Lecture 20
      
                        Psychoactive Substance Use Disorders
      
      
      Lecture Outline
      
      I.  Introduction
      II. Dependence and Abuse
           A. Dependence
           B. Abuse
      III.Patterns of Psychoactive Substance Use
      IV. Psychoactive Substance Use Disorders
      V.  Alcohol Use
           A. The Problem
           B. Short-term effects
           C. Long-term effects
           D. Definitions
           E. Etiology
      VI. Conclusion
      
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      I.  Introduction
      
           In most societies, use of substances to alter mood, behavior,
      perceptions, etc. is accepted.  In our culture, use of alcohol,
      caffeine, and nicotine is widely accepted as normal.  Nevertheless, as
      you are probably aware, these substances (esp. alcohol) can lead to all
      sorts of problems for the user.  And there are many other substances
      that people take which have even clearer risks associated with them:
      cocaine, LSD, heroin, PCP, barbiturates, etc.  In today's lecture, we
      will discuss disorders associated with more or less regular use of these
      "psychoactive substances" - chemicals which affect the central nervous
      system, thereby altering mental functioning.  Most people have had some
      experience with these drugs (how many of you had coffee or tea this
      morning?!).  The substances become a problem when their consumption
      becomes habitual, when a craving develops, leading to and/or
      exacerbating persistent social, occupational, psychological and physical
      problems.  The "use" we will be discussing refers to "abuse" and
      "dependence".
           Psychoactive substance use is one of the major public health
      problems in the USA.  Alcoholism affects millions of people; it is the
      most common substance use disorder.  Deaths associated with alcohol use
      ranks third, behind heart disease and cancer (Smith & Landry, 1988): 
      Substance use disorders know no social class boundaries: people at all
      levels of society may fall victim.  Understanding and dealing with
      substance use is very difficult and complex (Smith & Landry, 1988):  
                  o recreational drug use is so widespread;
                  o complex interactions of physical, chemical, psychological,
                    socio-cultural variables are involved in drug use;
                  o certain drugs (alcohol, tobacco), although culturally
                    accepted, pose serious dangers to users, while other drugs
                    may be illegal and culturally unaccepted, yet pose less of
                    a hazard.
      
      II.  Dependence and Abuse
      
           The DSM-III-R distinguishes between "dependence" and "abuse". 
      These categories vary in terms of severity.   
      
      A. Dependence is the more severe diagnosis of the two:  cognitive,
      behavioral, and physiological symptoms that indicate the person has
      impaired control over the psychoactive substance and continues to
      use the substance despite the adverse consequences.  These symptoms
      often include physiological tolerance to the drug, and withdrawal
      reactions when the drug is not available.  Note:  Tolerance/
      withdrawal symptoms can occur in other persons (eg: surgical
      patients on pain killer) - but there is no impaired control [their
      use of the substance is controlled by their physician].  Likewise,
      dependence (as defined here) can be present even in the absence of
      physiological tolerance/withdrawal symptoms (eg: marijuana).  So
      the key component:  impaired control.  
           What the DSM-III-R is doing, is distinguishing between
      physical dependence, and psychological dependence.
           Physical Dependence (or Addiction):  When certain drugs are
      ingested for an extended period of time, the body habituates to the
      particular substance - a tolerance is developed.  Thus, larger
      amounts are needed to achieve the same effects.  If the amount of
      the drug is reduced, the body (now habituated to the higher dosage)
      reacts with withdrawal: cramps, panic, restlessness, sweating,
      vomiting.
           Psychological Dependence:  Other types of drugs, although
      frequently taken, do not alter the body's tolerance for the drug. 
      Nevertheless, the person may become psychologically addicted to the
      substance:  they "need" the drug to help them reduce or cope with
      stress, anxiety, depression, or because it simply makes them feel
      good.  Although there is no actual physical dependency, the need
      for the drug can be just as powerful, and just as disruptive and
      maladaptive.
           In short, focusing on just physical dependency is insufficient
      for a comprehensive diagnostic category (Smith & Landry, 1988):
      some drugs do not produce tolerance/withdrawal reactions
      physical dependence may be absent in spite of maladaptive  
      behavior patterns
      physical dependence often represents a late stage of a  
      disorder.
      The DSM-III-R recognizes that dependency can include both physical
      and psychological addictions (a broadening of the criteria as
      defined in the DSM-III).  
      
           [insert DSM-III-R diagnostic criteria for Dependence]
      
           Note, dependence can be rated in terms of severity, from mild
      to severe, as well as in remission.
      
      
      B. Abuse refers to patterns of substance use that are not as
      extreme as seen in dependence, but that still warrant attention and
      concern.  This diagnosis is more likely with people who have just
      begun using psychoactive substances, or when the substances being
      used are less likely to produce withdrawal symptoms (and so the
      need to take the substance to avoid those symptoms), eg: cocaine,
      marijuana.
      
           [insert DSM-III-R diagnostic criteria]
      
           Two DSM-III-R examples:  
           1.A college student who binges on cocaine every few weekends,  
              and then "crashes" for a few days afterwards.
      
           2.A woman who continues to drink alcohol after her doctor has  
              told her that it is exacerbating the symptoms of her        
             ulcer.  There are no other symptoms.
      
      III.  Patterns of Psychoactive Substance Use
      
           The use of psychoactive drugs can be categorized into 5 basic
      patterns (Smith & Landry, 1988).  For many persons, they never progress
      to later patterns of abuse.  However, as dependency increases, so does
      the possibility for compulsive, dysfunctional drug use.  
      1. Experimental use: short-term use, motivated by curiosity, social
      contexts.
      2. Social-recreational use: friends and acquaintances wanting to
      share a pleasurable experience.
      3. Circumstantial-situational use: motivated by the desire to
      achieve a known drug effect in order to cope with a specific
      situation or event.
      4. Intensified use: long-term use (often once a day), motivated by
      a desire to obtain relief from problems and stress. 
      5. Compulsive use: frequent and intense use, producing some degree
      of psychological dependence and possible physical dependence.
           
           As use becomes increasingly compulsive, social, psychological and
      physical impairments become more pronounced.  Eventually, if the abuse
      goes unchecked, numerous and profound dysfunctions develop. Handout 20-1
      describes some of these problems.  This handout is based on cocaine use,
      but the patterns seen here are almost identical for other substances as
      well (Smith & Landry, 1988).  [Read excerpts from Handout 20-1].
      
      IV. Psychoactive Substance Use Disorders
      
           The DSM-III-R identifies numerous psychoactive substances.  These
      include:
              alcohol
              nicotine
              amphetamines (eg: "speed")
              cannabis (eg: marijuana, hashish)
              cocaine
              hallucinogens (eg: LSD, mescaline)
              opioids (eg: heroin, morphine, codeine)
              sedatives and hypnotics (eg: benzodiazepines, barbiturates)
      
      The use of these substances is not limited to back-street, dark alley-
      ways.  Many of these substances are found in easily available, every-day
      products and/or may have proven medicinal value.  For example:
              amphetamines - diet pills
              opioids - analgesics, anesthetics, cough suppressants
              sedatives - sleeping pills
      
           We don't have time to discuss all of these different substances. 
      So let us look at one of these substances, alcohol, in some detail. 
      Much of what we say about use and the symptoms of abuse of alcohol,
      however, will apply to other substances as well.  Table 20-2 outlines
      the characteristics of some of these other substances.
      
      V. Alcohol Use
      
      A. The Problem
           Excess alcohol consumption is one of the major health problems
      in the USA.  On the one hand, it is associated with increased
      probability of death.  For example (Logue, 1986):
      1. increased probability of all types of accidents (eg: 45-60%
      of all fatal motor vehicle accidents involve drivers who had
      been drinking - 50,000 Americans are killed each year in these
      accidents)
      2. aggravation of other diseases already present (eg: bleeding
      ulcer)
      3. increased chance of suicide and of being a victim of
      homicide
      4. alcohol poisoning, especially in interaction with other
      drugs (Handout 20-3)
      5. death due to effects of chronic alcoholism (eg: poor
      nutrition, cirrhosis of the liver)
      6. decreased probability of detecting an injury or illness
      that needs attention
      These data do not prove that alcohol causes all of these things,
      such as car deaths, suicides, and homicides.   Nevertheless,  the
      association is so consistent and strong, that a causal relationship
      is strongly suggested (Logue, 1986).  Causation, however, is
      certainly indicated in the increased rates of physical illnesses
      and death to poisoning.
           Alcoholism also has an adverse economic impact on society: 
      for example, it's been estimated that alcohol abuse cost the United
      States $50 billion in 1977, in treatment, lost employment,
      vandalism, crime, etc (Mayer, 1983).
           Add to this the problems that ensue with family and friends,
      and it is clear that alcohol abuse is a very serious problem.
      
      B. Short-term effects
           1. Physiological effects:  alcohol bypasses the usual
      digestive processes.  Some of it is immediately absorbed through
      the stomach lining, the rest through the intestines, into the
      blood.  At low dosages, alcohol acts as a stimulant; at high
      dosages as a depressant.  Thus many of alcohol's effects are dosage
      dependent (Logue, 1986).  Some of the effects are: "sleep apnea" (a
      disruption of breathing), a decrease in REM sleep, headaches,
      inhibition of the synthesis of the male hormone testosterone
      (Logue, 1986).
           2. Aggression:  Violent behavior becomes more likely
      (Tinklenberg, 1973)
           3. Memory: disrupted and impaired (Logue, 1986).
           4. Mood: Some studies have shown that mood is actually not as
      highly elevated as popular belief would have it (Polivy & Herman,
      1976).
           5. General effects:  In general, the short-term effects of
      alcohol seems to be tied to the person's beliefs about the effects
      of alcohol.  If the person believes alcohol will increase mood, it
      will (even when unknowingly s/he actually got vitamin C instead of
      alcohol) (eg: Polivy & Herman, 1976).
      
      C. Long-term effects
           1. Physiological effects:  Serious damage can ensue.  Eg:
      cirrhosis and hepatitis.  Physical dependence and tolerance
      develops.
           2. Eating behavior: Food intake becomes increasingly
      inadequate.  Vitamin deficiencies accompany this.  Malnutrition
      develops.  This problem is exacerbated by the fact that long-term
      consumption of alcohol can increase the body's general metabolic
      rate (Logue, 1986).
           3. Cognitive processes: Brain density decreases.  Brain
      damage.  Performance on many cognitive tasks is impaired.  Even
      when sober, the person's memory and learning abilities are
      impaired.  Korsakoff's disease may develop: irreversible memory
      disorder characterized by difficulty in remembering recent events. 
      It is caused, in part, by a thiamine (vitamin B1) deficiency -
      typical in alcoholics.
           4. Fetal alcohol syndrome (FAS): One of the most tragic
      consequences of alcohol use occurs when a woman drinks when she is
      pregnant.  The fetus is directly effected:  Structural
      abnormalities of the head and face, low birth weight, small size,
      brain damage and mental retardation.  Animal research has supported
      this direct link between alcohol consumption and FAS (Mukherjee &
      Hodgen, 1982; Sulik, Johnston, & Webb, 1981).
      
      D. Definitions
           There is no precise criterion by which a person can be
      described as alcoholic.  Oversimplistically, we can define
      alcoholism as consistently drinking too much so that some of the
      problems described above occur (Logue, 1986).  "Too much" is a
      relative term, depending on factors such as health, body water, and
      weight.  Handout 20-4 describes some of the typical symptoms for
      various amounts of alcohol in the blood.  "Consistently" is also a
      difficult term to pin down.  There tends to be different patterns
      of use: daily intake of large amounts, heavy drinking limited to
      the weekends, or long periods of sobriety interspersed with binges
      (weeks to months) of heavy drinking (APA, 1987).
           Jellinek (1946, 1952) proposed a sequence of stages through
      which people go as they become alcoholic.  
      1. Prealcoholic phase: periodic excessive drinking, typically
      in social situations (only 10% begin with solitary drinking). 
      Provides tension relief.
      
      2. Prodromal phase:  Tension relief drinking increases,
      "blackouts" first occur (periods of time in which, under the
      influence of alcohol, the person remains conscious but later
      has no memory of what he/she did), and "sneaking drinks"
      begins - to avoid public censure.  
      
      3. Crucial phase:  This is the "Crucial" phase because it is
      at this time that the person is at risk of losing everything:
      his/her friends, livelihood, and especially his/her control
      over the drinking.  Jellinek estimated this phase as typically
      occurring about two years after the beginning of the
      blackouts.  Patterns of drinking change - there is now morning
      drinking, s/he tries to swear off drinking or change types of
      drink (whiskey to wine perhaps).  Yet, in time, the person
      begins to experience "benders" - alcoholic binges lasting
      several days, during which s/he disregards all else.
      
      4. Chronic phase:  Within a few years after the first benders,
      the person's life becomes centered around alcohol.  S/he
      eventually ceases to care about anything else.  S/he is
      "defeated".  Drinking is continual and benders are frequent. 
      Physical dependence is now well established.  Deprived of
      alcohol, s/he experiences withdrawal symptoms, possibly
      including delirium tremens (the DTs): fever, sweating,
      trembling, and hallucinations.  S/he begins to suffer alcohol-
      related health problems as well (eg: malnutrition, cirrhosis
      of the liver).
      
      Jellinek's description of the development of alcoholism is
      consistent with more recent research (eg: Mandell, 1983).  People
      who end up alcoholic tend to pass through phases similar to those
      above.  Note:  A person in one of the earlier phases will not
      necessarily pass on to one of the more advanced phases. 
           Jellinek's model is certainly not perfect.  Not all data
      support it; for example: many alcoholics never experience blackouts
      (Goodwin, Crane, & Guze, 1969).  In addition, Jellinek's model is
      based on male alcoholics.  The pattern of drinking in alcoholic
      women differs in important ways.  For example:  Women tend to be
      less social and more solitary in their drinking, the period between
      onset and problem drinking tends to be shorter, binge drinking is
      less likely (Davison & Neale, 1986).
      
      E. Etiology
      
           Possible causes of excessive alcohol consumptions are
      numerous, and still debatable.  Many theories have been proposed.  
      1. Genetic factors:  There are some data that suggest a
      genetic component may predispose some people to alcoholism. 
      Identical twins tend to be more frequently concordant for the
      presence of alcoholism than are fraternal twins (Logue, 1986). 
      Even when these identical twins are reared apart, there
      remains this tendency.  In addition, an adopted child who had
      a biological parent who was alcoholic is more likely to also
      become alcoholic (Logue, 1986).  Note: The majority of
      alcoholic twins do not have an alcoholic co-twin, and the
      majority of biological children of alcoholics do not develop
      alcoholism (Murray, Clifford & Gurling, 1983).  So, there's
      much more to it than just genetics.
      
      2. Psycho-Social factors:  The presence of other people who
      are drinking appears to be a crucial factor in the amount a
      person will drink: the presence of others drinking leads to
      increased consumption (Logue, 1986).  Growing up in a family
      with an alcoholic member seems to predispose a person to
      develop alcoholism (Kanas, 1988).  Initial drinking may be
      motivated by a desire to reduce tension and stress.  Numerous
      studies support such a hypothesis (Davison & Neale, 1986). 
      However, tension reduction does not explain why drinking
      continues - anxiety and tension increase during long-term
      drinking (Logue, 1986).  What may be occurring is that alcohol
      decreases self-awareness, and so indirectly reduces tension
      (Davison & Neale, 1986).
           Cultural factors may also play a role:  The way a
      particular culture or society views alcohol use can have an
      impact on how individuals within that community consume
      alcohol.  Eg:  Certain Jewish, Italian, and Chinese ethnic
      groups tend to condone consumption for purely ceremonial,
      nutritional, or festive use.  Alcoholism is also low in these
      groups (Davison & Neale, 1986).
      
      VI.  Conclusion
      
           As our discussion of alcohol use illustrates, substance abuse is
      not a simple phenomenon.  Definitions of the disorder can be complex,
      and etiological factors numerous.  People who use psychoactive
      substances are a heterogenous group.