ADDICTION – SUBSTANCE ABUSE

An overview

AHMED ALBEHAIRY, M.DPSYCHIATRY CONSULTANT,

MOH

Essence of Addiction

“Compulsive drug seeking behavior, and use, in the face of negative consequences”

“Physical dependence is not that important”

Drug Abuse and Addiction ResearchThe Sixth Triennial Report to Congress from the

Secretary of Health and Human Services 1999, p.2.

Annual prevalence of global illicit drug use over the period

1998-2001

 

كل أنواع المواد

المخدرة

الحشي

ش

المنشطات

كوكايين

كل األفيونات

هيروين

أمفيتامينات

أكستا سي

عدد المتعاطين )بالمليون(

185.0 147.4 33.4 7.0 13.4 12.9 9.2

نسبة المتعاطين

من إجمالي

عدد السكان

3.1 2.5 0.6 0.1 0.2 0.2 0.15

نسبة  المتعاطين

من إجمالي

عدد السكان

سنة 15أو أكثر

4.3 3.5 0.8 0.2 0.3 0.3 0.22 

المخدر بداية سن

0%

5%

10%

15%

سنة 15-24 سنة 25-34 سنة 35-44 سنة 45-54 سنةفأكثر 55

إستعمالالموادالمغيرللعقلحسبالفئةالعمرية إنتشار

إستعمالالموادالمخدرةوالمسكرة

باإلضطرابات اإلصابة معدلإلستخدام المصاحبة النفسيةداخل للعقل المغيرة الموادالبحث

اإلضطرابات النفسية يستخدمال

يستخدم

المجموع

حدوث إضطرابات نفسية

العدد 561 1001 1562

% 35.9% 64.1% 100%

عدم حدوث أي إضطرابات نفسية

العدد 2305 25646 27951

% 8.2% 91.8% 100% 

Complex Illness Chronic use and abuse Relapsing condition Compulsive seeking and using Loss of control Changes in values Changes in lifestyle Problems in accountability Dishonesty Ambivalence

F1x.2 Dependence syndrome

Other Types of Addiction

Gambling/Eating/Internet/sex

Comorbidity

Substance Abuse in Suicide ADHD Chronic Pain Management Psychosis Among Substance Users. The Anxiety AIDS Care The Association Between Cannabis and

Alcohol Use and the Development of Mental  

Pathogenesis of Addiction

Etiological Factors

BIO

PSYCHO

SOCIAL

SPIRITUAL

( Multifactorial)

Biological aspects of addiction

- Reward circuits : DA mesolimbic pathway.

- Neurotransmitters of reward circuits: DA, CB1,2, U ENK,BZD-A, GABA, NMDA, m- Glu, Ach, 5HT, NA.

- VTA, NA, Amygdala, thalamus, DLPF, OFC.

- Bottom up, and Top down.- Molecular Mechanisms of Neuroadaptation

Neurobiology of addiction and seeking , motivational , learning , related memory .

Addiction: Dysregulationin the Motive Circuit

Stage 1: Acute Drug Effects

Stage 2: Transition to Addiction

Stage 3: End-Stage Addiction

The Neurobiologyof Adaptive Behavior

Dopamine can be seen as serving two functions in the circuit:

1) to alert the organism to the appearance of novel salient stimuli, and thereby promote neuroplasticity (learning), and

2) to alert the organism to the pending appearance of a familiar motivationally relevant event, on the basis of learned associations made with environmental stimuli predicting the event.( cues).

The orbitofrontal cortex and the anterior cingulate gyrus, which are regions neuroanatomically connected with limbic structures, are the frontal cortical areas most frequently implicated in drug

addiction.These regions are also involved in higher-order

cognitive and motivational functions, such as the ability to track, update, and modulate the salience of a reinforcer as a function of context and expectation and the ability to control and inhibit prepotent responses.

These results imply that addiction connotes cortically regulated cognitive and emotional processes, which result in the overvaluing of drug reinforcers, the undervaluing of alternative reinforcers, and deficits in inhibitory control for drug responses. These changes in addiction, which the authors call I-RISA (impaired response inhibition and salience attribution), expand the traditional concepts of drug dependence that emphasize limbic-regulated responses to pleasure and reward.

(Am J Psychiatry 2002; 159:1642–1652)

The Neural Basis of Addiction:A Pathology of Motivation and Choice

Cellular adaptations in prefrontal glutamatergic innervation

of the accumbens promote the compulsive character of

drug seeking in addicts by decreasing the value of natural

rewards, diminishing cognitive control (choice), and enhancing glutamatergic drive in response.

The Amygdala

The Amygdala is especially critical in establishing learned associations between motivationally relevant events and

otherwise

neutral stimuli that become predictors of the

event.

A Hijacking of Neural SystemsRelated to the Pursuit of Rewards

An explanation of addiction - long-term memories persist for many years

or even a lifetime . From this point of view, sensitized dopamine responses to drugs and

drug cues might lead to enhanced consolidation of drug-related associative memories,

but the persistence of addiction would seem to be based on the remodeling of synapses and circuits that are thought to be characteristic of long-term associative memory .

Potential Psychotherapeutic Targets

These include drugs that 1) decrease the motivational value of the drug, 2) increase the salience and

motivational value of nondrug reinforcers,

or 3) inhibit conditioned responses to stimuli predicting drug availability.

Addiction as a Brain Disease

Am J Psychiatry 155:6, June 1998EDITORIAL, THOMAS R. KOSTEN, M.D.

Will these demonstrations that addictive disorders are genetically influenced brain diseases persuade our

leaders and fellow citizens that these patients deserve the same level of compassion and treatment as is provided to other medical patients? Not without our help in educating them.

Management of Addiction

Assessment . Bio psycho social

Intervention bio psycho social

Follow up and maintenance

Implications for Treatment

Must restore Medical integrity Personal integrity Social integrity

Psychopharmacological Treatment of patients - Symptomatic detox treatment . Physical, psychological- Anticraving.- Antagonist.- Partial agonist.- Agonist or replacement.

Alcohol

- Benzodiazepine, chlordiazepoxide 5-20 mg three or four times daily.

- Antiepileptic ;carbamezapine .

- vitamin B, thiamine , wernick’s encephalopathy respectively.

Alcohol

-Naltrexone .At night , after meal, liver-Acomprosate. Campral 333mg, 2-1-1, renal , diarrhea, headach-Disulfram.500mg for 1st wk then 250mg, nausea,

metronidazole-Topramate.

opiate

- Alpha 2 agonist, naltrexone.

- symptomatic treatment .

- Naltrxone, xr.

- buperinophin, withdrawel, maintenance.

Cocaine & amphetamine

Antidepressants

Antiepileptic

Cocaine vaccine.

Nicotine - Symptomatic

- varencelline , chantix. Patial agonist, alpa2 B4. 0,5mg / day and in wk inc to 1mg/day

- wellbutrin. depression, suicidal thoughts, and

suicidal actions

- Nicotine replacement.

BZD, BARBITURATE

Symptomatic.

Taperring.

Vitamine B

antiepileptic.

Cannabinoids, hallucinogen, PCP, inhalent,

- Supportive .

- antidepressants.

- Antipsychotic.

Tools of managing self efficacy in addict

- Individual psychotherapy .- Group .- Team work.- Motivational skills.- Ex addict .- Family involvement.- Relapse and lapse investigations.

Self efficacy and solve problem - Psycho education - Anticipation of risky situations .- Discussion ??????- Training , motivation.- List of problems - Prioritize the problems .- Analysis of the problems.( cognitive

errors and other related psychosocial issues).

Problem solving

- Alternative solutions.- Choose the suitable solution ( with,

against, and key persons).- Test the solution .- Approve the solution or choose

other alternative.- Recycle and repeat.

Types of problems to be solved

- cues.- Craving - Psychiatric disorders.- Medical disorders.- Legal problem.- Family .- financial.

Self efficacy and problem solving mean

Continous motivation for change of - Attitude .

- Thoughts .

- Mood .

- Behavior .

The Stages of Change are:

Precontemplation (Not yet acknowledging that there is a problem behavior that needs to be changed)

Contemplation (Acknowledging that there is a problem but not yet ready or sure of wanting to make a change)

Preparation/Determination (Getting ready to change)

Action/Willpower (Changing behavior) Maintenance (Maintaining the behavior

change) and Relapse (Returning to older behaviors and

abandoning the new changes)

Possibility of relapse in addiction therapy

Relapse prevention

Key Themes in Relapse Prevention

1- identify risk relapse factors and develop strategies to deal with.

2- understand relapse as a process and as an event.

3- understand and deal with cues and cravings.

4- understand and deal with social pressures to use substance.

5- develop and enhance a supportive social network.

Key Themes in Relapse Prevention

6- develop methods of coping with negative emotional states.

7- assess the pt. for co morbid psychiatric disorder.

8- help and learn the pt. methods to cope with cognitive distortions.

Relapse warning signs!!!????

- Attitude changes.

- Thoughts changes.

- Mood changes.

- Behavior changes.

Cognitive behavioral model of the relapse process

High risk situations

Coping response

IncreasedSelf efficacy

Decreased Probability Of relapse

NoCoping

response

Decreased Self efficacy

Initial use Of

substance

AVE

disonance conflicts

Self attribution

Increased Probability

Of relapse

Family intervention in addiction treatment

- F Counseling- Enabling, coping with relapse and

craving.

- F therapy

Family Therapy confessions and confrontations. Parenting skills. Discussions skills. Solving problem skills. Anger management in the family. Family firmness. Therapeutic alliance ( patient ,

family and therapists).

Thank you