SubstanceSubstance--Related Related DisordersDisordersDisordersDisorders

Cornelia Pinnell, Ph.D.Cornelia Pinnell, Ph.D.Argosy University/PhoenixArgosy University/Phoenix

Lecture OutlineLecture Outline

•• DefinitionsDefinitions•• Psychoactive SubstancesPsychoactive Substances•• EpidemiologyEpidemiology•• Assessment Assessment •• Assessment Assessment •• Etiological ModelsEtiological Models•• TreatmentTreatment•• Stages of ChangeStages of Change

“Substances”“Substances”

In the DSMIn the DSM--IVIV--TR, the term ‘substance’ TR, the term ‘substance’ can refer to:can refer to:–– a a medicationmedication––a a medicationmedication––a a toxintoxin––a a drug of abusedrug of abuse

MedicationsMedications

Symptoms related to Symptoms related to medicationsmedications usuallyusually

•• Occur at high doses Occur at high doses •• Occur at high doses Occur at high doses

•• Disappear when the dose is lowered or Disappear when the dose is lowered or medication is discontinued medication is discontinued

ToxinsToxins

Toxic substancesToxic substances include heavy include heavy metals (e.g., lead or aluminum), rat metals (e.g., lead or aluminum), rat poisons containing strychnine, poisons containing strychnine, pesticides containing nicotine, pesticides containing nicotine, pesticides containing nicotine, pesticides containing nicotine, acetylcholinesterase inhibitors, nerve acetylcholinesterase inhibitors, nerve gases, ethylene glycol (antifreeze), gases, ethylene glycol (antifreeze), carbon monoxide, carbon dioxidecarbon monoxide, carbon dioxide

ToxinsToxins

Volatile substancesVolatile substances (e.g., fuel, paint) are (e.g., fuel, paint) are classified as: classified as:

•• toxins if exposure is accidental or part of toxins if exposure is accidental or part of •• toxins if exposure is accidental or part of toxins if exposure is accidental or part of intentional poisoningintentional poisoning

•• ‘inhalants’ if they are used for the ‘inhalants’ if they are used for the purpose of becoming intoxicated purpose of becoming intoxicated

Substances of AbuseSubstances of Abuse

These are grouped in These are grouped in 11 classes11 classes::

1) alcohol; 2) amphetamines; 3) caffeine; 1) alcohol; 2) amphetamines; 3) caffeine; 1) alcohol; 2) amphetamines; 3) caffeine; 1) alcohol; 2) amphetamines; 3) caffeine; 4) cannabis; 5) cocaine; 6) hallucinogens; 4) cannabis; 5) cocaine; 6) hallucinogens; 7) inhalants; 8) nicotine; 9) opioids; 7) inhalants; 8) nicotine; 9) opioids; 10) phencyclidine (PCP); 11) sedatives, 10) phencyclidine (PCP); 11) sedatives, hypnotics, anxiolytics hypnotics, anxiolytics

Classes of substances Classes of substances with similar featureswith similar features

•• Alcohol with sedatives, hypnotics & Alcohol with sedatives, hypnotics & anxiolyticsanxiolytics

•• Cocaine with amphetaminesCocaine with amphetamines

IntoxicationIntoxication

Development of Development of reversible substancereversible substance--specificspecific maladaptive behavioral and/or maladaptive behavioral and/or psychological changes due to the direct psychological changes due to the direct physiological effects of a substance physiological effects of a substance physiological effects of a substance physiological effects of a substance (recent ingestion or exposure to) (recent ingestion or exposure to) e.g., belligerence, mood lability, cognitive e.g., belligerence, mood lability, cognitive impairment, impaired judgment, social or impairment, impaired judgment, social or occupational functioningoccupational functioning

IntoxicationIntoxication

•• Clinical picture varies among individuals Clinical picture varies among individuals & depends on the substance involved& depends on the substance involved

•• ‘‘AcuteAcute’ vs. ‘’ vs. ‘chronicchronic’’•• ‘‘AcuteAcute’ vs. ‘’ vs. ‘chronicchronic’’

•• Longer term effects to be distinguished Longer term effects to be distinguished from withdrawalfrom withdrawal

AbuseAbuse

Persistent pattern of maladaptive Persistent pattern of maladaptive substance use resulting in substance use resulting in substance use resulting in substance use resulting in

significant adverse consequences significant adverse consequences over a period of 12 monthsover a period of 12 months

DependenceDependence

Cluster of cognitive, behavioral, and physiological Cluster of cognitive, behavioral, and physiological symptoms indicating that the individual symptoms indicating that the individual

continues use of substance continues use of substance despite significant substancedespite significant substance--related problemsrelated problemsdespite significant substancedespite significant substance--related problemsrelated problems

Repeated selfRepeated self--administration can result in administration can result in compulsive drugcompulsive drug--taking behavior (‘craving’ is taking behavior (‘craving’ is often experienced), tolerance & withdrawaloften experienced), tolerance & withdrawal

ToleranceTolerance

•• The need for The need for greatly increased amountsgreatly increased amounts of the of the substance to achieve intoxication (or the desired substance to achieve intoxication (or the desired effect) effect)

OROROROR•• A A markedly diminished effectmarkedly diminished effect with continued use with continued use of the same amount of the substanceof the same amount of the substance

It is difficult to determine by history alone It is difficult to determine by history alone ––laboratory tests are helpfullaboratory tests are helpful

CrossCross--ToleranceTolerance

Tolerance develops Tolerance develops across drugsacross drugs

to a combination of drugsto a combination of drugsto a combination of drugsto a combination of drugs

WithdrawalWithdrawal

A maladaptive behavioral change, A maladaptive behavioral change, with with physiological and cognitive concomitants,physiological and cognitive concomitants,that occurs when blood or tissue concentrations that occurs when blood or tissue concentrations that occurs when blood or tissue concentrations that occurs when blood or tissue concentrations of a substance decline in an individual who had of a substance decline in an individual who had maintained prolonged heavy use of the maintained prolonged heavy use of the substance to relieve or avoid those symptomssubstance to relieve or avoid those symptoms

WithdrawalWithdrawal

•• There are separate criteria listed for most There are separate criteria listed for most classesclasses

•• No significant withdrawal is seen after repeated No significant withdrawal is seen after repeated •• No significant withdrawal is seen after repeated No significant withdrawal is seen after repeated use of hallucinogensuse of hallucinogens

•• Marked & easily measured physiological signs Marked & easily measured physiological signs are common with alcohol, opiates,, sedatives, are common with alcohol, opiates,, sedatives, hypnotics, and anxiolyticshypnotics, and anxiolytics

Criteria for Substance DependenceCriteria for Substance Dependence

A maladaptive pattern of substance use, A maladaptive pattern of substance use, leading to clinically significant leading to clinically significant impairment or distress, as manifested by impairment or distress, as manifested by three (or more) of the following, three (or more) of the following, three (or more) of the following, three (or more) of the following, occurring during any time in the same 12 occurring during any time in the same 12 month period:month period:

Criteria for Substance DependenceCriteria for Substance Dependence

1.1. ToleranceTolerance

2.2. WithdrawalWithdrawal

3.3. Substance is taken in larger amounts or over Substance is taken in larger amounts or over longer periods than intendedlonger periods than intended

4.4. Persistent desire or unsuccessful efforts to Persistent desire or unsuccessful efforts to cut down or control substance usecut down or control substance use

Criteria for Substance DependenceCriteria for Substance Dependence

5.5. Great deal of time is spent in activities Great deal of time is spent in activities necessary to obtain the substancenecessary to obtain the substance

6.6. Important social, occupational or Important social, occupational or recreational activities are given up or recreational activities are given up or reduced because of substance usereduced because of substance usereduced because of substance usereduced because of substance use

7.7. The substance use is continued despite the The substance use is continued despite the knowledge of having persistent or recurrent knowledge of having persistent or recurrent physical or psychological problems that is physical or psychological problems that is likely to have been caused or exacerbated likely to have been caused or exacerbated by the substanceby the substance

SubstanceSubstance--Related DisordersRelated Disorders

•• Substance Use DisordersSubstance Use Disorders–– Dependence Dependence –– Abuse Abuse

•• SubstanceSubstance--Induced DisordersInduced Disorders•• SubstanceSubstance--Induced DisordersInduced Disorders–– IntoxicationIntoxication–– WithdrawalWithdrawal–– Persisting DeliriumPersisting Delirium–– Persisting DementiaPersisting Dementia–– Persisting Amnestic DisorderPersisting Amnestic Disorder

SpecifiersSpecifiers

•• With Physiological DependenceWith Physiological Dependence(if there is evidence of tolerance or (if there is evidence of tolerance or withdrawal)withdrawal)

•• Without Physiological Dependence Without Physiological Dependence (pattern of compulsive use without (pattern of compulsive use without evidence of tolerance or withdrawal)evidence of tolerance or withdrawal)

Course specifiersCourse specifiers

•• Early RemissionEarly Remission = = More than 1 month, up More than 1 month, up to 1 yearto 1 year

•• Sustained RemissionSustained Remission = Beyond 12 moths = Beyond 12 moths (1 year)(1 year)(1 year)(1 year)

•• Partial RemissionPartial Remission = = At least one criterion At least one criterion for Dependence or Abuse has been met, for Dependence or Abuse has been met, intermittently or continuously during the intermittently or continuously during the period of remissionperiod of remission

•• Full RemissionFull Remission = No criteria are met= No criteria are met

Course specifiersCourse specifiers

•• On Agonist TherapyOn Agonist Therapy = No criteria for = No criteria for Dependence or Abuse are met on agonist, Dependence or Abuse are met on agonist, for at least for 1 monthfor at least for 1 month

•• In a Controlled EnvironmentIn a Controlled Environment = No criteria = No criteria for Dependence or Abuse are met in a for Dependence or Abuse are met in a controlled environment, for at least for 1 controlled environment, for at least for 1 monthmonth

Agonist medicationAgonist medication

Agonist mAgonist m. = A chemical entity not . = A chemical entity not naturally occurring in the body that acts naturally occurring in the body that acts upon a receptor and is capable of upon a receptor and is capable of upon a receptor and is capable of upon a receptor and is capable of producing the producing the maximal effectmaximal effect that can be that can be produced by stimulating that receptor. produced by stimulating that receptor.

Agonist medicationAgonist medication

Partial agonist mPartial agonist m. = A chemical entity not . = A chemical entity not naturally occurring in the body that acts naturally occurring in the body that acts on a receptor and is capable of producing on a receptor and is capable of producing on a receptor and is capable of producing on a receptor and is capable of producing less than maximal effectless than maximal effect even when given even when given in concentrations sufficient to bind with all in concentrations sufficient to bind with all available receptorsavailable receptors

Antagonist medicationAntagonist medication

Antagonist m.Antagonist m. = A chemical entity not = A chemical entity not naturally occurring in the body, that naturally occurring in the body, that occupies a receptor, produces no occupies a receptor, produces no occupies a receptor, produces no occupies a receptor, produces no physiologic effects, and physiologic effects, and prevents prevents endogenous and exogenous chemicals endogenous and exogenous chemicals from producing an effect on that receptorfrom producing an effect on that receptor

Psychoactive substancesPsychoactive substances

•• CNS StimulantsCNS Stimulants

•• CNS DepressantsCNS Depressants

•• HallucinogensHallucinogens

•• InhalantsInhalants

Routes of administrationRoutes of administration

•• OralOral•• Inhalation (smoking)Inhalation (smoking)•• Intranasal (snorting)Intranasal (snorting)•• Intranasal (snorting)Intranasal (snorting)•• IV IV –– Intravenous Intravenous •• IM IM –– IntraIntra--muscularmuscular

Stimulants (‘uppers’)Stimulants (‘uppers’)

•• Types of stimulantsTypes of stimulants::––CaffeineCaffeine––NicotineNicotine––Amphetamines (benzedrine, Amphetamines (benzedrine, ––Amphetamines (benzedrine, Amphetamines (benzedrine, methedrine, methamphetmine, methedrine, methamphetmine, Dexedrine, ‘crystal meth’) Dexedrine, ‘crystal meth’)

––Cocaine Cocaine –– ‘ecstasy’, ‘crack’‘ecstasy’, ‘crack’

Stimulants (‘uppers’)Stimulants (‘uppers’)

Effects of stimulant useEffects of stimulant use: :

•• Users feel more alert & possibly some Users feel more alert & possibly some euphoriaeuphoriaeuphoriaeuphoria

•• Increased heart & respiratory rateIncreased heart & respiratory rate•• Increased blood pressure Increased blood pressure

AmphetaminesAmphetamines

•• Street namesStreet names: uppers, pep pills, beenies, : uppers, pep pills, beenies, whities, dexies, hearts, speed, black beauties, whities, dexies, hearts, speed, black beauties, copilots, bumblebees, footballscopilots, bumblebees, footballs

•• Tablets or capsules Tablets or capsules -- can be easily changed into can be easily changed into powder or liquid formpowder or liquid form

•• Modes of administrationModes of administration: orally, sniffed, or : orally, sniffed, or diluted & injected into the bloodstreamdiluted & injected into the bloodstream

AmphetaminesAmphetamines

The psychotic disorder resulting from The psychotic disorder resulting from withdrawal is undistinguishable from withdrawal is undistinguishable from withdrawal is undistinguishable from withdrawal is undistinguishable from schizophrenia and may last several yearsschizophrenia and may last several years

Methamphetamine hydrochlorideMethamphetamine hydrochloride

•• Street namesStreet names: ice, crystal, glass : ice, crystal, glass

•• Clear crystalClear crystal--shaped solidshaped solid

•• Mode of administrationMode of administration: smoked: smoked•• Mode of administrationMode of administration: smoked: smoked

•• Was used in the 1930s to treat depression, sleep Was used in the 1930s to treat depression, sleep disorders, and obesitydisorders, and obesity

Methamphetamine hydrochlorideMethamphetamine hydrochloride

•• Euphoria lasts for 2 to 8 hoursEuphoria lasts for 2 to 8 hours•• Addiction can develop after 1 useAddiction can develop after 1 use

•• Side effectsSide effects: Strokes, heart attacks, pulmonary : Strokes, heart attacks, pulmonary edema, comas, death; psychosis can follow edema, comas, death; psychosis can follow edema, comas, death; psychosis can follow edema, comas, death; psychosis can follow discontinuationdiscontinuation

•• Highest use in border states Highest use in border states –– San Diego, San Diego, PhoenixPhoenix

CocaineCocaine

•• Street namesStreet names: coke, C, big C, snow, snowbird, : coke, C, big C, snow, snowbird, lady, nose candy, blow, toot, leaf, flake, freeze, lady, nose candy, blow, toot, leaf, flake, freeze, happy dust, Peruvian lady, white girl happy dust, Peruvian lady, white girl

•• White, odorless crystals or crystaline powder; White, odorless crystals or crystaline powder; •• White, odorless crystals or crystaline powder; White, odorless crystals or crystaline powder; extracted fromextracted from leaves of coca plantleaves of coca plant

•• Mode of administrationMode of administration: : sniffedsniffed (snorting it is (snorting it is inefficient), inefficient), smokedsmoked (crack crystals or mixed with (crack crystals or mixed with other drugs) or other drugs) or IVIV -- smoke or IV injections are smoke or IV injections are preferred by userspreferred by users

CocaineCocaine

•• Cycle of useCycle of use: crash : crash –– crave crave –– binge binge –– get get high high –– crashcrash

•• Very short halfVery short half--life (approx. 50 minutes)life (approx. 50 minutes)•• Very short halfVery short half--life (approx. 50 minutes)life (approx. 50 minutes)

•• Severe depression during withdrawal, Severe depression during withdrawal, suicide attempts are commonsuicide attempts are common

CrackCrack

•• Cocaine derivativeCocaine derivative -- turned into a base, turned into a base, mixed with water and baking powdermixed with water and baking powder

•• Mode of administrationMode of administration: smoked in pipe, : smoked in pipe, •• Mode of administrationMode of administration: smoked in pipe, : smoked in pipe, sprinkled into a tobacco cigarette, mixed sprinkled into a tobacco cigarette, mixed with marijuanawith marijuana

CrackCrack

Pattern of usePattern of use: : •• Instant rush (after 30 min.) Instant rush (after 30 min.) •• ‘High’ lasts for 10‘High’ lasts for 10--15 min.15 min.•• ‘High’ lasts for 10‘High’ lasts for 10--15 min.15 min.

•• Heavy users 1x or 2x/week Heavy users 1x or 2x/week ––2/3 of crack users use daily2/3 of crack users use daily

CrackCrack

•• Public health issuesPublic health issues: : –– sex for drugs sex for drugs –– promiscuitypromiscuity––HIV infections (due to needle sharing)HIV infections (due to needle sharing)

•• Highly associated with Highly associated with crime and crime and violenceviolence (intensive craving & anxiety (intensive craving & anxiety & panic attacks during withdrawal)& panic attacks during withdrawal)

‘Depressants’ (‘downers’)‘Depressants’ (‘downers’)

Effects of depressantsEffects of depressants: :

•• May induce May induce euphoriaeuphoria (depends of context (depends of context & type of substance used)& type of substance used)& type of substance used)& type of substance used)

•• Users feel Users feel less ‘jitteryless ‘jittery’ and drowsy’ and drowsy

‘Depressants’ (‘downers’)‘Depressants’ (‘downers’)

Types of depressantsTypes of depressants::•• AlcoholAlcohol (ETOH): bi(ETOH): bi--phasic action phasic action

–– low doselow dose –– stimulantstimulant, lowers inhibition, , lowers inhibition, elevated moodelevated moodelevated moodelevated mood

––high dosehigh dose -- sedativesedative, muscular , muscular coordination and cognition are impairedcoordination and cognition are impaired

•• NarcoticsNarcotics//OpiatesOpiates

‘Depressants’ (‘downers’)‘Depressants’ (‘downers’)

Types of depressantsTypes of depressants (continued):(continued):

•• SedativesSedatives (legally prescribed drugs to (legally prescribed drugs to reduce anxiety, induce sleep, control reduce anxiety, induce sleep, control seizures, produce sedation/calm): seizures, produce sedation/calm): seizures, produce sedation/calm): seizures, produce sedation/calm): –– NonbarbituratesNonbarbiturates (Quaalude, Sopor, Parest) (Quaalude, Sopor, Parest) –– Barbiturates/ Benzodiazepines Barbiturates/ Benzodiazepines (Seconal, (Seconal, Tuinal, Nembutal) Tuinal, Nembutal) –– high potential for high potential for addiction; complicated medical detox picture addiction; complicated medical detox picture

‘Depressants’ (‘downers’)‘Depressants’ (‘downers’)

Types of depressantsTypes of depressants (continued):(continued):

•• TranquilizersTranquilizers::––MinorMinor (Librium) (Librium) ––MajorMajor (Thorazine, Stelazine)(Thorazine, Stelazine)––MajorMajor (Thorazine, Stelazine)(Thorazine, Stelazine)

Narcotics/OpiatesNarcotics/Opiates

•• NaturalNatural: Opium, Morphine, Codeine: Opium, Morphine, Codeine

•• SemiSemi--syntheticsynthetic: : HeroinHeroin, Hydromorphone , Hydromorphone (Dilaudid), Oxycodone (Percodan)(Dilaudid), Oxycodone (Percodan)(Dilaudid), Oxycodone (Percodan)(Dilaudid), Oxycodone (Percodan)

•• SyntheticSynthetic: Propoxyphene (Darvon), : Propoxyphene (Darvon), Mepreidine (Demoral), Dolophine Mepreidine (Demoral), Dolophine ((MethadoneMethadone))

SemiSemi--Synthetic Opiate Synthetic Opiate -- HeroinHeroin

•• Was introduced in 1898 as a cough suppressantWas introduced in 1898 as a cough suppressant

•• Street namesStreet names: smack, horse, brown sugar, junk, : smack, horse, brown sugar, junk, mud, Big H, tootsie roll, black tarmud, Big H, tootsie roll, black tarmud, Big H, tootsie roll, black tarmud, Big H, tootsie roll, black tar

•• Mode of administrationMode of administration: inhaled, smoked, or : inhaled, smoked, or injectedinjected

SemiSemi--Synthetic Opiate Synthetic Opiate -- HeroinHeroin

•• Withdrawal symptomsWithdrawal symptoms may include: may include: sweating, fever, nausea, vomiting, sweating, fever, nausea, vomiting, headaches, diarrhea headaches, diarrhea Severe anxiety and depression during Severe anxiety and depression during Severe anxiety and depression during Severe anxiety and depression during withdrawal withdrawal –– results in results in intense cravingintense craving

•• 5050--80% pure is lethal80% pure is lethal

Synthetic Opiate Synthetic Opiate -- MethadoneMethadone

•• Synthetic opiate was developed by the Synthetic opiate was developed by the Nazis Nazis –– initially used as analgesicinitially used as analgesic

•• Street namesStreet names: dollies, done, biscuits: dollies, done, biscuits

•• Mode of administrationMode of administration: oral, in a liquid solution, : oral, in a liquid solution, under the supervision of a tx professional under the supervision of a tx professional –– Used in the tx of opiate addiction, blocks Used in the tx of opiate addiction, blocks euphoric effect of heroineuphoric effect of heroin

Synthetic Opiate Synthetic Opiate -- MethadoneMethadone

•• Long halfLong half--time of 33time of 33--40 hours 40 hours

•• Psychiatric disorders due to methadone Psychiatric disorders due to methadone are uncommonare uncommonare uncommonare uncommon

HallucinogensHallucinogensTypes of hallucinogensTypes of hallucinogens: organic and synthetic agents: organic and synthetic agents•• Cannobinoids Cannobinoids -- marijuana, hashishmarijuana, hashish•• Psylocybin Psylocybin (naturally occurring in a variety of (naturally occurring in a variety of mushroomsmushrooms))

•• MescalineMescaline (naturally occurring in the (naturally occurring in the peyotepeyote•• MescalineMescaline (naturally occurring in the (naturally occurring in the peyotepeyotecactus)cactus)

•• LSDLSD (lysergic acid diethylamide) (lysergic acid diethylamide) –– synthesizedsynthesized(tablets, capsules, sugar cubes, or liquefied (tablets, capsules, sugar cubes, or liquefied --licked from a ‘postage stamp’licked from a ‘postage stamp’

•• PCPPCP (phencyclidine hydrochloride) (phencyclidine hydrochloride) -- synthesizedsynthesized•• EcstasyEcstasy

HallucinogensHallucinogens

•• Mode of administrationMode of administration: orally, in the form : orally, in the form of pills, tablets, capsules, or blotter papersof pills, tablets, capsules, or blotter papers

•• Use has decreased with the onset of the Use has decreased with the onset of the cocaine/crack epidemiccocaine/crack epidemic

HallucinogensHallucinogensEffects of hallucinogensEffects of hallucinogens::•• Disrupt cognition Disrupt cognition •• Alter consciousness, sensations & perceptions Alter consciousness, sensations & perceptions •• Induce visual, auditory, and tactile hallucinations Induce visual, auditory, and tactile hallucinations

•• The intoxication is a typical example of an acute The intoxication is a typical example of an acute psychotic statepsychotic state