Transcript Chapter 13

Chapter 13
Topics in Substance Use Disorders
In all of recorded history, every society has used drugs
to produce alterations in mood, thought, feeling, or
behavior or to provide temporary alterations in reality.
Moreover, there have always been some people within
societies who digressed from custom with respect to
the time, the amount, and the situation in which drugs
were used. Abuse has always produced problems for
these individual and society.
Today, these patterns of drug use differ considerably
from the traditional pattern.
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Nearly all psychoactive drugs ever identified throughout history are
available today in our society. Partly due to transportation technology.
Active ingredient has been identified, isolated and made available
Organic chemistry has created new drugs, synthetic, and more potent
New methods of drug delivery have been invented (hypodermic
needle, free base methods, etc) which increase dose, decrease onset of
effects, increase potency and toxicity compared to naturally occurring
drugs.
When a Drug is Called a
“Behavior Reinforcer”
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Drugs prone to compulsive abuse activate
brain mechanisms involved in reward &
positive reinforcement
– Dopamine, serotonin, opioid, GABA,
cannabinoid neurons/receptors
– Median forebrain bundle, ventral tegmentum,
hippocampus, frontal cortex, nucleus
accumbens
Why Study Drug Reinforcing
Properties in Animals?
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The rate to which lab animals self-administer
psychoactive drugs closely parallels the degree of
abuse by human users of the drug.
 Cocaine, for example, is excessively abused by
rats, squirrels, monkeys, baboons, dogs & humans.
 This study helps dispel the myth that there is
something inherently wrong with human drug
abusers.
Blame: Drug or Abuser?
Is it a propensity for abusing drugs caused by
psychopathological process in the user or is
it a property of the particular drug?
– It is the property of the particular drug
(reinforcing) not some psychopathology of
user.
– They activate reward mechanisms in the brain
Why aren’t phenothiazines or
antidepressants addictive?
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Phenothiazines and antidepressants lack
self-reinforcing actions:
– Drugs with negative-reward effects (such as
phenothiazines & antidepressants inhibit
activity or increase threshold of the nucleus
accumbens dopaminergic system in the medial
forebrain bundle (same system that abused
drugs stimulate)
Principles of Positive Drug
Education
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Teach pharmacology of drugs
Provide basic facts in straight forward & honest way
Teach means for changing behavior; such as training to
resist peer pressure/teach that drugs are not cool
Provide reinforcement (recognition, praise & other
rewards) for not using drugs
Tell them how it detracts from a healthy body and
attractive looks (adolescents focus on these qualities)
Build self-esteem
Drug Education Shortcomings
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Will not stop self-prescription for symptom relief
Is not as effective as potentially could be due to mixed
signals about other addicting drugs such as alcohol &
cigarettes
Can be seen as providing directions for taking drugs
Will not stop those already involved in drugs or those who
seek relief from psychiatric symptoms or disorders
No program can guarantee the reduction of the use of
psychoactive drugs
Works best with those least likely to use drugs
Areas of Improvement for
Drug Education
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Begin very young (because once they start
using, education is no longer effective)
 Change legislation to be consistent with
scientific evidence (do not allow addicting
drugs like alcohol & cigarettes to be
promoted, distributed & used)
Relationship of Age of First
Use and Development of
Substance Use Disorder
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Age of first exposure (at least to marijuana) is an
important predictor and estimate both of the
likelihood of developing a substance abuse
problem and of the number of people who
eventually will need treatment for illicit drug
abuse problems.
 Most start before age 21. Typically age 14-16 for
nicotine, alcohol, and marijuana.
What Psychoactive Drugs Are
Most & Least Harmful?
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Most
– Psychostimulants (cocaine, nicotine)
– Opioids
– Depressants (alcohol, inhalants, barbiturates,
benzodiazepines)
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Least
– Hallocinogenic & Psychedelic
– Antidepressants
– Antipsychotics
Should Some Drugs Be More
Readily Available?
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Antidepressants (for those who seek selfmedication)?
 Drug sensitizing drugs?
 Those that help with drug withdrawal?
 Other drugs that have low occurrence for
addiction?
Treatment Issues
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Early years: equated dependence with
addiction – addicted because needed to
avoid withdrawal symptoms
 Detox would free person from clutches of
drug – break free
 Problem: even after detox, high percentage
relapse
Treatment Issues 2
1990’s – focus on drug induced reward
 Addicted to the reinforcing properties of
drug
 Abstinence is not a return to normal for
addicted person
 Abstinence results in apathy, boredom,
depression, anhedonia, craving for relief
 Leads to relapse
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Treatment Issues 3
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More complex than simplistic concepts of
reward and withdrawal
 Not all individuals who experiment with
drugs become abusers
 Can we identify risk factors/ predisposing
variables
 Parent/ peer/ individual (biogenetic)
Treatment Issues 4
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Focusing just on physical brain changes is
not adequate; addicts will have to be able to
handle later exposure to craving-eliciting
cues in the environment and will need
rehabilitation to either learn or relearn
social skills or job skills.
 Combined behavioral and pharmacological
treatments will be truly synergistic
Treatment Issues 5
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Comprehensive treatment does work can be cost
effective
Outpatient more cost effective
Residential – only slight improvement at 5 times
the cost
Incarceration too costly
Any treatment better than none
12 step programs/ mutual help programs/
substance free lifestyle programs are available