Substance Related Disorders

When is it a disorder??? Substance-related disorders ◦ Arising form use of psychoactive substances ◦ Affects central nervous system ◦ Cause significant social, occupational, psychological, or physical problems ◦ Continued use despite significant substance- related problems

DSM-5 Checklist Maladaptive pattern of substance use leading to significant impairment or distress 2 or more of the following: Substance taken in larger amounts or over longer time than intended Persistent desire or unsuccessful attempts to reduce or control Excessive time spent drug seeking Failure to fulfull major role obligations (work, home) Continued use of substance despite social or personal prbs Reduction of important social or other activities Recurrent substance use in despite physical harm or knowing it’s causing problems Tolerance, withdrawal, craving

What substances does DSM 5 deal with???? Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives Stimulants Tobacco other

Diagnosing Substance-related Disorders with DSM-5 Differentiate substance-use disorders 2 ways ◦ By actual substance (depressants; stimulants; hallucinogens, etc) ◦ ABUSE or DEPENDENCE is now combined into SUBSTANCE USE DISORDER ◦ Look at symptoms occurring within 12 month period

DSM 5 Criteria for Substance Use Disorders Impaired Control-takes substance in larger amounts over longer period than was intended; desire to cut down fails; craving exists Social impairment-failure to fulfill major role obligations because of the substance use; interpersonal prbs because of the substance Risky use-using substance despite physical hazard; failure to abstain despite difficulties Pharmacological criteria-tolerance and withdrawal

Definitions Substances: alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogens inhalants, nicotine, opioids, phencyclidine, sedative, hypnotics, tobacco; pain relievers; methamphetamines; etc. Other (or unknown) Substance Use Disorder: can include steroids or other substance not listed above including nitrous oxide, betel nut (chewed in many countries and produces a mild euphoria), kava (pepper plant produced and grown in South Pacific that sedation and other symptoms); antihistamines

ETIOLGY of Substance Use Disorders Biological (heredity; dopamine reward system; endocrine & stress; activation of brain reward system that produces pleasure; brain reward system involves reinforcement of behaviors and production of memories)   SocioculturalPsychological (religious; national norms; gender(anxiety; depression; loss of Stressful SES; )inhibition; traits)   Social (parental & peer pressure; social pressure; stressful family environment)

MULTIMODAL approach treatment most successful: Ex…ALCOHOL *Detoxification for alcohol abuse * Inpatient hospitalization *Psychopharmacological Treatments some antidepressants help (welbutrin for smoking cessation) antagonist drugs like disulfiram (antabuse) (limited usefulness with alcoholism) naltrexone (reduce craving for alcohol) drug maintenance-methadone or suboxone for heroin addiction *Aversion therapy- emetics (agents that induce vomiting) *Covert sensitization- person imagines a noxious stimulus *Skills Training- learning to refuse; resolve emotional conflicts; effective communication; practice *Behavior Therapy-Relaxation, systematic desensitization to reduce anxiety; contingency management *Self-Help groups-AA

Problems in Treatment RELAPSE 

Treatment and Relapse Ntl Instit on Drug Abuse ◦ Substance abuse costs our Nation over $600 billion annually and treatment can help reduce these costs. Drug addiction treatment has been shown to reduce associated health and social costs by far more than the cost of the treatment itself. ◦ Unfortunately, when relapse occurs many deem treatment a failure. This is not the case: Successful treatment for addiction typically requires continual evaluation and modification as appropriate, similar to the approach taken for other chronic diseases. For example, when a patient is receiving active treatment for hypertension and symptoms decrease, treatment is deemed successful, even though symptoms may recur when treatment is discontinued. For the addicted individual, lapses to drug abuse do not indicate failure—rather, they signify that treatment needs to be reinstated or adjusted, or that alternate treatment is needed (see figure, "Why is Addiction Treatment Evaluated Differently?").

Psychosocial Treatments for Substance Use Disorders Modalities:  Cognitive-behavioral interventions (enhancing skills in coping, improving match between patient’s abilities and environmental demands)  social skills training (assertion, communication skills)  community reinforcement approach-take away positive reinforcement for drinking while reinforcing sobriety  Behavioral marital therapy (assess marital relationship, improving relationship, resolving conflicts, increasing caring and communication)  Motivational counseling-  Behavioral contracting; contingency management  Stress management training  Relapse prevention  12-Step approach (Alcoholics Anonymous) What doesn ’ t work educational films, confrontational interventions, general alcoholism counseling

Community Reinforcement Approach The following CRA procedures and descriptions are from Meyers, Roozen, and Smith for the substance user: [3] Functional Analysis of Substance explore the antecedents of a client’s substance use explore the positive and negative consequences of a client’s substance use Sobriety Sampling a gentle movement toward long-term abstinence that begins with a client’s agreement to sample a time-limited period of abstinence CRA Treatment Plan establish meaningful, objective goals in client-selected areas establish highly specified methods for obtaining those goals Behavior Skills Training teach three basic skills through instruction and role-playing: Problem-solving Communication skills Drink/drug refusal training ◦ identify high-risk situations ◦ teach assertiveness

continued Job Skills Training provide basic steps for obtaining and keeping a valued job Social and Recreational Counseling provide opportunities to sample new social and recreational activities Relapse Prevention teach clients how to identify high-risk situations teach clients how to anticipate and cope with a relapse Relationship Counseling improve the interaction between the client and his or her partner

Matching Patients to Modalities (not strong evidence for these findings yet) Relationship oriented treatment is more effective for those who are functioning better, have weaker urges to drink, good role-playing skills, less psychiatric diagnoses Cognitive-behavioral treatment better for more impaired patients, have more severe psychiatric disorders Behavioral programs like CRA and Contingency Management are seeing more success Communication skills training more effective for those who have less education, are more anxious, stronger urges to drink

Are Treatments Effective for Substance Use Disorders 1/2 million Americans under treatment for alcoholism Aprox 1/3 remain abstinent one yr after treatment Opiate-dependent clients & heroin addicts become re-addicted within first year Treated smokers return to smoking within one year; usually takes several attempts to stop Relapse occurs most frequently during 1st several mos. many do not continue treatment Many relapse and return to treatment