Addiction .pdf

ADDICTION Raafat Shuqdar  learning objectives To understand the significance of addiction as a clinical problem To understand basic pharmacology of abused drugs To understand conditioning, tolerance and withdrawal in addiction To appreciate the role of pharmacotherapy and psychological...

ADDICTION Raafat Shuqdar  learning objectives To understand the significance of addiction as a clinical problem To understand basic pharmacology of abused drugs To understand conditioning, tolerance and withdrawal in addiction To appreciate the role of pharmacotherapy and psychological therapies in addiction treatment Commonly abused drugs Alcohol Opioids Caffeine Sedatives, hypnotics, Cannabis and anxiolytics Hallucinogens Stimulants Phencyclidine (PCP) Nicotine Inhalants Other  Opiates Morphine Codeine Thebaine Heroin Powerful pain relief Euphoria Cocaine Increases alertness and energy, feelings of well-being and euphoria, feelings of competence and sexuality  8% of Saudis report having used drugs 70% of them are 12–22 years old Over the past decade, the use of cannabis and amphetamines has increased, while the use of heroin and volatile substances has decreased  Course of alcohol/drug use, misuse, addiction Experimental Use (large numbers) Increasingly regular use (lower numbers) Spiralling dependence (small number) Increasing problems  Terminology Drug abuse: substance used in a manner that does not conform to social norms; motivation to use the substance may or may not be particularly strong. Can abuse drugs without being dependent or addicted. Drug dependence: individual depends on drug for normal physiological functioning. Abstinence produces withdrawal reactions. Can be dependent without being addicted (eg to pain medication). Drug addiction: behavioral syndrome where acquiring and using drug are strong motivators of behavior. Compulsive use.  DSM V Continuing to use despite negative personal consequences Repeatedly unable to carry out major obligations Recurrent use in physically hazardous situations Continued use despite persistent or recurring social or interpersonal problems Tolerance (needing higher amounts of the substance to achieve the desired effect or experiencing diminished effects when repeating the same dose) Withdrawal (a substance-specific syndrome occurring when a patient stops or reduces heavy/prolonged substance use) DSM V cont… Persistent desire or unsuccessful efforts to cut down Spending a lot of time obtaining, using, or recovering Stopping or reducing important social, occupational, or recreational activities Consistent use despite persistent or recurrent physical or psychological difficulties Craving or a strong desire to use 2-3: Mild 4-5: Moderate 6-7: Severe  Addiction is a brain disease Drugs change how the brain works. – Many mimic the brain’s usual chemicals (eg endorphins & heroin) Brain changes can last for a long time. Problems with mood and cognition. Addiction is a disease. – Addiction is not simply a weakness. – People from all backgrounds, rich or poor, experience addiction. – Addiction can happen at any age, but often starts when a person is young. “Behavioural addictions” All drugs of abuse increase dopamine levels in ventral striatum Dopamine : cocaine, amphetamine VStriatum alcohol, opiates, nicotine, cannabinoids, MDMA Drugs of abuse increase dopamine concentration in the nucleus accumbens of the mesolimbic system NAC Movement Motivation Dopamine Addiction Reward & Well-being Drugs of abuse increase dopamine concentration in the nucleus accumbens of the mesolimbic system Dopamine system is modulated by other neurotransmitters: NAC GABA – inhibitory on dopamine neuron Opioids and alcohol– inhibitory on GABA neuron The dopamine reinforcement pathway stimulants GABA DA Nucleus accumbens opiates (mu) alcohol (via opiate mu) Pharmacotherapy Psychological therapies Neurochemistry Psychology Social Family therapies Substance-Induced Intoxication Anxiety Disorder Withdrawal Sleep Disorder Psychotic Disorder Delirium Bipolar Disorder Neurocognitive Depressive Disorder Sexual Dysfunction  Comorbidity Up to 50% of addicts have comorbid psychiatric disorder Antisocial PD Depression Suicide Opiods  OPIOIDS Bind to the mu receptors in the CNS to modulate pain Intoxication- pinpoint pupils, sedation, constipation, bradycardia, hypotension and decreased respiratory rate Withdrawal- not life threatening unless severe medical illness but extremely uncomfortable. s/s dilated pupils lacrimation, n/v, diarrhea, arthralgias, dysphoria or agitation Rx- symptomatically with antiemetic, antacid, antidiarrheal, muscle relaxant (methocarbamol), NSAIDS, clonidine and maybe BZD Neuroadaptation: increased DA and decreased NE Treatment - Opiate Use Disorder support, education, skills building, psychiatric and psychological treatment, Medications Methadone (opioid substitution) Naltrexone Buprenorphine (opioid substitution) Benzodiazepine( BZD)/ Barbiturates Stimulants Tobacco  Treatment Manage Intoxication & Withdrawal Breaking the cycle – Short-term / long-term substitution – Maintaining abstinence Intoxication Ranges: euphoria to life-threatening emergency Detoxification outpatient: "social detox” program inpatient: close medical care preparation for ongoing treatment  Treatment (cont ) Behavioral Interventions (target internal and external reinforcers) Motivation to change Group Therapy Individual Therapy Self-Help Recovery Groups (AA) Therapeutic Communities Family Involvement/Therapy Relapse Prevention  Summary 1 Addiction is a significant medical problem Legal substances (tobacco and alcohol) associated with high levels of mortality and harm Patterns of drug use change: e.g. increased non- medical use of prescription painkillers Importance of dopamine pathways and the ventral striatum Interaction with other neurotransmitters (GABA) Drug use driven by positive reinforcement (wanting pleasant effects) and negative reinforcement (avoiding withdrawal) Tolerance and craving important mechanisms  Summary 2 Aims of treatment: abstinence and/or harm reduction. Pharmacotherapy for managing withdrawal Pharmacotherapy for harm reduction and abstinence Psychological therapies for behavioural change Therapies for comorbid mental health problems Thank you