Chapter Twelve: Substance Use and Addictive Disorders

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