Substance Use Disorder (SUD) Overview

Module Overview

• Module 02 explores Substance Use Disorder (SUD) and substance misuse concepts.
• It applies these principles to stimulant drugs and drugs used in sports, considering both therapeutic uses and misuse potential.
• Section 01 provides a foundational understanding of SUDs and helps complete Assessment 2.

Introduction to the Opioid Crisis and Substance Use Disorder

• The opioid crisis highlights the significant impact and prevalence of SUDs in Canadian society.
• From January 2016 to September 2020, about every 2 hours, a Canadian life was lost to opioid use, with 19,355 accidental deaths.
• The opioid crisis has led to community intervention implementation programs, research into new therapies, and educational materials development.
• Lost productivity due to opioid overdose deaths impacts the economy since 70% of overdose fatalities occur in those younger than 50.

Defining Substance Use Disorder (SUD)

• SUD is clinically diagnosed based on several criteria.
• Meeting a minimum of two criteria classifies as a mild SUD, with severity increasing with more criteria met.
• Criteria includes:
  • Social Impairments: Failure to fulfill roles, persistent social or interpersonal problems, reduced activities.
  • Risky Use: Substance use in hazardous situations or despite problems.
  • Impaired Control: Persistent craving (addiction).
  • Withdrawal: Experiencing withdrawal syndrome after stopping use.
  • Tolerance: Developing tolerance to the substance.

Addiction

• Addiction is impaired control, showing as emotional and a mental preoccupation, regardless of consequences.
• Addiction involves stopping or reducing the dose of a drug, which produces non-physical symptoms.
• Addiction can occur with drugs and other stimuli like gambling, shopping, or video games.
• "Drug addiction" is sometimes used interchangeably with SUD, but the course uses a narrower definition (a component of a complex disorder).

Dopamine Hypothesis

• It's the predominant explanation for addiction.
• Commonly misused drugs increase dopamine in the brain's reward systems (limbic system).
• Dopamine increase is a key component of the brain's reward system, although other neurotransmitter systems may be involved in dependence.
• Dopamine systems relate to natural rewards (food, sex) and rewards from stimuli (video games).
• Addiction-linked drugs (like cocaine) cause a dopamine increase, altering communication in the brain.

Characteristics of Addictive Drugs

• Addictive drugs are classified into three categories based on effects:
  • Increase Dopamine: CNS stimulants (cocaine, amphetamines, nicotine, caffeine), opioids (morphine, heroin, oxycodone), alcohol, cannabis.
  • Produce Novelty: Lysergic acid diethylamide (LSD), Ecstasy (MDMA).
  • Reduce Anxiety: Benzodiazepines, Barbiturates.

Drug Withdrawal

• Defined as an abnormal physiological state from repeated drug administration.
• Leads to a withdrawal syndrome when drug use stops or the dose decreases.
• Severity increases with speed of withdrawal, as biological processes cannot reverse quickly enough.
• Fear of withdrawal contributes to continued drug use, although withdrawal does not have to be physical in nature.
• Withdrawal symptoms are usually opposite of the drug's effects.
• Stimulant withdrawal (cocaine, amphetamines) causes sleepiness, muscle pain, anxiety, tremors, and low mood.
• Opioid withdrawal (heroin, morphine, prescription painkillers) includes sweating, muscle aches, agitation, and diarrhea.

Drug Tolerance

• Defined as reduced pharmacological effect after repeated administration of a given drug dose.
• Or it's an increased dose needed for the same effect as the original dose.
• Biological system accommodates to the drug, indicated by rightward shift on the dose response curve.
• Expressed as a shorter duration of action and decreased magnitude of effect.
• Tolerance development is specific to each drug and effect, not developing to all drugs or all aspects of a drug's action.

Cross Tolerance

• This can occur between pharmacologically similar drugs.
• It's resistance/tolerance to one drug because of resistance/tolerance to a similar drug, revealed in the dose-response curve.
• Someone tolerant to alcohol will be tolerant to benzodiazepines, even without prior use.

Factors Influencing SUD

• Certain environments increase the likelihood of drug misuse and SUD.
• Exposure to environments promoting drug use and addiction (e.g., peer influence).
• Factors include genetics, pre-existing disorders, environment, and developmental stage.
• Genetic factors predispose via genetic mutations in dopaminergic pathways associated with addiction.
• Those with affective, anxiety, or schizophrenia disorders are at higher SUD risk than others.
• Family dynamics, trauma, social/work groups and environmental factors all alter SUD risk.
• Spouses & siblings of those with SUD have higher risk even after accounting for genetics.
• Adolescents & young adults are vulnerable with smoking starting before 18, 80% develop alcohol addiction before 30, and illicit drug uses starting in mid-teens.

Stigma of SUD

• People are stigmatized by society and medical professionals, leading to isolation and low self-esteem.
• Reduced chance of getting medical or social help.
• One can reduce stigma by changing language.
• Harm reduction seeks to minimize negative consequences and improve health.

Harm Reduction

• Approach seeks to reduce/prevent negative consequences and improve health.
• It improves harm without judgment, coercion, or discrimination without requiring abstinence.
• Focuses on reducing societal and health harms from addiction.
• Nicotine patch for smoking shows harm reduction.
• Wear a seatbelt is an unrelated example.
• Health harm goal—decreasing transmission of blood borne diseases and mortality.
• Societal harm goal—decrease lost productivity, apprehension of children, and criminal activity.
• Recognize that SUD can occur with prescribed meds or misused illegal substances.
• Misuse involves drug use deviating from prescribed use or social norms.

Potential for Misuse of a Drug

• Misuse potential is the tendency of a drug to be misused which varies by drug and individual.
• It is also determined by:
  • Nature of Drug: Pleasure increases likelihood of repeated use (heroin and cocaine have high potential).
  • Route of Administration: Rapid absorption routes lead to greater misuse potential, such intravenous.
  • Amount/Frequency of Use: Higher doses and frequency increase misuse potential.
  • Availability: Widespread availability increases misuse risk (alcohol example).
  • Inherent Harmfulness: If the drug is perceived as a serious health risk it might not be used.

Drug Classes: Tolerance, Withdrawal, and Addiction

• Different drugs have different propensities for causing:
  • Tolerance
  • Withdrawal
  • Addiction
• These include :
  • Opioids
  • CNS Depressants
  • CNS Stimulants
  • Hallucinogens
  • Cannabis

Illustrative Cases

• Charlie:
  • Engages in monthly binge drinking, experiencing "blackouts" and sickness.
  • Classified as misusing alcohol due to the pattern of heavy episodic consumption rather than dependence or withdrawal symptoms.
• Luisa:
  • Consumes four large coffees daily, experiencing withdrawal symptoms (headaches, irritability) if she doesn't drink coffee immediately.
  • Classified as experiencing caffeine withdrawal due to dependency on caffeine.

Summary

• A SUD is characterized by social impairments, risky use, impaired control (i.e., addiction), withdrawal, and the development of tolerance*

Section 02: Amphetamines and Cocaine

• Amphetamines and cocaine classes of CNS stimulant drugs with history of misuse.
• Section discusses mechanisms of action, therapeutic uses, and potential for misuse and SUD.
• Focus is given to the similarities and differences.

Overview of Amphetamines

• Drugs with high levels of widespread misuse in Canada making them a controlled substance.
• Includes amphetamine, dextroamphetamine, and methamphetamine.
• Amphetamine-related compounds :
  • Methylphenidate (Ritalin): Treats attention deficit hyperactivity disorder (ADHD).
  • MDMA (Ecstasy): Methamphetamine derivative, fostering feeling of intimacy and empathy, while improving intellectual capacities. It is known for a neurotoxic effect causing long lasting if not permanent damage and death.

Chemistry of Amphetamines

• Amphetamines are synthetic organic compounds.
• They are Structurally similar to norepinephrine and dopamine
• Can be synthesized easily, but the purity is variable and may contain dangerous chemicals.
• Mechanism of action of ecstasy is similar to amphetamines, yet it has a effect on serotonin containing neurons releasing serotonin.

Amphetamines: CNS Effects

• Four main effects include:
  • Decreased threshold for transmitting sensory input to the cerebral cortex, leading to CNS excitation.
  • Feeling of euphoria and reward.
  • Temperature-regulation and feeding centre modifications leading to temperature and appetite suppression.
  • Increase in aggressive behaviour and mood swings.
• Increased CNS excitation leads to alertness, a feeling of power, reduced fatigue, and increased responsiveness, rate and blood pressure.

Other Effects of Amphetamines

• In addition to CNS effects, amphetamine use has different effects depending on the duration of use and if taken with other drugs*
• Short-Term Effects: Chest pain, cardiovascular collapse, increases resperatory rate
• Long-Term Effects: Chronic sleeping problems, poor appetite, anxiety, repetitive behaviour and aggression, elevated blood pressure and abnormal cardiac rhythm Other drugs may be sought concurrently with amphetamines to antagonize various toxic effects. These effects can lead to issues in all the previous areas.

Therapeutic Use of Amphetamines

• Examples include:
  • Narcolepsy
  • ADHD
    • Methylphenidate (Ritalin): can be used to treat the above

Amphetamines: Potential for Misuse and SUD

• Amphetamines widely misused due to euphoric effects and effective CNS stimulants.
• Administration can be done orally, injected, or smoked.
• Misuse potential is high because of powerful euphoria and rapidly injectable water-soluble forms. Harmfulness does not deter misuse.

Amphetamines - Potential for SUD

• Tolerance: Develops to euphoria, mood elevation, anorectic effects, cardiovascular/respiratory stimulation, and lethal effects.
• Withdrawal: Results in profound mood depression, prolonged sleep, huge appetite, lack of energy, and fatigue.
• Addiction: Self-administered to produce euphoria and an awakening sensation; these effects drive craving

Pharmacology of Cocaine

• Classified as local anesthetic and CNS stimulant, legal terms categorize it as a narcotic..
• Widely used recreationally.
• Indistinguishable from amphetamine in acute impact and toxicity.

Pharmacology - Key Differences

• Duration of Action: Less than an hour vs up to 12 hours
• Routes of Administration: Sniffed or smoked vs intravenously
• The user is also subject to the effects of all listed amphetamine issues. Due to similar pharmacology

Mechanism of Action of Cocaine

• Generalized CNS stimulation is in a dose-dependent manner.
• Reuptake Inhibition: Cocaine inhibits re-uptake of dopamine and serotonin into neuron, increasing the concentration and activation of post receptors.
• Only legitimately used as a local anesthetic for the mouth and throat, is rarely used therapeutically due to better alternatives.
• Effects of Long-Term Use:
  • Toxic psychosis and paranoia.
  • Hallucinations or crawling sensations.
  • Impaired sexual function.
  • Permanent brain damage and neuron impairment.
  • High blood pressure and bad heart rhythm
  • Alters nasal passage is snorted

Did You Know?

• Consuming alcohol and Cocaine has shown to be dangerous due to an active part called Cocaethylene*
• increases blood pressure aggressive nature

Cocaine: Potential for Misuse and SUD

• One of the highest misuse liabilities.
• Quickly reached euphoria.
• Harmfulness: Long-term use can cause physical and psychological deficits does not appear to deter users
• Tolerance occurs for mood-elevating, not drug-induced psychotic effect; slower tolerance than for amphetamines
• Withdrawal also has similar symptoms of amphetamines and cocaine
• Addiction occurs due to the behavioural effect

Amphetamines vs Cocaine

Section 03: Nicotine and Caffeine

• In the past, two drugs were illegal, in this section two drugs are now used commonly.
• Both of routine usage
• Nicotine:
  • ADME: Nicotine exists in cigarette smoke, absorbed, distributed, and excreted. Half of the life in the body is two hours.
  • Nicotine stimulates nicotinic receptors increasing memory, psychomotor, tremors, and seizures
  • From 1940-1970 smoking was cool from the 1970 on its been declining.
  • Therapeutic Uses
  • The only therapeutic use of nicotine is in smoking cessation programs, where nicotine is administered This approach attempts to maintain the blood nicotine levels and satisfy the craving for a cigarette It is not for the faint of heart- Short-Term and Long-Term Effects of Nicotine

ADME - Nicotine and Caffeine

• Nicotine: Nicotine exists in cigarette smoke where smokers can control dose by the depth of inhalation and the
• Metabolites are excreted in the urine, half-life is two hours.
• Caffeine: Caffeine distributes to all parts of the body, genetics can decide how fast a the product metabolizes
• -* 2.5 to 10 for half-life.

Nicotine - Effects and Statistics

• Long term health effects of nicontine
  • Exposure increases cardio diseases and cancer
• The potential for nicontine is HIGH
  • The therapeutic use helps preterms
• Mechanisms - Caffeine can cause mild mood and elevate the thought process
  • Can cause nervousness, cardiac, and respiration issues.

Caffeine - Effects and Statistics

• Effects:
  • Can cause restless insomnia or gastric and rambling issues.
  • Has short/long term issues.
• Does not mix - Smoking and Preggo in many places
  • More research needeed
• Potential is Low to Moderate
  • Can cause mild withdrawal

Caffeine and nicotine have shown to have stimulant effects that may need to be considered.

Explore Substance Use Disorder (SUD), its principles, and application to stimulant drugs and drugs in sports. Understand the impact and prevalence of SUDs, highlighted by the opioid crisis in Canada. Learn about the clinical diagnosis and criteria for SUD.