Substance Related Disorders

Substance Use Disorder (DSM-5-TR)

  • impaired control

    • taking the substance in larger amounts or for longer than intended

    • inability to cut down or stop use despite wanting to

    • spending lots of time seeking, ingesting, and withdrawing from substance use

    • cravings or urges to use the substance

  • social impairment

    • failure to fulfill major obligations at work, home, or school

    • continued use, even when it causes or exacerbates problems in relationships

    • giving up important social, occupational, or recreational activities because of substance use

  • risky use

    • recurrent substance use in situations where it is physically hazardous (e.g., driving under the influence)

    • persistent substance use despite knowledge that it may cause or exacerbate physical or psychological problems

  • pharmacological

    • tolerance

    • withdrawal

  • severity

    • mild: 2-3 symptoms

    • moderate: 4-5 symptoms

    • severe: 6+ symptoms

Substances Related Disorders

  • “cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (APA, 2022, pg.544)

    • alcohol

    • caffeine

    • cannabis

    • hallucinogens

    • inhalants

    • opioids

    • sedatives

    • stimulants

    • tobacco

    • other (or unknown) substances

Dopamine activity in Nucleus Accumbens

  • reward/reinforcement

  • extreme amounts of dopamine with substance use → want to use more

  • tolerance

  • withdrawal

Comorbidity

  • high comorbidity within itself

  • substance use disorders are often secondary to other psychological disorders

  • about ½ of those with a substance use disorder will experience a second psychological disorder

Substances Associated with Abuse (there are more!)

  • depressants

  • stimulants

  • opiates

Depressants

  • neurochemistry

    • gamma-aminobutyric acid (GABA)

  • effect

    • relaxation, slowed behavior, reduced inhibitions

  • example

    • alcohol - most popular

Alcohol Consumption Classifications

  • moderate drinking

    • 1 drink for women, 2 for men

  • heavy drinking

    • 2+ drinks a day

  • binge drinking

    • 5+ drinks at one time for men, 4+ for women

  • people underestimate their drink size, especially once they have started drinking

Binge Drinking in College Students

  • 45% of emerging adults in the US (18-25) binge drink

  • college students engage in unsafe behaviors

    • not eating ahead of time to get drunk faster

Alcohol Dependence

  • withdrawal symptoms: headache, fatigue, sweating, body tremors, mood changes

  • delirium tremens: profound anxiety, agitation, and confusion followed by seizures, disorientation, hallucinations, or extreme lethargy

Stimulants

  • neurochemistry

    • dopamine & norepinephrine

  • effect

    • alertness, euphoria, irritability, paranoia

  • examples

    • caffeine*, cocaine, meth, etc.

Caffeine

  • most widely used psychoactive substance in the world

    • 400 mg: daily recommended limit for healthy adults

    • 100 mg: daily recommended limit for healthy adolescents

    • do caffeinated beverages properly display the amount of caffeine in them?

    • are most people aware of the caffeine content of their beverages

  • caffeine intoxication - restlessness, nervousness, insomnia, cardiac arrhythmia

  • caffeine withdrawal - headache, fatigue, irritability, difficulty with concentration

Caffeine + Alcohol + Other Substances

  • stimulants + depressants → affect heart muscles and cause arrhythmias

  • original Four Loko banned

    • 24 oz can contained 12% alcohol + 156 mg of caffeine (2 cups of coffee worth)

    • marketing towards college students - more likely to binge drink - 4/5/6 of them and then go to hospital

    • original was banned, changed to be safer

Amphetamines

  • can be used to treat ADHD + sleep disorders at lower doses - Ritalin, Adderall, Dexedrin

    • commonly abused by students

  • high addictive potentially, especially when taken intravenously or nasally

  • Methamphetamine (Meth)

    • low cost

    • permanent damage to heart, lungs, and immune system

    • can cause psychosis

Cocaine

  • 5.5 million cocaine users in the US (2% of the population), with about 1 million demonstrating a cocaine-use disorder

  • rapid cocaine intoxication, quick depletion

Opiates

  • neurochemistry

    • endorphins & dopamine

  • effect

    • pain relief, pleasure

  • examples

    • heroin, morphine, prescriptions (Vicodin, oxycontin)

Cannabis

  • active ingredients

    • THC (tetrahydrocannabinol)

    • Cannabidiol (CBD)

  • binds to cannabinoid receptors in the brain

    • CBI receptor (THC)

  • effects

    • calm and peace, relaxation, increased hunger, and pain relief

    • increased anxiety or paranoia, dizziness, and increased heart rate also occur

  • federally illegal

    • 39/50 states for medical use

    • 24 states for recreational use

Harm Reduction

  • represents a view that some learn to control but may not completely eliminate use of a substance in one’s life

  • examples in other areas:

    • sun screen

    • seat belts

    • speed limits

    • birth control

    • cigarette filters

  • examples of harm reduction

    • NARCAN distribution

    • needle exchange programs

    • having breathalyzers available in bars

    • safe consumption sites

    • designated driver’s programs

    • Good Samaritan laws

    • fentanyl testing strips

  • controversial:

    • pulls us out of “all or none”, “one size fits all” substance use counseling

    • no evidence to suggest it increases rates of substance use

    • it is enabling - enables people to:

      • stay alive

      • avoid transmitting illness

Biological Etiology of Substance Related Disorders

  • substances alter our neurotransmitters, etc. → dopamine reinforces continued drug use

  • 40-60% genetic

    • genes also impact important personality traits for substance use

Psychological Etiology of Substance Related Disorders

  • life stressors

    • general life stress (e.g. work difficulties)

    • stress resulting from trauma or catastrophic events

    • childhood stressors or maltreatment

    • discrimination related stress

  • personality traits (impulsivity, risk-taking, etc.)

  • expectancy effects

Social Etiology of Substance Related Disorders

  • childhood

    • victimization + stressful events

  • adolescence (especially vulnerable period)

    • affiliating with peers who use substances

    • peer victimization

    • peer pressure and wish to fit in socially

    • perceptions of peer substance use

    • parent’s own substance use

    • parental attitudes towards substance use

    • lack of parental monitoring

Social Isolation

  • rat park experiment

    • rats given 2 water bottles - one with drugs and one without

      • got addicted to one with drugs and died of malnutrition

    • then rats put in “park” with friends & enrichment

      • did not use drugged water

    • rats used drugged water for 57 days in isolation, then put in park and gradually stopped drug use

Stigma & Stereotypes

  • not a character flaw

  • not always a “menace to society”

  • language matters

  • study:

    • one person referred to as “substance abuser”

    • one person referred to as “having a substance use disorder”

    • person referred to as “substance abuser”

      • less likely to benefit from treatment

      • more likely to benefit from punishment

      • more likely to be socially threatening

      • more likely to be blamed for their substance related difficulties and less likely that their problem was the result of innate dysfunction over which they had no control

      • they were more able to control their substance used without help

Phases of Treatment (General)

  • detoxification - stops or reduces use of substance

    • medical supervision often recommended for specific substances (e.g. alcohol, opioids, etc.)

  • preventing relapse

    • may use medication to help prevent symptoms, craving, and relapse

    • identifying high risk situations for relapse - learning how to avoid or manage situations

    • can involve role playing

Biological Treatments

  • detoxification - medical supervision of withdrawal from a specified drug

  • agonist drugs

    • methadone - opiate agonist

    • eliminates adverse effects of unsterilized needles

    • does this just replace one substance with another?

  • antagonist drugs

    • disulfiram - produces negative side effects when couple with alcohol

    • naloxone - prevents opioids from having intended euphoric effect

Behavioral Treatments

  • contingency management - uses operant conditioning

  • successfully reduces substance use + increases treatment compliance

Motivational Interviewing

  • helps clients consider both the advantages and disadvantages of continued substance use

  • once there is a commitment to change, relapse risk is reduced & therapy moves forward with emphasis on life modifications that increase likelihood of abstinence

  • OARS - key aspects

    • O - open questions

      • allows client to provide more info including emotions, attitudes, overall understanding

    • A - affirmations

      • helps overcome self-limiting beliefs or negative thoughts of client

    • R - reflective listening

      • confirms the experienced emotions and encourages client to explore

    • S - summarize

      • assures client that they are heard and allows to organize the discussion

Stages of Change

  • 1 - pre-contemplation

    • no serious thoughts about behavior change, individual unable to acknowledge impact on mental and physical well-being

  • 2 - contemplation

    • costs start to influence thoughts about impact of maladaptive behavior, open to receiving info and suggestions

  • 3 - preparation/determination

    • individual made an internal commitment for change, and easily acknowledges global impact of behavior

  • 4 - action/willingness

    • early signs of self-efficacy, willingness to adapt change approach using a variety of acquired techniques

  • 5 - maintenance/lasting change

    • forward thinking with deeply internalized understanding about the impact of past behavior on mental and physical well-being

12 Step Programs (AA, NA, etc.)

  • goal: abstain from alcohol or other substances - “take it one day at a time”

  • builds community

  • Alcoholic’s Anonymous - no IRB or peer reviews*

    • 27% of members have been sober less than one year

    • 24% have been sober 1-5 years

    • 13% have been sober 5-10 years

    • 14% have been sober 10-20 years

    • more than 22% have been sober over 20 years

Residential Treatment

  • “Rehab” - drug free community

  • attend regular therapy

  • typically incorporate contingency programs + 12 step programs

  • cons

    • very expensive

    • go back to “real world” when yo leave - need follow up care