Alcohol and Substance Use Disorders

Alcohol and Substance Use Disorders

• N. Serkut BULUT, M.D., is an Associate Professor in the Department of Psychiatry at Marmara University Medical School.

Learning Objectives

• Grasp essential concepts and terminology related to alcohol and substance use disorders.
• Recognize the characteristics and diagnostic criteria for alcohol and other substance use disorders.
• Understand the biological, psychological, and sociocultural elements influencing alcohol use disorders.
• Identify and categorize major psychoactive substances based on their effects.
• Learn about different treatment strategies for alcohol/substance use disorders.

Basic Concepts Related to Addiction

• Addiction/dependence is related to abuse, and risky usage.
• Psychoactive substances impact the nervous system.
• Methods of administration are routes into the body.
• Intoxication: Physiological state after consuming a psychoactive substance, causing disturbances in mental functions and responses.
• Tolerance occurs when the body adapts to needing more of a substance to achieve the same effect.
• Withdrawal: Symptoms experienced upon reducing or stopping substance use after dependence has developed.
• Behavioral addictions: Compulsive engagement in behaviors, not involving substances, that activate the brain's reward system.

Addiction, Dependence, Abuse, Risky Usage

• Substance abuse usually involves the overuse of a substance leading to risky behaviors or ongoing use despite negative consequences.
• Substance dependence signifies a more severe form of substance use disorder, marked by a strong physical need for the substance.
• Can lead to tolerance and withdrawal symptoms.

Psychoactive Substance Effects

• Psychoactive substances are substances that can temporarily alter conscious awareness.
• They influence mental and behavioral functions.
• They bind to synaptic receptors.
• This can either inhibit or trigger specific neural responses.
• The interaction disrupts brain's communication pathways.
• It leads to changes in perception, memory, emotions, and behavior.

Methods of Administering Substances

• Substances can be administered through
• Oral Ingestion.
• Inhalation.
• Injection.
• Snorting.
• Sublingual/Buccal.
• Other routes (rectal, topical, etc.).

Intoxication Defined

• Intoxication is a temporary condition following psychoactive substance administration.
• It results in disturbances in consciousness, cognition, perception, judgment, affect, or behavior.
• Intoxication is reversible and temporary.
• Severity can vary based on individual sensitivity and dosage.
• Symptoms differ according to the psychoactive substance (stimulants vs. depressants).

Tolerance Explained

• Tolerance is defined as either a need for a significantly greater amount of a substance to achieve the desired effects or the same amount of a substance producing noticeably weaker effects with repeated use.
• It arises from biochemical alterations in the body affecting metabolism and substance elimination.

Withdrawal Defined

• Withdrawal refers to a cluster of physical and psychological symptoms.
• These occur when someone with physiological dependence reduces or stops using a substance.
• Symptoms occur after reducing or stopping a prolonged and/or heavy usage of a substance.
• It involves a predictable set of symptoms, which vary depending on the substance.
• Sweating, tremors, nausea, headaches, muscle pain, and seizures.
• Psychological symptoms can include anxiety, irritability, depression, insomnia, and agitation.
• Symptoms onset and duration are dependent on the specific drug and its half-life.

Behavioral Addictions not involving Substances

• Compulsive engagement in non-substance-related behaviors activates the brain’s reward system similarly to psychoactive substances.
• Despite adverse outcomes, individuals continue the behavior.
• They experience loss of control, craving, and withdrawal-like symptoms if they try to stop.
• Common examples include gambling disorder, which is officially recognized in DSM-5, and internet gaming disorder, listed in the DSM-5 as a condition for further study.

Alcohol Use Disorder

• Includes Basic Concepts.
• Includes Epidemiology.
• Includes Etiology and Causal Factors.

Core Concepts in Alcohol Use Disorder

• Ethanol, methanol, isopropanol etc.
• Alcohol Concentration Levels in Various Beverages.
• Standard drink.
• Blood alcohol concentration-promil and legal limits.
• Intoxication and withdrawal.

Alcohol Types

• Ethanol is safe for drinking when regulated.
• Used in alcoholic beverages, antiseptics, and as a fuel additive.
• Can cause intoxication, liver damage, and dependence.
• Methanol is not safe for drinking.
• Used as industrial solvent antifreeze and windshield fluid.
• It can cause blindness, metabolic acidosis, and death.
• Isopropanol is not safe for drinking.
• Used as a disinfectant, rubbing alcohol, and in cleaning agents.
• It can cause nausea, vomiting, CNS depression, and coma if ingested.

Understanding a Standard Drink

• A standard drink is a measurement used to quantify alcohol consumption.
• It allows for comparison across different beverage types.
• A standard drink contains 10-16 grams of pure alcohol.
• Sizes vary by country.

Calculating Alcohol Content

• To do this, use the formula Volume X alcohol % X converting coefficient
• To convert to pure ethanol milliliters, it includes 0.79 gr. pure ethanol.
• Calculations:
• A small bottle of beer (330 ml x 5%) contains 13 grams of ethanol.
• A glass of wine (140 ml x 12%) contains 13.3 grams of ethanol.
• A shot of vodka, gin, or whisky (40 ml x 40%) contains 12.6 grams of ethanol.
• A shot of raki (40 ml x 45% alcohol) contains 14.1 grams of ethanol.
• 500 ml of beer equals 1.5 standard drinks.
• A double raki equals 2 standard drinks.

Blood Alcohol Concentration

• Promil refers to grams of ethanol per liter of blood.
• BAC refers to grams of ethanol per 100 mL of blood.
• 0.8 promyl equals 0.08% BAC.
• Approximate promil levels
• Two small beers (850 ml) result in about 0.50 promil.
• Two glasses of wine (220 ml) result in about 0.50 promil.
• One double shot of whiskey, vodka, raki, or cognac (74 ml) results in about 0.50 promil.

DSM-5-TR Criteria for Alcohol Intoxication

• Recent ingestion of alcohol.
• Maladaptive behavioral or psychological changes.
• Includes inappropriate sexual or aggressive behavior.
• Includes mood lability.
• Includes impaired judgment.
• One or more of the following signs are present:
• Slurred speech.
• Incoordination.
• Unsteady gait.
• Nystagmus.
• Impairment in attention and memory.
• Stupor or coma.
• Symptoms are not due to a general medical condition or another mental disorder.

DSM-5-TR Alcohol Withdrawal Criteria

• Withdrawal begins a few hours or days after alcohol cessation, causing distress/impairment.
• Two or more of the following symptoms have to be present:
• Increased autonomic activity (sweating/pulse >100).
• Hand tremor.
• Insomnia.
• Nausea or vomiting.
• Hallucinations or illusions.
• Agitation.
• Anxiety.
• Grand mal seizures.

DSM-IV vs. DSM-5 Criteria Comparison for Alcohol Use Disorders

• The DSM-5 combines abuse and dependence into a single alcohol use disorder.
• DSM-5 Alcohol Use Disorder diagnostic criteria includes not fulfilling major role obligations, usage in physically hazardous situations, craving, social/interpersonal problems, substance taken in larger amounts or for longer than intended, persistent desire or unsuccessful efforts to cut down/control use, time spent in activities related to substance use, giving up important social or recreational activities, continued use despite physical or psychological problems, tolerance, and withdrawal.
• Having 2 or more symptoms means that someone has an alcohol use disorder.
• The severity is determined by the number of symptoms: mild (2-3 symptoms), moderate (4-5), severe (6 or more).

Alcohol Use: Epidemiology

• Alcohol use disorders are the most common mental disorders worldwide.
• Men have a higher prevalence (8.6%) than women (1.7%), with an average of 5.1%.
• The gap is decreasing between men and women.
• High-income countries show the highest prevalence at 8.6%.
• Risky drinking is defined for men as >4 standard drinks/day AND >14 standard drinks/week. For women and those over 65 this is defined as >3 standard drinks/day AND >7 standard drinks/week.
• According to WHO, 1 in 20 deaths is a result of harmful alcohol use.
• This equates to more than 3 million people each year.
• Most are men.

Etiology and Causal Factors for Alcohol Use Disorder

• Biological factors include:
• Activation of the brain's reward system.
• A genetic predisposition.
• Having pre-alcoholic personality traits.
• Psychological factors:
• Parental influence.
• Psychiatric comorbidity.
• Stress and tension reduction.
• Cognitive expectations.
• Trauma.
• Social factors:
• Cultural Norms and Attitudes.
• Social Environment and Relationships.
• Peer Influence.

Biological Causal Factors

• Activation of the brain's reward system occurs when alcohol stimulates the mesocorticolimbic dopamine pathway (MCLP).
• This includes the ventral tegmental area, nucleus accumbens, and prefrontal cortex.
• This leads to pleasure and reinforcement.
• Neuroadaptation: Prolonged use alters brain chemistry, leading to tolerance, dependence, and withdrawal.
• Individuals with a family history of alcoholism are at significantly higher risk.
• Twin and adoption studies support underlying genetic predispositions.
• Genetics may influence sensitivity to alcohol, stress response, and reward system reactivity.
• Pre-Alcoholic Personality Traits include impulsivity, risk-taking, emotional instability.
• A physiological reaction can include alcohol flush reactions in some ethnic groups, such as Asians, due to enzyme deficiencies which may deter alcohol use.

Psychological Causal Factors

• Parental factors can include poor supervision, parental substance abuse, and dysfunctional family dynamics increase risk.
• Negative early role models or inconsistent discipline are critical factors.
• Psychiatric Comorbidity includes a high co-occurrence with antisocial personality disorder, depression, and schizophrenia.
• These disorders increase vulnerability.
• They complicate treatment.
• Stress and Tension Reduction occurs when someone drinks to alleviate anxiety or cope with stress.
• Though alcohol reduces tension, this alone does not explain addiction.
• Cognitive Expectations include beliefs that alcohol increases social success, peer acceptance, and relaxation and drive early and continued use.
• Trauma and PTSD include a history of abuse or trauma.
• Especially in childhood, which is strongly linked to later alcohol problems.
• PTSD patients show high rates of substance abuse, potentially due to self-medication.

Sociocultural Causal Factors

• Cultural norms and attitudes.
• Alcohol is normalized in many Western cultures as a social lubricant.
• Religious groups that prohibit alcohol show low rates of alcoholism.
• European/Western-influenced nations have high consumption rates.
• Social Environmental and Relationships:
• Marital conflict, unsupportive relationships, or enabling behaviors can maintain or exacerbate drinking behavior.
• Relationship dynamics often center around the alcohol abuse, creating a feedback loop.
• Peer Influence:
• Adolescents with alcohol-abusing parents affiliate with substance-using peers.
• Lack of parental monitoring increases the risk of early alcohol exposure.

Alcohol Related Disorders

• Systemic diseases: pancreatitis, cardiomyopathy, hypertension, gastrointestinal bleeding.
• Liver diseases: alcoholic fatty liver, alcoholic hepatitis, alcoholic cirrhosis.
• Use in pregnancy: fetal alcohol syndrome.
• Alcohol-related amnestic disorders: Wernicke’s encephalopathy.
• Korsakoff’s syndrome: chronic memory loss, confabulation.

Treatment Approaches for Alcohol Use Disorder (AUD): Pharmacological Treatments

• Acute Phase - Detoxification:
• Goal: Manage withdrawal symptoms and prevent complications.
• Benzodiazepines (e.g., diazepam, lorazepam) reduce anxiety and seizures.
• Thiamine (Vitamin B1) prevents Wernicke's encephalopathy.
• Antipsychotics (if needed) manage severe agitation or hallucinations.
• Long-Term Phase - Maintenance and Relapse Prevention:
  • Disulfiram causes an aversive reaction if alcohol is consumed.
  • Naltrexone reduces euphoric effects of alcohol.
  • Acamprosate reduces cravings.

Treatment Approaches for Alcohol Use Disorder (AUD): Psychological Treatments

• Cognitive Behavioral Therapy (CBT): Focuses on identifying and changing negative thought patterns and behaviors associated with alcohol use.
• Group Therapies: Offers peer support, shared experiences, and reinforcement; useful in motivating abstinence and preventing relapse.
• Treatment Goals: Total Abstinence, for those with severe dependence or history of relapse and Controlled Drinking, a controversial goal of aiming for non-problematic levels.

Treatment approaches for Alcohol Use Disorder (AUD): Treatment settings

• Inpatient Hospital Treatment: Recommended for patients with severe withdrawal symptoms or psychiatric comorbidities.
• Alcoholics Anonymous (AA): It is an accessible 12-step program with community support.
• Halfway Houses: provides structured living for those transitioning from inpatient care.
• Court-Mandated Outpatient Programs/Probation-Based Treatment are involuntary treatments potentially including mandatory counseling.
• Day Hospitals - Structured treatment programs offered during the day. - Suitable for patients needing intensive therapy without full hospitalization.

Psychoactive Substances and Substance Use Disorders

• Psychoactive substances are classified in multiple ways depending on their effects, molecular structures, or areas of use.
• No single universal consensus or standard for categorization exists.
• CNS Depressants/Sedatives: include Alcohol, Benzodiazepines, Barbiturates, and Opioids.
• CNS Stimulants: include Cocaine, Amphetamine and its derivatives, MDMA (Ecstasy), Nicotine, and Caffeine.
• Hallucinogens: include LSD, Psilocybin, Mescaline, and Phencyclidine (PCP).
• Other/Mixed-Effect/Synthetic Substances: includes Cannabis (Marijuana) and its derivatives, Synthetic Cannabinoids, Synthetic Cathinones, Inhalants, and Others.

Opioids

• Types: Codeine, Morphine, Fentanyl and its derivatives, Pethidine (Meperidine), Heroin.
• Agonists: Methadone, buprenorphine.
• Effects: rush, relaxation, and lethargy.
• Withdrawal: Restlessness, insomnia, piloerection, pupillary dilatation, nasal discharge, sweating, vomiting, diarrhea, paresthesia.
• Treatment: Medication-assisted therapy (Methadone, Buprenorphine, etc.).

Stimulants

• Cocaine: Derived from coca leaves.
• Commonly smoked, snorted, or injected.
• Gives CNS stimulation and euphoria.
• People develop cravings, tolerance, and psychological dependence.
• Chronic use: can cause paranoia.
• Risks: Heart attack, seizures, anxiety, nasal damage, or sudden death.
• Methamphetamine: Meth, crystal, ice, and crank.
• Can be powder or clear crystals.
• Can be smoked, snorted, swallowed, or injected.
• Causes addiction and drug cravings.
• Causes psychosis, anxiety, irritability, malnutrition and memory loss and cognitive decline.
• Increases risk of stroke, heart problems, etc.
• MDMA (Ecstasy): synthetic drug
• Ecstasy is illegal and has hallucinogenic properties.

Commonly Used Hallucinogens

• Alter perception, thoughts, and feelings.
• Cause hallucinations! Bad trips or paranoia.
• Classic hallucinogens include LSD, psilocybin (magic mushrooms), mescaline (peyote)
• Dissociative hallucinogens include ketamine, PCP, nitrous oxide ect.
• Causes, anxiety confusion, or psychosis.
• Impaired judgment → dangerous behavior or accidents:

Cannabinoids

• Dried flowers/leaves of the Cannabis sativa or Cannabis indica plant
• Active compounds: THC & CBD
• Forms: Dried herb, hashish, oils, edibles, concentrates
• Routes of use: Smoked, vaped, eaten, applied topically
• Short-Term Effects: Euphoria and relaxation, time alteration, time senses, increased appetite, dry mouth, red eyes, impaired memory, concentration, anxiety or Paranoia
• Long-Term Effects: Tolerance Psychologica; dependence, impaired learning memories and attention, risk of CUD
• synthetic cannabinoids often sold under names such as "spice" or "K2,".
• stronger and more unpredictable effects resulting in more severe reactions.
• Medical Uses : Pain relief, Reducing Nausea, stimulating appetite, Managing Seizures

Intravenous Drug Use

• Drug users and intravenous drug users show increases of morality and morbity rates.
• Effects of drug effect like dependency withdrawal
• Social problems related to occupation legalities and family
• Method of administration: (dirty needles and un-sterile equipment) can cause infections or aids and tetanus.
• can cause failure of organs and systems
• Track Marks, Thrombophlebitis, Venous Thrombosis, Arterial Insufficiency.
• Respiratory Failure, Pulmonary Issues, Pulmonary Emboli.