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Substance Abuse vs. Substance Dependence (DSM IV)


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)

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

  • 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)

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?

  • 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).

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

  • Women may have less ADH, which could partially
    explain less efficient alcohol metabolism
  • Slower gastric emptying allows more ADH
  • Why is this important?
  • Aspirin inhibits ADH
  • This ADH pathway metabolizes approximately one
    drink per hour
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  • 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

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

  • 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)

  • .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,
  • Seizures and delirium are also possibl
  • Clinical implications?
  • May also induce other psychiatric disorders
  • Note difference between induced and co-occurring

  • 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

  • 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?

  • Principle legitimate use of opioids is pain
  • Opioids cause respiratory system to be less
    sensitive to carbon dioxide, which stimulates
  • 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)

  • 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

  • Clinically, perhaps the most challenging issues
    associated with opioid addiction involves dealing
  • 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
  • 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

  • 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

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

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)

  • 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?

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

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

  • 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

  • Cocaine is a stimulant, impacts many reward areas
    of the brain (GABA, dopamine, serotonin)
  • Blocks the reuptake of dopamine, serotonin, and
  • 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?

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

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

  • 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