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Brain diseases: Substance abuse and co-occurring disorders

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Title: Brain diseases: Substance abuse and co-occurring disorders


1
Brain diseases Substance abuse and co-occurring
disorders
  • Mark Publicker, MD FASAM

2
Addiction
  • A chronic but treatable brain disease
    characterized by
  • Loss of control
  • Compulsive use
  • Use despite known harm
  • Relapse
  • The emergence of a negative affect state

3
Questions
  • Does mental illness cause substance abuse?
  • Does substance abuse cause mental illness?

4
Questions
  • Are there differences in populations
  • Primarily psychiatric
  • Primarily substance dependent

5
Comorbid substance abuse
  • Common problem in psychiatric patients
  • Contributes to treatment failure and
    non-compliance
  • Increased health care costs

6
Neurobiology
  • Same neurotransmitter systems
  • Dopamine
  • Serotonin
  • GABA
  • Glutamate
  • Endogenous opioids

7
Neurobiology
  • Drugs of abuse interact and alter neural
    substrates of psychiatric disorders
  • More neuro-psychological impairment

8
Rand Survey 2001
  • 3 US population has co-occuring disorders
  • Of these
  • 72 received no treatment in previous 12 months
  • Only 8 received both mental and substance abuse
    treatment
  • Only 23 of those in treatment received
    appropriate treatment

9
Current situation in US treatment systems
  • Comorbid rates are high
  • Different services are provided according to
    entry portal

10
Co-morbid psychiatric disorders
  • Depression
  • Anxiety disorders
  • Bipolar disorder
  • Schizophrenia

11
Co-morbid psychiatric disorders
  • Attention deficit hyperactivity disorder
  • Post traumatic stress disorder
  • Antisocial personality disorder

12
Epidemiology substance abuse disorders
  • 50 lifetime prevalence for psychiatric patients
  • Among individuals with alcohol use disorders,
    about 22 will also have a drug use disorder
  • Among individuals with a drug use disorder,
    almost half (47) will have an alcohol use
    disorder
  • Schizophrenia 70prevalence rates
  • Earlier onset of symptoms

13
Epidemiology
  • Affective disorders are very common. Up to 67 of
    alcohol-dependent patients, 53 of
    cocaine-dependent patients, and 75 of
    opiate-dependent patients have comorbid affective
    disorders
  • Approximately 25-50 of alcohol dependent
    individuals meet criteria for an anxiety disorder
  • Approximately 30-60 of patients with an SUD have
    comorbid Antisocial Personality Disorder

14
14
15
Order of Onset
  • Mental disorders typically emerge before comorbid
    substance use disorders
  • This pattern is somewhat stronger for women than
    men
  • Data from a large epidemiologic study found that
    the median age of onset of mental disorders was
    11 yrs old as compared to 21 yrs old for
    substance disorder

15
16
Diagnostic Difficulties
  • Substance intoxication and withdrawal can mimic
    nearly any psychiatric disorder
  • Stimulants/hallucinogens/cannabinoids mania and
    schizophrenia
  • Alcohol/opiate/sedative-hypnotic withdrawal
  • depressive and anxiety disorder

16
17
Diagnostic Difficulties
  • Assess which disorder developed first
  • Ask about symptoms during periods of abstinence.
    Minimum acceptable period of abstinence necessary
    for diagnostic clarity will differ by diagnosis
  • Anxiety/depression most symptom overlap, 2-4
    weeks important.
  • Psychosis/mania 2-4 days sufficient in most
    cases.
  • Ask about family history
  • Consult multiple sources of information

18
Substance Use and Suicide
  • Substance induced depression
  • May resolve quickly with treatment but is still
    very dangerous
  • Increased suicidal thoughts, ideation
  • High risk group Diagnosis of major depression
    alcohol or drug abuse/dependence
  • Rates are 20-120X the general population

19
Epidemiology
  • Schizophrenia substance abuse associated with
    higher rates of homelessness, non-compliance,
    medical illness and violence
  • Bipolar disorder rates estimated to be 50-70
  • Associated with worse prognosis

20
Epidemiology
  • Unipolar depression 30-50
  • Associated with treatment resistance and greater
    severity
  • Worsens alcohol dependence treatment outcomes

21
Epidemiology
  • ADHD 50 of substance abuse patients
  • Increases risk of substance abuse
  • Effective childhood treatment reduces risk

22
Epidemiology
  • PTSD increased risk of substance abuse
  • Hypothalamic and noradrenergic mechanisms
  • Substance abuse increases PTSD symptoms which in
    turn intensify substance abuse

23
Post traumatic stress disorder
  • Withdrawal symptoms overlap with arousal symptoms
  • Increased stress sensitizes the Locus Ceruleus

24
Post traumatic stress disorder
  • Increased noradrenaline increases stress
  • Increased fear responses in amygdala

25
Epidemiology - Nicotine
  • Nicotine-dependent patients with comorbid
    disorders 7.1 US population consume 34.2 of
    all cigarettes smoked

26
Self-medication hypothesis
  • Nicotine decreases stress reactivity
  • Schizophrenia nicotine used to deal with
    negative symptoms
  • Sleepiness
  • Dysphoria
  • Antipsychotic adverse effects
  • Improve cognitive function

27
Cannabis
  • Heavy adolescent use increases psychiatric risk
  • Depression
  • Anxiety disorders
  • Schizophrenia

28
Summary
  • High rates of comorbidity
  • Each increases the risk of the other and
    complicates their management
  • Concurrent treatment yields best results
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