SUBSTANCE USE DISORDERS

SUBSTANCE USE DISORDERS
Chapter Eleven SUBSTANCE USE DISORDERS INSTRUCTOR INFO: First class session Bring Diagnosis according to DSM video, and Moyer’s addiction video administer quiz (15 minutes) Lecture (35 minutes) Watch and discuss Diagnosis video (10 minutes) Second class session Bring Moyer’s addiction video, Recap last lecture Lecture--start with etiology (30 mins) Watch a few segments of Moyers video (15 min) (Megan’s note – ask Ali which segments she recommends) Discuss special topic (15 minutes)

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) This lecture will cover 2 substance use disorders: Abuse and dependence. Because we will be discussing substance use disorders we need to know what DSM defines as a drug or substance that can be abused or on which one can become dependent. Give some examples of what are and are not drugs of abuse. Even though you may love krispy kreme donuts, they are not drugs of abuse . Substance Abuse also does not apply to caffeine and nicotine. (Issue of what is socially acceptable which we’ll mention later too) Example of polysubstance abuse: after Elvis Presley’s death at age 42, coroners found in his body tissues: codeine, steroids, quaaludes, demerol, valium and several other sedatives.

Definition of psychoactive substance Substance abuse and substance dependence definitions Course Epidemiology Etiology Treatment Special topic: Is college drinking a phase?

DSM-IV differentiates between two substance use disorders: Substance dependence abuse This distinction is based in part on the recognition that many people who suffer from serious impairment from substance abuse do not progress to the level of dependence Dependence is more severe. You may want to highlight here that DSM classifies substance use disorders into these two categories, regardless of which drug you are using. (You’ll come back to that idea later). Something else that students often have questions about – is ‘alcoholism’ in the DSM? Being an ‘alcoholic’ is not a diagnosis, however many people who are considered alcoholics meet criteria for either alcohol abuse or dependence (or they did at one point, even if they no longer do). You cannot have both diagnoses for the same substance. Once you are dependent on a substance, that becomes your diagnosis…it doesn’t change to abuse. You could, however, be have dependence for one substance and abuse for another (For example, you could have diagnoses of heroin dependence and alcohol abuse.) If there is a point in your life in which you don’t meet criteria anymore, you could still have the diagnosis, but a specifier, such as ‘In Sustained Full Remission’ could be added depending on the duration since the last use, total duration of use and need for continued evaluation.

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) Not everyone who uses drugs progresses to an impairment or distress level where they become dependent on their drug of choice Some people may suffer from substance abuse, which is less severe than substance dependence At the level of abuse an individual’s substance use leads to impairment or distress that is not as severe

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 The DSM defines substance abuse as a maladaptive patterns of substance use that (read slide) The recurrent substance use (read numbers) Repeated absences or poor work performance, suspensions or expulsions from school; neglect children or household chores Driving a car, operating heavy machinery, swimming or rock climbing 3. Disorderly conduct, assault and battery, driving while under the influence Legal problems must be persistent; So one charge of drunk driving would not be sufficient to diagnose someone 4. Marital difficulties, divorce, physical or verbal fights Note that abuse is differentiated from recreational use of drugs in that the DSM emphasizes maladaptive and recurrent use

Substance Dependence Repeated use of a drug that often results in tolerance, withdrawal, or compulsive drug taking behavior Commonly called addiction Substance Dependence is the more severe form of substance use disorder. It is characterized by (read bullet) Addiction is an older term that described such problems as alcoholism. It has now been replaced by substance dependence

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 We see two different types of dependence in people suffering from substance dependence. Psychological dependence is (read bullet)

Physiological Dependence
Tolerance and withdrawal are seen as indicators of a physiological dependence on a psychoactive substance The other type of dependence we might see is physiological dependence. Physiological dependence is characterized by tolerance and withdrawal.

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 Tolerance is when ( bullet) Need larger quantities of the drug to achieve the same effects (another example) Some drugs are more likely than others to produce a buildup of tolerance. We see the most substantial effects among heavy users of opiods (e.g., heroin) and CNS stimulants (e.g., cocaine). Evidence is unclear regarding tolerance effects of marijuana and hashish. Most people who use this drugs are unaware of tolerance effects, though they have been demonstrated in animal studies.

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 Withdrawal is another indicator of physiological dependence. It refers to the (read bullet) Withdrawal symptoms not often seen with cannabis or hallucinogens Alcohol withdrawal delirium is a confused state in which the person becomes less aware of their surroundings and has difficulties sustaining attention

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 3. For example, saying you are only going to have 2 drinks and you end up downing 5. In some instances, virtually all of the person’s activities revolve around the substance. Individual may withdraw from activities and hobbies in order to use substance in private or spend more time with friends who also use the substance Despite recognition of harmful consequences (e.g. depression or damage to organ systems), person continues use-individual fails to abstain despite knowledge/evidence of difficulty it is causing

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 Again, once you get the ‘dependence’ label, that’s your diagnosis, it doesn’t drop back down to ‘abuse’, but you may get a specifier tacked on

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

Lifetime Prevalence: Drug Use and Dependence (NCS data)
Proportion with Proportion with Dependence History of Use History of Among Users Dependence To better understand how prevalent drug use is, it is useful to know how many people in their lifetime have met the diagnosis for dependence, as well as how many who have ever tried a specific substance have become dependent on that substance. The National comorbidity study looked at this issue. Walk through one column at a time (3rd column is 2nd column divided 1st x 100) NCS completed by 8000 households throughout the US btw ’90-92 Table indicates of the 8000 who had a history of substance dependence (second column) , proportion that used some time in life (first column) and proportion of substance dependence among those who had used some time in life (third column) For the 1st two columns, dependence and history use: tobacco & alcohol had highest rates, with Alcohol most often used Within the total study population, the lifetime prevalence of tobacco dependence (24.1%) was greater than the lifetime prevalence of alcohol dependence (14.1%), even though more persons had consumed alcohol (91.5%) than had smoked tobacco (75.6%). Looking at the sub-sample of those with a history of use, substance dependence was higher (third column) than dependence in general population (second column) For example the 16% who reported cocaine use, also reported that ~17% had dependence some time in life. Compared to only ~3% in the overall sample of 8000 reporting dependence on cocaine If you never use, you cannot become dependent. However, certain drugs may be more likely to lead to dependence than others. Possible discussion – look at what % of users will become dependent for various drugs. Which drug has the highest % of dependence among users? (Tobacco is higher than even heroin, something that usually surprises students) What biological and social factors might play into this? Example – some drugs may be more likely to produce tolerance/withdrawal, as discussed earlier. Use of some drugs is more socially acceptable than others (see proportion with history of use for tobacco or alcohol, both legal, vs. heroin) Tobacco Alcohol Cannabis Cocaine Amphetamines Sedatives Hallucinogens Heroin

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 This is an article reporting findings from a drug use study with UIUC undergrads; it was conducted by Kimberly Shinew, a faculty in leisure studies.> > ( It's dated 10/01/02 COLLEGE STUDENTS Study examines 'other' leisure pursuits, such as drug use, gambling surveying 740 undergraduate students at Illinois “men were significantly more likely than women to use drugs and alcohol, Greek-system membership appeared to increase the likelihood of drug use, and religious beliefs did not affect students^Ò alcohol or drug use." Other findings included: The majority (83 percent) indicated they drink alcohol; 67 percent started in high school. Most (76 percent) indicated they do not use drugs; - among those who do, marijuana was the drug of choice (98 percent), followed by ecstasy (28 percent). The majority (85 percent) reported they are usually with friends when they drink or use drugs. More than 80 percent indicated drinking was a leisure activity for them.

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) 1 year prevalence rates (read slide) rates higher among Whites than among African-Americans; and (2) rates highest among Native-Americans For future semesters we should also consider including: Here is the reference: Slutske, Wendy S; Hunt-Carter, Erin E; Nabors-Oberg, Rachel E; Sher, Kenneth J; Bucholz, Kathleen K; Madden, Pamela AF; Anokhin, Andrey; Heath, Andrew C. Do College Students Drink More Than Their Non-College-Attending Peers? Evidence From a Population-Based Longitudinal Female Twin Study. Journal of Abnormal Psychology. Vol 113(4) Nov 2004,

Etiology of Substance Abuse/Dependence
Use this to start a conversation about causes of substance abuse, and to lead into the points on the next slide. Like her grandfather and father before her, actress Drew Barrymore has struggled with substance abuse and dependence. Discuss – what caused this? Genes & environment Her grandfather, John Barrymore, was a stage actor known for his heavy drinking. She is estranged from her father, actor John Drew Barrymore, whom she describes as an alcoholic. Barrymore’s chaotic childhood – began acting at age 3, youngest host of Saturday night live ever at age 7, began drinking at age 9, using marijuana at 10, cocaine at 12, and was in rehab by the age of 14. You can use this as another diathesis/stress example – Barrymore may have a genetic predisposition to abuse/become dependent on alcohol, given her family history. However, had she not been exposed to situations where alcohol was readily available to a 9 year old, she may not have developed the disorder, or it may not have developed until much later in her life. Multiple factors contribute to the development 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 Before we talk about specific causes, there are a few issues we should consider… 1: 2: People become addicted to drugs like morphine, heroin, nicotine, but not to antidepressants. Properties within one drug makes it addicting, while properties within other drugs do not make it addicting. Body’s response to these properties 3: Why do people use drugs in the first place? Social and psychological factors involved (I.e., marital issues, depression, anxiety)

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) Alcohol abuse tends to run in families. To understand the genetic influence on alcoholism, twins have been studied Twin studies have found a significant genetic influence for men and women (concordance rate for both ~2:1) adopted Twins however, give us a better differentiation between environmental and genetic influences For the same amount of alcohol, the physical effect on women is stronger than on men because of less total body water in women that dilutes alcohol Both men and women show negative attitudes toward…

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 Adoptees were born in Sweden btw

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 Genetic backgrounds based on biological fathers

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 People with Type 1 and Type 2 backgrounds were adopted into 2 types of homes. These people were also compared to a control group.

Rate of Alcoholism in Adult Children
Adoptive Father The combination of type 1 genes and heavy drinking adoptive father significantly increased risk for alcoholism Without genetic vulnerability didn’t make much difference whether adoptive fathers were heavy drinkers or not Gene/environment interaction for Type 1

Rate of Alcoholism in Adult Children (cont.)
Adoptive Father Having type 2 genes regardless of drinking of adoptive father significantly increased risk for alcoholism Primarily genetic effect for type 2

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 What social conditions might increase the risk for alcohol use?

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 Along with minimizing or eliminating drug use should treatment… As suggested by Howard, this might be a good place to cover the whole issue of AA -AA has been shown to be effective, but not more than any other program -Is abstinence necessary? (We know that folks who attend AA are not necessarily abstaining) -Should treatment decisions be based on testimonials (I.e., AA believers) or evidence? -Thoughts about a harm reduction approach to treating substance use (needle exchanges, methadone) -

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) For substance dependence any 3 or more symptoms are needed, not necessary to have tolerance and withdrawal symptoms (evidence of physiological dependence). People with a history of physiological tolerance report more severe drug related problems bullet 3: The criteria of withdrawal may not be applicable to all drugs

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? The same criteria is used for both dependence and abuse for varying drugs For example, read bullet two Possible discussion – what are the pros and cons of taking this approach? Are there feasible alternatives? -fewer criteria apply to some substances, so may be less likely to get that diagnosis although the severity of use may be equivalent to severity of use of another drug use that does meet criteria -alternatives? Have different criteria for each substance

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 To give you an idea of the course of alcohol abuse over the life span let’s look at a core sample of city and college men who abused alcohol and remained in the study until at least age 60. A classic study of alcoholism by George Vaillant (first bullet) (second bullet) Alcohol abuse defined as: presence of 4 or more problems in areas such as employer complaints, marital family difficulties, med complications, and legal problems (third bullet) (fourth bullet) Abstinence: less than 1 drink per month for more than a year. The longer one was abstinent the greater probability that he would remain abstinent Men in the city group began using earlier, but were more likely to achieve stable abstinence. Avg. age of onset of alcohol abuse was 40 years for college men and 29 years for core city men.

Alcohol Dependence Video: Educational Objectives
Highlights symptoms of alcohol dependence Shows the effects of alcohol dependence on individual functioning Considers the issue of comorbid conditions (e.g., depression) 10 min clip. Play the alcohol dependence video from diagnosis according to the DSM-IV (same tape with anorexia clip) This clip indicates both physiological effects of tolerance and withdrawal, compulsive use and problems in living as well comorbidity issues with depression May want to ask the class what was this person’s age of onset and what symptoms would lead to a diag of dependence? Would anyone diagnose this man with substance abuse in addition to dependence? Why or why not? Can’t get both dx for same substance

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 some effects of alcohol are due to what people THINK it will do to their behavior

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

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