*Will not be S U B S TA N C E - R E L AT E D A N D

tested on ADDICTIVE DISORDERS

Gambling
Disorder

CHAPTER 11
WHAT IS A SUBSTANCE USE
DISORDER?
• DSM-5 defines substance use disorders in terms
of maladaptive pattern of behaviors that are
related to the continued use of drugs despite
creating problems for the person, in at least 2 of
these 4 categories within a 12 month period:
– Inability to control use of drug
– Risky use of drug
– Tolerance/Withdrawal
– Social Impairment
HISTORY OF THE DSM
• In the DSM-IV-TR, Substance Use Disorders had
two categories
– Substance Abuse
– Substance Dependence (more severe)
• Due to some confusion, this distinction was
eliminated
• Now, Substance Use d/o are on a scale: Mild,
Moderate, or Severe, depends on # of symptoms
 OVERVIEW
• Abuse of alcohol and other drugs remains a serious problem
worldwide
• According to the WHO, alcohol use was responsible for 5% of
the total burden of disease and disability worldwide in 2004
• Cirrhosis of the liver, often a result of chronic alcoholism, is a
leading cause of death in the US
• Tobacco is expected to kill between 8-9 million people
annually worldwide
– More than any single disease, including AIDS
OVERVIEW
• Addiction is a term frequently used, and refers to severe
substance use problems and chemical dependence
• Psychoactive substances are chemicals that alter a
person’s mood, level of perception, or brain functioning
• All drugs of abuse can be used to increase a person’s
psychological comfort level (to be made “high”) or to alter
levels of consciousness
– Can refer to drugs that are legally available (i.e. prescriptions) or
those that are illegal
TYPES OF SUBSTANCES
• Depressants of the central nervous system (CNS) slow
physiological functioning and include alcohol,
medications designed to help people sleep (called
hypnotics), and anxiolytics or sedatives for relieving
anxiety
• Stimulants amplify physiological functioning of CNS,
and include nicotine, caffeine, amphetamine, and cocaine
• Opiates (also called narcotic analgesics) can be used
clinically to decrease pain, such as codeine and morphine
TYPES OF SUBSTANCES

• Cannabinoids, such as marijuana, produce

euphoria, altered sense of time, and hallucinations
at higher doses
• Polysubstance abuse refers to the idea that people
with a substance use disorder frequently abuse
several types of drugs
 SYMPTOMS
• Craving refers to a forceful urge to use a drug, but often
people report needing to take the drug to control how they are
feeling (to relieve negative moods or avoid withdrawal
symptoms)
• Withdrawal-The symptoms experienced when a person stops
using a drug, can last several days
– Symptoms of withdrawal are different for different types
of substances
• Unpleasant reactions are most evident during withdrawal from
alcohol, opioids, sedatives, hypnotics, and anxiolytics.
• Withdrawal symptoms are not often seen after repeated use of
hallucinogens, and have not been demonstrated with PCP
SYMPTOMS
• Tolerance refers to the process through which the nervous
system becomes less sensitive to the effects of alcohol or
any other drug of abuse
– More drug is needed to achieve the “desired effect” (buzz,
high, drunk, etc.)
• Metabolic tolerance develops when repeated exposure to a
drug causes the liver to produce more enzymes that are
used to metabolize (break down) the drug
– So drug is metabolized more quickly and person has to take
larger doses to maintain same level
• Pharmacodynamic tolerance occurs when receptors in the
brain adapt to continued presence of the drug
PSYCHOLOGICAL
DEPENDENCE
• The following are examples of Psychological
Dependence. The key is consistency.
• Using a substance to help with negative moods
• Using a substance after a bad day
• Using a substance to ignore problems
• Using a substance to “numb” oneself
• Using a substance while alone
• Using a substance on more days than not
DO ALL SUBSTANCES HAVE
WITHDRAWAL SYMPTOMS?
 ALCOHOL USE DISORDER
COURSE & PREVALENCE
• The most common Substance Use d/o
• Research shows that individuals usually alternate
between relative abstinence and heavy use periods
• 30% lifetime prevalence of AUD
– ONLY 24% of these ever received treatment
• Older people do not consume as much as younger people
 ALCOHOL USE D/O –
COURSE & PREVALENCE
• More than 88,000 die from alcohol-related causes
each year in the US
– 3rd leading cause in the country (1st-tobacco, 2nd diet)
• In the US, around 15 million people had AUD in 2016
• Globally, alcohol misuse is the seventh leading risk factor
for premature death and disability
• At least 60% of US women drink alcohol occasionally, but
develop fewer AUDs than men
Figure 11.4 Gender Differences in Substance Use Disorders Lifetime prevalence of substance use
disorders in the United States.
Source: Based on Agrawal, A., Heath, A. C., & Lynskey, M. T. 2011. DSM-IV to DSM-5: The impact of proposed
revisions on diagnosis of alcohol use disorders. Addiction; 106: 1935–1943.
ETIOLOGY: GENES
• Males: MZ = 56% DZ = 33%
• Females: MZ = 30% DZ = 17%
 MZ concordances are higher than DZ
concordances
 Higher concordance rates in male twins
reflect higher rates of alcoholism among
men
• 2/3 of the variance in risk for alcoholism is
thought to be due to genetic factors
ADOPTION STUDY

• Biological Factors
– Genetics of Alcoholism
– The offspring of alcoholic parents, who
are reared by nonalcoholic adoptive
parents, are more likely than people in
the general population to develop
drinking problems.
ETIOLOGY: SOCIAL FACTORS
• Culture or religion could influence how early
someone is exposed to alcohol, as well as their
attitudes toward drinking
• Initial experimentation more likely among
those who are rebellious, extraverted, and if
parents or peers model/encourage use
• In families where parents abuse alcohol -
unpleasant emotional environment and low
parental monitoring may increase risk that
children will affiliate with peers who use drugs
ETIOLOGY: PSYCHOLOGICAL
FACTORS/EXPECTATIONS
• Alcohol enhances social and physical pleasure
• Alcohol enhances sexual performance
• Alcohol improves mood
• Alcohol reduces tension
• Alcohol increases social assertiveness
• Alcohol is cool
• Drinking alcohol is an American pastime
MORE PSYCHOLOGICAL FACTORS

• Positive expectations have stronger influence on

increased drinking than negative expectations
have on decreased drinking
• Parents, peers, and media may influence
adolescents’ expectations of alcohol
– More than 10% of US children live with a parent
w/Alcohol problems (2017)
• Adolescents who experiment with alcohol and
have more positive expectations consume
greater amounts of alcohol
AMPHETAMINE & COCAINE
• Psychomotor stimulants produce effects by simulating
actions of neurotransmitters like dopamine, epinephrine,
norepinephrine, and serotonin
• Cocaine is a naturally occurring stimulant that is extracted
from a plant
• Amphetamines (such as Dexedrine and methamphetamine)
are produced synthetically
• Stimulants can be taken orally, injected, or inhaled
• Slower absorption and less potent when taken orally, faster
and dramatic effects when injecting or inhaling it
OPIATES
• Opiates are drugs that have similar properties to those of
opium (which comes from poppy)
• Main active ingredients in opium are morphine and codeine,
both of which are used in medicine to relieve pain
• “Opioids” are synthetic versions of opium, and often used to
reduce pain (OxyContin, Vicodin, Percocet, etc.)
• Heroin is a synthetic opiate that is made by modifying the
morphine molecule
• Opiates can be taken orally, injected, or inhaled; opium is
sometimes eaten or smoked
• People who abuse morphine often inject it because it leads
more quickly to high brain tissue concentration
SEDATIVES, HYPNOTICS, &
ANXIOLYTICS
• Tranquilizers are used to decrease anxiety or agitation
• Hypnotics (such as Ambien, Lunesta) are used to help
people sleep
• Sedative is a general term that describes drugs that calm
people or reduce excitement
• Barbiturates (such as Nembutal, Amytal) were used to
treat chronic anxiety
• Benzodiazepines (such as Valium, Xanax) are used more
than barbiturates due to lower potential for producing a
lethal overdoes
 CANNABIS
• Marijuana and hashish are derived from the hemp plant,
cannabis sativa
• Most common active ingredient in cannabis is delta-9-
tetrahydrocannabinol (THC)
• Marijuana refers to the dried leaves and flowers, which can be
smoked in a cigarette or pipe or baked in brownies and ingested
orally
• Hashish refers to the dried resin from the top of the female
cannabis plant, can be smoked or eaten
• Oral (eaten) administration of cannabis material leads to slow
and incomplete absorption, so dose must be two or three times
larger to achieve same subjective state as if it were smoked
• Most of the drug is metabolized in the liver
HALLUCINOGENS AND
RELATED DRUGS
• Cause people to experience hallucinations and at relatively low doses
• Most common is the synthetic drug LSD, which bears a strong
chemical resemblance to serotonin
• Psilocybin is another type of hallucinogen found in certain types of
mushrooms
• Mescaline resembles norepinephrine and it is the active ingredient in
the cactus peyote
• MDMA (ecstasy/molly) is sometimes also listed as a stimulant, and is
one of several synthetic amphetamine derivatives
• PCP is another synthetic drug and was originally developed as a
painkiller; can induce psychotic behavior, manic excitement, catatonic
motor behavior, and sudden mood changes
TREATMENT
• Detoxification
– Removal of the drug for 3 to 6 weeks
– Marked withdrawal symptoms
• Medications given to reduce risks and symptoms
– Dusulfiram (Antabuse) – causes illness if alcohol is
consumed
– Naltrexone (Revia) – helps reduce cravings
(GABA agonist, which produces feelings of
calmness)
– SSRIs (Prozac, etc.) useful in clients who are also
depressed, which is common
TREATMENT METHODS
• Most common is Abstinence
– “Disease model”
– All or nothing (nothing being the goal)
• Moderation/Harm Reduction
– Reducing harm (5x/week to 2x/week)
– Better than keeping current level
– Some are not capable of this
CONSIDERATIONS
• Motivation
– Treatment is usually NOT voluntary, unlike
other disorders
• Legally/socially/occupationally required
• Forced
• Friends/Family factors
• Stages of Change
• Motivational Interviewing
STAGES OF CHANGE
MOTIVATIONAL INTERVIEWING
• Developed by William R. Miller and Stephen Rollnick in
1983
• “…a collaborative, person-centered form of guiding to elicit
and strengthen motivation for change.” (2009)
• Stages include
– Identification (e.g., stages of change, situations)
– Examination (e.g., ambivalence, incongruencies)
– Resolution
MOTIVATIONAL INTERVIEWING
• What is a person-centered approach?
– Collaboration (vs. Confrontation)
– Evocation (vs. Drawing Out, Rather than Imposing
Ideas)
– Autonomy (vs. Authority)
• The OARS acronym
– Open ended questions
– Affirmations
– Reflections
– Summaries
• Focusing on “Change Talk”
MOTIVATIONAL INTERVIEWING
• DARN CAT
– Desire (I want to change)
– Ability (I can change)
– Reason (It’s important to change)
– Need (I should change)

– Commitment (I will make these changes)

– Activation (I am ready, prepared, willing to change)
– Taking Steps (I am taking specific actions to
change)
12-STEP MODEL TREATMENT
• 12-step facilitation program
– Peer led program, focus on principles to
maintain abstinence
– Has a group component with an individual
sponsor
– Strong “spiritual” component
– Started in 1935 with AA
• Has been expanded to many other behaviors
• NA, CA, CoDA, Al-Anon, SA, etc.
12-STEP MODEL TREATMENT
• Research Support
– Retention is low
– 1/3 of people leave after 1 month
– ½ leave after 3 months, leaving 1/6, or
0.1667%
– Not usually useful on its own
• Useful as an add-on to another treatment
method (counseling, medicine, groups)
 COGNITIVE-BEHAVIORAL
THERAPY (CBT)
• Behavioral component
– Identify situations that maintain use, for example:
• Triggers (time, day, smell of smoke)
• Emotions (anger, sadness, anxiety)
• Cravings (feeling like someone NEEDS it)
– Self-monitoring is key
Urges to Use Actual Drink/Drug Use
Time Strength Trigger Time Type Amount Trigger

6:30 3 End of
work
9:45 alcohol 3 beers Football
game
MORE CBT
Once identified, interventions are put in place
• People, places, and things
• Avoid situations where use is likely to happen
– Don’t go to bars
– Don’t hang out with people who use
• Social support
– Tell people you don’t want to use
– Have non-using friends to hold you accountable
MORE CBT
• Relapse Prevention
– Relapse is part of the stages of change
– Help the person deal with life’s challenges
without substances
– Work on adaptive (positive) coping skills
• Abstinence violation effects (lapse vs.
permanent)
– Reducing guilt is key, optimism vs. pessimism
LONG TERM OUTCOMES OF
ADDICTION TREATMENT
• Although improvement usually persists after
treatment, relapse is common
• Research evidence suggests that no one treatment is
clearly superior to others.
• Improvements in general health, social, and
occupational functioning usually accompany
reduction in drug use
• Long-term outcome is best predicted by the person's
coping resources, social support.
RESOURCES
• Counseling Center on Campus (UC 3400)
• Andrews Center
• UT Health Behavioral Health Center