substance use disorders what is a drug? any substance other than food that affects our bodies or...

Substance Use Disorders


Some substances can also lead to long-term problems

People who regularly ingest them may develop substance use disorders

Also called “addiction”

Depressants

Depressants slow the activity of the central nervous system (CNS) Reduce tension and inhibitions May interfere with judgment, motor activity, and

concentration Three most widely used depressants:

Alcohol Sedative-hypnotic drugs Opioids

Depressants: Alcohol

All alcoholic beverages contain ethyl alcohol It is absorbed into the blood through the stomach

lining and takes effect in the bloodstream and CNS Short-term: alcohol blocks messages between neurons Alcohol helps GABA (an inhibitory messenger) shut

down neurons and relax the drinker


The extent of the effect of ethyl alcohol is determined by its concentration (proportion) in the blood A given amount of alcohol has a lesser effect on a large

person than on a small one Gender also affects blood alcohol concentration

Women have less alcohol dehydrogenase, an enzyme in the stomach that metabolizes alcohol before it enters the blood

Women become more intoxicated than men on equal doses of alcohol


Levels of impairment are closely tied to the concentration of ethyl alcohol in the blood: BAC = 0.06: Relaxation and comfort BAC = 0.09: Intoxication BAC > 0.55: Death

Most people lose consciousness before they can drink this much


The effects of alcohol subside only after alcohol is metabolized by the liver The average rate of this metabolism is 25% of an ounce

per hour You can't increase the speed of this process!

Is All Drug Misuse the Same?DSM-5 has combined two past disorders, substance abuse (excessive and chronic reliance on drugs) and

substance dependence (excessive reliance accompanied by tolerance and withdrawal symptoms) into a single category—substance use disorder. Critics

worry that clinicians may now fail to recognize and address the different prognoses and treatment needs of individuals who abuse substances and those who

depend on substances.

Is All Drug Misuse the Same?DSM-5 has combined two past disorders, substance abuse (excessive and chronic reliance on drugs) and

substance dependence (excessive reliance accompanied by tolerance and withdrawal symptoms) into a single category—substance use disorder. Critics

worry that clinicians may now fail to recognize and address the different prognoses and treatment needs of individuals who abuse substances and those who

depend on substances.


Alcohol use disorder In general, people who abuse alcohol drink large

amounts regularly and rely on it to enable them to do things that would otherwise make them anxious Eventually the drinking interferes with social behavior and the

ability to think and work Individual patterns of alcohol abuse vary


Alcohol dependence For many people, the pattern of alcohol misuse includes

dependence They build up a physiological tolerance and need to drink

greater amounts to feel its effects They may experience withdrawal, including nausea and

vomiting, when they stop drinking A small percentage of alcohol-dependent people experience a

dramatic and dangerous withdrawal syndrome known as delirium tremens (“the DTs”)

Alcohol withdrawal can be fatal

What is the personal and social impact of alcoholism?

Depressants: Sedative-Hypnotic Drugs

Sedative-hypnotic (anxiolytic) drugs produce feelings of relaxation and drowsiness At low doses, they have a calming or sedative effect At high doses, they function as sleep inducers or

hypnotics Sedative-hypnotic drugs include barbiturates

and benzodiazepines

Depressants: Barbiturates

Widely prescribed in the first half of the 20th century to fight anxiety and to help people sleep They can cause many problems such as abuse,

dependence, and overdose At low doses, they reduce excitement in a manner

similar to alcohol by attaching to the GABA receptors and helping GABA operate

At too high a level, they can halt breathing, lower blood pressure, and can lead to coma and death

Depressants: Barbiturates

Repeated use of barbiturates can quickly result in a pattern of abuse and/or dependence A great danger of barbiturate dependence is that the

lethal dose of the drug remains the same, even while the body is building a tolerance for the sedative effects

Barbiturate withdrawal is particularly dangerous because it can cause convulsions

Depressants: Benzodiazepines

Benzodiazepines are often prescribed to relieve anxiety Most popular sedative-hypnotics available

Class includes Xanax, Ativan, and Valium

Benzodiazepines have a depressant effect on the CNS by binding to GABA receptors and increasing GABA activity Benzodiazepines relieve anxiety without causing

drowsiness Less likely to slow breathing and lead to death by overdose

Depressants: Opioids

This class of drug includes both natural (opium, heroin, morphine, codeine) and synthetic (methadone) compounds and is known collectively as “narcotics” Each drug has a different

strength, speed of action, and tolerance level


Narcotics are smoked, inhaled, injected by needle just under the skin (“skin popped”), or injected directly into the bloodstream (“mainlined”) Injection seems to be the most common method of use,

although other techniques have been increasing in recent years

An injection quickly brings on a “rush” – a spasm of warmth and ecstasy that is sometimes compared with orgasm

This spasm is followed by several hours of pleasurable feelings (called a “high” or “nod”)


Opioids create these effects by depressing the CNS Opioids bind to the receptors in the brain that ordinarily

receive endorphins (NTs that naturally help relieve pain and decrease emotional tension)

When these sites receive opioids, they produce pleasurable and calming feelings, just as endorphins do

In addition to reducing pain and tension, opioids can cause nausea, narrowing of the pupils, and constipation


Heroin use exemplifies the problems posed by opioids: After just a few weeks, users may become caught in a

pattern of abuse (and often dependence) Users quickly build a tolerance for the drug and

experience withdrawal when they stop taking it Early withdrawal symptoms include anxiety and

restlessness; later symptoms include twitching, aches, fever, vomiting, diarrhea, and weight loss from dehydration


What are the dangers of heroin abuse? The most immediate danger is overdose

The drug closes down the respiratory center in the brain, paralyzing breathing and causing death

Death is particularly likely during sleep

Ignorance of tolerance is also a problem About 2% of those dependent on heroin and other opioids die

under the influence of the drug each year Users run the risk of getting impure drugs

Opioids are often “cut” with noxious chemicals Dirty needles and other equipment can spread infection

Stimulants

Stimulants are substances that increase the activity of the central nervous system (CNS) Cause increases in blood pressure, heart rate, and

alertness Cause rapid behavior and thinking

The four most common stimulants are: Cocaine Amphetamines Caffeine Nicotine

Stimulants: Cocaine

Most powerful natural stimulant known

Cocaine produces a euphoric rush of well-being

Produces this effect largely by increasing supplies of dopamine at key neurons throughout the brain

Also appears to increase norepinephrine and serotonin

Stimulants: Cocaine

High doses of cocaine can produce cocaine intoxication, whose symptoms include mania, paranoia, and impaired judgment Some people also experience hallucinations and/or

delusions, a condition known as cocaine-induced psychotic disorder

As the stimulant effects of the drug subside, the user experiences a depression-like letdown, popularly called “crashing”

Stimulants: Cocaine

Cocaine abuse and dependence Regular use may lead to

a pattern of abuse in which the person remains under the effect of cocaine for much of each day and functions poorly in social relationships and at work

Dependence on the drug may also develop

Stimulants: Cocaine

Cocaine abuse and dependence Cocaine use in the past was limited by the drug's high

cost Since 1984, cheaper, more powerful versions of the

drug have become available, including: A “freebase” form where the drug is heated and inhaled with a

pipe “Crack,” a powerful form of freebase that has been boiled down

for smoking in a pipe Currently, 0.5% of all people over the age of 11 in the

U.S. manifest cocaine abuse or dependence in a given year

Stimulants: Cocaine

What are the dangers of cocaine? Aside from its behavioral effects, cocaine poses

significant physical danger The greatest danger of use is the risk of overdose

Excessive doses depress the brain's respiratory function, and stop breathing

Cocaine use can also cause heart failure Pregnant women who use cocaine have an increased likelihood

of miscarriage and of having children with abnormalities

Stimulants: Amphetamines

Amphetamines: stimulant drugs manufactured in the laboratory Most often taken in pill or capsule form

Some people inject the drugs intravenously or smoke them for a quicker, more powerful effect

Like cocaine, amphetamines: 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

Stimulants: Amphetamines

One kind of amphetamine, methamphetamine, has had a major surge in popularity in recent years Almost 6% of all persons over the age of 11 in the US

have used this stimulant at least once Most of the nonmedical meth is made in “stovetop

laboratories”

Stimulant Use Disorder

Regular use of either cocaine or amphetamines may lead to stimulant use disorder

The stimulant dominates the individual’s life Leads to poor function in social relationships and

at work

Stimulants: Caffeine

World’s most widely used stimulant 80% of the world's population consumes it daily

Most is in the form of coffee; the rest is in the form of tea, cola, energy drinks, chocolate, and over-the-counter medications

99% of ingested caffeine is absorbed by the body and reaches its peak concentration within an hour

Caffeine acts as a stimulant in the CNS, producing a release of dopamine, serotonin, and norepinephrine in the brain More than 2 to 3 cups of brewed coffee can lead to caffeine

intoxication Seizures and respiratory failure can occur at doses greater

than 10 grams of caffeine (about 100 cups of coffee)

Stimulants: Caffeine

Many people who suddenly stop or cut back their usual intake experience withdrawal symptoms, including headaches, depression, anxiety, and fatigue Studies suggest correlations between high doses of

caffeine and heart rhythm irregularities, high cholesterol levels, and risk of heart attacks High doses during pregnancy also increase the risk of

miscarriage

Hallucinogens, Cannabis, and Combinations of Substances

Hallucinogens Produce delusions, hallucinations, and other sensory

changes Cannabis substances

Produce sensory changes, but have both depressant and stimulant effects

Combinations of substances

Hallucinogens

Hallucinogens produce powerful changes in sensory perceptions (sometimes called “trips”) Natural hallucinogens

Mescaline Psilocybin

Laboratory-produced hallucinogens Lysergic acid diethylamide (LSD) MDMA (Ecstasy)

Hallucinogens

LSD is one of the most powerful hallucinogens Brings on a state of hallucinogen intoxication

(hallucinosis) Increased and altered sensory perception Hallucinations and/or synesthisia

Effects wear off in about six hours LSD produces these symptoms by binding to

serotonin receptors These neurons help control visual information and

emotions, thereby causing the various effects of the drug on the user

Hallucinogens

More than 14% of Americans have used hallucinogens at some point in their lives

Tolerance and withdrawal are rare But the drugs do pose dangers

Users may experience a “bad trip” – the experience of enormous unpleasant perceptual, emotional, and behavioral reactions

Another danger is the risk of “flashbacks” Can occur days or months after last drug use

Cannabis

The drugs produced from varieties of the hemp plant are, as a group, called cannabis They include:

Hashish, the solidified resin of the cannabis plant

Marijuana, a mixture of buds, crushed leaves, and flowering tops

The major active ingredient in cannabis is tetrahydrocannabinol (THC) The greater the THC content,

the more powerful the drug

Cannabis

When smoked, cannabis produces a mixture of hallucinogenic, depressant, and stimulant effects At low doses, the user feels joy and relaxation

May become anxious, suspicious, or irritated This overall “high” is technically called cannabis intoxication

At high doses, cannabis produces odd visual experiences, changes in body image, and hallucinations

Most of the effects of cannabis last 2 to 6 hours Mood changes may continue longer

Cannabis abuse and Dependence

Marijuana was once thought not to cause abuse or dependence

One theory about the increase in abuse and dependence is the change in the drug itself The marijuana available today is significantly more

potent than the drug used in the early 1970s

Cannabis

Cannabis

Cannabis and Society: A Rocky Relationship For centuries, cannabis played a respected role in

medicine, but its use fell out of favor and was criminalized

In the late 1980s, several interest groups campaigned for the medical legalization of marijuana

The U.S. Federal Government has continued to fight and punish the production and distribution of marijuana for medical purposes However, in 2009, the US Attorney General directed federal

prosecutors to not pursue cases against medical marijuana users complying with state laws

Both the Netherlands and Canada permit its use

Teenagers and Substance Use

Combinations of Substances

People often take more than one drug at a time, a pattern called polysubstance use Researchers have studied the ways in which drugs

interact with one another, focusing on cross-tolerance and synergistic effects


Each year tens of thousands of people are admitted to hospitals because of polysubstance use May be accidental or intentional

As many as 90% of people who use one illegal drug are also using another to some extent

What Causes Substance Use Disorders?

Clinical theorists have developed sociocultural, psychological, and biological explanations for substance abuse and dependence No single explanation has gained broad support Best explanation: a COMBINATION of factors

Causes of Substance Use Disorders: Sociocultural Views

Causes of Substance Use Disorders: Psychodynamic Views

Psychodynamic theorists believe that people who abuse substances have powerful dependency needs that can be traced to their early years Caused by a lack of parental nurturing

Some people may develop a “substance abuse personality” as a result

Limited research does link early impulsivity to later substance use, but the findings are correlational and researchers cannot presently conclude that any one personality trait or group of traits stands out in substance use disorders

Causes of Substance Use Disorders: Cognitive-Behavioral Views

According to behaviorists, operant conditioning may play a key role in substance abuse They argue that the temporary reduction of tension

produced by a drug has a rewarding effect, thus increasing the likelihood that the user will seek this reaction again

Similarly, the rewarding effects may also lead users to try higher doses or more powerful methods of ingestion

Causes of Substance Use Disorders: Cognitive-Behavioral Views

Other behaviorists have proposed that classical conditioning may play a role in substance abuse and dependence Objects present at the time drugs are taken may act as

classically conditioned stimuli and come to produce some of the pleasure brought on by the drugs themselves

Although classical conditioning may be at work, it has not received widespread research support as the key factor in such patterns

Causes of Substance Use Disorders: Biological Views

Pleasure Centers in the Brain

Causes of Substance Use Disorders: Biological Views

How Are Substance Use Disorders Treated?

Many approaches have been used to treat substance use disorders, including psychodynamic, behavioral, cognitive-behavioral, and biological, along with sociocultural therapies

Although these treatments sometimes meet with great success, more often they are only moderately helpful

Today treatments are typically used in combination on both an outpatient and inpatient basis

How Are Substance Use Disorders Treated?

The value of treatment for substance abuse or dependence can be difficult to determine Different substance use disorders pose different

problems Many people with substance abuse patterns drop out of

treatment early Some people recover without any intervention at all Different criteria are used by different clinical

researchers

Psychodynamic Therapies

Psychodynamic therapists first guide clients to uncover and work through the underlying needs and conflicts that they believe led to the disorder then try to help them change their styles of living

Research has not found this model to be very effective Tends to be of greater help when combined with other

approaches in a multidimensional treatment program

Behavioral Therapies

A widely used behavioral treatment is aversion therapy, an approach based on classical conditioning principles Individuals are repeatedly presented with an unpleasant

stimulus at the very moment they are taking a drug After repeated pairings, they are expected to react

negatively to the substance itself and to lose their craving for it

Behavioral Therapies

Aversion therapy is most commonly applied to alcohol abuse/dependence In one version, drinking behavior is paired with drug-

induced nausea and vomiting Another version of this approach requires people with

alcoholism to imagine extremely upsetting, repulsive, or frightening scenes while they are drinking

A behavioral approach that has been successful in the short-term is contingency management This procedure makes incentives contingent on the

submission of drug-free urine specimens

Cognitive-Behavioral Therapies

These treatments help clients identify and change the patterns and cognitions contributing to their patterns of use

Relapse-prevention training The overall goal is for clients to gain control over their

substance-related behaviors Clients are taught to identify and plan ahead for high-risk

situations and to learn from mistakes and lapses This approach is used particularly to treat alcohol use;

also used to treat cocaine and marijuana abuse

Biological Treatments

Biological approaches may be used to help people withdraw from substances, abstain from them, or simply maintain their level of use without further increases These approaches have limited long-term success

when used alone, but can be helpful when combined with other approaches


Detoxification Systematic and medically supervised withdrawal from a

drug Can be outpatient or inpatient

Two strategies: Gradual withdrawal by tapering doses of the substance Induce withdrawal but give additional medication to block

symptoms Detoxification programs seem to help motivated people

withdraw from drugs For people who fail to receive psychotherapy after withdrawal,

however, relapse rates tend to be high


Antagonist drugs As an aid to resist falling back into a pattern of

substance abuse or dependence, antagonist drugs block or change the effects of the addictive substance Example: disulfiram (Antabuse) for alcohol Example: naloxone for narcotics, naltrexone for alcohol


Drug maintenance therapy A drug-related lifestyle may be a greater problem than

the drug's direct effects Example: heroin addiction

Methadone maintenance programs are designed to provide a safe substitute for heroin Methadone is a laboratory opioid with a long half-life, taken

orally once a day Programs were roundly criticized as “substituting addictions” but

are regaining popularity, partly because of the spread of HIV/AIDS

Sociocultural Therapies


Self-help and residential treatment programs Most common: Alcoholics Anonymous (AA)

Offers peer support along with moral and spiritual guidelines to help people overcome alcoholism

It is worth noting that the abstinence goal of AA directly opposes the controlled-drinking goal of relapse prevention training and several other interventions for substance misuse – this issue has been debated for years

Many self-help programs have expanded into residential treatment centers or therapeutic communities People formerly dependent on drugs live, work, and socialize in

a drug-free environment while undergoing individual, group, and family therapies


Culture- and gender-sensitive programs A growing number of treatment programs try to be

sensitive to the special sociocultural pressures and problems faced by drug abusers who are poor, homeless, or members of ethnic minority groups

Similarly, therapists have become more aware that women often require treatment methods different from those designed for men


Community prevention programs Perhaps the most effective approach to substance use

disorders is to prevent them Some prevention programs argue for total abstinence

from drugs, while others teach responsible use Prevention programs may focus on the individual, the

family, the peer group, the school, or the community at large The most effective of these prevention efforts focuses on

multiple areas to provide a consistent message about drug use in all areas of life

substance use disorders what is a drug? any substance other than food that affects our bodies or...

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