Substance Abuse and Co-Occurring Mental Health Disorders

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• Integrative Management of Substance Use Disorders and Co-Occurring Mental Health Disorders*

Overview

• Approximately 9.2 million American adults and 358,000 adolescents have co-occurring substance use disorders (SUDs) and mental health/psychiatric disorders (CODs).
• The combination of SUDs and CODs (dual diagnosis) affects treatment outcomes and poses numerous challenges for mental health clinicians.

Epidemiology

• 20% of individuals with severe mental illness (SMI) will develop a SUD during their lifetime.
• Only 7.4% of individuals with SUDs and CODs receive treatment for both disorders, and 55% receive no treatment at all.
• Globally, alcohol, tobacco, and illicit substance use are directly and indirectly responsible for 11.8 million deaths each year.

Neurobiology of Addiction

• Dopamine release in the brain plays a key role in addiction, as it associates with pleasure and motivation.
• Repeated exposure to addictive substances changes brain structure and function, leading to long-term adaptations in brain reward systems.
• Environmental and genetic factors contribute to an individual's susceptibility to addiction.

Theories of Addiction

• The self-medication hypothesis proposes that substances of abuse are used to cope with psychiatric symptoms and negative emotions.
• The gateway hypothesis suggests that the use of legal substances (e.g., nicotine and alcohol) can progress to the use of illicit substances (e.g., cocaine and heroin).

Dopamine Theory

• All addictive drugs increase extracellular dopamine concentration in the striatum, leading to addiction.
• The transition from recreational drug use to compulsive drug-seeking habits involves a shift in the locus of control over behavior from the ventral to the dorsolateral striatum.

Co-Occurring Substance Use and Mental Health Disorders

• CODs and SUDs are underrepresented in neuroimaging and psychiatric research.
• Brain structure and function changes are more pronounced in individuals with CODs and SUDs compared to those with only one disorder.
• Integrated social, medical, and mental healthcare support is essential for recovery from SUDs and CODs.### Common Liability to Addiction
• The concept of common liability to addiction (CLA) is grounded in genetic theory and supported by data identifying common sources of variation in the risk for specific addictions.
• CLA has identifiable neurobiological substrates and plausible evolutionary explanations.
• The CLA concept provides a theoretical and empirical foundation for research in etiology, quantitative risk, and severity measurement, and targeted non-drug-specific interventions.

Genetics

• Scientists estimate that genes, including the effects of environmental factors on a person's gene expression, or epigenetics, account for between 40% and 60% of a person's risk of addiction.
• Family studies suggest that as much as half of a person's risk of becoming addicted to nicotine, alcohol, or other drugs depends on their genetic makeup.
• Finding the biological basis for this risk is an important avenue of drug addiction research and treatments.

Environmental Factors

• Environmental factors, such as parental history of divorce, death, criminal activity, and alcohol problems at home, strongly predict the risk for drug abuse.
• Environmental factors are more pathogenic in individuals who have high levels of genetic risk.
• Personality traits, such as socialization, can also be considered predictive of substance abuse.

Establishing a Diagnosis of Substance Use Disorder

• The gold standard for effective treatment begins with an accurate and comprehensive assessment, diagnosis, and early intervention.
• Diagnostic criteria for establishment of SUDs are delineated in the DSM-5.
• Applying these criteria often requires training and supervision.

Substances of Abuse

Alcohol

• Alcohol is a toxic and psychoactive substance with dependence-producing properties.
• Alcohol consumption is a leading risk factor for death and disability worldwide, contributing to 3 million deaths per year.
• Harmful use of alcohol is responsible for 5.1% of the global burden of disease.
• Vulnerable populations have higher rates of alcohol-related death and hospitalization.
• Binge drinking, defined as a pattern of drinking that brings a person's blood alcohol concentration (BAC) to 0.08 g/dL or above, typically happens when men consume five or more drinks or women consume four or more drinks in about 2 hours.

Clinical Manifestation of Use

• Alcohol use and abuse results in accidents, trauma, injury, social or legal problems, and suicide.
• Every day, 29 people in the United States die in motor vehicle crashes involving an alcohol-impaired driver.
• The annual cost of alcohol-related crashes totals more than $44 billion.

Screening Tests

• The NIH's NIDA recommends a number of evidence-based screening and assessment tools of varying lengths that can be used across categories (drugs and alcohol) and ages (adults and adolescents).
• The AUDIT-C is a shortened version of the AUDIT consisting of three questions scored from 0 to 12.
• A score of 3 or more in women and 4 or more in men is considered positive.### Single-Item Screening Questions (SISQs)
• Can facilitate SUD screening in healthcare settings
• Self-administered SISQs are easier to administer, valid, and potentially remove implementation obstacles
• Examples of SISQs:
  • "How many drinks containing alcohol do you have on a typical day when you are drinking?"
  • "How many times in the past year have you had X or more drinks in a day?" (X = 5 for men, X = 4 for women)
  • "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?"

CAGE Questionnaire

• Developed by Dr. John Ewing in 1984
• A four-question, easy-to-use survey tool
• Two positive responses indicate severe alcohol dependence or AUD
• The tool can be adapted to any substance of abuse by replacing "drinking" with the appropriate drug
• Questions:
  • Have you ever felt you should Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt bad or Guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

Alcohol Use Disorders Identification Test (AUDIT)

• A 10-item tool that identifies individuals with or without AUDs with 95% accuracy
• Score responses range from 0 to 40
• A score of 8 or greater is considered a positive test for unhealthy alcohol use
• A score of 20 or greater suggests the presence of AUD

Treatment

• Treatment options include pharmacotherapy, biofeedback, support group therapy, and psychotherapy
• Support groups such as Al-Anon Family Group, Adult Children of Alcoholics (ACOA), and Alateen exist to help with recovery of an alcoholic's family and friends
• Pharmacotherapy is recommended for clients with moderate to severe drug alcohol use who want to reduce their alcohol intake, have current heavy use and ongoing risk for consequences, prefer medication, and do not have contraindications to using the drugs

Intoxication

• Mild intoxication typically occurs after two drinks
• Early stages after alcohol ingestion produce a euphoric, bright mood, reduce social anxiety, and encourage talkativeness
• As the blood alcohol level falls, individuals become progressively withdrawn and depressed
• Extremely high alcohol levels can cause the individual to fall asleep, inhibit respiration and pulse, and even result in death
• Signs of intoxication include:
  • Slurred speech
  • Incoordination
  • Unsteady gait
  • Nystagmus
  • Disinhibited behavior
  • Impaired judgment
  • Memory impairment
  • Hypotension
  • Tachycardia
  • Stupor
  • Coma

Withdrawal

• Minor symptoms are present within 6 hours of the last drink as a result of central nervous system (CNS) hyperactivity
• Symptoms include:
  • Insomnia
  • Tremor
  • Anxiety
  • Nausea
  • Vomiting
  • Palpitations
  • Headache
• Major withdrawal symptoms such as seizures, hallucinations, and delirium tremens (DTs) typically occur from 6 hours to 5 days after the last drink
• DTs are more likely in clients with a history of DTs, sustained drinking, concurrent illnesses, and signs of alcohol withdrawal while blood alcohol levels are elevated

Laboratory Testing

• Testing can establish recent or heavy use but is not as useful for screening
• Clinician screening and assessment of alcohol misuse should occur at least annually
• Laboratory tests may generally reveal:
  • An increase in liver enzymes (AST:ALT ratio increases in alcoholic liver disease [ALD])
  • Elevation of GGT
  • Pancytopenia
  • Macrocytosis
  • Increased carbohydrate-deficient transferrin (CDT), indicating alcohol use or abuse
• CDT is more sensitive and specific, and correlates better with the amount of alcohol consumed