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Substance Abuse vs. Substance Dependence (DSM IV)

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Substance Abuse vs. Substance Dependence (DSM IV) Dependence Three or more of the following in the same 12 month period Tolerance Withdrawal Often using more of the ... – PowerPoint PPT presentation

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Title: Substance Abuse vs. Substance Dependence (DSM IV)


1
Substance Abuse vs. Substance Dependence (DSM IV)
  • Dependence
  • Three or more of the following in the same 12
    month period
  • Tolerance
  • Withdrawal
  • Often using more of the substance than intended
  • Desire or unsuccessful efforts to cut down on use
  • Great deal of time spent in activities related to
    obtaining the substance
  • Important social, occupation, or recreational
    activities given up because of the substance
  • Substance use continued despite knowledge of a
    persistent problem caused by the substance

2
  • Abuse
  • One or more of the following in a 12 month period
  • Failure to fulfill major role obligations at
    work, school, or home
  • Recurrent use in hazardous situations
  • Recurrent legal problems
  • Continued use despite social or interpersonal
    problems caused or exacerbated by the substance
  • Note that tolerance or withdrawal are not present
  • Why is this distinction (abuse vs. dependence)
    useful?

3
Prevalence of Substance Use Disorders in the
United States
  • 9 of the adult population (appx. 20 million
    people) experienced some type of disorder in the
    past year (Grant et al., 2004a b c)
  • 8.5 experienced alcohol abuse or dependence in
    the past year
  • 2 experienced drug abuse or dependence
  • Why dont the percentages add up?

4
  • Approximately 12 of adolescents report a
    lifetime history of substance abuse or dependence
    (Costello et al., 2003)
  • Those with SUDs are more likely than others to
    experience mood, anxiety, and personality
    disorders (Grant et al., 2004 b c), and an
    association exists between substance use and some
    disordered eating behaviors (Dansky et al., 2000)
  • SUDs cost at least 300 billion annually (e.g.,
    sick leave, lost productivity, treatment costs)
    (Harwood, 1998 Rice, 1999).

5
Alcohol
  • Metabolism of alcohol
  • Alcohol absorbed from stomach and metabolized in
    liver by alcohol dehydrogenase (ADH)

6
  • Women may have less ADH, which could partially
    explain less efficient alcohol metabolism
  • Slower gastric emptying allows more ADH
    metabolism
  • Why is this important?
  • Aspirin inhibits ADH
  • This ADH pathway metabolizes approximately one
    drink per hour
  • http//depts.washington.edu/mcsurvey/bal/index.php

7
  • Most important effect of alcohol is on the
    gamma-aminobutyric acid (GABA) system
  • GABA neurotransmitters are primarily inhibitory
    and anxiolytic (anxiety-reducing)
  • Alcohol binds to GABA receptors in the brain,
    results in sedative and anxiolytic effects
  • However, chronic alcohol use causes the GABA
    system to not function on its own-meaning alcohol
    is required for it to function
  • What are the clinical implications of this?
  • Alcohol also inhibits the NMDA receptor (related
    to a number of excitatory physiological
    processes)

8
  • Low doses of alcohol activate norepinephrine
    system and dopamine pathways-brains reward
    center (e.g., feelings of pleasure)

9
  • Clinical features of alcohol
  • Intoxication
  • Measured by the percentage of alcohol in the
    bloodstream (i.e., blood alcohol content)
  • In this country its usually grams of
    alcohol/1000grams of blood (e.g., BAC of .20 2
    grams/1000 grams)

10
  • .08 is legal intoxication
  • .25 is blackout territory
  • .40 or higher may result in death
  • Withdrawal
  • Recall that long-term use of alcohol
    down-regulates inhibitory GABA receptors (alcohol
    takes its place) and inhibits NMDA (excitatory)
    receptors When alcohol is removed, decrease in
    inhibiting GABA and increase in NMDA
  • Results in tremor, sweats, anxiety, agitation,
    etc.
  • Seizures and delirium are also possibl
  • Clinical implications?
  • May also induce other psychiatric disorders
  • Note difference between induced and co-occurring

11
  • A host of medical problems are associated with
    alcohol abuse and dependence
  • Most common involve the liver
  • Why?
  • Hepatic Steatosis (fatty liver) is most common,
    and reversible
  • Alcohol hepatitis
  • Cirrhosis (about 10-20 of heavy drinkers)
  • Liver tissue replaced by scar tissue

12
Opioids
  • Because of their strong physiologically addicting
    properties, they have a well-defined syndrome of
    administration, tolerance, and withdrawal
  • Unlike some other substances, linear progression
    in use is most common
  • Opioids bind to specific receptors in the brain
    (mu, kappa, and delta)
  • This has clinical implications for opioid
    antagonists (e.g., naltrexone) that bind to the
    same sites
  • Most opioids have short half-lives
  • Clinical implications?

13
  • Principle legitimate use of opioids is pain
    relief
  • Opioids cause respiratory system to be less
    sensitive to carbon dioxide, which stimulates
    breathing
  • Impact of this?
  • Opioids cross placental barrier
  • Opioids result in changes at the receptor site by
    opioid occupation (i.e., the site does not
    function as it should)
  • Removal of the opioid causes the withdrawal
    syndromes (recall the half-life issue)

14
  • Opioid intoxication
  • Euphoria, anxiety relief, slow respiration,
    impaired judgment
  • Opioid withdrawal
  • Craving, sweating, tremors, irritability,
    insomnia, nausea, etc.
  • Opioid overdose
  • Decreased respiration, cardiovascular collapse
  • Treated usually with opioid antagonist

15
  • Clinically, perhaps the most challenging issues
    associated with opioid addiction involves dealing
    withdrawal
  • Extremely uncomfortable for the individual
  • Withdrawal symptoms can be alleviated by
    introducing a substance that is a same-receptor
    agonist as the opioid, but presumably less
    addicting
  • Clonidine suppresses many withdrawal symptoms
  • Methadone maintenance
  • Longer half-life than most opioids, administered
    once a day
  • Idea is to reduce drug-seeking behavior
  • Usually used with long-term users
  • Heavily regulated
  • Long-acting antagonist like naltrexone may also
    be used

16
Marijuana
  • Most common illicit drug in the US
  • Most potent active ingredient is
    delta-9-tetrahydrocannabinol (THC)
  • Main psychoactive substance
  • Peak effect occurs about 20 minutes after
    ingestion, although some effects immediately
  • Euphoria, sensory alteration, time perceptions
  • Activates pleasure/reward system in brain

17
  • Effects of marijuana use
  • Poor reaction time
  • Decreased coordination
  • High doses can result in panic attacks,
    hypervigilance
  • Some evidence that heavy use is associated with
    psychotic disorders (effect size is small,
    though)
  • Issue of amotivational syndrome is unclear
  • What causes what-common issue in behavioral
    research
  • Probably does not cause permanent cognitive
    damage
  • Inhibits learning in the moment-could be a
    problem for habitual users
  • Withdrawal symptoms can occur, but not as intense
    as other drugs

18
Club Drugs
  • MDMA (ecstasy)
  • Dramatic psychological effect of feeling close
    and related to others
  • Explains popularity at raves
  • Most likely neurotoxic in humans (destroys
    serotonin neurons)
  • Rush occurs about 20-40 minutes after ingestion
  • Can result in increased desire for sex (although
    performance is inhibited)

19
  • MDMA affects many systems, but primarily works as
    an indirect serotonin agonist (blocks serotonin
    reuptake while also releasing serotonin stores)
  • Subsequent doses produce diminished high and
    greater side effects-drug tends to be used much
    more sporadically
  • Doesnt have the withdrawal symptoms of other
    drugs-no negative reinforcement motivation
  • Clinical implications?

20
  • Ketamine
  • Main result is a dissociative episode
  • GHB
  • Results in relaxation, tranquility, numbing,
    disinhibition
  • Dose response curve is steep-OD can easily occur

21
Other Hallucinogens
  • Effect of hallucinogen is not predictable
  • Can result in accidents and suicides
  • Flashbacks are a unique feature
  • LSD is most common
  • Period of effect is usually 8-12 hours
  • Does not cause physical dependence

22
Cocaine
  • Cocaine occurs in the leaves of the coca plant
    (Peru, Columbia)
  • Chewing the leaves seems to have a mild effect
  • Powder cocaine is cocaine hydrochloride
  • 30-120 minutes for peak effects
  • Intravenous or smoking cocaine (crack) causes an
    almost instant effect

23
  • Cocaine is a stimulant, impacts many reward areas
    of the brain (GABA, dopamine, serotonin)
  • Blocks the reuptake of dopamine, serotonin, and
    norepinephrine
  • Results in increased energy, alertness,
    self-confidence, etc.
  • Chronic use results in depletion of these
    neurotransmitters, though (paradox of drug use)
  • Cocaine has a short rush and 15-20 minutes of
    euphoria, but then withdrawal and craving
  • Withdrawal is not physiological-results primarily
    in psychological cravings
  • Clinical implications?

24
  • Primary medical complication involves increased
    workload on the heart, which leads to a number of
    cardiovascular problems
  • Cocaine also passes the placental barrier

25
Methamphetamine
  • Produces similar effects as cocaine, but 10 to 12
    hour half life as opposed to 20-120 minutes of
    cocaine
  • Produces typical amphetamine symptoms (euphoria,
    enhanced self-esteem, but leading to paranoia,
    anxiety, etc.)
  • Effects multiple organ systems

26
Sedatives/Benzodiazepines
  • The issue of using benzodiazepines often comes up
    in treatment settings
  • Useful for anxiety and insomnia
  • Barbiturates were first generation of
    sedatives-easy to OD on
  • Benzos have slower onset, less abuse potential,
    harder to OD on
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