Chapter 9: Substance Use Disorders

FACT or CRAP

Over the past few years, alcohol sales have been sharply dropping while sales of wine and hard liquor have been sharply increasing.

FACT What are some possible reasons why? People care more about health, more concerned about

gaining weight, so lower calorie alcohol is more popular (Skinnygirl)

Addiction

Addiction = having a compulsion to engage in a behavior (such as use a drug) and experiencing withdrawal symptoms when the behavior is not engaged in Not a term used by the DSM-5

DSM uses the term “dependence” Addiction is like being caught in quicksand

Let’s write some things people can be addicted to on the next slide. Q: Which addictions are socially acceptable and

which are not?

Types of Addiction:

Let’s make this slide as a class…CaffeineAlcoholNicoteneSocial mediaPornographyOpioids (heroin, etc)EatingTelevision

Contemporary Issue: “Bath Salt” Abuse

Contemporary Issue: “Bath Salt” Abuse

Methylenedioxypyrovalerone More commonly known as MDPV Nicknames = Ivory Wave, Vanilla Sky, Red Dove,

Cloud 9, White Lightning, & many othersActive ingredients federally banned, but…

…the makers of “designer drugs” are usually one step ahead of the law

Very difficult to regulate

Contemporary Issue: “Bath Salt” Abuse

Effect is similar to cocaine or methamphetamineAdverse health consequences:

Tachycardia (rapid heart beat) Hypertension Insomnia Nausea Bruxism Headaches Kidney pain Tinnitus

Can lead to depression, suicide, anxiety & psychosis High doses can lead to severe, prolonged panic attacks

Contemporary Issue: “Bath Salt” Abuse

Questions & comments?Let’s briefly discuss this issue

Another contemporary issue: synthetic cannabis marketed as “incense” Less understood and more dangerous than

marijuana

Salvia Divinorum

Aka “diviner’s sage”Powerful hallucinogenSalvia Divinorum presence on YouTube Used by ~1 million Americans per yearQ: How many of you are familiar with

Salvia?

Contemporary Issue: Salvia Divinorum

Used by Mazatec shamans in Mexico to facilitate shamanic visions in healing or divination rituals NOT intended for recreational use Associated with an intense hallucinatory trip

lasting ~10 minutes Leaves are smoked or chewed

Salvia is associated with “bad trips” and negative experiences when used recreationally

“Molly”

The name is short for “molecule”Pure, crystal or powder form of MDMA

(ecstasy)Ecstasy is usually laced with other

ingredients such as caffeine or methamphetamine Molly is not, however

Most users are 16-24 years of age

Health Consequences of “Molly”

~120% increase in emergency room visits for MDMA over the past several years

Disrupts the body’s ability to temperature Hyperthermia, dehydration, danger of water overdose Liver, kidney, & heart failure

Other health repercussions: Sleep problems Confusion Anxiety & depression Paranoia Bruxism

Another contemporary issue: prescription drug abuse

Commonly abused prescription drugs = Vicodin (opiate, similar to heroine) Oxycontin (opiate)

Has slow release over 14 hours, probably strongest pain reliever

Percocet (opiate) Xanax (benzodiazapene) Adderall (speed) Ritalin (speed)

“deadly cocktails” = combining more than one prescription drug at one time Or combining prescription drugs with other substances

A large number of elderly individuals are addicted to prescription drugs

If Time

Let’s watch a clip (or clips) about prescription drug abuse.

Drug Schedules

Schedule I: Drugs with a high potential for abuse that have no accepted medical use in the U.S. Heroine -MDPV Marijuana -Hashish LSD -Mescaline (~ to LSD) Psilocybin (shrooms) -Rohypnol (roofies) MDMA (Ecstasy) -GHB Q: Is there anything strange about some of the

drugs on this list given the definition of Schedule I?

Drug Schedules

Schedule II: Drug has a high potential for abuse but has a currently accepted medical use with severe restrictions Methadone -Marinol (marijuana pill)

(used to treat heroine, very similar but not as bad) Amphetamine -Percocet Cocaine -Oxycodone Morphine -Ritalin Opium -Methamphetamine Ketamine

Drug Schedules

Schedule III: Has the potential for abuse; currently accepted medical use in the U.S.; moderate to low risk of physical dependence Anabolic Steroids Vicodin Testosterone

Drug Schedules

Schedule IV: Relatively low potential for abuse; currently accepted medical use; limited risk of physical dependence Valium Xanax Phenobarbital Klonopin (anxiety drug) Chloral Hydrate (related to chloroform) Ambien (treats insomnia)

Drug Schedules

Schedule V: Relatively low potential for abuse; currently accepted medical use; abuse has a narrow scope for physical & psychological dependence Robitussin

Another contemporary issue = cough syrup abuse Buprenex Kapectolin PG Thymergix

Activity

Let’s play a game in which I show a famous person and you tell me either their cause of death or the substance they struggled with…

Definitions

Definitions/Levels of Severity: Substance Intoxication Substance Abuse

Maladaptive pattern of substance use leading to clinically significant impairment or distress

Recurrent substance use resulting in failure to fulfill role obligations

Recurrent substance use in situations in which it is physically hazardous

Recurrent substance-related legal problems Continued use despite persistent social or

interpersonal problems

Definitions

*Substance Dependence Maladaptive pattern of substance use, leading to clinically

significant impairment or distress Tolerance

Need for increased amounts to achieve same effect Diminished effect with continued use of same amount of the substance

Consuming more than was originally intended Persistent desire or unsuccessful attempts to control

use Spending a great deal of time on acquiring, using, or

recovering from the substance Important social, occupational, or recreational

activities are given up or reduced due to substance use Substance use is continued despite persistent problems Withdrawal

Definitions

Definitions continued: Substance Withdrawal

Development of a substance-specific syndrome due to cessation or reduction of substance use that has been heavy & prolonged

Causes clinically significant distress/impairment Physical vs. psychological dependence

Physical dependence involves physiological withdrawal symptoms

Class Activity

What constitutes a “standard drink”? http://www.alcohol.org.nz/alcohol-you/whats-

standard-drink/can-you-pour-standard-drink-game

History of Alcohol Use

Humans have been consuming alcohol since before recorded history

18th Century England Cheap gin from distilleries → widespread consumption

& drunkenness among lower and working classes The rich mostly drank wine

Colonial America Drinking was acceptable

Alcohol was safer than unpurified water or milk Drunkenness was not acceptable, however Even children drink alcohol

History of Alcohol Use

19th Century: Prohibition movement Alcohol was snubbed by middle and upper classes Alcohol use confined to saloons

1919: 18th Amendment Outlawing alcohol Q: What were some problems with this?

1934: 21st Amendment repealed the 18th amendment

Alcohol consumption peaked in ~1830Modern alcohol consumption peaked in

~1980 Has been slowly declining ever since

Contemporary Alcohol Use

~61% of adult Americans are current drinkers 20% engage in binge drinking

Definition = Heavy alcohol consumption in a relatively brief period of time

Aka “heavy episodic drinking” ~5drinks on one occasion for males, ~4for females

European Americans drink more than other ethnicities American Indians have highest rates of binge drinking,

however 25 -44 age range most likely to drink

18 – 24 range most likely to binge drink Q: Why is binge drinking more prevalent among this age

group?

Alcohol Dependence

3 stages of alcoholism Use Abuse/Dependence Complete loss of control

The Stages of Alcoholism(these stages can be applied to any addiction,

however)

Stage 1: Increased use Increasing tolerance Lack of recognition that a problem may be

developing Actively seeking out drinking opportunities Drinking stops being social and starts becoming a

psychological escape

The Stages of Alcoholism

Stage 2: *This stage is the best opportunity for

intervation Denial Increasing health problems & blackouts Experiencing losses (job, relationships, control,

etc.) Blaming problems on others Sneaking drinks Guilt and shame Unsuccessful attempts to stop drinking

The Stages of Alcoholism

Stage 3: Complete loss of control Slowly drinking oneself to death Avoiding friends and family Drinking in the morning

I once had a client who would gargle with alcohol Serious life functioning problems Aggressive behavior Tremors Loss of interests Legal & health problems Unreasonable resentments

Alcohol Dependence

Alcohol Withdrawal = Sweating Hand tremor Insomnia Nausea Hallucinations Anxiety Grand mal seizures

The importance of detox

Blackouts

Occurs when excessive alcohol consumption overloads the hippocampus in the brain Become temporarily incapable of forming new

memories Like a video camera that is working but not

recording anything Similar to “anterograde amnesia”

2 kinds of “blackouts” Fragmentary

Partial memory loss for a given time period Enbloc

Complete memory loss for a given time period

Blackouts

People who have “blacked out” still function but have no control over themselves & no memory of their behaviors Anecdotes about client experiences with blackouts

Popularity of Drinking

Q: Why is drinking popular? William James, from The Varieties of

Religious Experience (1902): “The sway of alcohol over mankind is

unquestionably due to its power to stimulate the mystical faculties of human nature, usually crushed to Earth by the cold facts and dry criticisms of the sober hour. Sobriety diminishes, discriminates, and says no; drunkenness expands, unites, and says yes.”

Altered States of Consciousness:

“…our normal waking consciousness…is but one special type of consciousness, whilst all about it, parted from it by the filmiest of screens, there lie potential forms of consciousness entirely different. We may go through life without suspecting their existence; but apply the requisite stimulus, and at a touch they are there in all their completeness…No account of the universe in its totality can be final which leaves these other forms of consciousness quite disregarded”

-William James

Cannabis Dependence

No physical withdrawal Very psychologically addictive, however

THC stays in one’s system for a very long time Stored in fat

Marijuana is legal for medicinal use in many states

Trivia Q: In which 2 states is marijuana legal for recreational use?

How Long Does THC Stay in One’s System?

Varies based on weight, body fat %, frequency of use, amount used, & potency

General guidelines One use: 1-6 days Moderate use: 7-13 days Frequent use: 14-30 days Heavy use: 30+ days; as long as 3 months for long

term users

Cocaine/Crack

Cocaine/crack stimulates the Central Nervous System

Withdrawal symptoms = Dysphoric mood Fatigue Vivid, unpleasant dreams Insomnia/hypersomnia Increased appetite Psychomotor agitation or psychomotor

retardation Depression

Opioid Dependence

Includes heroin, OxyContin, morphine, methadone, & many others

Heroin withdrawal = “Flu-like” symptoms

Goose bumps Sweating Fever Nausea Abdominal cramps Diarrhea Agitation/restlessness Insomnia Dysphoric mood

Tx’s for Heroin

Methadone clinics Similar to heroin, not as dangerous

Suboxone Medication to treat heroin

Tx for Substance Abuse

The “Old School” Way: Shame and blame Boot camp mentality “Scared straight” Q: What are some problems with this approach?

Preferred Contemporary Tx = Motivational interviewing

Motivational Interviewing (MI)

READS Roll with resistance Express empathy Avoid argumentation Develop discrepancy

Point out discrepancy between actions/behaviors and goals (how behavior is countered to their goal, let them make the connection)

Support self-efficiancyHelps people to progress to a higher stage of

change

Remember the Stages of Change

General Tx for Substance Abuse

Group therapy & support groups such as Alcoholics Anonymous & Narcotics Anonymous

Levels of care (PCPC): Outpatient Intensive Outpatient (IOP)

I ran an IOP group on my post-doctoral internship Halfway House Medically Monitored Detox Inpatient

E.g. White Deer Run Medically Monitored Inpatient

Addendum: Energy Drinks

The information in this section is from Wimer & Levant (2013)

Energy Drinks

Definition = Beverages purported to boost mental & physical energy that contain high amounts of caffeine

Originated in Japan in 1962 The first energy (or “genki”) drink = Lipvitan-D

Increased in popularity when Red Bull hit the market in 1997

Now: $2.3 billion in sales per year & growing#1 market =young people (esp. young men)

Problems

Energy drinks are poorly regulated in the USA compared with other countries Companies are not required to display the actual

caffeine content on labels People don’t know what they’re really drinking

Aggressive marketing campaigns give people misconceptions Energy drinks are NOT good for athletic activity

Diuretic

Health Problems

Caffeine toxicity & poisoningMental health symptoms = anxiety, insomnia,

tachycardia, tremors, psychomotor agitation, & even death

Three most serious health problems: Dehydration during athletic involvement Combining energy drinks w/alcohol Increased propensity for violent behavior

Energy Drinks & Alcohol

Reduces one’s perception of intoxication without reducing cognitive & motor impairment

People do not feel as drunk as you really are More likely to drive a car, etc.

Energy Drinks & Violent Behavior

Energy drink use is associated with a greater likelihood of engaging in violence One reason = facilitates longer involvement in late

nighttime situations with more opportunities to engage in problematic behaviors

Questions & Discussion