Causes and Treatment of Substance Use Disorders Chapter 11

The Spectrum of Use Use – Noncompulsive and nonconsequential use Misuse – Periodic negative consueqnces Abuse – A pattern of misuse Dependence – Compulisve use with significant consequences often w/physiological dependence

Moving Through the Spectrum Depends on numerous issues –The drug itself (The Agent) –The person (The Host) –The person’s environment (The Environment) With some drugs it is difficult to maintain the line between use, misuse, abuse and dependence

DSM – IV Criteria Substance Abuse A maladaptive pattern of substance use occurring within a 12 month period –Impairment/Distress –One of the following Failure to fulfill major role obligation Use in physically hazardous situations Recurrent legal problems Continued use despite recurrent psychosocial problems

DSM-IV Substance Dependence A maladaptive pattern of substance use occurring within a 12 month period Three of the following: –Tolerance (increased drinking to achieve same effect) –Withdrawal –Drinking more than intended –Unsuccessful attempts to cut down on use –Excessive time related to obtaining, using and or recovering from –Impaired social or work activities due to alcohol –Use despite physical or psychological consequences

Causes - Multidimensional Abuse/Dependence is an interaction between –Pharmacological –Biological/Genetic –Psychological/Behavioral –Social/Environmental

Pharmacologic Drugs differ in terms of the potential for physiological addiction. –Nicotine – High –Heroin – High –Cocaine – High –Alcohol – Moderate –Marijuana – Low –Hallucinogens - Low

Biologic/Genetic Substance Abuse and Dependence runs in families. –Diathesis for certain types of alcohol dependence. Mechanism seems to tolerance –Diathesis for other drugs is less clear. Probably through a temperamental characteristic, psychopathology and/or dopamine NT system sensitivity

Psychological/Behavioral Alcohol/Drug use is functional and is reinforcing. Use is subject to the laws of behavioral reinforcement (positive and negative). Self-regulation/Coping Certain personality characteristics are predictive.

Social/Environmental Certain developmental insults Access Social norms Using peers

Substance Abuse Treatment Three main philosophies/modalities –Mutual-help –Psychosocial –Pharmacological In the past there has been much conflict between these philosophies. Not so much now.

Mutual Help Philosophy Twelve Step Fellowship –Alcoholics Anonymous –Narcotics Anonymous Spiritual Disease Model Mechanisms –Acceptance of loss of control and higher power –Working the steps –Most probably powerful social support and behavioral management

Psychosocial Treatment Psychological Treatments –Motivational Interviewing/MET Empathy Rolling with resistance Develop Discrepancy –Community Reinforcement Approach Rearrange reinforcement contingencies –CBT Skills training and cognitive restructuring Psychotherapy and Educational alone are ineffective

Project MATCH Mulitsite clinical trial of psychosocial treatments Three alcohol dependence treatments treatments –MET –CBT –12 Step Facilitation Results –TSF marginally better. AA meetings –MET as good over time with less treatment. Better for those high in anger –Behavioral treatments work

Pharmacotherapy Alcohol –Antabuse – Become ill if one drinks –Naltrexone – Opiate antagonist Heroin/Opiates –Methadone – An agonist. Opiate replacement –Buprinorphine – A partial agonist. –Naltrexone – Blocks opiate action Cocaine –Haven’t found one yet Overall not many meds work. Compliance is the ultimate issue.

Treatment Integration Combine treatment philosophies/modalities –Motivation Enhancement Increase readiness CRA/CBT Active treatment Rearrange reinforcement structure Teach coping skills Address psychopathology –Pharmacotherapy –Mutual-help groups Social Support Maintenance

Project COMBINE Multisite clinical trial addressing the combination of drugs and psychosocial treatments –Acamprosate (a benzo) and/or Naltrexone –Medication management or Psychosocial Treatment Psychosocial Treatment is a combo of MET and CRA