Substance Related & Addictive Disorders 2024 PDF

PSYC30014 SUBSTANCE RELATED AND ADDICTIVE DISORDERS Lisa Phillips [email protected] 2024  2 WHAT IS INCLUDED IN THIS SECTION OF THE DSM5? 'substance-related disorders’: references 10 separate classes o...

PSYC30014 SUBSTANCE RELATED AND ADDICTIVE DISORDERS Lisa Phillips [email protected] 2024  2 WHAT IS INCLUDED IN THIS SECTION OF THE DSM5? 'substance-related disorders’: references 10 separate classes of drugs that can directly activate the brain reward systems, and can produce such an intense activation of the reward system that normal activities may be neglected; gambling disorder: inclusion reflects evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and that produce some behavioral symptoms that appear comparable to those produced by the substance use disorders. SUBSTANCE RELATED DISORDERS  BASIC DEFINITION A substance use disorder (SUD) is a treatable mental disorder that affects a person’s brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications. Symptoms can be moderate to severe, with dependence being the most severe form of SUD People with a SUD may also have other mental health disorders, and people with mental health disorders may also struggle with substance use.  5 CO-OCCURRING SUBSTANCE USE AND OTHER MENTAL DISORDER More often the rule rather than the exception, and is associated with Poorer prognosis - more likely to become chronic and disabled. Higher utilisation of services. Greater stigma Higher illness burden CO-OCCURRENCE OF MENTAL 6 HEALTH DISORDERS AND SUD CO-OCCURRENCE OF MENTAL HEALTH DISORDERS AND SUD Direct causal relationship between the two? Indirect causal relationship between the two? Are there are common factors that increase the risk of both disorders?  8 ATTITUDES TOWARDS OF SUBSTANCE USE OVER HISTORY Ancient writings (Egyptian, Greek, early Christian) wrote of negative impact of too much alcohol on behaviour and thought processes. Middle ages: alcohol was preferred to water because of the lack of clean water, Christian church emphasized idea of ‘moderation’, use beyond ‘moderation’ was viewed as a character flaw for succumbing to temptation (latter an issue of the spirit) Early psychiatrists (Pinel, Rush, Kraepelin, Bleuler) began to promote the idea that addiction was a medical illness Current separation of drug/alcohol treatment from other mental health treatment partially continuation of historic separation Nathan et al. (2016). Annu Rev Clin Psychol, 12, 29-51.  9 TERMINOLOGY: SUBSTANCE…. Use - Any use of a given substance/drug Misuse - Harmful use of substances (incl. use for non-medicinal purposes) Abuse (DSMIV Category) - A pattern of repeated drug or alcohol use that often interferes with health, work or social relationships Dependence (DSM-IV Category) - an adaptive state that develops from repeated drug administration, and which results in (physical and/or psychological) withdrawal upon cessation of drug use Use Disorder (DSM5 Category) - takes the place of Abuse/Dependence as of DSM5  10 WHAT IS ‘ADDICTION’? - The term we often use to indicate the disease process underlying a substance use disorder or problematic behavioural compulsion (e.g., gambling). - Note that addiction itself is NOT a diagnosis or a medical label. DSM5: SUBSTANCE- RELATED & ADDICTIVE DISORDERS DSM5 substance related disorders Substance- Substance-use induced disorders disorders DSM5: SUBSTANCE- RELATED & ADDICTIVE DISORDERS DSM5 substance related disorders Substance- Substance-use induced disorders disorders  DSM5: SUBSTANCE USE DISORDERS “essential feature…is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.” DSM5: SUBSTANCE USE DISORDERS- 14 GENERAL DIAGNOSTIC CRITERIA Impaired control over substance use 1.The individual may take the substance in larger amounts or over a longer period than was originally intended 2.The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use 3.The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects. 4.Craving: An intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used. Social impairment 5.Recurrent substance use may result in a failure to fulfil major role obligations at work, school, or home 6.The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance 7.Important social, occupational, or recreational activities may be given up or reduced because of substance use DSM5: SUBSTANCE USE DISORDERS- 15 GENERAL DIAGNOSTIC CRITERIA Risky use of the substance 8.Recurrent substance use in situations in which it is physically hazardous 9.The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance Pharmacological criteria 10.Tolerance is signalled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed. 11.Withdrawal is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing withdrawal symptoms, the individual is likely to consume the substance to relieve the symptoms  16 Use + physical dependence (tolerance and/or withdrawal) DSM5: SUBSTANCE USE DISORDERS- SEVERITY OF DISORDER a mild substance use disorder is suggested by the presence of two to three symptoms, moderate by four to five symptoms, and severe by six or more symptoms. Course specifiers and descriptive features specifiers: “in early remission,” “in sustained remission,” “on maintenance therapy,” “in a controlled environment.” DSM5 ALCOHOL USE DISORDER A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: Alcohol is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. Craving, or a strong desire or urge to use alcohol. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. Recurrent alcohol use in situations in which it is physically hazardous. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.  DSM5 ALCOHOL USE DISORDER, CONT., Tolerance, as defined by either of the following: A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. A markedly diminished effect with continued use of the same amount of alcohol. Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal). Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms. Specify if: In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met). In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met). Specify if: In a controlled environment: This additional specifier is used if the individual is in an environment where access to alcohol is restricted. Specify current severity: Mild: Presence of 2–3 symptoms. Moderate: Presence of 4–5 symptoms. Severe: Presence of 6 or more symptoms. DSM5: SUBSTANCE- RELATED & ADDICTIVE DISORDERS DSM5 substance related disorders Substance- Substance-use induced disorders disorders DSM5 SUBSTANCE- RELATED & ADDICTIVE DISORDERS DSM5 substance use disorders Substance Substance induced use disorders disorders Other substance/ Intoxication Withdrawal medication induced mental disorders DSM5: SUBSTANCE INDUCED DISORDER- GENERAL DIAGNOSTIC CRITERIA Disorder associated with Substance intoxication The essential feature is the development of a reversible substance-specific syndrome due to the recent ingestion of a substance The clinically significant problematic behavioural or psychological changes associated with intoxication (e.g., belligerence, mood lability, impaired judgment) are attributable to the physiological effects of the substance on the central nervous system and develop during or shortly after use of the substance The symptoms are not attributable to another medical condition and are not better explained by another mental disorder  DSM5: SUBSTANCE INDUCED DISORDER- GENERAL DIAGNOSTIC CRITERIA Disorder associated with Substance Withdrawal The essential feature is the development of a substance- specific problematic behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The symptoms are not due to another medical condition and are not better explained by another mental disorder DSM5: ALCOHOL INTOXICATION A. Recent ingestion of alcohol. B. Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol ingestion. C. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use: 1. Slurred speech. 2. Incoordination. 3. Unsteady gait. 4. Nystagmus. 5. Impairment in attention or memory. 6. Stupor or coma. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. DSM5: ALCOHOL WITHDRAWAL A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A: 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm). 2. Increased hand tremor. 3. Insomnia. 4. Nausea or vomiting. 5. Transient visual, tactile, or auditory hallucinations or illusions. 6. Psychomotor agitation. 7. Anxiety. 8. Generalized tonic-clonic seizures. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. Specify if: With perceptual disturbances: This specifier applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual, or tactile illusions occur in the absence of a delirium.  26 WITHDRAWAL: ALCOHOL - Symptoms: - Tremor - Insomnia - Nausea/Vomiting - Transient hallucinations - Psychomotor agitation - Anxiety - Seizures Delirium tremens (5-20% of patients undergoing detox): hyperadrenergic state, disorientation, tremors, diaphoresis, impaired attention/consciousness, and visual and auditory hallucinations WITHDRAWAL: 27 CAFFEINE Withdrawal effects of caffeine can reliably be demonstrated in nearly 100% of individuals with as little as 100mg of caffeine per day (1 cup of coffee) Withdrawal entails: - Headache - Fatigue - Anxiety - Concentration Difficulties - Depression/Flat Affect - Irritability - Tremors - Low Energy WITHDRAWAL: CANNABIS 28 - reported in ~1/3 of users in general population - reported by 50-95% of heavy users Hasin et al. (2013). Am J Psychiatry, 170, 834-851. Budney & Hughes(2012). Curr Opinion in Psychiatry, 19, 233-238.  DSM5 SUBSTANCE/MEDICATION- INDUCED MENTAL DISORDERS All substance/medication-induced disorders share common characteristics:  The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder.  There is evidence from the history, physical examination, or laboratory findings of both of the following:  The disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication; and  The involved substance/medication is capable of producing the mental disorder.  The disorder is not better explained by an independent mental disorder (i.e., one that is not substance- or medication-induced). Such evidence of an independent mental disorder could include the following:  The disorder preceded the onset of severe intoxication or withdrawal or exposure to the medication; or  The full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication. This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which persist beyond the cessation of acute intoxication or withdrawal.  The disorder does not occur exclusively during the course of a delirium.  The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. DSM5 SUBSTANCE/MEDICATION- INDUCED MENTAL DISORDERS Substance intoxication delirium Substance withdrawal delirium S-I persisting dementia S-I persisting amnestic disorder S-I psychotic disorder S-I mood disorder S-I anxiety disorder S-I sexual dysfunction S-I sleep disorder EPIDEMIOLOGY OF SUD WHICH SUBSTANCES ARE USED? 32 Global Drug Survey 2018  33 DRUG USE IN AUSTRALIA Harmful use (in a Dependence (in a Any use in a year year) year) Caffeine 90.0 ? ? Alcohol 80.0 2.9 1.4 Tobacco (Regular) 15.1 - - Cannabis 10.0 0.6 0.4 Stimulants 2.0 0.4 0.3 Cocaine 2.2 0.1 Sedatives 1.5 0.04 0.1 Opioids 0.1 0.1 0.1 Regier. Abnormal Psychology (4e) SUD EPIDEMIOLOGY Drug dependence is the single largest contributor to disease burden affecting Australians Alcohol abuse and cigarette smoking are the two highest causes of preventable deaths (app. 15,000 per year) 38% of Australians have used an illicit drug during their lifetime – 9% have used a psychostimulant in the last 12 months WHO IS MORE 35 LIKELY TO DEVELOP A SUD? Demographic correlates Age of illicit users: highest amongst 18-25 Males significant more likely to use Urban dwellers more likely than non-metro Regional differences exist (also influenced by industry, geography, cultural groups) In USA black more likely to be illicit users, Indigenous Australians more likely to use harmful amounts of alcohol than non- Indigenous Psychiatric patients user higher amounts  36 MOST COMMON INITIAL (ILLICIT) DRUG US National Institute on Drug Abuse (NIDA)  37 AGE OF PEAK USE DEPENDENCE AMONG 38 USERS 35 30 % of Users Who are Dependent 25 20 15 10 5 0 Anthony et al. (1994). Experimental & Clinical Psychopharm, 2, 244-268.  39 DEPENDENCE 70% 20% Lopez-Quintero et al. (2011). Drug Alcohol Depend, 115, 120-130. ABUSE POTENTIAL 40 - partially relates to how quickly a drug has its effects (varies by drug and route of administration) - the quicker the drug ‘acts’, the faster it usually stops acting - half-life (how long it takes for your body to clear a drug) is also important to abuse potential - quick up, quick down = high abuse potential  41 AETIOLOGY OF PROBLEMATIC DRUG USE WHY DO PEOPLE USE DRUGS/ SUBSTANCES? Ritual / Cultural Medical / Therapeutic Social / Recreational Occupational / Functional AETIOLOGY OF PROBLEMATIC DRUG USE: ‘MORAL’ MODELS Moral weakness/‘addictive personality’ Sensation seeking/novelty seeking Impulsivity Future time orientation/consideration of future consequences Harm avoidance and reward dependence AETIOLOGY OF PROBLEMATIC 44 DRUG USE: ‘DISEASE’ MODELS Use of drug outside medical setting == abnormality, outside of medical setting Use is "caused" by some pathology, and "causes" further problems User is sick==> needs treatment Enlightenment model- addiction is a disease that is lifelong and progressive. To change the “addict” must become enlightened, by realising that change is possible only by relinquishing personal control to a ‘higher power’. ALCOHOLICS ANONYMOUS ‘Alcoholism’ is a disease characterized as a unique and progressive condition that is both qualitatively and quantitatively different from normality. The cardinal symptom of alcoholism is loss of control over alcohol, the inability to restrain oneself from further drinking (e.g. "One drink, one drunk"). The disease is understood to be irreversible, incapable of being cured, but possible to arrested through total abstinence from drinking alcohol. The intervention implications - Individuals with this condition should be identified, informed of their abnormal condition, brought to accept the diagnosis and then persuaded to abstain from drinking alcohol for the rest of their lives. Relies heavily on peer support for the treatment. AETIOLOGY OF PROBLEMATIC DRUG USE: EDUCATION MODEL SUD evolve from a knowledge deficit and a lack of accurate information. Therefore, when armed with correct information about the dangerous effects of alcohol or drugs, individuals are presumed to be less likely to use alcohol in a hazardous fashion. Treatment: education of patients about the dangers of drinking and use of drugs. AETIOLOGY OF 47 PROBLEMATIC DRUG USE: SOCIAL LEARNING Parenting / Familial Influence= permissive Environment - individual may never have used if not exposed to situation Social Economic System - influences which drugs are popular (e.g.80s=cocaine, 90s=e, depression-era 1930s=alcohol) Cultural Factors – eg religion, Influences of Peers Socialization and Social Skills - normative behavior (beer at barbeque) AETIOLOGY OF PROBLEMATIC DRUG USE: OPERANT CONDITIONING AETIOLOGY OF PROBLEMATIC DRUG USE: CLASSICAL CONDITIONING  50 AETIOLOGY OF PROBLEMATIC DRUG USE: BIOLOGICAL Deficits in neural circuitry underpinning incentive salience, executive function, and abnormal reward/stress resp. fuel addiction cycle of binge/intoxication, withdrawal, and preoccupation Genetic factors Koob & Volkow (2016). Lancet Psychiatry, 3, 760-773. AETIOLOGY OF 51 PROBLEMATIC DRUG USE : BIOPSYCHOSOCIAL MODEL Considers the etiology of addiction to be a multifactorial phenomenon consisting of biological, psychological and social components Looks at the whole individual and the interaction of multiple factors in determining progression Rejects a reductionistic view of addiction and emphasizes that it is the result of several forces; "is a primary, chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestation. The disease is often progressive and fatal.". AETIOLOGY OF PROBLEMATIC DRUG USE: BIOPSYCHOSOCIAL MODEL Drug use is universal Humans are born with the drive - We experiment early in life Receive rewards and punishment for trying various ways Develop preferred methods and tend to persist in attempts Shaped by psycho-social processes (desires, availability norms, etc.) Set and setting shape experience (can be positive and valuable) AETIOLOGY OF PROBLEMATIC DRUG USE : PUBLIC HEALTH MODEL TREATMENT  55 PROHIBITION/LEGALISATION: EG ALCOHOL  56 SUD TREATMENT Typically entails: - psychotherapy and/our behavioral counselling - medication - management of withdrawal symptoms - evaluation/treatment for co-occurring mental health conditions - relapse prevention - detoxification (?)  57 PSYCHOLOGICAL APPROACHES TO TX OF SUD Alcoholics/Narcotics Anonymous Group-based treatment based on principles of 12-steps (abstinence) Contingency management (use principles of reinforcement, reward, Behavioural therapy punishment) Cognitive behavioral therapy Recognition of triggers/cues for use and facilitation of coping strategies Goal of reducing harmful use to less harmful use or reducing means of use to Harm reduction/minimization less harmful approach. Focus on functionality. Motivational enhancement therapy Effort to facilitate movement through stages of change (2 slides) HARM 58 REDUCTION/MINIMISATION Extreme High Risk: Very heavy use, life in danger, risky behaviours, etc. High Risk: Heavy use, some risky behaviours, relationships/job in jeopardy Medium Risk: Moderate/binge use, some risky behaviours, some relationships/job impairment Low Risk: Some use, ~occasional impairment No Risk: Abstinence Goal may not be abstinence, but just reduction to Medium or Low Risk. STAGES OF CHANGE 59 PUBLIC HEALTH MODEL EXAMPLES OF HARM MINIMISATION PROGRAMS Needle and syringe programs Medication-Assisted Treatment for Opioid Dependence Diversion programs Sobering up services GAMBLING DISORDER  63 GAMBLING DISORDER  64 EPIDEMIOLOGY OF GAMBLING DISORDER - ~ 70% of Australians have participated in some form of gambling over the past year. - Estimates suggest about 1% of population meets criteria with 4% at risk - Across countries, there is some variability, with a range of about 1-5% - In countries where gambling is not heavily regulated (e.g., Australia), rates are higher than countries where it is regulated (e.g., USA) Thomas SA, Browning CJ. Treatment of gambling problems in adults. In: Grossman L, Walfish S, editors. Translating Psychological Research into Practice. New York: Springer Publishing, 2013. PROBLEM GAMBLING IN AUSTRALIA Problems tend to be concentrated more highly in certain demographic groups: Males (usually 60% at the population level), younger people (aged 18–35 years), Aboriginal people, people who are not in a stable relationship, and among lower socioeconomic groups. Problem gamblers also tend to have: a greater likelihood of having started gambling at a young age, to have experienced larger wins when they first started gambling and to have a history of problem gambling in their families.  66 AETIOLOGY OF GAMBLING DISORDER Gambling machines typically operate on a schedule of intermittent reinforcement. This is the strongest type of behavioral learning. There are undoubtedly neurobiological, cognitive, and personality factors that contribute as well, but the influence of learning is most well understood.  DSM5: FURTHER STUDY REQUIRED  INTERNET GAMING DISORDER “…a pattern of excessive and prolonged Internet gaming that results in a cluster of cognitive and behavioral symptoms, including progressive loss of control over gaming, tolerance, and withdrawal symptoms, analogous to the symptoms of substance use disorders. (DSM5) THANK YOU