Chapter 13 Topics in Substance Use Disorders In all of recorded history, every society has used drugs to produce alterations in mood, thought, feeling, or behavior or to provide temporary alterations in reality. Moreover, there have always been some people within societies who digressed from custom with respect to the time, the amount, and the situation in which drugs were used. Abuse has always produced problems for these individual and society.

Today, these patterns of drug use differ considerably from the traditional pattern. Nearly all psychoactive drugs ever identified throughout history are available today in our society. Partly due to transportation technology. Active ingredient has been identified, isolated and made available Organic chemistry has created new drugs, synthetic, and more potent New methods of drug delivery have been invented (hypodermic needle, free base methods, etc) which increase dose, decrease onset of effects, increase potency and toxicity compared to naturally occurring drugs.

When a Drug is Called a “Behavior Reinforcer” Drugs prone to compulsive abuse activate brain mechanisms involved in reward & positive reinforcement – Dopamine, serotonin, opioid, GABA, cannabinoid neurons/receptors – Median forebrain bundle, ventral tegmentum, hippocampus, frontal cortex, nucleus accumbens

Why Study Drug Reinforcing Properties in Animals? The rate to which lab animals self-administer psychoactive drugs closely parallels the degree of abuse by human users of the drug. Cocaine, for example, is excessively abused by rats, squirrels, monkeys, baboons, dogs & humans. This study helps dispel the myth that there is something inherently wrong with human drug abusers.

Blame: Drug or Abuser? Is it a propensity for abusing drugs caused by psychopathological process in the user or is it a property of the particular drug? – It is the property of the particular drug (reinforcing) not some psychopathology of user. – They activate reward mechanisms in the brain

Why aren’t phenothiazines or antidepressants addictive? Phenothiazines and antidepressants lack self-reinforcing actions: – Drugs with negative-reward effects (such as phenothiazines & antidepressants inhibit activity or increase threshold of the nucleus accumbens dopaminergic system in the medial forebrain bundle (same system that abused drugs stimulate)

Principles of Positive Drug Education Teach pharmacology of drugs Provide basic facts in straight forward & honest way Teach means for changing behavior; such as training to resist peer pressure/teach that drugs are not cool Provide reinforcement (recognition, praise & other rewards) for not using drugs Tell them how it detracts from a healthy body and attractive looks (adolescents focus on these qualities) Build self-esteem

Drug Education Shortcomings Will not stop self-prescription for symptom relief Is not as effective as potentially could be due to mixed signals about other addicting drugs such as alcohol & cigarettes Can be seen as providing directions for taking drugs Will not stop those already involved in drugs or those who seek relief from psychiatric symptoms or disorders No program can guarantee the reduction of the use of psychoactive drugs Works best with those least likely to use drugs

Areas of Improvement for Drug Education Begin very young (because once they start using, education is no longer effective) Change legislation to be consistent with scientific evidence (do not allow addicting drugs like alcohol & cigarettes to be promoted, distributed & used)

Relationship of Age of First Use and Development of Substance Use Disorder Age of first exposure (at least to marijuana) is an important predictor and estimate both of the likelihood of developing a substance abuse problem and of the number of people who eventually will need treatment for illicit drug abuse problems. Most start before age 21. Typically age for nicotine, alcohol, and marijuana.

What Psychoactive Drugs Are Most & Least Harmful? Most – Psychostimulants (cocaine, nicotine) – Opioids – Depressants (alcohol, inhalants, barbiturates, benzodiazepines) Least – Hallocinogenic & Psychedelic – Antidepressants – Antipsychotics

Should Some Drugs Be More Readily Available? Antidepressants (for those who seek self- medication)? Drug sensitizing drugs? Those that help with drug withdrawal? Other drugs that have low occurrence for addiction?

Treatment Issues Early years: equated dependence with addiction – addicted because needed to avoid withdrawal symptoms Detox would free person from clutches of drug – break free Problem: even after detox, high percentage relapse

Treatment Issues ’s – focus on drug induced reward Addicted to the reinforcing properties of drug Abstinence is not a return to normal for addicted person Abstinence results in apathy, boredom, depression, anhedonia, craving for relief Leads to relapse

Treatment Issues 3 More complex than simplistic concepts of reward and withdrawal Not all individuals who experiment with drugs become abusers Can we identify risk factors/ predisposing variables Parent/ peer/ individual (biogenetic)

Treatment Issues 4 Focusing just on physical brain changes is not adequate; addicts will have to be able to handle later exposure to craving-eliciting cues in the environment and will need rehabilitation to either learn or relearn social skills or job skills. Combined behavioral and pharmacological treatments will be truly synergistic

Treatment Issues 5 Comprehensive treatment does work can be cost effective Outpatient more cost effective Residential – only slight improvement at 5 times the cost Incarceration too costly Any treatment better than none 12 step programs/ mutual help programs/ substance free lifestyle programs are available