Transcript Substance Use Disorders

Chapter Eleven
SUBSTANCE USE
DISORDERS
Substance Use Disorders
 Definition 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 Disorders
 Definition of psychoactive substance
 Substance abuse and substance dependence
definitions
 Course
 Epidemiology
 Etiology
 Treatment
 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
 Withdrawal
 Substance taken in larger amounts or for longer periods
of time than intended
 Persistent desire or failed efforts to reduce drug use
 Great deal of time spent trying to obtain, use, or recover
from effects of the drug
 Important social or occupational activities are given up or
reduced because of drug use
 Continuous 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
Substance Use Disorders
 Definition of psychoactive substance
 Substance abuse and substance dependence
definitions
 Course
 Epidemiology
 Etiology
 Treatment
 Special topic: Is college drinking a phase?
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
Substance Use Disorders
 Definition of psychoactive substance
 Substance abuse and substance dependence
definitions
 Course
 Epidemiology
 Etiology
 Treatment
 Special topic: Is college drinking a phase?
Lifetime Prevalence: Drug Use
and Dependence (NCS data)
Proportion with
History of Use








Tobacco
Alcohol
Cannabis
Cocaine
Amphetamines
Sedatives
Hallucinogens
Heroin
75.6
91.5
46.3
16.2
15.3
12.7
10.6
01.5
Proportion with Dependence
History of
Among Users
Dependence
24.1
14.1
04.2
02.7
01.7
01.2
00.5
00.4
31.9
15.4
09.1
16.7
11.2
09.2
04.9
23.1
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 Abuse
 Gender 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)
Substance Use Disorders
 Definition of psychoactive substance
 Substance abuse and substance dependence
definitions
 Course
 Epidemiology
 Etiology
 Treatment
 Special topic: Is college drinking a phase?
Etiology of Substance
Abuse/Dependence
Three generations of the
Barrymore family
Etiological Considerations
 Not 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: Genes
 Males:
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
12
Adoptive
Father
10
Heavy
drinker
8
6
Not heavy
drinker
4
2
0
Type 1 Genes
No Type 1 Genes
Rate of Alcoholism in Adult
Children (cont.)
20
Adoptive
Father
16
Heavy
drinker
12
8
Not heavy
drinker
4
0
Type 2 Genes
No Type 2 Genes
Etiology: Social Factors
 Culture 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
Substance Use Disorders
 Definition of psychoactive substance
 Substance abuse and substance dependence
definitions
 Course
 Epidemiology
 Etiology
 Treatment
 Special topic: Is college drinking a phase?
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