The Spectrum of Use and the Historical Context

Lecture 2

Chapter 1 & 2

Drugs Are Old

Drugs have been around since the dawn of time… Probably

Coming on the Scene• Alcohol as early as 6400 years BC (Middle East)• Cannabis 3000 years BC (Middle East)• Opium 5000 BC (China)• Tobacco 100 BC (Mexico)• Coca 3000 BC • Cocaine Extracted 1855• Heroin 1874• MDMA (XTC) 1912• LSD 1938

Despite the Laws People Still Use

Does Use Mean Abuse?

The Spectrum of Use

• Use – Periodic non-problematic use

• Misuse – Periodic Use

• Abuse – A pattern of misuse

• Dependence – Compulsive problematic use often with physiological dependence

Use

• Many drugs can be used relatively safely• Most people who use drugs do not develop

problems, however this depends on the drug• Drugs are used for many reasons

– Social– Religious– Coping– Experimentation

Misuse

• Periodic circumscribed negative consequences– College students and alcohol– “It only happened once.”– Sometimes the consequences are catastrophic

DSM-IV Abuse

1. Failure to fulfill major role obligations

2. Use in hazardous situations

3. Legal Problems

4. Use despite problems

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DSM-IV Dependence

1. Tolerance

2. Withdrawal

3. Larger amounts/longer period than intended

4. Inability to, or persistent desire to, cut down or control

5. A great deal of time spent obtaining, using, or recovering

6. Important activities given up or reduced

7. Use despite problems caused or exacerbated by use

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How Does One Move Through the Spectrum?

Public Health Model

• Agent Factors – Properties of the drug or substance

• Host Factors – Characteristics of the person

• Environment Factors – Context/Situation

Perspectives on Substance-Related

Disorders: An Overview (cont.)• Five Main Categories of Substances

– Depressants – Result in behavioral sedation – Stimulants – Increase alertness and elevate

mood – Opiates – Primarily produce analgesia and

euphoria – Hallucinogens – Alter sensory perception – Other drugs of abuse – Include inhalants,

anabolic steroids, medications

The Depressants: Alcohol Use Disorders

• Psychological and Physiological Effects of Alcohol– Central Nervous system depressant– Affects several neurotransmitter systems– Specific target is GABA

• Effects of Chronic Alcohol Use– Alcohol intoxication & withdrawal – Associated conditions – Dementia & Wernicke’s

disease– Fetal alcohol syndrome

• In the United States– Most adults view themselves light drinkers or abstainers– Over 50% of the U.S. (> 12 years age) report current use– 15 million Americans are alcohol dependent– Rates are highest among Caucasian & Native Americans – Males use and abuse alcohol more than females– Violence is associated with alcohol– Alcohol alone does not cause aggression

Alcohol: Some Facts and Statistics

Stimulants: An Overview

• Nature of Stimulants– Most widely consumed drug in the United

States– Such drugs increase alertness and increase

energy– Examples include amphetamines, cocaine,

nicotine, and caffeine

Stimulants: Amphetamine Use Disorders• Effects of Amphetamines

– Produce elation, vigor, reduce fatigue

– Effects are followed by extreme fatigue and depression

• DSM-IV-TR Criteria for Amphetamine Intoxication• Ecstasy and Ice

– Produces effects similar to speed, but no “comedown”

– 2% of college students report using Ecstasy

– Both drugs can result in dependence

• Amphetamines stimulate CNS by – Enhancing release of norepinephrine and dopamine

– Reuptake is subsequently blocked

Stimulants: Cocaine Use Disorders

• Effects of Cocaine– Short lived sensations of elation, vigor, reduce fatigue– Blocks reuptake of dopamine– Highly addictive, but addiction develops slowly

• DSM-IV-TR Criteria for Cocaine Intoxication and Withdrawal– Psychological symptoms– Physiological symptoms

• Most Cycle Through Patterns of Tolerance and Withdrawal

Opioids: An Overview• The Nature of Opiates and Opioids

– Opiate – Narcotic like chemical in the opium poppy – Opioids – Substances that produce narcotic effects– Often referred to as analgesics (i.e., help relieve pain)– Examples include heroin, opium, codeine, and

morphine

• Effects of Opioids– Activate body’s enkephalins and endorphins– Low doses – Euphoria, drowsiness, and slow breathing– High doses can be fatal– Withdrawal symptoms can be lasting and severe

Other Drugs of Abuse: Designer Drugs• Designer Drugs

– Drugs produced by pharmaceutical companies for diseases

– Ecstasy, MDEA (“eve”), BDMPEA (“nexus”), ketamine (“special K”) are examples

– All heighten auditory and visual perception (taste and touch)

– Popular in nightclubs, raves, or large social gatherings

– All designer drugs can produce tolerance and dependence

Causes of Substance-Related Disorders:

Family and Genetic Influences• Results of Family, Twin, and Adoption

Studies – Substance abuse has a genetic component– Much of the focus has been on alcoholism– Genetic differences in alcohol metabolism– Multiple genes are involved in substance abuse

Causes of Substance-Related Disorders:

Neurobiological Influences• Results of Neurobiological Research

– Drugs affect the pleasure or reward centers in the brain

– The pleasure center – Dopamine, midbrain, frontal cortex

– GABA turns off reward-pleasure system– Inhibition of neurotransmitters for anxiety /

negative affect

Causes of Substance-Related Disorders:

Psychological Dimensions• Role of Positive and Negative Reinforcement

– The self-medication and the tension reduction hypotheses

– Substance abuse as a means to cope with negative affect

• Opponent-Process Theory – Why the crash after drug use fails to stop drug use

• Role of Expectancy Effects – Expectancies influence drug use and relapse

Causes of Substance-Related Disorders:

Social and Cultural Dimensions• Exposure to Drugs is a Prerequisite for Use of Drugs

– Media, family, peers

– Parents and the family appear critical

• Societal Views About Drug Abuse – Sign of moral weakness – Failure of self-control

– Sign of a disease – Caused by underlying processes

• The Role of Cultural Factors – Influence the manifestation of substance abuse

• Exposure or Access to a Drug– Is necessary, but not sufficient for abuse and addiction

• Drug Use Depends on Social and Cultural Expectations

• Drugs Are Used Because of their Pleasurable Effects• Drugs Are Abused for Reasons that are More

Complex– The premise of equifinality– Stress may interact with psychological, genetic, social,

and learning factors

An Integrative Model of Substance-Related Disorders

From A Psychological Standpoint

• Drug abuse and dependence are disorders of behavior• Not only do each have health implications, abuse and

dependence have extreme psychosocial implications• People make changes in their alcohol/drug abuse behavior

in the same way they make changes in all other behaviors• Much alcohol and drug abuse/dependence is related to

psychopathology• Most people stop on their own

Substance Abuse Treatment

• “Self-Help” (AA NA CA Rational Recovery)

• Psychosocial Interventions

• Medications

Self-Help 12 Step Fellowships• Alcoholics Anonymous Narcotics Anonymous

– View of Problem: Spiritual disease

– Tools: 12 steps to recovery

– Mechanism: Powerful social support

– Issues: Effective for those who stick. Can be difficult to stick

Psychosocial Interventions• Behavioral and Cognitive Behavioral

– View of Problem: Behavioral disorder.

– Tools: Functional analysis, contingency management and

cognitive interventions as well as relapse prevention

– Mechanisms: Skills improvement, attitude change, coping w/psychopathology

– Issues: Highly researched treatments. Very effective. Not sure how they work actually.

Psychosocial Interventions

• Motivational Interviewing– Alternative to confrontational approach– Designed to move individual through stages of

change– Brief (1-4 sessions)– Effective as stand-alone and a booster to

treatment

Pharmacotherapy

• Alcohol Dependence– Antabuse– Naltrexone

• Drug Dependence– Methadone & Naltrexone (Heroin)– Antidepressants (Cocaine)– Cocaine vaccine?????

Outcome• Abstinence vs. Harm Reduction

• AA/NA, CBT, MI are all effective

• Meds can be as well

• Stage-matched interventions

• The longer people stick the better they do

• Most often takes multiple treatments

• Social support after treatment is critical

• Treatment works better than jail in the short and long run