Chapter Eleven

Chapter Chapter ElevenEleven

SUBSTANCE USE SUBSTANCE USE DISORDERSDISORDERS

Substance Use DisordersDefinition of psychoactive substance

Substance abuse and substance dependence definitions

Course

Epidemiology

Etiology

Treatment

Drugs of Abuse (Psychoactive Substance) A chemical substance that alters

mood, changes perception, or changes brain functioning

These substances can range from legal (Nicotine) to prescription (Valium) to illegal (LSD) drugs

It is not unusual for people with substance abuse to use more than one drug (polysubstance abuse)

Substance Use DisordersDefinition of psychoactive substanceDefinition of psychoactive substance

Substance abuse and substance dependence Substance abuse and substance dependence definitionsdefinitions

Course Course

EpidemiologyEpidemiology

EtiologyEtiology

TreatmentTreatment

Special topic: Is college drinking a phase?Special topic: Is college drinking a phase?

Substance Use Disorders DSM-IV differentiates between two

substance use disorders: Substance

dependence Substance

abuse

Substance Abuse

A person’s ability to function becomes impaired

Harmful results appear, without signs of tolerance, withdrawal, or compulsive drug use (i.e., not meet criteria for dependence)

DSM-IV Definition of Substance Abuse

During a 12 month period, 1 or more of the following 4 criteria caused clinically significant impairment or distress:

Recurrent substance use: Resulting in failure to fulfill role obligations In situations in which it is hazardous That result in substance-related legal problems Despite continued social or occupational problems

caused by the drug

Substance Dependence

Repeated use of a drug that often results in tolerance, withdrawal, or compulsive drug taking behavior

Commonly called addiction

Psychological Dependence

The urge to take a psychoactive substance for reasons such as alleviating negative moods, avoiding withdrawal symptoms, and preparing for public speaking or writing

Physiological Dependence

Tolerance and withdrawal are seen as indicators of a physiological dependence on a psychoactive substance

Tolerance

Through the ongoing use of any drug of abuse the nervous system becomes less sensitive to the physiological effects of that chemical over time

For example: You now need to drink 4 beers to get the same ‘high’ you used to get from drinking 2 beers

Withdrawal

Physiological symptoms a person experiences when drug use is stopped (specific symptoms depend on substance)

Withdrawal symptoms for nicotine include: drowsiness, muscle tremors and nausea

Withdrawal symptoms for alcohol in the most severe cases include: convulsions, hallucinations, and possibly alcohol withdrawal delirium

DSM-IV Substance Dependence Criteria

During a 12 month period, 3 or more of the following caused clinically significant impairment or distress:

Tolerance WithdrawalSubstance taken in larger amounts or for longer periods

of time than intendedPersistent desire or failed efforts to reduce drug useGreat deal of time spent trying to obtain, use, or recover

from effects of the drugImportant social or occupational activities are given up

or reduced because of drug useContinuous substance use despite knowledge of

consequences of drug use

Substance Dependence vs. Substance Abuse

The level of impairment or distress caused by the use of psychoactive substances differentiates dependence from abuse

Substance dependence is the more severe disorder



Course


EtiologyEtiology

TreatmentTreatment


Course

For both dependence and abuse: the course as well as the age of onset vary from one person to the next

Alcoholism research indicates that individuals alternate between periods of heavy use and periods of relative abstinence

Lifetime prevalence rate of alcohol abuse or dependence is 14%

Young adults have highest prevalence rate for alcohol dependence



CourseCourse

Epidemiology

EtiologyEtiology

TreatmentTreatment


Lifetime Prevalence: Drug Use and Dependence (NCS

data)

Tobacco 75.6 24.1 31.9Alcohol 91.5 14.1 15.4Cannabis 46.3 04.2 09.1Cocaine 16.2 02.7 16.7Amphetamines 15.3 01.7 11.2Sedatives 12.7 01.2 09.2Hallucinogens 10.6 00.5 04.9Heroin 01.5 00.4 23.1

Proportion with Proportion with Dependence History of Use History of Among Users Dependence

Substance Use Among College Students (Shinew,

2002)83% drink alcohol

67% started in high school

24% use drugs Marijuana (98%) and

ecstasy (28%)

80% indicated drinking as a leisure activity

Prevalence of Alcohol Dependence and AbuseGender differences

Men five times more likely to chronically abuse alcohol than women

Age differences Rates higher among young adults (18-29)

and lowest among elderly (65 and over)



CourseCourse


Etiology

TreatmentTreatment


Etiology of Substance Abuse/Dependence

Three generations of the Barrymore family

Etiological ConsiderationsNot everyone who uses drugs will move to the

level of abuse or dependence The role of biological factors in substance

addictions Social and psychological factors play a role in

substance use

The etiological factors that will be presented for the rest of the lecture will be those that influence alcoholism

Etiology: GenesMales: MZ = 56% DZ = 33%

Females: MZ = 30% DZ = 17% MZ concordances are higher than DZ concordances Higher concordance rates in male twins reflect higher

rates of alcoholism among men

Gender difference in alcoholism for MZ and DZ twins could be attributed to: Women have lower physical tolerance Negative social attitudes towards public intoxication

(for women)

Cloninger Adoption Study

Examined alcohol abuse in adoptees in Sweden (males born out of wedlock and adopted at an early age)

Collected data from official records of hospitals, insurance companies and national criminal register

Cloninger’s System of Alcoholism

TYPE 1: Biological parents had later onset (after age

25) of drinking problems with absence of criminal behavior

TYPE 2: Biological parents had early onset (before age

25) of drinking problems, and had undergone treatment or presence of criminal behavior

Comparison Groups

Type 1 and Type 2 children of alcoholic parents were adopted into two kinds of homes: Heavy drinking Absence of heavy drinking

Control group

Rate of Alcoholism in Adult Children

0

2

4

6

8

10

12

Type 1 Genes No Type 1 Genes

Heavydrinker

Not heavydrinker

Adoptive Father

Rate of Alcoholism in Adult Children (cont.)

0

4

8

12

16

20

Type 2 Genes No Type 2 Genes

Heavydrinker

Not heavydrinker

Adoptive Father

Etiology: Social FactorsCulture or religion could influence how early

someone is exposed to alcohol, as well as their attitudes toward drinking

Initial experimentation more likely among those who are rebellious, extraverted, and if parents or peers model/encourage use

Unpleasant emotional environment and low parental monitoring increase risk that children will affiliate with peers who use drugs



CourseCourse


EtiologyEtiology

Treatment


Treatment Considerations

Most people do not seek treatment in part because they refuse to acknowledge they have a problem

When treatment is initiated compliance is low and dropout rates are high

High comorbidity rate of alcoholism with other mental disorders makes treatment more challenging

Treatment Goals

Abstinence versus moderation Some treatment programs’ goal may be

abstinence (e.g., AA), whereas the goal of others may be drinking in moderation

Scope of treatment Should treatment address

areas such as occupational, social, or medical problems

Treatment Outcomes

Consistent findings across studies

Although improvement usually persists after treatment, relapse is not uncommon

Research evidence suggests that no one treatment is clearly superior to others. However, 12 step programs, such as AA, are usually more successful at achieving abstinence

Treatment Outcomes

Improvements in general health, social, and occupational functioning usually accompany reduction in drug use

Positive long-term outcomes are most favorable for individuals who have a high degree of coping resources, available social support, and low stress situations

Optional Slides

Substance Dependence

Tolerance and withdrawal are not required for diagnosis

Not requiring tolerance or withdrawal for diagnosis broadens the number of people who may meet the criteria for substance dependence

Not all psychoactive substances result in withdrawal symptoms after drug has been stopped (e.g., cannabis, LSD typically do not lead to withdrawal symptoms)

Diagnosing Substance Use Disorders

Although different drugs produce different physiological and psychological effects, the same criteria list is used to diagnose both substance dependence and substance abuse

What are the implications for diagnosing cannabis dependence (no withdrawal symptoms) and alcohol dependence, which does lead to withdrawal symptoms?

City Men/College Men Study

Longitudinal study examined 456 inner-city adolescents from Boston and 268 former undergrads from Harvard

Begun in 1940 and followed both groups past the age of 60

35% of city men and 21% of college men met diagnosis for alcohol abuse at some point in their life

Men who abused alcohol died earlier than those who did not

Most alcoholic men went through repeated cycles of abstinence followed by relapse

Current, Binge, and Heavy Alcohol Use Among Persons Aged 12 or Older, by Race/Ethnicity: 2003

Etiology: Psychological Factors (Expectations)

Alcohol Expectancies Alcohol enhances social

and physical pleasure Alcohol enhances sexual

performance Alcohol improves mood Alcohol reduces tension Alcohol increases social

assertiveness

Etiology: Psychological Factors (Expectations)

Positive expectations have stronger influence on increased drinking than negative expectations have on decreased drinking

Parents, peers, and media may influence adolescents’ expectations of alcohol

Adolescents who experiment with alcohol and have more positive expectations consume greater amounts of alcohol

Chapter Eleven

Documents

abuse substance dependence

recurrent substance

chemical substance

substance withdrawal

substance use disordersdsmiv

compulsive drug use

ongoing use

use of psychoactive