Substance Use Disorders

A maladaptive pattern of substance use leading to clinically significant social, emotional, or occupational impairment or distress A maladaptive pattern of substance use leading to clinically significant social, emotional, or occupational impairment or distress

Substance Dependence Tolerance, as evidenced by either Tolerance, as evidenced by either A need for more of the substance to achieve intoxication or the desired effect A need for more of the substance to achieve intoxication or the desired effect Diminished effect with continued use of the same amount Diminished effect with continued use of the same amount Withdrawal, as evidenced by either Withdrawal, as evidenced by either Characteristic withdrawal symptoms for the substance Characteristic withdrawal symptoms for the substance The same or a different substance is taken to relieve or avoid withdrawal symptoms The same or a different substance is taken to relieve or avoid withdrawal symptoms

Substance Dependence Must meet 3+ symptoms during a 12 month period Tolerance Withdrawal Substance is taken in larger amounts or for longer periods than intended Persistent desire and unsuccessful efforts to cut down A lot of time is spent getting, using or recovering from use Important social, occupational or other activities are given up because of use Use is continued despite significant negative consequences

Robert Downey, Jr. It’s like I’ve got a gun in my mouth, and my hand on the trigger and I like the taste of the gunmetal It’s like I’ve got a gun in my mouth, and my hand on the trigger and I like the taste of the gunmetal

Substance Abuse Must meet one or more symptoms during a 1 year period Recurrent use resulting in a failure to meet major role obligations at work, school, or home Recurrent use in situations where it is physically hazardous Recurrent substance-related legal problems Continued use despite having persistent or recurrent social or interpersonal problems

Causes Genetics (Marc Schuckitt) Genetics (Marc Schuckitt) 227 sons of alcoholics & 227 matched controls at age sons of alcoholics & 227 matched controls at age 20 Administered alcohol Administered alcohol Sensitivity to alcohol assessed Sensitivity to alcohol assessed Subjective rating: How High are You? Subjective rating: How High are You? Objective measure: Body Sway Objective measure: Body Sway Interviewed 10 years later re: symptoms of alcohol dependence Interviewed 10 years later re: symptoms of alcohol dependence

Genetics

Causes Biological Biological Areas associated with drug reward Areas associated with drug reward Ventral Tegmental Area (VTA) in the brainstem Ventral Tegmental Area (VTA) in the brainstem Nucleus Accumbens (NA) in the midbrain Nucleus Accumbens (NA) in the midbrain VTA projects to the the NA VTA projects to the the NA

Causes Drugs of Abuse produce their rewarding effects by increasing dopamine in the Nucleus Accumbens, either by Drugs of Abuse produce their rewarding effects by increasing dopamine in the Nucleus Accumbens, either by Stimulating the VTA to release dopamine onto the cells of the NA Stimulating the VTA to release dopamine onto the cells of the NA Directly exciting the receptors in the NA Directly exciting the receptors in the NA Blocking reuptake of Dopamine in the NA Blocking reuptake of Dopamine in the NA

Causes Social Learning Social Learning Vicarious Learning Vicarious Learning Learn about the consequences of a behavior by observing a model engage in the behavior and experience consequences Learn about the consequences of a behavior by observing a model engage in the behavior and experience consequences Outcome Expectancies Outcome Expectancies Learned association between a specific behavior and a specific consequence OR Learned association between a specific behavior and a specific consequence OR Belief about the consequences of a behavior Belief about the consequences of a behavior

Causes Positive Expectancies Positive Expectancies Belief that substance use will result in positive outcomes  Increased or continued substance use Belief that substance use will result in positive outcomes  Increased or continued substance use Negative Expectancies Negative Expectancies Belief that substance use will result in negative outcomes  decreased or discontinued substance use Belief that substance use will result in negative outcomes  decreased or discontinued substance use

Causes Operant Conditioning Operant Conditioning Behaviors that are followed by reinforcement are repeated Behaviors that are followed by reinforcement are repeated Initial substance use is reinforced by its effects Initial substance use is reinforced by its effects High High Relaxation Relaxation Social disinhibition Social disinhibition Elevated mood Elevated mood

Causes Drugs are powerful reinforcers Drugs are powerful reinforcers Role model uses drugs  gets high; less stressed  + expectancy developed Role model uses drugs  gets high; less stressed  + expectancy developed Opportunity arises  Use drug  get high; reduce stress  + expectancies reinforced  repeat behavior Opportunity arises  Use drug  get high; reduce stress  + expectancies reinforced  repeat behavior

Causes Classical Conditioning Classical Conditioning Substance use becomes associated with internal and environmental cues Substance use becomes associated with internal and environmental cues E.G., People, Places, Things, Thoughts, & Feelings E.G., People, Places, Things, Thoughts, & Feelings More frequent pairing results in a stronger association More frequent pairing results in a stronger association Exposure to these cues triggers thoughts about using and craving Exposure to these cues triggers thoughts about using and craving Opiates, Alcohol, Nicotine  compensatory response Opiates, Alcohol, Nicotine  compensatory response Cocaine  anticipatory response Cocaine  anticipatory response

Treatment

Medication Alcohol Alcohol Disulfiram (antabuse) Disulfiram (antabuse) Naltrexone Naltrexone Acamprosate (campral) Acamprosate (campral) Nicotine Nicotine Nicotine Replacement Nicotine Replacement Bupropion Bupropion

Medication Opiates Opiates Methadone Methadone Buprenorphine/Naloxone Buprenorphine/Naloxone Cocaine Cocaine No effective medications No effective medications Marijuana Marijuana No effective medications No effective medications

Behavioral Self-Help Self-Help AA/NA AA/NA Rational Recovery Rational Recovery Contingency Management Contingency Management Offer rewards that compete with the reinforcing effects of the drug Offer rewards that compete with the reinforcing effects of the drug

Behavioral Cognitive Behavioral Therapy Cognitive Behavioral Therapy Substance Use represents maladaptive coping strategy Substance Use represents maladaptive coping strategy Treatment involves Treatment involves Identifying High Risk Situations Identifying High Risk Situations Teaching skills for coping with those High Risk Situations Teaching skills for coping with those High Risk Situations Differentiating Slips/Lapses from Relapses Differentiating Slips/Lapses from Relapses

High Risk Situation Cope Don’t Use Increase Self-Efficacy Risk of Relapse Decreases Don’t Cope Pos. Expectancies of Use triggered Lapse Or Slip Abstinence Violation Effect Risk of Relapse Increases