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.