Week 9 - Substance Use Disorders PDF

Week 9 – Substance use disorders PSYC 376 Fall 2024 Dr. Laura Lambe StFX University Housekeeping Written assignment – suggested due date Nov 21st One week grace period – can submit up to Nov 28th without penalty. No assignments will be accepted after this date. Submit on Moodle (we...

Week 9 – Substance use disorders PSYC 376 Fall 2024 Dr. Laura Lambe StFX University Housekeeping Written assignment – suggested due date Nov 21st One week grace period – can submit up to Nov 28th without penalty. No assignments will be accepted after this date. Submit on Moodle (week 0) Remember to look at the instructions + rubric and include your AI appendix! Service learning You do not need to submit any “sign off” or “hours log” – this is all dealt with through the service learning dept Media critique Make sure you include the link to the video you are critiquing so I can see it ☺ Housekeeping Final exam has been scheduled – Dec 11 9am-11am This classroom It is generally the same format as the midterms! 40 multiple choice, some short answer questions based on a case study, + one integrative question Moodle exam using LockDown browser I will allow you to have a piece of blank scrap paper if you show it to me in advance You will only have 2 hours Not cumulative – just the last 4 chapters + integrative content (e.g., case conceptualization, big themes throughout the course) Learning Objectives Understand the context of Apply the DSM-5-TR substance substance use in Canada, use disorder criteria to case including myths/stigma and examples. Indigenous perspectives. Describe the biopsychosocial Compare and contrast abstinence factors associated with substance and harm-reduction based use disorders, including approaches to substance use concurrent disorders. treatment and prevention. History Early examples of drug use date back as far as human history Archeological evidence indicates presence of psychoactive plant use about 200 million years ago Mead use 8000 BCE Opium use around 5000 BCE Indigenous peoples in North America using tobacco  Current Canadian Context - Alcohol Canadian Alcohol and Drugs Survey (CADS), 2019 Canada’s Low-Risk Drinking Guidelines 21% of Canadian drinkers experienced 1+ alcohol-related harm in the past year 18% of female drinkers reported alcohol use during their last pregnancy 8% have been a passenger and 6% have driven a car within 2 hours of having 2+ drinks Canadian Centre on Substance Use and Addiction, 2023  Past-year cannabis use, 2008–2019 Canadian Alcohol and Drugs Survey (CADS), 2019 Canadian Alcohol and Drugs Survey (CADS), 2019 Problematic use of psychoactive pharmaceuticals Canadian Alcohol and Drugs Survey (CADS), 2019 Problematic use of psychoactive pharmaceuticals, among users Canadian Alcohol and Drugs Survey (CADS), 2019 Illegal drug use, 2008-2019 Canadian Alcohol and Drugs Survey (CADS), 2019  Spectrum of Use Lifetime prevalence of any substance use disorder in Canada 21% (CMHA, 2023) What comes to mind when you think of “addiction”? Barry et al., 2014 Where does the stigma around addiction come from?  Common stories about addiction Moral failing model Brain disease model Relies heavily on the idea of “choice” Medicalized model Consistent with the just-world hypothesis Deterministic Seen as a solution to the stigmatizing moral failing model “Whichever way you slice it, addicts lose. Either we are deliberately making bad choices and must be locked up…or we are mindlessly driven by compulsions and must be locked up”  People with addiction need to hit “rock bottom” before they can change Addiction is a choice/it’s their fault Once an addict, always an addict (lifelong affliction) Harm reduction enables substance use Myths about Addicts must completely abstain to recover addiction Do a drug once and you’re addicted Cannabis is not addictive Addiction is a brain disease We just need to get all of the drugs/drug dealers out of the community  Myth: “The drunken Indian” Indigenous individuals have a greater biological predisposition to alcoholism relative to the general population. Myths about Indigenous Peoples FACT: and Alcohol Use - “Firewater” or A higher % of Indigenous individuals are abstinent from alcohol than the general population in Canada “Crazywater” and the US Alcohol use problems among Indigenous Peoples are part of settler-colonialism No evidence for a “greater biological predisposition” Disparities in alcohol use disorders are greatly reduced when we control for social factors (e.g., education, income) Wendt, 2022  Substances are neither good nor bad Our stance in Language matters A person with a substance use disorder (not “addicts”) PSYC 376: Drug use is responsive to social policy, but also it is not 100% preventable Diagnostic criteria What are the DSM-5-TR criteria for substance use disorders?  Alcohol Caffeine Cannabis Hallucinogen (PCP, MDMA, DMT, LSD psyilocybin, salvia) Inhalant (e.g., paint thinner, gasoline, glue, DSM-5 aerosols) Opioids (e.g., heroin, OxyContin/oxycodone, substances fentanyl, hydrocodone, morphine, codeine, hydromorphone) Sedative, hypnotic, or anxiolytics (e.g., benzodiazepines, barbiturates, all sleep medications, all anxiolytics) Stimulants (e.g., amphetamines, methamphetamine, Adderal, Dexedrine, Concerta, Ritalin, cocaine, crack cocaine) Tobacco  A pattern of substance use, leading to clinically significant impairment or distress, exemplified by at least two of the following (out of eleven), within a 12m period: DSM-5-TR Impaired control social impairment Substance risky use pharmacological criteria use Severity based on # of symptoms: disorder 2-3 – mild 4-5 – moderate 6+ - severe Complete absence of quantity/frequency criteria!  1. X is taken in larger amounts or over a longer period than was intended Impaired 2. A persistent desire or unsuccessful efforts to cut down or control X use control 3. A great deal of time is spent in activities to obtain X, use X, or recover from its effects symptoms 4. Craving, or a strong desire to use X 5. Recurrent X use resulting in a failure to fulfill major role obligations at work, school, or home Social 6. Recurrent X use despite having persistent or recurrent social or interpersonal problems impairment symptoms caused by or exacerbated by X use 7. Important social, occupational, or recreational activities are given up or reduced because of X use Risky use symptoms 8. Recurrent X use in situations when it is physically hazardous 9. X use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by or exacerbated by X al g i c 10. Tolerance, as defined by either of: colo r a m oms 1. A need for markedly increased amounts of X to achieve the same level of a t Ph mp intoxication or desired effect sy 2. A markedly diminished effect with continued use of the same amount of X 11. Withdrawal, as defined by either of: 1. The characteristic withdrawal symptoms for X  1. X is taken in larger amounts or over a longer period than was intended. Impaired 2. A persistent desire or unsuccessful efforts to cut down or control X use. control 3. A great deal of time is spent in activities symptoms to obtain X, use X, or recover from its effects. 4. Craving, or a strong desire to use X.  5. Recurrent X use resulting in a failure to fulfill major role obligations at work, school, or home Social 6. Recurrent X use despite having persistent impairment or recurrent social or interpersonal problems caused by or exacerbated by X symptoms use. 7. Important social, occupational, or recreational activities are given up or reduced because of X use. Case example Brad, a 23-year-old man who sometimes works in construction, describes himself as a “fun guy who likes to have a good time”. As a child, he was the class clown, always jumping up from his seat and shouting out jokes—and always getting into mischief. Now, his “good times” often involve high-risk and thrill-seeking activities. He has recently discovered something that gives him the greatest rush of all: cocaine. Brad currently feels that it isn’t a problem for him, since he only does it a couple of times a week when he’s drinking. However, his friends notice that Brad seems to always want to get high, even when no one else is using, and tends to use more than he says he will. Brad has missed out on a few jobs because he knew he wouldn’t be able to pass the drug screening test to be on the construction site. Can you identify any 1) impaired control symptoms and 1) social impairment symptoms?  8. Recurrent X use in situations when it is physically hazardous. Risky use 9. X use is continued despite knowledge of symptoms having a persistent or recurrent physical or psychological problem that is likely to have been caused by or exacerbated by X.  10. Tolerance: A need for markedly increased amounts of X to achieve the same level of intoxication or desired effect. A markedly diminished effect with continued use of the same amount of X. Pharmacologica 11. Withdrawal: l symptoms The characteristic withdrawal symptoms for X X (or a closely related substance) is taken to relieve or avoid withdrawal symptoms Tolerance and Withdrawal Fulton, 2023  Case example continued Brad has been getting into frequent arguments with his girlfriend because of his cocaine use. She does not approve and thinks Brad gets out of control when he is using. Recently, he jumped out of a moving car when he was high and almost broke his leg. He tried cut down on his cocaine use for a bit afterwards but it didn’t last as he was feeling down and restless. Additionally, Brad stole a substantial amount of money from his parents a while back and they’re concerned about what he might do next. Brad didn’t really think about what he was doing at the time he stole the money and he did apologize afterwards. He finds it difficult to understand why they can’t just forgive and forget. Brad doesn’t think his behaviour is any problem—it’s just part of who he is. Can you identify any 1) risky use symptoms and 2) pharmacological symptoms? Biopsychosocial Model What biological, psychological, and social factors contribute to substance use disorders?  Biopsychosocial model overview Trauma/stressful experiences Societal norms/acceptance Peer pressure Availability Psychoactive substances: affect how the brain works Learning - classical conditioning and operant conditioning Genetics Comorbid psychopathology Biological response to the (concurrent disorders) substance Personality Changes in the brain Emotion dysregulation structure/functioning resulting from substance use Motivations  Evidence of shared genetic risk for SUDs Polygenic AUD – 40-60% heritable Biological: Genetics Genetic factors risk and protective Low sensitivity to the pharmacological effects of alcohol is a risk factor Low-risk with low aldehyde dehydrogenase 2  Biological: wanting vs liking a drug “LIKING”: “WANTING” : Feelings of enjoyment; bliss; Anticipation; pleasure; serotonin and agitation; motivated to seek out; opioid pathways desire; dopamine pathways How much we enjoy something. How much we “want” something. Subjective sense of “goodness” Incentive salience and reward. CONSUMMATORY PLEASURE ANTICIPATORY PLEASURE 34  Incentive-sensitization theory ◉ Liking more related to etiology ◉ Wanting more related to maintenance 35  All abused substances affect the brain’s “pleasure pathways” “Liking” = Small range of “hedonic hotspots” in brain, separate from… “Wanting” = mesocortico-limbic dopamine system – High density of dopamine-sensitive neurons – Repeated exposure leads to sensitization 🡪 increased dopamine release with drug use 36 Psychological: Operant Conditioning POSITIVE REINFORCEMENT = NEGATIVE REINFORCEMENT = RELIEF PRODUCE PLEASURABLE FEELINGS FROM UNPLEASANT FEELINGS  Cued craving Psychological: Sounds, smells, locations, people Classical Conditioned compensatory response Conditioning Occurs when our body anticipates impending drug use and prepares by producing the opposite of the drug’s original effects Tolerance, cravings, and overdose Psychological: Personality “Addictive personality” – oversimplification However, some personality traits are known risk factors Anxiety Sensation Hopelessness Impulsivity sensitivty seeking Personality Vulnerability Model Conrod & Nikolaou (2016) Castellanos-Ryan & Conrod (2012) 40 Psychological: Motivations Reward source Internal External Positive Enhancement Social Vale nce Negative Coping Conformity Cooper et al., 1994 Psychological: Concurrent disorders Substance use disorder(s) occurring Mood/anxiety and substance use most common together with another psychopathology. (1.2% of Canadian population) Dual nature can trigger a Can be truly bidirectional self-perpetuating cycle contributing to Requires integrated care systems poor outcomes Also have a high rate of physical health 29% of people with concurrent disorders have 2+ conditions chronic health conditions Khan et al., 2017  Substance use and the pandemic Increased feelings of isolation, stress and hopelessness, and greater barriers to accessing health and social supports Social: Stressful life Alcohol and cannabis use changed among Canadians aged 15+ who were using these substances prior to the events COVID-19 pandemic: 24% reported increased consumption of alcohol during the COVID-19 pandemic 34% reported increased consumption of cannabis during the COVID-19 pandemic Government of Canada, 2022  879 undergraduate drinkers (79% female, 18-25 years old) 5 Canadian Universities Winter semester 2021 Self-reported personality, anxiety, depression, COVID-19 distress, and coping drinking motives 25% met clinical cut-offs for severe anxiety, 11% for severe depression!  Social: The 3 “As” Availability Acceptability Approval Geographic location Descriptive norms Injunctive norms Discussion: How can we apply the 3 A’s to understand cannabis use trends?  Associated with increase risk of SUDs High PTSD-SUD comorbidity rates Social: Each ACE increases likelihood of early Trauma/ drug use initiation by 2-4X; ACE scores have strong graded relationships ACEs/ to drug use problems and drug addiction Compared to those with 0 ACEs, those with > Adversity 4 were 7-10X more likely to have substance abuse as adults  Participants: 8971 youth from 173 neighbourhoods across Canada 15.3 years old on average 50.6% female Mediational role of peer deviancy and mood Peer.66.38 deviancy.67.16 Frequent Bullying.13 drunkenness.14.17.12 Victimization Frequent.03 cannabis use Negative.69 affect.04 Lambe & Craig, 2017  Case Example: Jenna Jenna, a 25-year-old university student, was sexually assaulted two years ago by a guy she met at a party. She’s never told anyone about it and carries a lot of guilt, believing it was her fault, since she’d had a little too much to drink. Since then, Jenna finds that the memories of that night run through her mind over and over again, whether she’s awake or asleep. She is easily startled and has difficulty sleeping. Jenna used to enjoy reading, playing music and going to parties but no longer finds pleasure in those activities. In fact, because of the painful reminders of the assault, she avoids attending parties whenever she can. There is one thing though, that Jenna finds helpful: alcohol. After a few drinks, she doesn’t feel so keyed up and on edge; she can even sleep. The alcohol helps to block out the memories of that night. It can even make her brave enough to venture out to a party with friends. There is a catch though. Jenna is finding that she needs more and more alcohol to achieve the calm she is seeking. And after a night of drinking, she’s even more edgy and jumpy than usual. Jenna feels like she’s caught in a downward spiral— her anxiety leads her to drink, but the drinking eventually makes her more anxious. The only solution she sees at this point is to simply keep drinking. Work with a small group to conceptualize the case. What differential diagnoses are you considering? Treatment (and Prevention) What are the evidence-based approaches for treating SUDs?  Evidence-based approaches Motivational 12 Step Medication CBT interviewing Facilitation Behavioural Mindfulness Cue exposure Contingency couples based relapse treatment management therapy prevention Is abstinence the treatment goal? Traditional view that Many people with SUDs do How do you know who treatment success = very well on moderated use does best with which goal? abstinence, and that any use = as an outcome relapse Harm Reduction A set of strategies aimed at reducing the negative consequences of drug use without attempting to condemn or prevent drug use Quality of life, health outcomes, and community outcomes rather than cessation outcomes Does not attempt to minimize or ignore the real harm and danger associated with drug use Video: Indigenous harm reduction While watching, consider: How are Indigenous approaches to harm reduction different from colonial approaches?  Client readiness to change Less severe substance use disorder Predictors Self-efficacy of Mono-substance use successful Low comorbidity treatment Social support Lower impulsivity Summary Substance use is normative in Canada and most people who use substances will not experience a substance use disorder. Substance use disorders involve symptoms of impaired control, social impairment, risky use, and pharmacological criteria. Biopsychosocial factors are implicated in the development and maintenance of SUDs. There are many evidence-based treatments for SUDs from both abstinence and harm-reduction approaches. For next time… Quiz 7 suggested due date Nov 14 Written assignment suggested due date Nov 21 Grace period Nov 28