Psych - Substance Use Disorders Flashcards
Defining Addiction
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry
NOT the result of something else, but a primary disease – it is CHRONIC not recurrent too
NOT to be confused with DEPENDENCE –> physical dependence can develop from use of substances that are NOT addictive
SPEED OF ADMINISTRATION is what determines addiction most –> SMOKING is the fastest way!!!
TOBACCO
Morality due to tobacco = 400,000/year is MORE than the mortality due to alcohol and ALL OTHER DRUGS combined
Use is declining in the US (down from 40% to 20% in the past 50 years), but there are ~3,000 new smokers each day with an average starting age of 16 years old
Genetic influences –> component of tobacco, ACETALDEHYDE, synergistically interacts with nicotine to make BOTH more reinforcing and addictive
Use of tobacco by addicts of OTHER substances is ~70%
ALCOHOL
65% of adults in the US drank in the past year
Used to think of alcoholism as a disease of middle age, but in reality it is a disorder of YOUNG ADULTS (18-30 y.o.)
Alcohol use disorder doesn’t become very diagnosable until ages 25-40
The majority of those with alcohol use disorder DO have stable jobs and DO NOT abuse other drugs
**TOLERANCE lends itself to addiction –> 0.40 mg% is technically the LETHAL level of BAC, but many alcoholics can reach this level EASILY!
Alcoholics who’s BAC is 0.2 mg% (2.5 times the limit) can show no impairment whatsoever
**Alcoholics also have DECREASED INTERNAL CONTROL –> alcoholic has trouble stopping themselves from drinking
Marijuana
Most frequently used illicit drug in the US – peaked in the 1960s and 1970s, rising again now
Because the use of marijuana is becoming more and more legal, it is possible that the PERCEIVED DANGER IS DECREASING and thus illicit use is increasing
Marijuana is perceived as harmless, but there are SIDE EFFECTS, including impaired judgment, amotivational syndrome, reduced IQ in those who begin early, pulmonary problems, and possible withdrawal
Opioids
Obviously are useful and provide effective relief from pain, coughing, anxiety and depression, but can cause a lot of problems when they become addictive!!!
Older, street heroin users common
Middle-class younger demographic is ON THE RISE! These guys use PRESCRIPTION PAIN PILLS, though as their tolerance builds up, they may switch to heroin
DEATHS from PRESCRIPTIONS are more common than those from heroin!
Prescription use has leveled off, but heroin use has started to rise again (cheaper)
Opioid system resensitizes (receptor population changes) during a period of abstinence –> thus RELAPSE can be PARTICULARLY FATAL
More prescriptions written in the past decade, so we are perpetuating the addiction!
Stimulants
Less common
Cocaine use is actually down, amphetamines are rising
This has to do with the increased use of crystal meth in the past decade or so (MDMA - ecstasy) is also increasing
People generally DONT use stimulants on the daily; more of a BINGE and CRASH cycle
Stimulants are HIGHLY REINFORCING AND ADDICTIVE, but there is NO SIGNIFICANT WITHDRAWAL from them
Caffeine
Can have excess amounts of caffeine and can get withdrawal headaches, but there is no real dependence diagnosis for caffeine abuse
Genetics and Addiction
Genes can be protective!! The ABSENCE of ACETALDEHYDE DEHYDROGENASE in some Asian populations can be protective against becoming an alcoholic
Genetic influences can also be bad! Alcoholism in biological parents can lead to HIGHER TOLERANCE in children; those with high tolerance tend to become alcoholics; CHILDREN OF ALCOHOLIC PARENTS WILL HAVE A QUANTITATIVE HIGHER TOLERANCE (decreased sensitivity) BUT ALSO A QUALITATIVE INCREASED SENSITIVITY TO ALCOHOL
OPRM1
OPRM1 –> encodes the mu opioid receptor; particular allele of the gene will make the mu receptor more sensitive in a subset of children with alcoholic patients; MORE LIKELY TO BECOME ALCOHOLIC BEFORE AGE 25!
“G” allele –> more positive reinforcing effect when they drink, via a greater beta endorphin release and spike. Large endorphin spike hits a more sensitive receptor, so these patients experience alcohol in a more pleasurable way. QUALITATIVE increased sensitivity to alcohol
Consider this mutation if you have an alcoholic patient < 25 with alcoholic parents
CNS changes that result in heavy use
Decreased activity of the prefrontal cortex
Morphological changes in dendrites in the nucleus accumbens
Brain stress system changes
Decreased executive function, impaired learning and memory, impaired inhibition
When a person’s alcohol intake is chronically elevated, their glutamate levels are also elevated in a compensatory mechanism called ALLOSTASIS –> when we remove alcohol, there will be a persistently high level of glutamate –> this contributes to post-acute withdrawal symptoms and relapse!
Summary of Addictive Behavior
Neurobiological changes seen in addiction and substance use disorders is a SHIFT IN THE BALANCE BETWEEN REFLECTIVE AND IMPULSIVE PARTS OF OUR BRAIN
Our inhibitory functions and functions of the FRONTAL CORTEX are REDUCED, and our LIMBIC SYSTEM IS ENHANCED –> leads to addictive behaviors!
Genetic differences in sensitivities to certain substances combined with environmental circumstances contribute to this change and should be considered when dealing with patients that have substance use disorders.
What is “safe drinking”
Men –> 2-14-5: No more than 2 drinks per day, 14 drinks per week, or 5 drinks per occasion
Women = 1-7-4; no more than 1 drink per day, 7 drinks per week, 4 drinks per occasion
AUDIT Questionnaire
When evaluating a patient’s alcohol use, ask “how many times in the past year have you had 5 (4 for women) or more drinks in a day?”
If they answer one or more times, follow up with the AUDIT (Alcohol Use Disorder Identification Test) questionnaire –> help to elucidate whether a problem exists, and if it does, what the severity of the problem is
It is a series of 10 questions, takes 5 minutes to administer, and can help detect any alcohol problems within the past year
AUDIT-C is a shortened version that takes about 3 minutes to administer and assesses hazardous use of alcohol
Operational Diagnosis of Substance Disorders
Continued use of alcohol and/or drugs despite a pattern of adverse consequences
Therefore, diagnosis is made based upon the CONSEQUENCES of drinking or drug use, as opposed to the AMOUNT or FREQUENCY.
Treating Substance Abuse Disorders
Diagnosed addict is ALWAYS an addict! Goal of treatment is RECOVERY, not CURE!
BEcause thy are always an addict, abstinence is recommended over moderation and the addiction must be monitored over time
Patient should be separate from the substance and placed in a healing environment that includes family, friends and community support
Support groups are also key for managing substance abuse disorders
