Substance Abuse and Dependence
DSM-IV-TR uses two terms to describe substance use disorders, and these terms reflect different levels of severity:substance dependence and substance abuse
The Concept of Substance Dependence
Cravings and psychological dependence are key to the concept of substance abuse dependence. It is not unusual for the person who abuses drugs to try to stop. Diminished control over drinking is a crucial feature of the disorder.
Tolerance and withdrawal are also key.
Tolerance refers to the process through which the nervous system becomes less sensitive to the effects of alcohol or any other drug of abuse. Withdrawal refers to the symptoms experienced when a person stops using a drug.
Alcohol affects virtually every organ and system in the body. The rate at which it is absorbed is influenced by many variables, including: the concentration of alcohol in the beverage, the volume and rate of consumption, and the presence of food in the digestive system.
There is a strong correlation between blood alcohol levels and CNS intoxicating effects. Symptoms of alcohol intoxication include slurred speech, lack of coordination, an unsteady gait, nystagmus, impaired attention or memory, and stupor or coma.
The effects of nicotine on the peripheral nervous system include increases in heart rate and blood pressure. In the central nervous system, nicotine has pervasive effects on a number of neurotransmitter systems. Nicotine has a complex influence on subjective mood states. It’s effects are often thought to be a paradoxical phenomenon.
Nicotine is one of the most harmful and deadly addicting drugs. People who are attempting to quit smoking typically experience sleeping problems, weight gain, concentration difficulties, and mood swings ranging from anxiety to anger and depression. 80% of all deaths caused by lung cancer can be attributed to smoking tobacco. More than 3.5 million people in the world die prematurely each year as a result of tobacco.
Amphetamine and Cocaine
They are called stimulants because they activate the sympathetic nervous system. They increase heart rate and blood pressure and dilate the blood vessels and the air passages of the lungs. Stimulants also suppress the appetite and prevent sleep. Evidence suggests that prolonged use leads to sexual dysfunction. Acute overdoses of stimulant drugs can result in irregular heartbeat, convulsions, coma, and death.
High doses can lead to the onset of psychosis. The most devastating effects of stimulant drugs frequently center around the disruption of occupational and social roles. Prolonged use of amphetamines has also been linked to an increase in violent behavior, but it is not clear whether this phenomenon is due to the drug itself or to the lifestyles with which it is frequently associated.
Can induce a state of dreamlike euphoria, which may be accompanied by increased sensitivity in hearing and vision. Positive, emotional effects of opiates do not last. Can induce nausea and vomiting among novice users, constrict the pupils of the eye, and disrupt the coordination of the digestive system.
At high doses, people who are addicted to opiates become chronically lethargic and lose their motivation to remain productive.
Tolerance develops rather quickly. Severe health consequences of opiate use are the result of the lifestyle of the addict rather than the drug itself.
Barbiturates and Benzodiazepines
Discontinuance syndrome. In some cases, a worsening of the original anxiety symptoms. Withdrawal can include irritability, paranoia, sleep disturbance, agitation, muscle tension, restlessness, and perceptual disturbances. Also known informally as tranquilizers, hypnotics, and sedatives.
Can lead to a state of intoxication that is identical to that associated with alcohol. Characterized by impaired judgment, slowness of speech, lack of coordination, a narrowed range of attention, and disinhibition of sexual and aggressive impulses.
Marijuana and hashish are derived from the hempplant, Cannabis sativa.
The subjective effects of marijuana are almost always pleasant. Marijuana can have variable effects on a person’s mood. Cannabis intoxication is often accompanied by temporal disintegration, a condition in which people have trouble retaining and organizing information.
Tolerance effects in humans remain ambiguous. Withdrawal symptoms are unlikely to develop among occasional smokers of marijuana. Prolonged heavy use of marijuana may lead to certain types of performance deficits on neuropsychological tests, especially those involving sustained attention, learning, and decision making.
Hallucinogens and Related Drugs
Hallucinogens cause people to experience hallucinations.
LSD – most common
MDMA (ecstasy) – the “club drug”
PCP – originally developed as a pain killer
Difficult to study empirically because the effects are based in primarily subjective experience.
The use of hallucinogens follows a different pattern than that associated with most other drugs.
Hallucinogens, with the possible exception of PCP, are used sporadically and on special occasions rather than continuously.
There seems to be no withdrawal symptoms associated with the hallucinogens.
Some people who have taken hallucinogens experience flashbacks.
DSM-IV-TR divides addictions into two categories: substance abuse and substance dependence. The manual lists 11 types of drugs that can lead to problems of abuse and dependence. A person must exhibit at least 3 of the 7 criteria for a diagnosis of substance dependence to be made. If there is evidence of either tolerance or withdrawal (or both), the additional specification of physiological dependence is made.
DSM-IV-TR does not recognize any systems for subtyping substance dependence, other than the presence or absence of physiological symptoms (tolerance or withdrawal).
Abuse versus recreational use?
The diagnostic manual emphasizes the terms recurrent and maladaptive pattern for this purpose. The problem must be persistent before this diagnosis would be considered. Someone involved in a single drug-related incident would not meet the criteria for this disorder, regardless of how serious the incident might have been.
Course and Outcome
It is impossible to specify a typical course for substance dependence, especially alcoholism. The only thing that seems to be certain is that periods of heavy use alternate with periods of relative abstinence, however short-lived they may be.
The use of specific drugs is determined, in part, by their availability. Culture shapes people’s choices about the use of drugs and the way in which they are used.
Approximately two out of every three males in Western countries drink alcohol regularly, at least on a social basis. Less than 25% abstain from drinking completely. Among all men and women who have ever used alcohol, roughly 20% will develop serious problems – abuse or dependence.
Prevalence of Alcohol
Fewer women develop alcoholism compared to men. The disparity is narrower today than 50 years ago. Social disapproval of women drive solitary drinking. A single standard dose of alcohol, measured in proportion to total body weight, will produce a higher peak blood alcohol level in women than in men.
Prevalence of Drug and Nicotine Dependence
The lifetime prevalence of nicotine dependence was reported to be 24% in the National Comorbidity Survey. The percentage of adults in the United States who smoke tobacco has actually declined since 1964.
Risk factors in adolescents
Parental modeling of appropriate versus inappropriate use of alcohol.
Adolescents with alcoholic parents.
High levels of negative affect in the home.
Girls with opposite-sex friends.
Data from a large sample of twins in Australia found concordance rates for alcohol dependence of 56% in male mono-zygotic twins and 33% in male dizygotic twins. Monozygotic and dizygotic female twin pairs were 30% and 17%, respectively.
The offspring of alcoholic parents who are reared by nonalcoholic adoptive parents are more likely than people in the general population to develop drinking problems of their own.
People may become dependent on psychoactive drugs because they stimulate areas of the brain that are known as “reward pathways.”
Alcohol affects several different types of neurotransmitters.
Endogenous Opioid Peptides
Endorphins are endogenous endorphins, short chains of amino acids, or neuropeptides. They appear to be important in the activities associated with systems that control pain, emotion, stress, and reward. It is theorized that alcoholism is associated with activation of this system in response to alcohol.
Tension-reduction Hypothesis is popular. Expectations about drug effects are very influential in developing abuse or dependence. Expectations play a role in the onset of the problem rather than being consequences of heavy drinking.
Longitudinal studies: adolescents who are just beginning to experiment with alcohol and who initially have the most positive expectations about the effects of alcohol go on to consume greater amounts of alcoholic beverages.
Detox is the removal of the drug for three to six weeks. Experience marked withdrawal symptoms. Patients are given various medications as a way of minimizing withdrawal symptoms.
Disulfiram (Antabuse) makes a person extremely sick when they consume alcohol. The person has to take the medicine every day for it to be effective.
Naltrexone (Revia) may dampen cravings.
Self-Help Groups and Alcoholics Anonymous are fundamentally spiritual. It is difficult to evaluate its efficacy because long-term follow-up difficult due to early dropout. It appears to help people, it is not clear how it helps, or why though.
Coping Skills Training
Anger management focuses on factors that create and maintain drinking. It addresses negative patterns of thinking, expectations.
Relapse is nearly expected. Relapse prevention focuses on increasing sense of control of one’s life.
Adaptive Coping Skills
Abstinence violation effects are worked on. Do you spiral downwards if you slip up and have a beer? Or are you able to realize you messed up and stop there.
Project MATCH evaluated three forms of psychological treatments: cognitive behavior therapy, 12-step facilitation therapy, and motivational enhancement therapy
Long-term outcome is best predicted by the person’s coping resources, social support.