Transcript Martin_MARC_Summer_School

Historical Perspectives on
Substance Use and
Substance Use Disorders
Chris Martin, Ph.D.
Department of Psychiatry
University of Pittsburgh
History of Substance Abuse
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Humans have been using alcohol and marijuana for at least
10,000 years
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Historical and literary references to substance use go back
thousands of years, including the Bible, the Iliad and the
Odyssey
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Drug use spread via war, migration and trade
Napoleon, Egypt and Hashish
 Columbus, America and Tobacco
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Important Drugs of Abuse
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Alcohol
Cannabis
Cocaine
Stimulants
Opiates
Nicotine
Prescription Drugs
“Club drugs”
Appearance/Performance Enhancing Drugs
Patterns of
Substance Abuse
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Substance use is different than substance
problems or disorders (most users’ substance
use is not that harmful or impairing)
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Patterns vary by type of drug, route of
administration, frequency and quantity of use
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Polydrug use
Polydrug Use
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Alcohol with tobacco is most common
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Alcohol with marijuana most common combination
including an illegal drug
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Drug combinations can have additive or synergistic
effects on intoxication and impairment
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Many “alcohol-related” fatalities and injuries involve
other drug use
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Same for “heroin” overdoses
Drug Experimentation Among Teens
Delphi Study of Comparative Harm
of 20 Drugs of Abuse
Nutt et al, 2007
Delphi Study of Comparative Harm
of 20 Drugs of Abuse
Nutt et al, 2007
Philosophies of Pleasure
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Philosophies that place high value on the
pursuit of pleasure and avoidance of pain
have a long tradition – Epicurus, Thomas
More, Diderot
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Both Bentham and Mill postulated that
pleasure is desirable and a positive good in
and of itself, because only that which can
be experienced directly has any value.
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In Mills’ view, the most refined pleasures
are most to be desired, and improving the
human being’s ability to experience
refined pleasures enhances the overall
welfare of humankind.
Bentham
Mill
Historical Developments in
Understanding and Classifying
Mental Disorders
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Hippocrates, Galen: physical and mental problems due
to imbalance of various elements in the body (e.g., bile)
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Paracelsus (1400s): Syndromal Diagnosis: co-occurring
symptoms represent a disease state even if the cause is
unknown
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Pinel (late 1600s-early 1700s): hierarchical classification
system for mental problems
Historical Developments in
Understanding and Classifying
Mental Disorders (con’t)
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Kraepelin (late 1800s early 1900s): advanced classification,
emphasized careful observation of signs and symptoms,
differential diagnosis, understanding mental illness as brain
disease
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Wakefield (current): Mental Disorder as Harmful Dysfunction
(Internal mechanism does not function properly, causing harm to
the individual)
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DSM (current): Clinically significant behavioral or psychological
syndromes defined by a cluster of co-occurring symptoms
Historical Descriptions of
Substance Problems
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Numerous historical and literary descriptions,
including the Bible
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Benjamin Rush (1787): described the disease of
“Inebrity” or “Intemperance”
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Magnus Huss (1849): his “Alcoholismus
Chronicus” introduced the term “Alcoholism”
Glatt’s (1948) Chart of
Alcohol Addiction and Recovery
Historical Descriptions of
Substance Problems (con’t)
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E.M. Jellinek (Mid-20th century)
 Alcoholism
as a disease
 Progression and developmental staging of signs and
symptoms of alcohol problems
 Also described different sub-types of alcoholism
DSM-I (1952) and DSM-II (1968)
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Described alcoholism in general terms
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DSM-II described episodic heavy drinking,
habitual heavy drinking, and “alcohol addiction”
as separate forms of alcoholism
Alcohol Dependence Syndrome (ADS)
Edwards and Gross (1976)
 Did not include symptoms that were culturallyor historically-bound
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Defined a core syndrome related to compulsive
use patterns, motivational drive toward alcohol,
and physiological features of tolerance and
withdrawal
DSM-III (1980)
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Highly influenced by descriptions of the
Alcohol Dependence Syndrome
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Substance “Abuse”: pathological patterns of use
OR social consequences
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Substance “Dependence”: pathological patterns
OR social consequences AND tolerance OR
withdrawal
DSM-III-R (1987)
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Substance Abuse: hazardous use OR continued
use despite social consequences
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Substance Dependence: 3/9 co-occurring
symptoms related to ADS and social
consequences
DSM-IV Diagnostic Algorithms
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Dependence = 3/7 symptoms
Abuse = 1/4 symptoms
Abuse and Dependence Symptoms are mutually
exclusive
Dependence Precludes an Abuse Diagnosis
DSM-IV Alcohol Dependence
Symptoms
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D1 - Tolerance
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D2 - Withdrawal
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D3 - Drinking More Longer than Intended
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D4 - Unsuccessful Attempts to Quit/Cut Down
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D5 - Much Time Spent in Using Alcohol
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D6 - Social/Occupational Activities Diminished by Drinking
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D7 - Continued Use Despite a Physical or Psychological Problem
Caused/Exacerbated by Alcohol Use
DSM-IV Alcohol Abuse
Symptoms
Symptom
Brief Identifier
Abstracted DSM-IV Definition
A1
Role Obligations
Frequent intoxication leading to a
failure to fulfill major role obligations
at school/work/home
A2
Hazardous Use
Recurrent use when it is physically
hazardous (e.g., drunk driving)
A3
Legal Problems
Recurrent alcohol-related legal
problems
A4
Social Problems
Continued use despite knowledge of
recurrent social or interpersonal
problems caused/exacerbated by
alcohol use
Problems with
DSM-IV Criteria
Solutions to
Consider in DSM-V
 the Substance Abuse diagnosis
does not have a clear conceptual
core and does not meet standards for
the concept of “mental disorder”.
“Abuse” has multiple divergent
meanings.
 Abandon the category of
Substance Abuse in DSM-V. Define a
single category of Substance
Dependence using revised DSM-IV
SUD criteria and new symptoms such
as a consumption criterion.
 Lack of empirical distinctions
between DSM-IV’s mutually exclusive
criteria for Substance Abuse and
Dependence. DSM-IV algorithms
produce Diagnostic Orphans and
Imposters.
 Define SUDs in DSM-IV using a
combined criterion set, reflecting
evidence for a unidimensional
continuum of substance problems.
Problems with
DSM-IV Criteria
Solutions to
Consider in DSM-V
 DSM-IV’s change-based definition
of Tolerance leads to a lack of
symptom assignment in many heavy
users
 Revise the definition of Tolerance
to allow symptom assignment in
sufficiently heavy users.
 DSM-IV Abuse and Dependence
are defined by a “maladaptive pattern
of use”, but actual substance use
patterns are not described or used as
a diagnostic criterion.
 Incorporate a consumption
criterion such as a 5+ (men) and 4+
(women) US standard drinks within
two hours at least once/week for
alcohol, and any use at least
once/week for other drugs
Problems with
DSM-IV Criteria
Solutions to
Consider in DSM-V
 Hazardous Use and Legal
Problems poorly discriminate
substance problem severity, show
gender bias and are influenced by
cultural differences and secular
trends.
 These symptoms should be
removed as diagnostic criteria for
SUDs. Substance-related illegal
behavior should remain as a criterion
for antisocial disorders.
 SUD symptoms oversample
moderate levels of pathology and are
less accurate in scaling mild and
severe levels of substance problem
severity.
 Consider candidate criteria that
may help measure mild and severe
levels of substance problems, such
as a consumption criterion, craving
and rapid reinstatement.
Problems with
DSM-IV Criteria
Solutions to
Consider in DSM-V
DSM-IV is largely categorical
and does not elaborate a
framework for integrating
categorical and dimensional
approaches to diagnosis.
DSM-V should integrate categorical
and dimensional approaches to
diagnosis with attention to subdiagnostic manifestation of symptoms
and SUDs, scaling the severity of SUDs,
and describing non-criterion features
The comorbidity and shared
underlying risk factors of SUDs
with other externalizing disorders
such as CD and ASPD are not
well represented in the structure
and description of DSM-IV
diagnostic groupings.
DSM-V should group SUDs with
and externalizing spectrum of
psychopathology the include CD
and ASPD. The test of this
“chapter” of the manual should
highlight the associations among
and shared risk factors underlying
externalizing syndromes.
Number of Symptoms
Spectrum Nosology
Non-criterion
symptoms
All DSM-IV
symptoms
Super threshold
DSM-IV
threshold
Sub threshold
Non-criterion
symptoms
All DSM-IV
symptoms
Super threshold
DSM-IV
threshold
Sub threshold
Substance Use Disorders Alcohol Use Disorders
Non-criterion
symptoms
All DSM-IV
symptoms
Super threshold
DSM-IV
threshold
Sub threshold
Conduct Disorders
Proposed DSM-5 criteria for SUDs
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Combine abuse and dependence symptoms into
a single category (e.g., “Alcohol Use Disorder”)
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All DSM-IV symptoms except for Legal
Problems, and the addition of Craving
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Disorder defined by at least 2 of 11 symptoms
(severe disorder = 4/11 symptoms)
Modern Understanding of
Substance Dependence
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Neuroadaptation: alcohol and drug use change your
brain
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Changes in the structure and function of brain
circuits related to Reward, Motivation, Emotional
Regulation, Inhibitory Control, and
Tolerance/Withdrawal
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Neuroadaptations can persist for years even after a
person has quit using; sometimes a lifetime
The Reward Circuit
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For a species to survive, its members must carry out such
vital functions as eating, reproducing, and responding to
aggression.
Evolution has therefore developed certain brain areas
responsible for providing a pleasurable sensation as a
“reward” for carrying out these vital functions.
These areas are interconnected with one another to form
what is known as the reward circuit, contained in the medial
forebrain bundle which includes:
The ventral tegmental area (VTA), a group of neurons at the
very centre of the brain, receives information from other regions
that signal satisfaction or deficits in basic needs.
 The VTA then forwards this information to another structure
further forward in the brain: the nucleus accumbens, which
activates the individual’s motor functions, and the prefrontal
cortex, which focuses his or her attention.
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The Reward Circuit (cont.)
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The VTA contains the
dopaminergic neurons that
innervate the limbic system
and the prefrontal cortex.
The nucleus accumbens is
innervated by the ventral
tegmental area and interfaces
between the limbic system
and the motor system;
The prefrontal cortex
controls attention and
motivation
The reward circuit includes several other structures such as the septum and the
amygdala.
All of these innervate the hypothalamus – particularly the lateral and ventromedial
nuclei of the hypothalamus – alerting it to the presence or absence of reward
The hypothalamus then influences the autonomic and endocrine functions of the
entire body, through the pituitary gland.
The result of this activity is the experience of “feelings” of pleasure or the absence
of pleasure, which can act as a drive.
Reward Circuitry
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Drugs can hijack brain systems involved in the
critical evolutionary function of assigning
significance to natural rewards like food, water,
and sex
Inhibitory Control
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In chronic and acute ways, drug use can impair
inhibitory control, including via its effects on
the brain’s prefrontal cortex
Future Questions
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Will new drugs emerge that increase rates of
SUDs?
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Will the number of persons with SUDs in the
third world increase due to economic expansion
and globalization?