PSY 183 Substance-Related and Addictive Disorders 2024 Lecture Notes PDF

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2018, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D. All Rights Reserved. They May Be Downloaded for Private Use Only by Students Currently Registered in UCSB...

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2018, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D. All Rights Reserved. They May Be Downloaded for Private Use Only by Students Currently Registered in UCSB Psych 183. For-Profit Reproduction in Whole or In Part Without Written Permission of the Instructor Is a Violation of U.C. Regulations and the DMCA and Is Expressly Prohibited.  Notice All Course materials (class lectures and discussions, handouts, examinations, Web materials) and the intellectual content of the Course itself are protected by United States Federal Copyright Law, and the California Civil Code. UC Policy 102.23 expressly prohibits students (and all other persons) from recording lectures or discussions and from distributing or selling lectures notes and all other course materials without the prior written permission of the Instructor (See http://policy.ucop.edu/doc/2710530/PACAOS-100). 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You are granted permission in Psych 183 to download and retain personal copies of these slides solely for your own use. Substance-Related and Addictive Disorders  What is Addiction? ⚫ The uncontrolled, compulsive use of a substance despite ongoing negative consequences to one’s health, mental state, or social life. ⚫ All addictions share the experience of “loss of control” over the substance or behavior, and how to explain this “loss of control” led to two classic views about addictions, the Moral View and the Medical (Disease) View. ⚫ “Addiction” is a term in common use but, due to its vague definition and moral connotations, it is not a diagnostic term, and DSM-5-TR does not use it within its diagnoses.  Loss of Control in Substance Use: Two Classic Views ⚫ Moral View – Addicts are morally weak, choose to yield to temptation, and are consciously self-destructive and uncaring about the damage they cause others. They need to start making good choices and “get their act together.” ⚫ Medical (Disease) View – Possibly aided by a genetic predisposition and/or social learning, addicts begin using voluntarily, but then have their brains biologically “hijacked” by the addictive substances. They need treatments that block the hijacking, restore normal brain function, and thereby give them back their “will.”  Substance Use Norms ⚫ Every culture has norms about the ingestion of substances that dictate: – what should be consumed. – when it can be consumed. – who can consume them. – how much should be consumed. – what range of reactions is permissible. ⚫ Use – ingesting a drug in accordance within those sociocultural norms (e.g., peyote in Native American “vision quests”, ceremonial wine at Christian communions, champagne at wedding receptions, and wine and beer for the adults at quinceañeras). ⚫ Abuse – taking a drug outside of sociocultural norms, causing personal and social problems as a result. Substance Use Disorders: Spectrum of Severity ⚫ Intoxication: Ingestion of a substance leading to (typically reversible) impairment. Withdrawal: Signs and symptoms associated with metabolism of substance, usually opposite to More those of ingestion. Severe ⚫ Abuse: Harmful pattern of use, e.g., regular periods of intoxication (and withdrawal). ⚫ Dependence: Habitual abuse, and development of “cravings” and tolerance (needing increasing amounts for desired effects). DSM-5-TR Substance Use Disorders include separate diagnoses for each level of severity, and for each of the 10 classes of abused substances.  Ten Classes of Substance Use Disorders in DSM-5-TR ⚫ Ethyl alcohol (ETOH) ⚫ Opioids ⚫ Caffeine – Morphine, Heroin ⚫ Cannabis – Codeine, Hydrocodone, Oxycodone, Fentanyl – Hashish, Marijuana ⚫ Phencyclidine – Related ⚫ Sedatives, Hypnotics, Hallucinogens* Anxiolytics – Barbiturates – PCP, ketamine – Benzodiazepines ⚫ Other Hallucinogens ⚫ Stimulants – LSD, psilocybin (“mushrooms”), peyote, – Amphetamines salvia, MDMA (“ecstasy”), – Ritalin ayahuasca, DMT, – Cocaine dextromethorphan – MDMA (X or Ecstasy) ⚫ Inhalants ⚫ Tobacco – Nitrous oxide, glue, solvents, aerosols, cleaning fluids * Phencyclidine (PCP) is a separate category because of its extreme cardiovascular and neurological toxicity. Ketamine is chemically related but it much weaker and not as toxic. The “Other Hallucinogens” have much more favorable safety profiles.  What Are the Substances Likely To Be Abused? ⚫ Typically work on neurotransmitter systems that affect mood and motivation. ⚫ Some (e.g., opioids) are ways plants have evolved to exploit animals. ⚫ Most abused substances have beneficial effects, and many have been used as medicines: – Heroin and other opioids are used as analgesics (pain relievers), antidiarrheal agents, and in cough medicines. – Cocaine is a mental stimulant, local anesthetic (e.g., dentistry), appetite suppressant, and was once in Coca-Cola. The Coca-Cola Company now has exclusive rights to import coca leaves to the U.S. for its cola flavorings, and it sells the cocaine extract to pharmaceutical firms. – Alcohol (ETOH) is a potent anti-anxiety agent, and moderate use of red wine (under a physician’s guidance) appears to be cardio-protective. – Nicotine is a mental stimulant, produces weight loss, and may be beneficial in Schizophrenia and Parkinson’s disease. – Cannabis is now finding use in otherwise intractable seizure disorders. ⚫ As a side effect, these substances may generate a temporary “buzz,” euphoria, calm, and/or disinhibition, and these reactions make them prime candidates for abuse and dependence.  Non-Substance “Behavioral Addictions” ⚫ Historically, addiction referred just to substances like alcohol, stimulants and narcotics. ⚫ More recently, some observers have argued for widening “addictions” to include behaviors like sex, exercise, eating, gambling, shopping, pornography, and the Internet. This is controversial. ⚫ In DSM-5-TR, the “behavioral addiction” of Gambling Disorder is listed as a “Non-Substance-Related Disorder” within the Substance Use Disorders because of its addictive pattern. Due to lack of data, all other behavioral addictions are excluded in DSM-5-TR.  DSM-5-TR Substance Use Disorder ⚫ Maladaptive pattern of substance use leading to significant impairment or distress. ⚫ Presence of 2 or more of the following within a 12 month period: – Taking the substance in larger amounts or for longer than you intended. – Wanting to cut down or stop using the substance but not doing so. – Spending a lot of time obtaining, using, or recovering from use of the substance. – Not managing to do what you should at work, home or school, because of substance use. – Continuing to use, even when it causes problems in relationships. – Giving up important social, occupational, or recreational activities because of substance use. – Using substances repeatedly even when it puts you or others in danger. – Continuing to use, even despite physical or psychological problems that could have been caused or made worse by the substance. – Needing more of the substance to get the effect you want (tolerance). – Development of withdrawal symptoms, which you relieve by taking more of the substance. – Cravings and urges to use the substance.  Cannabis Use Disorder (Includes Dx’s of Cannabis Intoxication, Withdrawal, Abuse, & Dependence) (Please Also Read Assigned Textbook Addendum, “Can Marijuana Cause Mental Illness?”)  Cannabis Use Disorder (DSM-5-TR) 35-95% of cannabis users will have normally have some withdrawal symptoms characterized by fatigue, yawning, difficulty concentrating, loss of appetite, and insomnia. Many will use more cannabis to reduce these withdrawal symptoms, which sets the stage for heavier use and the development of Cannabis Use Disorder. ⚫ Cannabis Use Disorder has all the characteristics of other DSM-5-TR Substance Use Disorders, and includes separate signs and symptoms for Cannabis Intoxication, Cannabis Withdrawal, Cannabis Abuse, and Cannabis Dependence. ⚫ DSM-5-TR also notes that Cannabis Use Disorder is associated: – substantially with Use Disorders involving other substances, including tobacco, alcohol, cocaine, methamphetamine/ amphetamine, and heroin or other opiates. – in adolescents, especially with: anxiety disorders, Major Depression, PTSD, Conduct Disorder, and ADHD. – increasingly with Cannabinoid Hyperemesis Syndrome, consisting of episodes of uncontrollable nausea and vomiting. – with chronic respiratory disorders such as asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. – with a 3-fold increase in psychosis. Vulnerability to Schizophrenia and other psychotic disorders is partly heritable, suggesting a genetic component, and also due to the greatly increased potency of cannabis over last 25-30 years. Not Your Parents’ Marijuana  Cannabis: Short Research Reports (free login to medscape.com) The Bad ⚫ Parental Cannabis Use Tied to Child Psychosis Risk ⚫ Cannabidiol Cuts Seizure Severity, Frequency in Resistant Epilepsy ⚫ Habitual Cannabis Use May Slow Visual Perception ⚫ Drug-Induced Psychosis Ups Schizophrenia, Bipolar Risk ⚫ Prenatal Cannabis Exposure May Affect Kids' Brain Development ⚫ Cannabis Use Directly Linked to Psychosis Relapse ⚫ Heavy Cannabis Use Associated With Depression, Suicidality ⚫ Legalized Marijuana Boosts High School Dropout Rates The Good ⚫ Cannabidiol Cuts Seizure Severity, Frequency in Resistant Epilepsy ⚫ FDA Panel Unanimously Backs Cannabis Drug for Severe Epilepsy ⚫ Medical Cannabis for Pain May Reduce Need for Opioids ⚫ For Cancer, Cannabis Has Many Virtues, Says Large Study ⚫ FDA Clears Oral Cannabis Drug for AIDS, Cancer Patients ⚫ Cannabis-Derived Agent May Offer Type 2 Diabetes Benefit  Alcohol (ETOH) Use Disorder (Includes Dx’s of ETOH Intoxication, Withdrawal, Abuse, & Dependence)  What is Alcohol? ⚫ Ethanol, ethyl alcohol (ETOH), C2H5OH. ⚫ Volatile, clear, flammable liquid produced by the fermentation of sugar. Its manufacture and use go back thousands of years. ⚫ Acts as a temporary central nervous system depressant: – by stimulating certain brain receptors for GABA, the major known inhibitory neurotransmitter in the brain (and one related to anxiety). – by blocking receptors for glutamate, probably the main excitatory neurotransmitter in the brain (and one especially involved in memory and cognition). ⚫ ETOH is a potent neurotoxin that can cause loss of gray matter (mostly dendritic loss), especially in the hippocampus (long-term memory) and inner cerebellum (coordination). These neurological changes are mostly reversible if the drinking is only moderate and the drinker is young.  Alcohol Use in U.S. ⚫ Ethyl alcohol (ETOH) is consumed by 80% of the population in the form of beer, wine, spirits, etc. ⚫ Despite increase in cannabis use, ETOH remains the most common substance of abuse / dependence. ⚫ In U.S. (and Western Europe), the lifetime prevalence of ETOH abuse and dependence is ~ 15 %. ⚫ Point prevalence is 25-50% among medical-surgical inpatients, and in ~ 50 % of psychiatric inpatients.  Alcohol’s Effects: Dependent on Blood Alcohol Concentration (BAC %) ⚫.03-.06 Sense of well-being or confidence, or sedation and tranquility; lowered anxiety contributes to its role as “social lubricant” ⚫.06-.10 Incoordination and irritability, impaired reaction time and judgment ⚫.11-.20 Slurred speech, ataxia (wide-spaced unsteady gait), nystagmus ⚫.21 -.29 Blackouts (periods of anterograde amnesia), passing out ⚫ >.30 Coma, respiratory and cardiac depression, possible death NOTE: Above a BAC of.06%, more alcohol produces less “buzz” and more dysphoria. Alcohol Withdrawal Syndrome from Severe Dependence (lasts 3-4 days) ⚫ “Shakes” (within 12-18 hrs after drinking), weakness, sweating, nausea & vomiting ⚫ Alcoholic seizures (“rum fits”) ⚫ Alcoholic hallucinosis (vivid, unpleasant auditory hallucinations) ⚫ Delirium (delirium tremens or “the DT’s”) – confusion, disorientation, agitation, vivid and frightening visual hallucinations ⚫ Alcohol withdrawal is: – much more severe than opiate withdrawal, and can be fatal if unsupervised. – safely done only within a hospital or ETOH detox facility.  Who Develops Alcohol Use Disorder (I)? ⚫ Age: younger drinking predicts later problems – Typical age of onset is 16 to 30. – People who begin drinking before age 15 are 4X as likely to become ETOH-dependent, compared to those whose first drink is at age 20 or older. – About 50% of people who are ETOH-dependent in the U.S. are adolescents or young adults; few seek help for their problem drinking. ⚫ Sex: – Males are 4X as likely as females to have ETOH Use Disorders. – ETOH-dependent females, however, suffer more than males from health problems and die ~11 yrs earlier than males with ETOH dependence. ⚫ Level of Response (LR) to Alcohol: How much ETOH does it take to “feel good”? People who need more ETOH to get a buzz are likelier to develop ETOH Use Disorders.  Who Develops Alcohol Use Disorder (II)? ⚫ Family History – More than ½ of current drinkers have a family history of ETOH abuse or dependence. – Children of people who are ETOH-dependent are 4X as likely to be ETOH-dependent themselves, even when reared by non-ETOH- dependent adoptive parents. ⚫ Ethnicity: – Ethnic groups differ in their susceptibility (most likely, a mixture of genetics and culture). – Asians as a whole have very low rates of ETOH Use Disorders, probably because about ½ of Asians have a genetic variation that complicates the metabolism of ETOH and causes an unpleasant facial flushing response. – Native Americans, Alaskan Natives, and Mexican Hispanics have the highest U.S. rates of ETOH Use Disorders, but the rates vary tribally and by community.  Who Develops Alcohol Use Disorders (III)? ⚫ Personality: – Impulsive, sensation-seeking traits – Unstable Personality Disorders (esp. Borderline, Histrionic PDs) – History of Conduct Disorder / Antisocial Personality Disorder ⚫ Social: – Peer pressure – Availability of ETOH ⚫ Education: – College students drink more than same-age people not in college. – In college, being a member of a Greek Letter Organization (GLO) is associated with higher rates of drinking, and may be a risk factor for later ETOH Use Disorder. It is unclear whether GLO membership is causal, or people join a GLO in order to drink. – College drinking is associated with much higher rates of sexual and physical assault, unprotected sex, motor vehicle and other accidents, campus arrests, and dropping out of college. The Maybe Not- So-Good News: The Decline in Adolescent / Young Adult Drinking (and Cigarette Smoking)* May Be a Shift to Cannabis * Statistics on vaped nicotine are unreliable.  Consequences of Alcohol Use Disorder ⚫ ½ of all traffic fatalities and 1/3 of all traffic injuries are ETOH- related. ⚫ Great social costs in accidents and death, criminal behavior, community and domestic violence, marital and family strife, poor work and school performance and absenteeism. ⚫ Personal damage due to disease and premature death, with greater risk of: – gastric irritation and bleeding – breast, oral and intestinal tract cancer – heart disease and stroke – liver, testicular and pancreatic disease – peripheral neuropathy (nerve degeneration causing weakness and sensory loss) – anxiety, depression and suicide – dementia with chronic heavy use (Korsakoff’s Syndrome) ⚫ Fetal damage  Fetal Alcohol Spectrum Disorders (~ 1% of U.S. Population) ⚫ Associated with heavy drinking in pregnancy Effects on Children: ⚫ Craniofacial deformities ⚫ Physical and mental retardation ⚫ Learning disabilities and behavioral disorders (e.g., ADHD) ⚫ Skeletal (esp. hand and finger malformations) Source: AAFP Am I Going To Develop an Alcohol Use Disorder? Quick Screening for ETOH Problems (estimates likelihood of later Alcohol Use Disorder) Single-Question Screening (Taj et al., 1998) “On any single occasion during the past 3 months, have you had more than 5 drinks containing alcohol?” CAGE Questionnaire (Ewing, 1984) http://pubs.niaaa.nih.gov/publications/aa65/aa65.htm The Opioid Crisis  The U.S.’s Opioid (Narcotic) Crisis ⚫ “Opiates”, also known as narcotics, are derivatives of morphine, a natural substance in the seeds of the Opium Poppy found throughout Asia (and made in small quantities by animal cells), used to make heroin and other synthetic medications. Opiates have many proper medical uses in treating diarrhea, cough, shortness of breath, and in control of severe pain. ⚫ BUT more than 90 people in the U.S. die daily from opioid OD’s, including prescription pain relievers (Butrans, Vicodin, Oxycontin, Percocet, Codeine, Fentanyl), and illicit heroin and Fentanyl (mostly smuggled by cartels over the U. S. Southern border). ⚫ Opiate abuse, dependence and OD’s affect mostly white, middle-class, young adults ages 18-25. Overall U.S. opioid OD death rate is 1 every 12 minutes.  America’s Opioid Crisis: Fentanyl ⚫ Black-market Fentanyl (synthetic opioid) 100X more potent than heroin, now “cut” into drugs like heroin and cocaine, and made into colorful pills to appeal to young users. ⚫ Now accounts for more than 70% of opioid OD’s ⚫ New “super-Fentanyl” synthetics, the “nitrazenes”, are up to 10x more potent than Fentanyl, and have been found in street drugs throughout the U.S.  Current Strategies in Treatment of Opioid Use Disorders ⚫ Better training of physicians on pain management (opiates should rarely be used for >30 days), and better patient education on risks. ⚫ Substitution treatments: – Prescribed daily use of low-potency opioids (mainly, Methadone). – Abuse-deterrent formulations (ADF’s) of opiates; e.g., Suboxone = Buprenorphene (narcotic) + naloxone (narcotic antagonist). Suboxone use reduces the mortality of Opioid-Use Disorders by 50%. ⚫ Rapid-response opiate OD training, with community rapid-response teams equipped with naloxone (Narcan) auto-injectors for on-the-spot OD treatment. ⚫ FDA approval in March 2023 of over-the-counter availability of Narcan nasal spray for OD’s. ⚫ Clinical trials are underway for the psychedelic treatment of Opiate Use Disorders using Ibogaine, a West African herb extract related to peyote and ayahuasca. ⚫ New non-narcotic, non-addictive analgesics to treat chronic pain are under development. General Treatment of Substance Use Disorders  Stages of Substance Use Disorder Treatment ⚫ Acute Management (usually in inpatient detox facility) – Treatment of acute withdrawal symptoms, often with physiologically similar medications. In ETOH dependence, use of benzodiazepines for “shakes” and delirium, antipsychotics for hallucinosis, and sometimes anticonvulsants for seizures. – During inpatient stay, group and family therapy. ⚫ Rehabilitation (outpatient) … outcomes/prognosis are guarded, and complicated by denial by the user (e.g., “I don’t really have a problem,” “It’s not my fault,” “It’s not that serious.”) ⚫ Treat co-morbid conditions (e.g., depression, anxiety, pain), seen in up to 2/3 of substance-dependent patients. – Refer patient to: ⚫ therapy/education programs focusing on coping strategies, cue avoidance, and relapse prevention. ⚫ a “12-Step Program” (for ETOH, Alcoholics Anonymous). – Refer family to a support group (e.g., Al-Anon for ETOH abuse/dependence) for education and issues of “enabling” and “co-dependency.” Treatments for Common Substance-Use Disorders Show Low Rates of Abstention  AA and 12-Step Groups ⚫ Based informally on a Medical (“Disease”) model of causation, but a “Moral View” of recovery. ⚫ First 12-Step Group was Protestant-inspired Alcoholics Anonymous, founded in 1935 by two ETOH-dependent people, Bill Wilson (“Bill W.”) and Dr. Robert Smith (“Dr. Bob”). ⚫ AA teachings, including the 12 Steps, are contained in the “Big Book,” which stresses: – a frank and total admission of one’s drinking problem. – confessing that one is powerless to handle one’s drinking problem by oneself, and acknowledging a “higher power” in order to succeed. – a vow to stay abstinent - “clean and sober” - one day at a time. – making personal amends for all the damage one has caused. – helping others to achieve their own sobriety (“sponsoring”). ⚫ Studies suggest that AA participation results in higher abstinence rates than other kinds of ETOH treatment. ⚫ Other 12-Step Programs based on AA: – Cocaine Anonymous (CA) – Crystal Meth Anonymous (CMA) – Marijuana Anonymous (MA) – Nicotine Anonymous (NicA) – Narcotics Anonymous (NA) “Big Book” of AA  Trends in Substance Use Disorder Treatment ⚫ 12 Step abstinence groups remain a mainstay of treatment. ⚫ There is greater willingness to treat co-morbid mental disorders even while the patient is using, especially if the issue is self- medication – but most common practice is still “detox first.” ⚫ There is more emphasis on: – early education, detection and community and school prevention programs: “the path to addiction is set by high school.” – pharmacological treatments: ⚫ Antagonists (e.g., daily Naloxone for ETOH Use Disorder, which dulls the “buzz” and euphoria from ETOH) ⚫ Maintenance treatments using less-harmful substitutes (daily AM doses of Methadone for Opioid Use Disorder, or Nicorette gum and lozenges for Nicotine Dependence) ⚫ Abuse-deterrent formulations (ADFs) that chemically are more difficult to abuse (e.g., Vyvanse for ADHD, which unlike Ritalin or Adderall, only becomes active via normal digestion). ⚫ Overall evidence is that these treatments are not cures, but are modestly successful in preventing abuse and reducing relapse. Addiction and Crime End