Substance Related and Addictive Disorders Flashcards Preview

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Flashcards in Substance Related and Addictive Disorders Deck (107):
1

substance

-Any natural or synthesized product that has psychoactive properties.
- Acts primarily upon the central nervous system where it alters brain function. (crosses blood brain barrier)
- Acute/temporary changes in perceptions, thoughts, emotions, and behaviors.

2

Main Categories

!Depressants
! Stimulants
! Opioids
! Cannabis
! Hallucinogens
! Other drugs of abuse
Inhalants
Anabolic steroids
Medications
! Gambling disorder
-We look at "what things are being given up?"

3

only behavioral disorder

gambling

4

Substance Use Disorders in the USA

About 9% of all teens and adults in the U.S. display
substance use disorders
• Lowest rate among Asian Americans (3.5%)
• White Americans, Hispanic Americans, and African
Americans display rates between 9-10%
• Only 11% receive treatment from a mental health
professional

5

Immigration Paradox

Immigrants to the United States, relative to the native born, are less likely to initiate and develop substance use disorders.
--The paradox is that, despite having disproportionately lower income and education levels, immigrants are often healthier than their native-born counterparts.
-immigration is stressful & this not only exists in substance abuse disorder but can be seen across other health aspects

6

The Criteria (within 12-month period)

1. Taking the substance in larger amounts or for longer than intended
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home or school, because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational or recreational activities because of substance use
8. Using substances again and again, even when it puts you in danger
9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
10. Tolerance
11. Withdrawal

7

Severity

Depends on number of symptom criteria endorsed
Mild: 2-3 symptoms
Moderate: 4-5 symptoms
Severe: 6 or more symptoms

8

Addiction

you cannot be addicted to anything
-substance abuse can rob people of insight
#9>> good example is depression

9

Tolerance

1. Requires increasingly greater amounts of the drug
to experience same/desired effect.
OR
2. Markedly diminished effect with continued use of
same amount
Physiological reaction
-Examples >> cigarettes

10

Withdrawl

1. Characteristic withdrawal syndrome for substance
2. Same (or closely related) substance take to relieve
or avoid withdrawal
-- Sometimes substance must be withdrawn gradually
-- Symptoms tend to be the opposite of drug’s direct
effect on body

11

Specifiers

# In early remission: no criteria for > 3 months but 12 months
(except craving)
# In a controlled environment: access to substance
restricted (ex. Jail)

12

Substance-Induced

" Intoxication
" Withdrawal
" Psychotic Disorder
" Bipolar Disorder
" Depressive Disorder
" Anxiety Disorder
" Sleep Disorder
" Delirium
" Neurocognitive
" Sexual Dysfunction

13

DSM5 Criteria

Substance Use Disorder: addressed as a separate
use disorder (e.g., alcohol use disorder, stimulant
use disorder, etc.)
--Major change from DSM-IV to DSM5 was to remove
the criterion related to legal problems and to add
one related to substance craving

14

Depressants

Decrease CNS functioning
less neuronal firing (increases GABA and suppresses glutamate)
--Slurred speech, decreased motor functioning, memory impairments,
perceptual slowing, less inhibition

15

Alcohol use in the USA

24% of all people in the U.S. over the age of 11, most of them male,
binge-drink each month
• Nearly 7% of people over age the age of 11 binge-drink at least 5 times
each month
• Considered heavy drinkers, males outnumber females by more than 2:1
(around 8% to 4%)
-42% of college aged report binge drinking

16

Alcohol

•The first brain area affected is that
which controls judgment and
inhibition
• Next affected are additional areas
in the CNS, leaving the drinker
even less able to make sound
judgments, speak clearly, and
remember well
• Motor difficulties increase as
drinking continues, and reaction
times slow

17

Depressants: Alcohol

• The extent of the effect of alcohol is determined by
its concentration (proportion) in the blood
• A given amount of alcohol has a lesser effect on a
large person than on a small one
• Gender also affects blood alcohol concentration
• Women have less alcohol dehydrogenase, an enzyme
in the stomach that metabolizes alcohol before it
enters the blood
• Women become more intoxicated than men on equal
doses of alcohol
Difference in if you are a fast or slow metabolizer & big difference in gender

18

Slow metabolizer

for a certain substance is a protective factors

19

Asian countries

small alcohol abuse
except for South Korea b/c of culture

20

Alcohol Level of impairment

closely tied to the
concentration of ethyl alcohol in the blood:
--BAC = 0.06: Relaxation and comfort
-- BAC = 0.09: Intoxication
--BAC > 0.55: Death
-- Most people lose consciousness before they can drink this
much

21

Metabolic Tolerance

The liver reacts to greater
consumption of alcohol by producing more of the
enzyme (alcohol dehydrogenase) that metabolizes
alcohol. In chronic users, this can result in the
significantly faster metabolization of alcohol.
----The increase in alcohol dehydrogenase (toxic) is one factor that leads to the destruction of the liver in chronic users.

22

Functional Tolerance

sway test standing on line

23

Mild alcohol withdrawal

occurs within 24 hours of last drink. tremulousness (shakes),
insomnia, anxiety, panic, twitching, sweating, raised blood pressure
and pulse, and stomach upset
(most people experience this)

24

moderate alcohol withdrawal

usually occurs 24-36 hours after the cessation of alcohol
intake. Intense anxiety, tremors, insomnia, seizures, hallucinations,
high blood pressure, racing pulse.

25

severe alcohol withdrawal

Delirium Tremens (D.T.s). More than 48 hours after a
cessation or decrease in alcohol consumption. Disorientation,
agitation, hallucinations, racing heart, rapid breathing, fever, irregular
heartbeat, blood pressure spikes, and intense sweating.
(had to be drunk for a very very long time)

26

Delirium Tremens

! Delirium, Hallucinations, Extreme, Fluctuations in Blood Pressure,
Grand mal seizures, Heart attacks!

27

Alcohol withdrawal

• When untreated about one person in five will die of
D.T.s. Some people refer to shakes as D.T.s but this
is inaccurate.
• Even mild or moderate withdrawal can be
dangerous for people with high blood pressure or
bad hearts.
• Withdrawal raises blood pressure ! danger of heart
attack or stroke. The longer and harder a person has
drunk alcohol--the more severe the withdrawal will be.

28

Alcohol subsiding

Nothing can lower BAC except time
•The effects of alcohol
subside only after alcohol
is metabolized by the liver
•The average rate of this
metabolism is 25% of an
ounce per hour
•You can’t increase the
speed of this process!

29

Alcohol culture

•People in countries who
combine alcohol with
meals (France) have lower
alcohol-related substance
disorders
•Empty stomach results in
rapid delivery of alcohol
into blood stream. (more likely to black out)
•Full stomach slows rate of
absorption & more drinks
needed to reach dangerous
blood levels.

30

Passing out

•Colloquial term for syncope (loss of consciousness)
•Alcohol lowers blood pressure
•When sober, body constricts veins upon standing up
to increase blood pressure and prevent the person
from passing out as their blood falls due to gravity.
•After consuming 2-3 drinks, alcohol prevents the
blood vessels from constricting, and blood pressure
drops twice as much when the person stands up as it
would if they were sober.
Lose ability to compensate gag reflex while vomiting

31

Blacking out

Picture---
alcohol impacts the transfer from short term memory to long term memory
Blacking out once makes you more vulnerable to black out
black out a little or a lot

32

Hangover

• Vasopressin
• Normally vasopressin
repurposes water released
by the kidneys back into the
body.
• Absence of vasopressin, that
water is marked for the
bladder and eliminated.
• Alcohol also causes
inflammation of the
stomach lining, which can
cause diarrhea -- another
dehydrating condition.
• Acetaldehyde toxicity

33

Sedative-Hypnotic Drugs

Sedative-hypnotic (anxiolytic) drugs produce
feelings of relaxation and drowsiness
• At low doses, they have a calming or sedative effect
• At high doses, they function as sleep inducers or
hypnotics
• Sedative-hypnotic drugs include barbituates and
benzodiazepines

34

Barbituates &
Benzodiazepines

•Barbituates (seconal, nembutal): sedative drugs prescribed for sleep (decrease in use post-1960)
•Benzos (valium, xanax, rohypnol): reduce anxiety
•less dangerous than barbituates but still carry significant addiction potential if used incorrectly.
•Intoxication symptoms similar to alcohol.
•High doses; diaphragm muscles relax so much that they
cause death by suffocation.
• OD on barbs common form of suicide
• Synergistic effect with alcohol

35

Barbituates

considered old school-easily overdosed & now used in lethal injections

36

intoxication agnosognia

lack of insight

37

Alcohol & Benzos

•Marilyn Monroe may have
unintentionally killed
herself with this combo
• Heath Leger barbs, benzos,
& pain killers
• Whitney Houston xanax,
cocaine
• Medication “spellbinding:”
individuals have no idea
how badly they are being
impaired

38

Benzodiazepine Withdrawal

• Overwhelming anxiety and panic, insomnia (far worse
than the individual has ever before experienced).
• Irritability ! uncontrollable anger & violence (at
extreme).
• Muscle spasms, painful feelings in the extremities,
painfully-heightened awareness of diminished mental
faculties, confusion, depression, suicidality, paranoia,
hallucinations
• Weeping, terror, negative looping thoughts (severe)
• Keep in mind CONTINUUM (mild, moderate, severe)
You have to wean off the benzos

39

Opioids

Pain relief, sedation,
euphoria, slowed breathing

40

opiate

any natural
chemical deriving from
opium poppy

41

opioid

all inclusive term
for natural opiates,
synthetic variations
(heroin, methadone,
oxycodone), & the
comparable substances in
brain

42

Morphius

God of Sleep

43

slow vs. fast delivery

fast= injecting, inhaling, snorting
slow= ingesting
the faster the delivery the more addictive

44

Opiods

•smoked, inhaled,
injected by needle
directly into the
bloodstream
(“mainlined”) ! Injection ! most
common method of
use
• An injection quickly
brings on a “rush”: a spasm of warmth and
ecstasy
•followed by several
hours of pleasurable
feelings (called a
“high” or “nod”) I don't care feeling

45

tolerance for opiods

super rapid (vicadin)

46

dependence vs. addiction

dependence: withdrawal tolerance NOT behaviors
addiction: compulsive drug seeking behaviors-largely dictated by behaviors

47

Opioids create these effects by depressing the CNS..

• Opioids bind to the receptors in the brain that
ordinarily receive endorphins (NTs that naturally help
relieve pain and decrease emotional tension)
• When these sites receive opioids, they produce
pleasurable and calming feelings
• In addition to reducing pain and tension, opioids can
cause nausea, narrowing of the pupils, and
severe constipation
heroin makes you vomit

48

What are the dangers of opiod use?

• Once again, heroin provides a good example:
• The most immediate danger is overdose
• The drug closes down the respiratory center in the brain,
paralyzing breathing and causing death
• Death is particularly likely during sleep
• Ignorance of tolerance is also a problem (tolerance happends rapidly and decreases rapidly)
• People who resume use after having avoided it for some time
often make the fatal mistake of taking the same dose they had
built up to before

49

Pain killers in the USA

Since 1997, the number of Americans seeking treatment for
addiction to painkillers increased by 900%. this is an epidemic

50

Narcan

a nasal mist for opiate overdose reversal--now available in stores where no prescription is needed
the narcan occupies the receptor

51

Opioid Withdrawl

•restlessness, muscle and bone pain, insomnia, diarrhea and
vomiting, cold flashes with goose bumps(vasoconstriction) (“cold turkey”), and
kicking movements (“kicking the habit”).
• Severe craving can precipitate continued abuse and/or
relapse.
•Major withdrawal symptoms peak between 48 and 72 hours
after the last dose of the drug and typically subside after
about 1 week.
• Some individuals, however, may show persistent withdrawal
symptoms for months.
• Fatal in highly dependent & in poor health (somewhat rare)

52

Stimulants

(amphetamines, caffeine,
nicotine, cocaine)
• Cause increases in blood
pressure, heart rate, and
alertness
• Cause rapid behavior and
thinking
• Alert/energetic ! crash
(depressed/tired)
• Long-haul truck drivers,
pilots, some college
students
coffee 2nd most traded after oil

53

John oliver Tobacco Video

psychosocial factors that maintain addiction

54

Nicotine

• Cigarettes most popular nicotine-delivery device
•Nicotine addicts need nicotine to feel normal (report “stress
management”)
• Over 70% of people who smoke report wanting to quit
• Difficult due to withdrawal (depressed mood, irritability,
anger, anxiety, restlessness, difficulty concentrating)
•Only 7% who attempt to quit remain smoke-free after 1-year

55

Nicotine effects

•Reaches brain 7-19
seconds after inhaled
• Smokers dose throughout
the day to keep “steady
state” in bloodstream & to
avoid withdrawal
• Complex bi-directional
relationship between
cigarette smoking &
negative affect (anxiety,
depression, irritability)

56

Tobacco industry is brilliant

Pay hollywood to not negatively depict cigarette smoking
smoke more, ^anxiety
smoke less, ^anxiety

57

Cocaine

•1885: Park, Davis, & Co manufactured coca &
cocaine in many forms: coca-leaf cigarettes, cigars,
inhalants, & crystals.
• Can’t afford those? Drink coca-cola! (until 1903)
• 1970’s -Replaced amphetamines as stimulant of
choice
• Increased alertness, euphoria, increase blood
pressure & pulse, insomnia, loss of appetite.
• Inhale (“snort”), smoked
• Short-lived (use repeatedly during binge) aka multiple times per hour

58

Stimulant: Cocaine

• Cocaine produces a euphoric rush of well-being
• It seems to work by
increasing dopamine at key receptors in the brain and overstimulating them
• Also appears to increase norepinephrine and
serotonin

59

Cocaine effects

•Cocaine-induced paranoia: > 2/3
of users will experience.
•Smoked cocaine = “crack”
• levels of dopamine in the brain
take a long time to replenish
themselves, and each hit taken
in rapid succession leads to
progressively less intense highs
** health effects can be worse due
to adulterants (substances used
to bulk up appearance/volume of
drug)

60

What are the dangers of cocaine?

•Aside from its behavioral effects, cocaine poses
significant physical danger
•The greatest danger of use is the risk of overdose
•Excessive doses depress the brain’s respiratory function,
and stop breathing
• Cocaine use can also cause heart failure
• Pregnant women who use cocaine have an increased
likelihood of miscarriage and of having children with
abnormalities

61

Hallucinogens

• Change perception of world in
terms of sights, sounds,
feelings, taste, smells
• Marijuana (some place in own
category of “cannabis”), LSD,
Psilocybin Mushrooms, Peyote
(mescaline), Ayahuasca, DMT,
STP
• Psychological introspection that
may lead to great elation, fear,
or illumination
-zero addiction potential
-huge expectancy effect

62

Senses on hallucinogens

-sense of time is another sense
more than 5 senses

63

Hallucinogen effects

• Anxiety, depression, fear of
losing one’s mind,
paranoia, impaired
judgment
• subjective intensification of
perceptions,
depersonalization,
derealization,
hallucinations, synesthesia
• Insight, religious/spiritual
realizations

64

Cannabis

• Marijuana – most routinely
used illegal (federal law)
substance
• impaired motor
coordination, euphoria,
anxiety, sensation of
slowed time, impaired
judgment, social
withdrawal, increased
appetite, dry mouth,
tachycardia
• Huge individual variation in
reactions (sense of wellbeing
to paranoia)

65

synesthesia

overlap of two senses like taste color or see sound

66

Smoked cannabis

! When smoked, cannabis produces a mixture of
hallucinogenic, depressant, and stimulant effects
! At low doses, the user feels joy and relaxation
! May become anxious, suspicious, or irritated
! This overall “high” is technically called cannabis intoxication
! At high doses, cannabis produces odd visual
experiences, changes in body image, and
hallucinations
! Most of the effects of cannabis last 2 to 6 hours
! Mood changes may continue longer

67

Cannabis uses and tolerance

! Tolerance? (heavy users report
less euphoric high)
! Medicinal uses
! chemo-therapy induced nausea/
vomiting
! neuropathic pain from multiple
sclerosis
! cancer pain
! seizures
! controversial

68

Cannabis withdrawal

>3 develop within
approximately 1 week of
cessation:
! Irritability, anger, or
aggression
! Nervousness or anxiety
! Sleep difficulty (eg,
insomnia, disturbing
dreams)
! Decreased appetite or
weight loss
! Restlessness
! Depressed mood
! At least one of the
following physical
symptoms causing
significant discomfort:
! abdominal pain
! shakiness/tremors,
sweating,
! fever, chills
! headache

69

Timing of Exposure

! With the brain developing
into the mid-20s, young
people who smoke early
and often are more likely to
have learning and mental
health problems
! Moderate marijuana use by
healthy adults seems to
pose relatively minor risks

70

synergist effect:

one drug with similar action enhances another drug

71

entourage effect

different components hang out together & need to be present to have effect

72

cannabis has higher internal validity

infer causation
(sleep drugs will stop working)

73

What maintains problematic use?

-coping mechanism
-environment/exposure
-withdrawal

74

Etiology

• Multiple interacting factors influence using behavior and
loss of decisional flexibility
• Not all who become dependent experience it same way
or motivated by same factors
• Different factors may be more or less important at
different stages (drug initiation, maintenance, relapse)

75

Risk factors

-- People of any age, sex, or
economic status
--Higher risk if:
Family history
Male 3:1
Comorbid psychopathology
(MDD, PTSD)
Peer pressure
Lack of family involvement
Anxiety, depression, loneliness
Highly addictive drug (heroin,
cocaine)

76

Place preference?

Box of heroin, cocaine, etc.
nictotine: 93% will use next year after quitting
alcohol: serious health issues
heroin & meth have faster mechanism of action, more people like it

77

Pleasure Pathway

! All drugs work on this
internal reward center
! Ventral Tegmental area
(midbrain) ! Nucleus
Accumbens ! Frontal
Cortex
! Primarily dopaminesensitive
neurons (other
neurotransmitters important
in reward, 5-HT, NE)
! Directly dopamine (cocaine)
! Indirectly via GABA
inhibition (heroin)

78

Drugs of Abuse primarily exert effect on

Ventral Tegmental area
(midbrain) ! Nucleus
Accumbens ! Frontal
Cortex

79

impacts

cocaine impacts directly & heroin impacts indirectly

80

Learning and Physiological Basis for Dependence

•After using drugs or when stop – leads to a depleted
state resulting in dysphoria and/or cravings to use,
reinforcing the use of more drug.
• Response of brain cells is to downregulate receptors
and/or decrease production of neurotransmitters that
are in excess of normal levels.

81

Biological Influences

•Genes confer risk in a number of ways - influence
greater for transition from use to dependence
• Alcohol Dependence (AlcDep) in biological parents
strong predictor of AlcDep in adopted children
• AlcDep in adoptive parents not strongly related to
AlcDep in adoptees
•Concordance rate of alcohol dependence in identical
twins – 50-60%
• Sons of AlcDep parents may be more sensitive to
highs of drinking & less sensitive to lows (less
sensitive to alcohol (“low level of response”) = drink
more) Genes confer risk in a number of ways - influence
greater for transition from use to dependence
•Alcohol Dependence (AlcDep) in biological parents
strong predictor of AlcDep in adopted children
• AlcDep in adoptive parents not strongly related to
AlcDep in adoptees
•Concordance rate of alcohol dependence in identical
twins – 50-60%
• Sons of AlcDep parents may be more sensitive to
highs of drinking & less sensitive to lows (less
sensitive to alcohol (“low level of response”) = drink
more)

82

You can inherit

drug liking
drug effects/ speed of drug metabolism

83

the alcohol gene

•Genetic contribution involves
multiple physiological pathways
(drug metabolism, GABA, dopamine)
•Genes that contribute to inefficient
processing of alcohol metabolism
>> protective factor (Asian &
Jewish populations)
•Genes that allow more rapid
metabolism ! risk factor
•Some genes influence reaction to specific drug

84

epigentic factors

• Cocaine abuse in a male
rat rendered the next
generation of animals
resistant to the rewarding
properties of the drug --
those offspring were less
likely to take cocaine.
•Sons, but not daughters, of
male rats on cocaine were
not only less likely to want
the drug, but also resistant
to effects of it.

85

Psychological influences

•Positive Reinforcement = pleasure!
•Lab animals will self-administer same drugs as
humans
•Negative Reinforcement = stop feeling bad (even
outside context of withdrawal)
•Escape physical pain, stress, anxiety
• Expectancy effect
•Craving
Knowledge is power to an extent
--experience
--effective escape mechanism

86

Sports as a protective factor(?)

sports are a protective factor in HS but risk in college "totally present"

87

Social Influences

Media may have greater role than peer influence on
whether adolescents smoke cigarettes
•2002: 74% of all US movies depicted smoking,
including ¾ of films for youth
•Tobacco manufacturers pay for
exposure
•Ex: Philip Morris & Lois Lane
•Contracts with Hollywood to
avoid negative portrayal of smoking

88

The Rational Choice of Addiction

Biggest problem is drug policy not drug addiction
Money vs. Drugs -->majority will pick money

89

Social Influences

• Lack of supervision
• Cultural norms
• Number of substance using
friends
• Peer pressure
• Prescription drug abuse
• sales of oxycodone
increases 16-fold between
2000-1010
• 14,800 overdose deaths in
2008 alone
• Protective: sports

90

Prescription Drug Abuse

• 2010: In USA, pharmacies
dispensed 69 tons of
oxycodone & 42 tons of
hydrocodone
• Enough to give 40 5-mg
Percocets and 24 5-mg
Vicodins to every person in
the United States.
• Misperceptions about
safety (particularly in
younger people)
It is legal, safer, your dealer is your doctor

91

substance use disorder is predominantly defined by

behaviors

92

Drugs drugs

better to titrate down than titrate up
-use less when start high
Diathesis Stress model

93

How Are Substance Use
Disorders Treated?

• The value of treatment for
substance use disorders can be
difficult to determine
• Different substance use disorders
pose different problems
• Many people with such disorders
drop out of treatment early
• Some people recover without any
intervention at all
• Different criteria are used by
different clinical researchers

94

How to quit?

methedone
cold-turkey
rehab
AA meetings

95

Evidence based treatment?

the way we treat substance use disorder is nonmedical
Harm reduction approach
Mandated treatment works (license revoked after DUI)

96

Biological Treatments

• Agonist substitution: safer
than drug abused
(methadone = opiate
agonist, nicotine
replacement) >>Harm Reduction approach
• Antagonist treatments:
block effect of drug
abused (naltrexone for
heroin, alcohol)
• Aversive treatment:
disulfiram (antabuse for
alcohol)

97

Methadone

controversial
it has a street value
can switch addictions
taken daily
good for communities
treating community or the individual?

98

antabuse

makes you throw up

99

Antagoinist treatments

have to be motivated (Naltrexone)

100

Vaccines

• Theoretical basis:
sequester the drug in the
blood via antibodies
•Drug of abuse is prevented
from crossing the blood
brain barrier

101

Psychosocial treatments

CBT
Behavioral couples therapy
motivational interviewing
AA/NA

102

CBT

what to do when craving hits, activity planning, avoiding
drug cues, high risk situations,
refusal skills (thoughts/
behaviors), relapse prevention
(lapse vs. relapse) *Best data

103

Behavioral Couples Therapy

support around recovery,
communication, shared
rewarding activities

104

Motivational Interviewing

(helps with gaining insight &
willingness to change; taps into
core values facilitating change)

105

AA/NA

12-steps, avoid people/
places/things

106

Why do we need to hit rock bottom before getting treatment

nonmedical

107

Abstinence Violation Effect

relapse-->reinstate problematic use -had a slip up so will keep using & quit another time

lapse--> predictable using a drug that tried to quit