Lecture - Substance Related Disorders Pt. I - Spring 2024 PDF

 QPR SUICIDE PREVENTION GATEKEEPER TRAINING: During a QPR training session, instructors will present, discuss, and role-play scenarios until participants feel comfortable with the material QPR-trained gatekeepers are not “suicide counselors” – rather, they learn to recognize the warning signs of su...

 QPR SUICIDE PREVENTION GATEKEEPER TRAINING: During a QPR training session, instructors will present, discuss, and role-play scenarios until participants feel comfortable with the material QPR-trained gatekeepers are not “suicide counselors” – rather, they learn to recognize the warning signs of suicide, how to offer hope, and how to get helpto hopefully save a life The schedule, along with instructions on how to register, for Purdue QPR Suicide Prevention Gatekeeper Training sessions FOR SPRING 2024 can be found here. Substance Related, Addictive, and Impulse-Control Disorders  Substance-Related and Addictive Disorders Depressants Stimulants Opioids Cannabis, other hallucinogens and other drugs  Causes of substance-related disorders  Treatment of substance-related disorders  Gambling Disorder  Other Impulse-control disorders  The nature of substance use disorders Wide-ranging physiological, psychological, and behavioral effects Associated with impairment and significant costs  Some important terms and distinctions Substance use  Ingestion of moderate amounts of a substance in a way that doesn’t interfere with functioning Substance intoxication  Immediate physiological reaction to ingesting a substance  Substance abuse Use substance in a way that is dangerous or causes substantial impairment (e.g., affecting job or relationships)  Substance dependence May be defined by tolerance and withdrawal Sometimes defined by drug-seeking behavior (e.g., spending too much money on substance)  Tolerance Needing more of a substance to get the same effect / reduced effects from the same amount  Withdrawal Physical symptom reaction when substance is discontinued after regular use  Depressants Behavioral sedation (e.g., alcohol, sedative, anxiolytic drugs)  Stimulants Increase alertness and elevate mood (e.g., cocaine, nicotine)  Opiates Produce analgesia and euphoria (e.g., heroin, morphine, codeine)  Hallucinogens Alter sensory perception (e.g., marijuana, LSD)  Other drugs of abuse Include inhalants, anabolic steroids, OTC medications  DSM-5-TR has separate SUBSTANCE SPECIFIC disorders for: Substance intoxication Substance use disorders  (includes issues of abuse/dependence) – e.g., “Alcohol Use Disorder” Substance use withdrawal  e.g, “Cannabis Withdrawal Disorder” (need 2+ within a year): of  Symptoms Taking more of the substance than intended substance Desire to cut down use time spent use leading Excessive using/acquiring/recovering to significant Craving for the substance disruption impairment Role e.g., can’t perform at work/school and distress Interpersonal problems Pattern Reduction of important activities Use in physically hazardous situations  e.g., driving Keep using despite causing physical or psychological problems Tolerance Withdrawal - Also provide severity rating based on # of symptoms  Can you use alcohol and not misuse it? Yes  Can you misuse alcohol and not become addicted to it? Yes (problem is that we don’t really know why some become addicted)  How much is too much? Is alcohol actually that bad? The answer: depends not only on how much you drink, but on how and where and with whom you do it  Bigger question: Why do we drink in the first place? Part of the answer: “Because it’s fun”  Drinking releases endorphins Another part of the answer: “Because we can”  Natural selection has endowed humans with the ability to drink most other mammals under the table  While many species have enzymes that break alcohol down and allow the body to excrete it (avoiding death by poisoning), about 10 million years ago a genetic mutation left our ancestors with a souped-up enzyme that increased alcohol metabolism 40-fold  More importantly, alcohol has fostered social connection birth/marriage/death – alcohol at the center of communal living  Gobleki Tepe in eastern Turkey– dates to about 10,000 BCE - The “pilgrims” and Plymouth Rock How alcohol became more of a problem: 1) Shift from low ethanol drinks to distilled spirits 2) Shift from drinking as social bonding to drinking alone  Distilled, high-ethanol content alcohol is recent -- became widespread in China in the 13th century and in Europe from the 16th-18th centuries Early Greeks watered down their wine; drinking it full- strength was, they believed, barbaric—a recipe for chaos and violence  Fallen grapes fermented on the ground ~ 3% alcohol by volume  Beer and wine = 5 – 11% ethanol  Modern distilled liquor = 40-50% ethanol Beer Street Gin Lane Beer Street / Gin Lane, Hogarth, 1751   Just as people were learning to love their gin and whiskey, more of them started drinking outside of family meals and social gatherings In US, industrial revolution saw largescale population shifts from rural to urban settings Cheap liquor easy to obtain (whiskey, rum) Jobs were scarce, people were lonely, stress was high, & drunkenness became epidemic  During this time, alcohol use became less leisurely, more isolated Drinking establishments started to feature long counters (a “bar”), enabling people to drink on the go, rather than around a table with other drinkers  Dramatic break from tradition:  in nearly every era and society, solitary drinking almost unheard-of among humans  This trend helps us understand this finding: people who drink lightly or moderately are happier and psychologically healthier than those who abstain Dunbar (2022): those who regularly visit pubs are happier than those who don’t  not because they drink, but because they have more friends  it’s typically the pub-going that leads to more friends, rather than the other way around  ITALY: Despite high alcohol consumption, Italy has low rate of alcoholism Italians drink mostly wine and beer, almost exclusively over meals with other people When liquor is consumed, it’s usually in small quantities, either right before or after a meal Alcohol is seen as a food, not a drug  Drinking to get drunk is discouraged, as is drinking alone; helps limit its harms  Per capita alcohol use hit a modern peak in early 80’s – response? Change in drinking age More alcohol taxes Warning labels Increased DUI penalties Alcohol use dropped by 20%  By late 1990’s alcohol use started to steadily increase New products to initiate nondrinkers Enhanced alcohol marketing Increases in female drinking Cocktails in a can 2020: Dog Brew  “You’ll never drink alone again” Pandemic shifts? Per capita consumption of ethanol in 2021 = 2.51 gallons (per person per year), a 2.9 percent increase from 2.44 gallons in 2020 and a 5.5 percent increase from 2.38 gallons in 2019 This was the largest two-year increase since 1969, when there was a 5.9 percent increase (2.37 gal in 1967 to 2.51 gal in 1969)  2015 National Survey on Drug Use and Health: 86.4% of people ages 18 or older reported that they drank alcohol at some point in their lifetime; 70.1% reported that they drank in the past year; 56.0% reported that they drank in the past month  Overall: Over 2021-2022, 63% of U.S. adults aged 18 and older consumed alcohol Most adults consider themselves light drinkers Alcohol use is highest among Euro/White Americans (56.8%) Men have more alcohol-related health problems and have more alcoholrelated diagnoses than women  But women show largest increases in heavy drinking, hospitalizations etc ~25% of Americans report binge drinking in last month Violence is associated with alcohol  But alcohol consumption alone does not cause aggression  Binge Drinking - 5 or more drinks per occasion for men, 4 for women, on at least 1 day in the past 30 days pattern of drinking that brings blood alcohol concentrations (BAC) > 0.08   Heavy Episodic Drinking = binge drinking on 5+ days in past month High Intensity Drinking = drinking at levels far beyond binge threshold 2 or more times the gender-specific binge drinking thresholds (i.e., 10 or more standard drinks for men, and 8 or more for women).  Binge drinking is strikingly prevalent in the United States 66.7 million (24.9%) Americans age 12 or older report binge drinking in the past month (National Survey on Drug Use and Health, NSDUH, 2016) Wilsnack et al. (2017) 5. North Dakota -Adults who drink excessively: 24.1% (US rate: 19.8%) 4. Montana -Adults who drink excessively: 24.3% (US rate: 19.8% - also has highest rate of fatal car accidents involving alcohol, 46.4%; US rate: 26.6%) 3.South Dakota -Adults who drink excessively: 24.4% (US rate: 19.8%) 2. Iowa -Adults who drink excessively: 24.6% (US rate: 19.8%) 1. WISCONSIN -Adults who drink excessively: 24.6% (US rate: 19.8%) Data sources: The state and county rankings are based on data from the County Health Rankings & Roadmaps, produced by the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. Data sources: CDC. Youth Risk Behavior Surveillance System and Behavioral Risk Factor Surveillance System, 2015. Data source: 2021 NIDA/UM Monitoring the Future Survey  Alcohol is a solvent characterized by a hydroxyl group (-OH)  Ethyl alcohol (ETOH) is the only form that can be safely consumed  It is produced by fermentation: the interaction of yeast with sugar The type of sugar determines the type of beverage:  Grapes = ?  Grain = ?  Rice = ?  Fermentation process – 2 byproducts of glucose metabolism = CO2 and ethanol 200 quintillion ethanol molecules in.5 oz ethanol  Typical fermentation produces a maximum alcohol content of around 15%  To get a higher alcohol content one has to “distill” the alcohol from the water Distilled alcohol became widespread in China in 13th century and in Europe from 16th-18th centuries  Alcohol molecules are hydrophilic and lipophilic  ABSORPTION: Small amounts are absorbed in the mouth Most absorbed in the small intestine  Alcohol metabolism is a two step process. Alcohol travels to the liver via capillaries in small intestine and portal vein  (1) The enzyme alcohol dehydrogenase (ADH) converts ethanol to acetaldehyde.  (2) Aldehyde dehydrogenase (ALDH) breaks down acetaldehyde into acetate and water  Women have less alcohol dehydrogenase Women become more intoxicated than men on equal doses  The rate of absorption, distribution, and clearance of alcohol are affected by many factors so behavioral effects are described based upon Blood Alcohol Content (B.A.C.) B.A.C. = # milligrams ETOH per 100 milliliters of blood  In general, measurable behavioral effects begin to occur at a B.A.C. of 0.04%  1 standard drink = ~.5 oz of ethanol (almost 15 ml) One drink equivalent is the amount of alcohol that the average body metabolizes in 1 hour  If an individual weighing 160 lbs. consumes 2 drinks per hour, what will their BAC level be at the end of five hours of drinking? Hour 1:.02 +.02 =.04 -.02 =.02% Hour 2:.02 +.02 =.04 -.02 +.02 =.04% Hour 3:.02 +.02 =.04 -.02 +.04 =.06% Hour 4:.02 +.02 =.04 -.02 +.06 =.08% DUI Hour 5:.02 +.02 =.04 -.02 +.08 =.10% 1 standard drink =.5 oz of ethanol (~ 15 ml)  FOR A 160 LB. INDIVIDUAL, EACH DRINK =.02 BAC%  Body can metabolize about.5 oz (.02 BAC%) per hour THERE IS NOTHING THAT SPEEDS THIS!  Really? The Borg ("black out rage gallon” -- a personal one-gallon plastic container filled with part water, part hard liquor, and flavored with a drink enhancer of choice. Recipes for a 50/50 ratio using vodka are popular on TikTok) University of Massachusetts warns of TikTok drinking trend March 5, 2023 - Some things to consider: - A fifth of vodka is about 16 shots of ETOH - That doesn’t change if you mix it with water and electrolytes … and it doesn’t become safer by spreading it out over a few hours - Stay hydrated, but don’t consume this much ETOH AMHERST, Mass. (AP) — The University of Massachusetts is warning about a TikTok drinking trend after 28 ambulances were summoned to offcampus parties.  CENTRAL NERVOUS SYSTEM: 1 dk/hr = BAC.02: little change 2 dk/hr = BAC.05: drinker “buzzed”, judgment center of brain affected, inhibitions lowered 3 dk/hr= BAC.10: judgment very poor, muscle coordination depressed, staggered gait, slurred speech  10 dk/hr = BAC.20: severe impairment, emotions erratic, poor memory  Hurray you’re 21! 21 drinks = 315 ml ethanol/hr = BAC.35 -.40: coma, brain center which controls heart & lungs partially anesthetized How common?  Rutledge et al. (2008): 12% of both male and female 21st birthday drinkers reported consuming exactly 21 drinks  an additional 22% of male birthday drinkers and 12% of female birthday drinkers reported consuming more than 21 drinks  35% of female and 49% of male birthday drinkers had BACs of 0.26 or higher (a level associated with potential serious medical outcomes)  Alcohol increases blood circulation to the skin  Increase in loss of body heat (hypothermia)  Sweat response is suppressed  Heart rate decreases  Stimulation of acid and pepsin in stomach  Reduced release of antidiuretic hormone = increased urination = dehydration  Acetaminophen (e.g., Tylenol):  Alcohol use increases certain liver enzymes that convert acetaminophen into a toxic substance – NO DRINKING IF YOU’VE TAKEN TYLENOL!!  Inhibition of frontal lobe: Loss of behavioral inhibition, loss of planning, loss of impulse control = increased aggression, increased use, poor judgment.  Inhibition of amygdala: Fearlessness/Loss of anxiety  Euphoria: Dopamine release in ventral tegmental area of nucleus accumbens (reward areas)  Analgesia: Inhibition of motor areas: slowed reaction time, poor coordination, decreased sexual performance  Learning/memory disrupted: Attention, encoding, short-term memory become inhibited Reduced ability to retrieve info from long term memory (e.g., knowing where one lives)  Alcohol has both specific and nonspecific effects on neurotransmitters (NT): GLUTAMATE -- major excitatory NT in CNS.  ethanol reduces glutamate activity in brain’s memory centers  Decreased ability to consolidate memory (i.e., “blackouts”)  Rebound hyperexcitability caused by up-regulation of NMDA (Nmethyl-D-aspartate) receptors (e.g., withdrawal symptoms) GABA INCREASES – major inhibitory NT  agonist on the GABAa receptor in a similar fashion to benzodiazepines (i.e., alcohol increases GABA activity)  increases Cl- influx thus increasing neural inhibition DOPAMINE INCREASES - in brain’s“reward centers”  Chronic ETOH use produces down regulation of DA receptors = distress and depression when ETOH use stops  HOW DOES THIS CHANGE REASONS FOR USE OVER TIME?  Malnutrition Calories from alcohol lack nutrients Alcohol interferes with digestion and absorption of vitamins from food  Deficiency of B-complex vitamins Amnestic syndromes  Severe loss of memory for both long and short term information (WernickeKorsakoff Syndrome)  Cirrhosis of the liver Liver cells engorged with fat and protein impeding functioning Cells die triggering scar tissue which obstructs blood flow In 2020-21, Liver disease and cirrhosis rank 9th in US causes of death Damage to endocrine glands and pancreas  Heart failure  Erectile dysfunction  Hypertension  Stroke  Capillary hemorrhages  Facial swelling and redness, especially in nose  Destruction of brain cells Less than previously thought, but some loss in memory areas  89,697 of an estimated 140,557 deaths due to excessive alcohol use annually during the 20152019 study period, or nearly 2/3 of the deaths, were among adults aged 20 to 64 years   Alcohol-attributable deaths were responsible for 1 in 8 deaths among adults aged 20 to 64 years, including 1 in 5 deaths among adults aged 20 to 49 years Compared with 2019, death rates involving alcohol as an underlying or contributing cause of death increased during the first year of the COVID-19 pandemic in 2020, including among adults aged 20 to 64 years. Therefore, the proportion of deaths due to excessive drinking among total deaths might be higher than reported in this study  US alcohol deaths rose nearly 30% in first year of pandemic  Ex: alcohol-caused liver or pancreas failure, alcohol poisoning, withdrawal;  More than 52,000 such deaths in 2020, up from 39,000 in 2019  Problem drinking in the US costs an estimated $249 billion per year and is the fourth-leading cause of preventable mortality The rate of such deaths had been increasing in the two decades before the pandemic, by 7% or less each year But in 2020, they rose 26%, to about 13 deaths per 100,000 Americans (highest rate recorded in 40 yrs)  Possible causes: Acetaldehyde buildup Gastric irritation Rebound drop in blood sugar Dehydration Toxic effects of congeners  Possible cures: There are no scientifically verified cures other than rehydration and rest No effects on hangover symptoms The hangover cures assessed in this study included Curcumin, Duolac ProAP4 (probiotics), L-cysteine, N-Acetyl-L-Cysteine (NAC), Rapid Recovery (L-cysteine, thiamine, pyridoxine and ascorbic acid), Loxoprofen (loxoprofen sodium), SJP-001 (naproxen and fexofenadine), Phyllpro (Phyllanthus amarus), Clovinol (extract of clove buds), Hovenia dulcis Thunb. fruit extract (HDE), Polysaccharide rich extract of Acanthopanax (PEA), Red Ginseng, Korean Pear Juice, L-ornithine, Prickly Pear, Artichoke extract, 'Morning-Fit' (dried yeast, thiamine nitrate, pyridoxine hydrochloride, and riboflavin), Propranolol, Tolfenamic acid, Chlormethiazole, and -from Wolfe et al. (2020)