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 ------------------------------------------- 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.