaction: delirium tremens
    • Terrifying visual hallucinations that begin within three days after they stop or reduce their drinking
    • May cause seizures and strokes
    • Can die
• Personal and Social Impacts of Alcoholism
  • Alcoholism plays a role in ⅓ of all suicides, homicides, assaults, rapes, and accidental deaths, including in car accidents
  • Intoxicated drivers are responsible for more than 10,000 deaths each year
  • Home life for children of alcoholics
  • Much conflict
  • May have sexual / other forms of abuse
  • Higher rates of psychological problems
  • Low self-esteem, poor communication skills, poor sociability, maritial problems
  • Physical health
  • Cirrhosis: Liver becomes scarred and dysfunctional
  • Damage the heart
  • Lowers the immune system’s ability to fight off cancer, bacterial infections, and AIDS
  • Nutritional problems
  • Makes people feel full and lowers their desire for food, but has no nutritional value
    • Chronic drinkers become malnourished, weak, and prone to disease
  • Korsakoff’s syndrome: An alcohol related disorder caused by a deficiency of vitamin B
    • Marked by extreme confusion, memory loss, and other neurological symptoms
    • Confabulating: Reciting made-up events to fill in the gaps
    • Cannot remember the past or learn new info
  • Fetal Alcohol Syndrome: A pattern of abnormalities that can include intellectual disability disorder, hyperactivity, head and face deformities, heart defects, and slow growth
  • Caused by excessive alcohol use during pregnancy
  • Heavy drinking early in pregnancy often leads to a miscarriage

Sedative-Hypnotic Drugs

• Also called anxiolytic (anxiety-reducing) drugs
• Produces feelings of relaxation and drowsiness
• Low doses: drugs have a calming or sedative effect
• Higher doses: sleep inducers / hypnotics
• Most widely prescribed sedative-hypnotic drugs
  • In the past: barbiturates
  • Now: benzodiazepines
• ex: xanax, ativan, valium
• These drugs calm people by binding to receptors on the neurons that receive GABA and by increasing GABA’s activity at those neurons
• Benzodiazepines
  • Generally safer
  • Less likely to lead to intoxication, tolerance effects, and withdrawal reactions
  • Relieve anxiety without making people as drowsy as other kinds of sedative-hypnotics
  • Less likely to slow a person’s breathing - less likely to cause death in the event of an overdose
• In high enough doses, these drugs can cause intoxication and lead to sedative-hypnotic use disorder
• Sedative-hypnotic Use Disorder: A pattern marked by craving for the drugs, tolerance effects, and withdrawal reactions
  • 0.4% of all adults in the US display this disorder in a year

Opioids

• Opioid: Opium, drugs derived from opium, and other synthetic drugs
  • Heroin, morphine, codeine
• Opium: A highly addictive substance made from the sap of the opium poppy
• Widely used in the past because of its ability to reduce both physical and emotional pain
• Morphine: A highly addictive substance derived from opium that is particularly effective in relieving pain
  • Can lead to addiction
  • Morphine addiction became known as soldier’s disease
• Heroin: One of the most addictive substances derived from opium
• 1917: US Congress concluded that all drugs derived from opium were addictive and passed a law making opioids illegal except for medical purposes
• Opioid Use Disorder
  • Heroin use interferes significantly with their social and occupational functioning, and their lives center around the drug
  • Build a tolerance for heroin and experience a withdrawal reaction when they stop taking it
  • Symptoms peak by the third day, gradually subside, and disappear by the eighth day
  • Person in withdrawal can either wait out the symptoms or end withdrawal by taking the drug again
  • People need heroin just to avoid going into withdrawal
  • Must continually increase their doses to achieve relief
  • 1% of adults in the US display an opioid use disorder within a given year
• Dangers of Opioid Use
  • Overdose: Closes down the respiratory center in the brain, almost paralyzing breathing and in many cases causing death
  • Heroin can be mixed with other drugs / deadly substances
  • Dirty needles and other unsterilized equipment spreads infections

Stimulants

• Stimulants: Substances that increase the activity of the central nervous system, resulting in increased blood pressure and heart rate, more alertness, and sped-up behavior and thinking

Cocaine

• Cocaine: An addictive stimulant obtained from the coco plant and the most powerful natural stimulant known
• Brings on a euphoric rush of well-being and confidence
• Increases the supplies of dopamine at key neurons throughout the brain
• Increases the activity of norepinephrine and serotonin in some areas of the brain
• Cocaine Intoxication: Symptoms are poor muscle coordination, grandiosity, bad judgment, anger, aggression, compulsive behavior, anxiety, and confusion
• Cocaine-induced Psychosis: Some people have hallucinations, delusions, or both
• Crashing: As the stimulant effects of cocaine subside, the user goes through a depression-like letdown, causing a pattern that may also include headaches, dizziness, and fainting
• Ingesting Cocaine
  • In the past, it was usually snorted
  • Freebasing: A technique in which the pure cocaine basic alkaloid is chemically separated (freed) from processed cocaine, vaporized by heat from a flame, and inhaled through a pipe
  • Crack: A powerful, ready-to-smoke freebase cocaine
• Dangers
  • Linked to many suicides
  • Overdose
  • Major heart irregularities or brain seizures that bring breathing or heart functioning to a sudden stop
  • Pregnant women who use cocaine run the risk of having a miscarriage and of having children with predispositions to drug use and other abnormalities

Amphetamines

• Amphetamines: Stimulant drugs that are manufactured in the laboratory
• Benzedrine, dexedrine, methedrine
• First produced to help treat asthma
• Most often taken in pill or capsule form
• Increase energy and alertness and reduce appetite when taken in small doses
• Produce a rush, intoxication, and psychosis in high doses
• Cause an emotional letdown as they leave the body
• Stimulate the CNS by increasing the release of the neurotransmitters dopamine, norepinephrine, and serotonin through the brain
• Methamphetamine: A kind of amphetamine that has surged in popularity in recent years, posing major health and law enforcement problems
  • Most is made in small “stovetop laboratories” which can expel dangerous fumes and residue
  • About as likely to be used by women as men
  • Increases activity of the neurotransmitters dopamine, serotonin, and norepinephrine, producing increased arousal, attention, and related effects
  • Neurotoxicity: Damages nerve endings

Stimulant Use Disorder

• Caused by regular use of either cocaine or amphetamines

Caffeine

• World’s most widely used stimulant
• Coffee, tea, energy drinks, chocolate, numerous prescription/over-the-counter meds
• Acts as a stimulant of the cns
• Raises a person’s arousal and motor activity, enhances physical stamina, reduces fatigue
• Disrupt mood, fine motor movement, and reaction time
• May interfere with sleep
• High doses: Increases gastric acid secretions in the stomach and the rate of breathing
• 250+ milligrams of caffeine can produce caffeine intoxication
  • 2-3 cups of coffee
  • 6 cans of soda
  • 3 cans of energy drinks
• Doses larger than 10 grams of caffeine can cause grand mal seizures and fatal respiratory failure
  • 100 cups of coffee
• People who suddenly stop or cut back on their usual intake have withdrawal symptoms

Hallucinogens, Cannabis, and Combinations of Substances

Hallucinogens

• Hallucinogens: Substances that cause powerful changes in sensory perception
• Produce delusions, hallucinations, and other sensory changes also called psychedelic drugs
• LSD, mescaline, psilocybin, MDMA (ecstacy)
• LSD
  • Brings on a state of hallucinogen intoxication / hallucinosis
  • Strengthening of perceptions, psychological changes, and physical symptoms
  • Cause one to hear sounds more clearly, feel tingling or numbness in the limbs, or confuse the sensations of hot and cold
  • Synesthesia
  • Can induce strong emotions
  • Perception of time may slow dramatically
  • Physical symptoms
  • Binds to some of the neurons that normally receive serotonin, changing the neurotransmitter’s activity at those sites
  • 15+% of all ppl in the US have used LSD or another hallucinogen at some point in their lives
  • People don’t develop tolerance to LSD or have withdrawal symptoms when they stop taking it
  • Any dose, no matter how small, is likely to produce an enormous reaction
  • Users eventually develop psychosis or a mood or anxiety disorder
  • Flashbacks: A recurrence of the sensory and emotional changes after the LSD has left the body
  • May occur days or months after the last LSD experience

Cannabis

• produces sensory changes and has depressant and stimulant effects
• The higher the THC content, the more powerful the cannabis
• Produces a mixture of hallucinogenic, depressant, and stimulant effects
• High is called Cannabis Intoxication
• Cannabis Use Disorder
• Dangers
  • Occasionally causes panic reactions similar to the ones caused by hallucinogens
  • Can interfere with the performance of complex sensorimotor tasks and with cognitive functioning
  • Caused many automobile accidents
  • Fail to remember information no matter how hard they try to concentrate
  • Chronic users have higher blood flow
  • Long-term health problems
  • Reduces the ability to expel air from the lungs
  • Lower sperm counts and abnormal ovulation
• Cannabis and Society
  • Used to play a respected role in medicine
  • Began to be used as a recreational drug
  • Assumed to be highly dangerous and was outlawed
  • Campaigned for the medical legalization of marijuana
  • Moved to legalize the recreational use of marijuana

Combinations of Substances

• Polysubstance Use: People often take more than one drug at a time
• Cross-tolerance: Tolerance for a substance one has not taken before as a result of using another substance similar to it
• Synergistic Effect: In pharmacology, an increase of effects that occurs when more than one substance is acting on the body at the same time
  • Two or more drugs have similar actions
  • Combining them, even in small doses, can lead to extreme intoxication, coma, and even death
  • ex: alcohol and opioids
  • Two or more drugs have opposite / antagonistic actions
  • Build up toxic, even lethal, levels of the depressant drugs in their systems
  • Cory Monteith

What Causes Substance Use Disorders?

Sociocultural Views

• People are most likely to develop substance use disorders when they live under stressful socioeconomic conditions
  • Unemployment, low socioeconomic classes
• People confronted regularly by other kinds of stress have a heightened risk of developing substance use disorder
• People are more likely to develop substance use disorders if they’re part of a family or social environment in which substance use is valued or at least accepted

Psychodynamic Views

• People with substance use disorders have powerful dependency needs that can be traced to their early years
  • When parents fail to satisfy a young child’s need for nurturance, the child is likely to grow up depending excessively on others for help and comfort
  • Develop a dependent relationship with a substance
• Certain people respond to their early deprivations by developing a substance abuse personality that leaves them particularly prone to drug abuse
  • Individuals who abuse drugs tend to be more dependent, antisocial, impulsive, and depressive than other individuals
  • Cannot presently conclude any one personality trait or group of traits that stands out in the development of the disorders

Cognitive-Behavioral Views

• Operant conditioning may play a key role in substance use disorders
• Temporary reduction of tension / raising of spirits produced by the drug has a rewarding effect
  • Increases the likelihood that the user will seek that reaction again
  • Lead users to try higher dosages or more powerful methods of ingestion
  • Produce an expectancy that substances will be rewarding, which helps motivate people to increase drug use at times of tension
• Many people do drink more alcohol or seek heroin when they feel tense
• Many people take drugs to medicate themselves when they feel tense
• Classical conditioning may also play a role in these disorders
• Cues or objects present at the time a person takes a drug may come to produce some of the same pleasure brought on by the drugs themselves

Biological Views

• Genetic Predisposition - People may inherit a predisposition to misuse substances
  • Alcohol concordance rate of around 50% in identical twins
• Neurotransmitters
  • When a particular drug is ingested, it increases the activity of certain neurotransmitters whose normal purpose is to calm, reduce pain, lift mood, or increase alertness
  • Drug takers build tolerance for a drug, becoming more and more reliant on it rather than on their own biological processes
  • If they suddenly stop taking the drug, their natural supply of neurotransmitters will be low for a time, producing the symptoms of withdrawal
  • The abused substance dictates which neurotransmitters will be affected
  • Alcohol/benzos: GABA
  • Opioids: Endorphins
  • Cocaine/Amphetamines: Dopamine
  • Marijuana: Anandamide (neurotransmitter that operates like THC)
• Reward Circuit: A dopamine-rich circuit in the brain that produces feelings of pleasure when activated
  • When a person ingests a substance, the substance eventually activates the brain’s reward circuit
  • When dopamine is activated throughout this circuit, a person feels pleasure
  • Certain drugs stimulate the structures in the reward circuit, others stimulate it in roundabout ways
  • Leads to increased dopamine in the reward circuit and excessive communications between the structures in the reward circuit
  • Incentive-sensitization Theory of Addiction: As substances repeatedly stimulate this reward circuit, the circuit develops a hypersensitivity to the substances, contributing to future desires for them
  • Reward Deficiency Syndrome: People who chronically use drugs have a reward circuit that is not readily activated by the usual events in their lives, so they turn to drugs to stimulate the pleasure pathway, particularly in times of stress
  • Abnormal D2 receptor gene is a possible contributor

The Developmental Psychopathology View

• Genetically inherited predispositions
  • Less-than-optimal reward circuit in the brain
  • Problematic temperament
• Will eventually result in a substance use disorder if the individual further experiences numerous stressors
  • Ppl who experience manageable adversities can develop a level of resilience
• Temperaments that can set the stage for later substance abuse
  • Disinhibited / Externalizing Temperament
  • Impulsivity, aggressiveness, overactivity, limited persistence, low frustration tolerance, inattention
  • Great difficulty controlling their behaviors
  • Internalizing Temperament
  • Temperament of inhibition and negative affectivity
  • Multiple fears, depression, negative thinking, and dependence
  • Turn to substances to reduce their emotional pain, quiet their troublesome thoughts, and help them through interpersonal difficulties
• Equifinality: The principle that different developmental pathways can lead to the same psychological disorder

How Are Substance Use Disorders Treated?

• Motivational Interviewing: Therapists help motivate the clients to make constructive choices and behavioral changes
• Effectiveness of treatment for substance use disorders can be difficult to determine
  • Different substance use disorders pose different problems
  • Many people with such disorders drop out of treatment very early
  • Some people recover without any intervention while others recover and then relapse
  • Different criteria are used by different clinical researchers

Psychodynamic Therapies

• Guide clients to uncover and work through the underlying needs and conflicts that led to the substance use disorder
• Try to help the clients change their substance-related styles of living
• Tends to be of more help when combined with other approaches in a multidimensional treatment program

Cognitive-Behavioral Therapies

• Help clients identify and change the behaviors and cognitions that keep contributing to their patterns of substance misuse
• Aversion Therapy: Clients are repeatedly presented with an unpleasant stimulus at the very moment that they are taking a drug
  • Expected to react negatively to the substance itself and lose their craving for it
  • Used to treat alcoholism most
  • Limited success when its the sole form of treatment
  • Approach can only be effective if people are motivated to subject themselves to multiple sessions
• Contingency Management: Offers clients incentives that are contingent on the submission of drug-free urine specimens
  • Rewards clients from abstaining from substance use
  • Clients in these programs maintain a higher attendance record than those in other kinds of programs
  • Moderately effective
  • Can be effective only when people are motivated to continue despite its demands
  • Most useful in the treatment of stimulant use disorder and opioid use disorder
  • The larger the rewards offered, the greater the client’s improvement
• Relapse-Prevention Training
  • Goal: For clients to gain control over their substance-related behaviors
  • Taught to identify high risk situations, look at the range of decisions they can make, change their dysfunctional lifestyles, and learn from their mistakes
  • Strategies for alcoholism
  • Therapists have clients keep track of their drinking
  • Helps them become aware of the situations that place them at risk for excessive drinking
  • Therapists teach clients coping situations to use when such situations arise
  • Therapists teach clients to plan ahead of time
  • Determine beforehand how many drinks are appropriate, etc.
• Acceptance and Commitment Therapy
  • Use a mindfulness based approach to help clients become aware of their streams of thoughts as they’re occurring and to accept them as mere thoughts of mind
  • Increasing their awareness and acceptance of their drug cravings, worries, and depressive thoughts

Biological Treatments

• Detoxification: Systematic and medically supervised withdrawal from a drug
  • Clients take smaller and smaller doses until they’re off the drug completely
  • Give clients other drugs that reduce the symptoms of withdrawal (like anti anxiety meds)
  • Relapse rates tend to be high for those who don’t receive a follow-up treatment after successfully detoxifying
• Antagonist Drugs: Drugs that block or change the effects of the addictive drug as an aid to resisting temptation
  • Disulfiram - increases negative effects of alcohol
  • Opioid antagonist drugs like naloxone
  • Attach to endorphin receptor sites throughout the brain and make it impossible for the opioids to have their usual effect
    • Reduces cravings for alcohol as well
  • Continued drug use becomes pointless
  • Can reverse the deadly effect of respiratory depression
  • Partial Antagonists: Opioid antagonists that produce less severe withdrawal symptoms
  • Causes rapid detoxification - helps speed things along
• Drug Maintenance Therapy
  • Methadone Maintenance Programs: A treatment approach in which clients are given legally and medically supervised doses of methadone - a heroin substitute - to treat various opioid use disorders
  • Developed in the 1960s to treat heroin addiction
  • Ppl with an addiction were given methadone as a substitute for heroin
  • They then became addicted to methadone, but this addiction was maintained under safe medical supervision
  • Methadone produces a moderate high, can be taken by mouth, and only needs to taken once a day
  • Was very effective at first, now less possible bc substituting one addiction for another isn’t very acceptable
  • Methadone is sometimes harder to withdraw from - symptoms can last longer
  • Methadone treatment is safer than street opioid use
  • Most effective when combined with education, psychotherapy, family therapy, and employment counseling
  • Buprenorphine: An opioid substitute drug being used as a form of maintenance therapy
  • Opioid that is administered to patients as a safer alternative to heroin, painkillers, etc.
  • Permitted by law to be prescribed by physicians in their offices rather than as part of a highly structured clinic program

Sociocultural Therapies

• Psychological problems emerge in a social setting and are best treated in a social context
• Self-Help and Residential Treatment Programs
  • Alcoholics Anonymous: A self-help organization that provides support and guidance for people with alcohol use disorder
  • Promotes abstinence instead of controlled drinking
  • Abstinence is a more appropriate goal for ppl who have a long-standing alcohol use disorder
  • Controlled drinking is a helpful goal for younger drinkers whose pattern doesn’t include tolerance and withdrawal reactions
  • Residential Treatment Centers / Therapeutic Communities: A place where people formerly addicted to drugs live, work, and socialize in a drug-free environment while undergoing therapy and making a transition back to community life
• Culture and Gender-Sensitive Programs
  • Therapists should be sensitive to their clients’ life challenges - the special sociocultural pressures and problems faced by drug abusers who are poor, homeless, or members of minority groups
  • Women often require different treatment methods than those designed for men
• Community Prevention Programs
  • Prevention Program Model
  • Total abstinence
  • Responsible use
  • Interrupt drug use
  • Delay the age of onset for drug use
  • Programs can
  • Offer drug education
  • Teach alternatives to drug use
  • Try to change the psychological state of the potential user
  • Help people change their peer relationships
  • Program Focus
  • Individual: Providing education about unpleasant drug effects
  • Family: Teaching parenting skills
  • Peer group: Teaching resistance to peer pressure
  • School: Setting up firm enforcement of drug policies community
  • Not always effective

Other Addictive Disorders

• People may become addicted to behaviors and activities beyond substance use

Gambling Disorder

• Preoccupied with gambling and cannot walk away from a bet
• Continue gambling even in the face of financial, social, occupational, and health problems
• Gamble more when feeling distressed
• Lie to cover up the extent of their gambling
• Have symptoms that are similar to the tolerance and withdrawal reactions often associated with substance use disorder
• People with gambling disorder may
  • Inherit a genetic predisposition to develop the disorder
  • Experience heightened dopamine activity and dysfunction of the brain’s reward circuit when they gamble
  • Have impulsive, novelty-seeking, and other personality styles that leave them prone to gambling disorder
  • Make repeated and cognitive mistakes such as inaccurate expectations and misinterpretations of their emotions and bodily states
• Gamblers Anonymous: A self-help group problem for gamblers modeled after Alcoholics Anonymous

Internet Gaming Disorder: Awaiting Official Status

• Internet Use Disorder: An uncontrollable need to be online
• Ppl spend all their waking moments online
• Parallels symptoms found in substance use disorders and gambling disorder
• Possible withdrawal reactions when internet use is not possible
• Not included in the DSM-5

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