Chapter 12Substance-Related Disorders

•Key Terms – Substance-related and addictive disorders

•Alcohol • Inhalant Use Disorder•Nicotine and Cigarette Smoking•Marijuana•Sedatives and Stimulants •LSD and Other Hallucinogens •Etiology •Therapy•Prevention of Substance Use

Chapter Outline

Substance-related and addictive disorders

•Key terms: DSM-IV-TR• Substance Dependence

• Tolerance: larger doses are needed to get same desired effect

• Withdrawal: negative physical and/or psychological effects when person stops taking the drug

•Substance Abuse• considered to be less serious•must have experienced one of the following as a

result of recurrent use:• Failure to fulfill major obligations • Exposure to physical dangers • Legal problems • Persistent social or interpersonal problems

Substance Related and Addictive Disorders (DSM-5)

•Eliminated DSM-IV-TR classifications of dependence and abuse since the distinction was considered to be one of severity not distinct categories

•DSM-5 has single broad category of substance-related and addictive disorders

•Addictions now include ‘gambling disorders’

Alcohol Dependence

•Alcohol dependence may include tolerance or withdrawal reactions • People who are physically dependent on alcohol tend to

have more severe symptoms of the disorder

•Alcohol dependence is often part of polydrug (or polysubstance) use• Using more than one drug at a time• Effects of drugs can be synergistic (combine to produce

very strong reaction)• Potentially fatal overdoses (i.e., alcohol can reduce

amount of narcotics needed to make a lethal dose)

Alcohol DependencePrevalence and Comorbidity

• Alcohol dependence• Lifetime prevalence rate: 12.5%• 12-month prevalence: 3.8%• Higher among men, younger cohorts and whites

• Comorbid with mood and anxiety disorders, other drug use and schizophrenia

• Comorbidity (psychiatric disorders and substance dependence) is important because:• predicts high relapse rates• less initial treatment improvement

High Risk Drinking

•Defined as more than two drinks per day•Higher rates in men (25.1%) compared to

women (8.9%)•Prototypic heavy drinker in Canada:

• Male• Not married• Relatively well-off financially

Binge Drinking at University

• 1 in every 4 university students is a frequent binge drinkers (usually once per week) (US stats)

• 32% of undergraduates report hazardous or harmful patterns of drinking (compare to 17% in the general population)

•More Canadian students drink some alcohol; • American students who use alcohol are

heavier drinkers • First experience of drunkenness prior to age 16 is

more likely to lead to heavy drinking later • 1 in 4 Ontarians in grades 7 to 12 admit binge

drinking within last month – no gender differences was found

Short-Term Effects of Alcohol

• Metabolized by enzymes after swallowed and enters stomach

• Most goes into small intestines where absorbed into blood

• Broken down in liver• can metabolize about 30 millilitres of 100-proof (50%

alcohol) whisky/hour • quantities in excess of this amount stay in the

bloodstream

• Biphasic effect• Initial effect of alcohol: acts as a stimulant• Later effect of alcohol: acts as a depressant

Short-Term Effects of AlcoholBiological Mechanism

•Produces effects through interactions with several neural systems in the brain • Stimulates GABA receptors

• Reducing tension

• Increases levels of serotonin and dopamine• Pleasurable effects

• Inhibits glutamate receptors• Cognitive effects of alcohol intoxication,

such as slurred speech and memory loss

Long-Term Effects

•Chronic drinking causes severe biological damage and psychological deterioration

•Almost every tissue and organ is adversely affected: •Malnutrition •Deficiency of B-complex vitamins →

amnestic syndrome•Cirrhosis of the liver•Damage to the endocrine glands and

pancreas•Heart failure, hypertension, stroke, and

capillary hemorrhages, which in turn can produce:

•Brain damage

Fetal Alcohol Syndrome

•Leading cause of mental retardation— heavy alcohol consumption during pregnancy

•growth of the fetus is slowed

•cranial, facial, and limb anomalies are produced

•known as fetal alcohol syndrome

•see also partial fetal alcohol syndrome and alcohol-related neurodevelopmental disorder (ARND)

Inhalant Use Disorders

•Although use not confined to children and adolescents, alarming # of young people begin their substance abuse by inhaling substances•Glue, correction fluid, spray paint,

cosmetics, gasoline, household aerosol sprays, nitrous oxide found in spray cans of whipped cream

• Inhalant use among young people = 17.3%

Nicotine Use and Cigarette Smoking

•Single most preventable cause of premature death (1 in every 5 deaths)

•Nicotine— addictive ingredient of tobacco•stimulates nicotinic receptors in brain• facilitate release of neurotransmitter

dopamine •produces reinforcing (pleasurable)

effects•Harmful components of cigarettes

include: nicotine, carbon monoxide and tar

Health Consequences

•Medical problems associated with cigarette smoking include:• Lung cancer• Emphysema• Cancer of larynx and esophagus• Cardiovascular diseases

Smoking Statistics• In 2009, ~17% of Canadians aged 15 > are

current smokers • But fewer Canadians are smoking and smokers

are smoking fewer cigarettes on a daily basis

• Men smoke more cigarettes per day than women

• Rates of smoking have declined steadily overall among teenagers in Canada except for increased rates in Quebec (where 1 in 5 smoke)

• Second hand smoke (toxic exposure to environmental tobacco smoke) causes more than 50,000 deaths per year (USA)

• Children with second hand smoke exposure showed:• self-reported aggression• teacher-rated anti-social behaviour

Marijuana

•Marijuana—dried and crushed leaves and flowering tops of Cannabis sativa• Major active chemical is delta-9-tetrahydrocannabinol

(THC)

• Psychological Effects of Marijuana• Feel more relaxed and sociable• Can dull attention, fragment thoughts, and impair

memory • Extremely heavy doses can induce hallucinations and

extreme panic

• Somatic Effects• Specific cannabinoid receptors in brain (CB) have been

located in various brain regions• receptors in hippocampus may account for short-term

memory loss effects following marijuana use

• Therapeutic Effects• Reduce nausea and appetite loss that accompanies

chemotherapy

Sedatives

•Sedatives (‘downers’) slow activities of body and reduce responsiveness. • Includes opiates—opium and its derivatives,

morphine, heroin, and codeine•and synthetic barbiturates and tranquilizers,

such as secobarbital (Seconal) and diazepam (Valium)

•Group of drugs used medically (in moderate doses) to relieve pain and induce sleep

Sedatives (Cont.)Psychological and Physical

Effects •Opium and derivatives (morphine and heroin) produce:

•Euphoria, drowsiness, daydream, and lack of coordination

•Heroin has an additional initial effect— the rush•Effects produced by stimulating neural

receptors of the body’s own opioid system•Heroin (example) converted into morphine in

brain and then binds to opioid receptors•Body produces opioids (endorphins and

enkephalins)•Opium and derivatives fit into receptors and

stimulate them• In 24-year follow-up of 500 heroin addicts•28% had died by age 40

Stimulants

•Stimulants (‘uppers’) such as cocaine, act on brain and sympathetic nervous system to increase alertness and motor activity

•Amphetamines•Originally used to control control mild

depression and appetite•Today used to treat hyperactive children•Examples: Benzedrine, Dexedrine, and

Methedrine•Produce effects by causing the release of

norepinephrine and dopamine and blocking the reuptake of these neurotransmitters

•Cocaine•Pleasure induced by cocaine related to has

blocked dopamine reuptake

LSD and Other Hallucinogens

•LSD= d-lysergic acid diethylamide•LSD is a hallucinogen

• Main effect of drug is hallucinations• Other effects include flashbacks

•Other important hallucinogens are:• Mescaline• Psilocybin• Synthetic compounds MDA and MDMA

Etiology of Substance Use and Dependence Disorders

Psychological Variables

•Role of cognition•Positive expectations predict use•Expectancies:

•Drinking helps one cope with stress•Drinking enhances sexual pleasure

•Personality•Novelty-seeking is associated with

alcohol dependence•Psychoticism and anti-social traits

associted with drug use

Biological Variables•Evidence for genetic predisposition for alcohol abuse

•Research: identical twins more likely than fraternal twins to have concordance for alcohol, caffeine, nicotine and heavy cannabis and drug use

•Conditioning theory of tolerance— underscores need to jointly consider biological processes and environmental stimuli • Based on notion that tolerance is a learned response• Environmental cues present when addictive behaviours

are developed influence behaviours because these cues come to be associated with substance use (classical conditioning)

•Feedforward mechanisms— regulatory responses made in anticipation of a drug

•We learn to anticipate drug effects even before they actually occur

Therapy•Admitting the Problem

• Do you sometimes feel uncomfortable when alcohol is not available?

• Do you drink more heavily than usual when you are under pressure?

• Are you in more of a hurry to get to the first drink than you used to be?

• Do you sometimes feel guilty about your drinking?• Are you annoyed when people talk about your drinking?• When drinking socially, do you try to sneak in some extra

drinks?• Are you constantly making rules for yourself about what

and when to drink?

•Traditional Hospital Treatment• Detoxification

•Biological Treatments• Example: disulfiram (Antabuse)

•Alcoholics Anonymous

Therapy (Cont.)12 Steps of AA

Therapy (cont.)

•Couples and Family Therapy

•Adolescent Treatment Centre

•Cognitive and Behavioural Treatment

•Aversion Therapy• Covert sensitization

•Contingent-Management Therapy• emphasizes patient control and includes:

• Stimulus control

• Modification of the topography of drinking

• Reinforcing abstinence

•Moderation in Drinking• Controlled drinking

• Harm reduction therapy

Therapy for Use of Illicit Drugs

•Detoxification—central to treatment of people who use addicting drugs

•Biological Treatments•Heroin substitutes

• Drugs chemically similar to heroin that replace body’s craving

• Example: methadone, levomethadyl acetate, bupreorphine

•Heroin antagonists• Drugs that prevent user from experiencing

heroin high

• Psychological Treatments•CBT and Motivational Interviewing

Therapy for Smoking

•Biological Treatment• Nicotine replacement therapy

• Nicotine gum, patches, inhalers etc.

•Psychological Treatment• Various coping strategies (relaxation, positive self-talk)• Evidence for combined approaches (counseling and

biological interventions)

Prevention

• Peer-pressure resistance training

•Correction of normative expectations

• Inoculation against mass-media messages

• Information about parental and other adult influences

• Peer leadership

•Affective education, self-image enhancement.

•Other components

• Providing information about harmful effect

• Encouraging students to make public commitment not to smoke

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