Substance Related Disorders pt 1.pdf - nocookie.net

Substance
Substance-Related Related
Disorders
Cornelia Pinnell, Ph.D.
Argosy University/Phoenix

• Definitions
Lecture Outline
• Psychoactive Substances
• Epidemiology
• Assessment
• Etiological Models
• Treatment
• Stages of Change

“Substances”
In the DSM DSM-IV IV-TR, TR, the term ‘substance’
can refer to:
– a
a medication medication medication medication
– a toxin toxin
– a drug drug of of abuse abuse

Medications
Symptoms related to medications
medications usually
• Occur at high doses
• Disappear when the dose is lowered or
medication is discontinued

Toxins
Toxic Toxic substances substances include heavy
metals (e.g., lead or aluminum), rat
poisons containing strychnine,
pesticides containing nicotine,
acetylcholinesterase inhibitors, nerve
gases, ethylene glycol (antifreeze),
carbon monoxide, carbon dioxide

Toxins
Volatile Volatile substances substances (e.g., fuel, paint) are
classified as:
• toxins if exposure is accidental or part of
intentional poisoning
• ‘inhalants’ if they are used for the
purpose of becoming intoxicated

Substances of Abuse
These are grouped in 11 11 classes: classes
1) alcohol; 2) amphetamines; 3) caffeine;
4) cannabis; 5) cocaine; 6) hallucinogens;
7) inhalants; 8) nicotine; 9) opioids;
10) phencyclidine (PCP); 11) sedatives,
hypnotics, anxiolytics

Classes of substances
with similar features
• Alcohol with sedatives, hypnotics &
anxiolytics
• Cocaine with amphetamines

Intoxication
Development of reversible substance-
specific maladaptive behavioral and/or
psychological changes due to the direct
physiological effects of a substance
(recent ingestion or exposure to)
e.g., belligerence, mood lability, cognitive
impairment, impaired judgment, social or
occupational functioning

Intoxication
• Clinical picture varies among individuals
& depends on the substance involved
• Acute’ ‘Acute ‘Acute ’ vs. ‘ chronic’ ‘chronic ‘chronic
• Longer term effects to be distinguished
from withdrawal

Abuse
Persistent pattern of maladaptive
substance use resulting in
significant adverse consequences
over a period of 12 months

Dependence
Cluster of cognitive, behavioral, and physiological
symptoms indicating that the individual
continues use of substance
despite significant substance substance-related substance substance-related related problems
Repeated self self-administration administration can result in
compulsive drug drug-taking taking behavior (‘craving’ is
often experienced), tolerance & withdrawal

Tolerance
• The need for greatly greatly increased increased amounts amounts of the
substance to achieve intoxication (or the desired
effect)
OR
OR
• A markedly markedly diminished diminished effect effect with continued use
of the same amount of the substance
It is difficult to determine by history alone –
laboratory tests are helpful

Cross Cross-Tolerance Tolerance
Tolerance develops
across drugs
to a combination of drugs

Withdrawal
A maladaptive behavioral change,
with physiological physiological and and cognitive cognitive concomitants,
concomitants,
that occurs when blood or tissue concentrations
of a substance decline in an individual who had
maintained prolonged heavy use of the
substance to relieve or avoid those symptoms

Withdrawal
• There are separate criteria listed for most
classes
• No significant withdrawal is seen after repeated
use of hallucinogens
• Marked & easily measured physiological signs
are common with alcohol, opiates,, sedatives,
hypnotics, and anxiolytics

Criteria for Substance Dependence
A maladaptive pattern of substance use,
leading to clinically significant
impairment or distress, as manifested by
three (or more) of the following,
occurring during any time in the same 12
month period:

Criteria for Substance Dependence
1. Tolerance
2. Withdrawal
3. Substance is taken in larger amounts or over
longer periods than intended
4. Persistent desire or unsuccessful efforts to
cut down or control substance use

Criteria for Substance Dependence
5. Great deal of time is spent in activities
necessary to obtain the substance
6. Important social, occupational or
recreational activities are given up or
reduced because of substance use
7. The substance use is continued despite the
knowledge of having persistent or recurrent
physical or psychological problems that is
likely to have been caused or exacerbated
by the substance

Substance
Substance-Related Related Disorders
• Substance Substance Use Use Disorders Disorders
– Dependence
– Abuse
• Substance Substance--Induced Substance Substance--Induced Induced Induced Disorders Disorders Disorders Disorders
– Intoxication
– Withdrawal
– Persisting Delirium
– Persisting Dementia
– Persisting Amnestic Disorder

Specifiers
• With With Physiological Physiological Dependence
Dependence
(if there is evidence of tolerance or
withdrawal)
• Without Without Physiological Physiological Dependence
Dependence
(pattern of compulsive use without
evidence of tolerance or withdrawal)

Course specifiers
• Early Early Remission Remission = More than 1 month, up
to 1 year
• Sustained Sustained Remission Remission = Beyond 12 moths
(1 year)
• Partial Partial Remission Remission = At least one criterion
for Dependence or Abuse has been met,
intermittently or continuously during the
period of remission
• Full Full Remission Remission = No criteria are met

Course specifiers
• On On Agonist Agonist Therapy Therapy = No criteria for
Dependence or Abuse are met on agonist,
for at least for 1 month
• In In a a Controlled Controlled Environment
Environment = No criteria
for Dependence or Abuse are met in a
controlled environment, for at least for 1
month

Agonist medication
Agonist Agonist m. = A chemical entity not
naturally occurring in the body that acts
upon a receptor and is capable of
producing the maximal effect that can be
produced by stimulating that receptor.

Agonist medication
Partial Partial agonist agonist m. = A chemical entity not
naturally occurring in the body that acts
on a receptor and is capable of producing
less than maximal effect even when given
in concentrations sufficient to bind with all
available receptors

Antagonist medication
Antagonist Antagonist m. m. = A chemical entity not
naturally occurring in the body, that
occupies a receptor, produces no
physiologic effects, and prevents
endogenous and exogenous chemicals
from producing an effect on that receptor

Psychoactive substances
• CNS Stimulants
• CNS Depressants
• Hallucinogens
• Inhalants

Routes of administration
• Oral
• Inhalation (smoking)
• Intranasal (snorting)
• IV – Intravenous
• IM – Intra-muscular
Intra muscular

Stimulants (‘uppers’)
• Types of stimulants stimulants:
– Caffeine
– Nicotine
– Amphetamines (benzedrine,
methedrine, methamphetmine,
Dexedrine, ‘crystal meth’)
– Cocaine – ‘ecstasy’, ‘crack’

Stimulants (‘uppers’)
Effects of stimulant use use: :
• Users feel more alert & possibly some
euphoria
• Increased heart & respiratory rate
• Increased blood pressure

Amphetamines
• Street names names: : uppers, pep pills, beenies,
whities, dexies, hearts, speed, black beauties,
copilots, bumblebees, footballs
• Tablets or capsules - can be easily changed into
powder or liquid form
• Modes of administration
administration: : orally, sniffed, or
diluted & injected into the bloodstream

Amphetamines
The psychotic disorder resulting from
withdrawal is undistinguishable from
schizophrenia and may last several years

Methamphetamine hydrochloride
• Street names names: : ice, crystal, glass
• Clear crystal crystal-shaped shaped solid
• Mode of administration
administration: administration
administration: : smoked
• Was used in the 1930s to treat depression, sleep
disorders, and obesity

Methamphetamine hydrochloride
• Euphoria lasts for 2 to 8 hours
• Addiction can develop after 1 use
• Side effects effects: : Strokes, heart attacks, pulmonary
edema, comas, death; psychosis can follow
discontinuation
• Highest use in border states – San Diego,
Phoenix

Cocaine
• Street names names: : coke, C, big C, snow, snowbird,
lady, nose candy, blow, toot, leaf, flake, freeze,
happy dust, Peruvian lady, white girl
• White, odorless crystals or crystaline powder;
extracted from leaves of coca plant
• Mode of administration
administration: : sniffed sniffed (snorting it is
inefficient), smoked smoked (crack crystals or mixed with
other drugs) or IV IV - smoke or IV injections are
preferred by users

Cocaine
• Cycle of use use: : crash – crave – binge – get
high – crash
• Very short half half-life half half-life life (approx. 50 minutes)
• Severe depression during withdrawal,
suicide attempts are common

Crack
• Cocaine derivative - turned into a base,
mixed with water and baking powder
• Mode of administration
administration: administration
administration: : smoked in pipe,
sprinkled into a tobacco cigarette, mixed
with marijuana

Pattern of use use: :
Crack
• Instant rush (after 30 min.)
• ‘High’ lasts for 10 10-15 10 10-15 15 min.
• Heavy users 1x or 2x/week –
2/3 of crack users use daily

Crack
• Public Public health health issues:
– sex for drugs – promiscuity
– HIV infections (due to needle sharing)
• Highly associated with crime crime and and
violence violence (intensive craving & anxiety
& panic attacks during withdrawal)

‘Depressants’ (‘downers’)
Effects of depressants
depressants: :
• May induce euphoria euphoria (depends of context
& type of substance used)
• Users feel less less ‘jittery’ and drowsy

‘Depressants’ (‘downers’)
Types of depressants
depressants:
• Alcohol Alcohol (ETOH): bi bi-phasic phasic action
– low dose – stimulant, lowers inhibition,
elevated mood
– high dose - sedative, muscular
coordination and cognition are impaired
• Narcotics Narcotics/Opiates Opiates

‘Depressants’ (‘downers’)
Types of depressants (continued):
• Sedatives Sedatives (legally prescribed drugs to
reduce anxiety, induce sleep, control
seizures, produce sedation/calm):
– Nonbarbiturates
Nonbarbiturates (Quaalude, Sopor, Parest)
– Barbiturates/ Barbiturates/ Benzodiazepines
Benzodiazepines (Seconal,
Tuinal, Nembutal) – high potential for
addiction; complicated medical detox picture

‘Depressants’ (‘downers’)
Types of depressants (continued):
• Tranquilizers:
Tranquilizers
– Minor Minor (Librium)
– Major Major Major Major (Thorazine, Stelazine)

Narcotics/Opiates
• Natural: Opium, Morphine, Codeine
• Semi Semi--synthetic synthetic: : Heroin, Hydromorphone
(Dilaudid), Oxycodone (Percodan)
• Synthetic: Propoxyphene (Darvon),
Mepreidine (Demoral), Dolophine
(Methadone Methadone)

Semi Semi-Synthetic Synthetic Opiate - Heroin
• Was introduced in 1898 as a cough suppressant
• Street names names: : smack, horse, brown sugar, junk,
mud, Big H, tootsie roll, black tar
• Mode of administration
administration: : inhaled, smoked, or
injected

Semi Semi-Synthetic Synthetic Opiate - Heroin
• Withdrawal symptoms may include:
sweating, fever, nausea, vomiting,
headaches, diarrhea
Severe anxiety and depression during
withdrawal – results in intense intense craving craving
• 50 50-80% 80% pure is lethal

Synthetic Opiate - Methadone
• Synthetic opiate was developed by the
Nazis – initially used as analgesic
• Street names names: : dollies, done, biscuits
• Mode of administration
administration: : oral, in a liquid solution,
under the supervision of a tx professional
– Used in the tx of opiate addiction, blocks
euphoric effect of heroin

Synthetic Opiate - Methadone
• Long half half-time time of 33-40 33 40 hours
• Psychiatric disorders due to methadone
are uncommon

Hallucinogens
Types of hallucinogens
hallucinogens: : organic and synthetic agents
• Cannobinoids
Cannobinoids -- marijuana, marijuana, hashish hashish
• Psylocybin
Psylocybin (naturally occurring in a variety of
mushrooms)
mushrooms
• Mescaline Mescaline Mescaline Mescaline (naturally occurring in the peyote peyote peyote peyote
cactus)
• LSD LSD (lysergic acid diethylamide) – synthesized
synthesized
(tablets, capsules, sugar cubes, or liquefied -
licked from a ‘postage stamp’
• PCP PCP (phencyclidine hydrochloride) - synthesized
synthesized
• Ecstasy Ecstasy

Hallucinogens
• Mode of administration
administration: : orally, in the form
of pills, tablets, capsules, or blotter papers
• Use has decreased with the onset of the
cocaine/crack epidemic

Hallucinogens
Effects of hallucinogens
hallucinogens:
• Disrupt cognition
• Alter consciousness, sensations & perceptions
• Induce visual, auditory, and tactile hallucinations
• The intoxication is a typical example of an acute
psychotic state