1. Substance Use Disorders Chapter 11

2. What is a drug?  A drug is a substance that has an action on biological tissues when administered  Some drugs influence mood cognition and behavior  Aspirin doesn’t  Cocaine does – Psychoactive/Psychotropic  Psychoactive drugs are used for a variety of purposes  Medicinal  Spiritiual  Recreational

3. Psychoactive Drugs  Substances active on CNS tissues when administered thereby causing changes in mood, cognition, behavior

4. Drug Action on the Nervous System  Pharmacokinetics  Administration  Oral, IV, Smoke  Absorption/Distribution  Metabolization  Elimination  Pharmacodynamics  Action on NT systems  Agonist  Antagonist Most drugs that are abused have a common effect on a particular NT pathway. They also have unique effects

5. Drug Action on the Nervous System – Reinforcement

7. Drug Action on the Nervous System – Repaeated Use  Tolerance  Decreased response to repeated exposure  Dependence  System adapts to presence of drug. Drug necessary for homeostasis  Withdrawal  Response to drug leaving the system  Addiction  Compulsive engagement in reinforcing behavior

8. The Spectrum of Drug Involvement  Everyone has a relationship to drugs. Drugs are used for one simple reason. The effect of that drug for that person is FUNCTIONAL  No use  Use  Misuse  Abuse  Dependence Does Use Mean Abuse?

9. DSM-IV Abuse A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12- month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) (2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) B.The symptoms have never met the criteria for Substance Dependence for this class of substance.

10. DSM-IV Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: (1)tolerance, as defined by either of the following:  (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of the substance

11. DSM-IV Dependence (2)withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (3)the substance is often taken in larger amounts or over a longer period than was intended (4)there is a persistent desire or unsuccessful efforts to cut down or control substance use

12. DSM-IV Dependence (5)a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects (6)important social, occupational, or recreational activities are given up or reduced because of substance use (7)the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine- induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

13. Causes of Drug Disorders

14. Causes of Drug Use Disorders - Risks  Genes  Moreso for acohol (LR, 5-HT Transporter)  Temperament  Negative affectivity  Impulsiviity  Psychopathology  Bipolar  PTSD  ASPD  Peer  Permissive norms around use

15. Public Health Model Agent – Drug Properties Host – Person Characteristics Environment Access, Norms Media

16. Treatment - Medication  Agonist Substitution  Substitute safer drug with a similar chemical composition  methadone and nicotine gum or patch  Antagonistic Treatment  Drugs that block or counteract pleasurable drug effects  naltrexone for opiate and alcohol problems  Other drugs  Antidepressants, Acamprosate

17. Treatment – Psychological Treatments  Motivational Enhancement  Increase motivation to change  Behavioral/CBT Approaches  Rely on functional analysis  Alter structure of reinforcement  Skills training  Cognitive Restructuring

18. Treatment??? – The 12 steps The 12 Steps of Alcoholics Anonymous  We admitted we were powerless over alcohol--that our lives had become unmanageable.  Came to believe that a Power greater than ourselves could restore us to sanity.  Made a decision to turn our will and our lives over to the care of God as we understood Him.  Made a searching and fearless moral inventory of ourselves.  Admitted to God, to ourselves and to another human being the exact nature of our wrongs.  Were entirely ready to have God remove all these defects of character.  Humbly asked Him to remove our shortcomings.  Made a list of all persons we had harmed, and became willing to make amends to them all.  Made direct amends to such people wherever possible, except when to do so would injure them or others.  Continued to take personal inventory and when we were wrong promptly admitted it.  Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.  Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

19. Evaluating the 12 steps  No data support the 12 step model of causality  Very good data to suggest that involvement increases abstinence  Involvement in more than just going  Active ingredient seems to be the strong social support for abstinence that 12 fellowships provide  Many people don’t take to it, but for those who do it’s highly efficacious