Substance induced disorders: secondary to substance use (eg withdrawal, psychosis, persisting dementia or amnestic disorders, etc). Require evidence of substance use and are not related to pre-existing problems
Abuse vs. dependence:
Abuse implies use is causing job, social, legal or physical problems or impairing function in some way
Dependence (a step worse) requires signs of withdrawal and tolerance
Used to be a definition for „the addictive personality type‟: but research has shown no consistent correlation with the proposed criteria
Substance Abuse
A maladaptive pattern of substance use leading to significant impairment or distress, manifested by one (ie fairly low threshold) or more of the following occurring in the same 12 month period:
Recurrent substance use resulting in a failure to fulfil major role obligations at work, school or home
Recurrent substance use in which it is physically hazardous (eg driving)
Recurrent substance-related legal problems (eg arrests for disorderly conduct)
Continued use despite it causing or exacerbating persistent or recurrent social or interpersonal problems
Symptoms have never meet the criteria for substance dependence for this class of substance
Substance Dependence
A maladaptive pattern of substance use leading to significant impairment or distress, manifested by three or more of the following occurring in the same 12 month period:
Tolerance: either amounts to achieve intoxication or diminished effect with same amount
Withdrawal: either characteristic withdrawal syndrome for that substance, or the same or a closely related substance is taken to avoid withdrawal symptoms
Substance is taken in larger amounts or over a longer period than was intended
There is a persistent desire or unsuccessful efforts to cut down or control use
A great deal of time is spent obtaining, using or recovering from its effects
Important social, occupational or recreational activities are given up or reduced as a result
Use is continued despite knowing that has caused or exacerbated a physical or psychological problem
5% of 15 year olds meet criteria for alcohol abuse (Fergusson 1994)
Cannabis dependence 7% at 18 years, 10% at 21 years. Higher in males
Co-morbidity or Dual Diagnosis:
Epidemiologic Catchment Area (ECA) Study 1990 found the lifetime co-morbidity of substance use disorders by specific diagnoses:
Those with a mental disorder have twice the risk of an alcohol disorder and 4 times the risk of any other drug disorder
Those with a lifetime alcohol disorder have twice the risk of another mental disorder (37%) and 6 times the risk of another drug disorder (22%)
Those with a lifetime other drug disorder have a 4 times risk of another mental disorder (53%) and 7 times the risk of an alcohol disorder (47%)
Co-morbidity is higher in institutional settings (70- 80%) than in the community
Þ Dual diagnosis is an expectation not an exception
Models of Aetiology of Addiction
Disease model: emphasises the biological and genetic basis of addition. Loss of control is a central feature
Self-medication hypothesis: use specific pharmacological effects to self medicate for psychological disturbance and painful affects
Biopsychosocial model: Multifactorial causality, interaction of genetic predisposition, biological factors, and psychological and sociocultural factors
Biological model: impact on mesolimbic reward system – extends from the ventral tegmentum to the nucleus accumbens, with projections to areas such as the limbic system and the orbitofrontal cortex
Factors influencing behaviour*
Early childhood learning: modelling by parents and significant others
Current environment: reinforcement or punishment for different practices (especially if immediate)
Views/knowledge/beliefs about risk: usually over-rate our health and under-rate the risks
Our resources (usually an excuse)
Physical environment (work/home)
Social influences (friends/media)
History Taking
Attitude of interviewer important: non-judgemental, empathic, detached, normalising behaviour, start estimates of use at a high level, person can then say „no, not that much‟ – feels less judgemental
Often illegal: won‟t tell unless good rapport
Signs of Substance Abuse
Changed behaviour
Skipping work/school
Drug seeking behaviour
Money problems
Relationship problems
Questions:
Reason for presentation
Which drugs
Ever intravenous
What are the useful effects – why do you continue to use
Quantity and frequency, pattern of use (regular or binge)
Cost per week
Duration of use, age at first use, reason for first use
Heaviest use
Have you or others ever been concerned about your use
Attempts at cutting down and duration of abstinence, what made you start again
Problems associated with use, including relationships, job, legal considerations, etc
Any withdrawal effects
Past treatment and outcome, what was and wasn‟t helpful
Relationship to psychiatric symptoms. Do they drink when they‟re anxious? Have panic attacks followed drug use, etc
If alcohol, ever been in an accident, had a head injury or fracture
Medical history, psychological history, social situation
Family History: check psych, suicide and A&D history
Corroborative interview
Drug users have high mortality: health consequences, accidents, suicide, high-risk neighbourhoods, etc
Blood tests for drug levels: benzodiazepines & morphine levels
Cannabis: creatinine/cannabis ratio over time
If any intravenous use check for viral serology: Hep B, C, HIV
Urine tests: useful for tracking abstinence, but not reliably effective as a treatment strategy. Can do a full drug screen (drugs + prescription medications) for $160. Verification of sample source is important – minimise the risk of substitution (eg giving you someone else‟s urine sample).
Drugs of Abuse
If therapeutic index is wide, then it‟s good for addiction: good effect but few side effects
IV drugs: opiates, speed, and benzodiazepines. Health risks include infection and non-infectious sequalae
Marijuana
Ecstasy – amphetamine (party scene)
Fantasy – GHBA
Solvents: younger, failing at school, worried parents, neurological impairment
Tobacco
Dependence resulting from various drugs
Cannabis/Marijuana
Psycho active ingredient is D9 tetrahydrocannabinol (D9 THC)
Receptor targets in the CNS = CB1, in PNS = CB2
Synthetic cannabinoid drugs used therapeutically for appetite stimulation (eg in cancer), anticonvulsant/antispastic, analgesic
Effects:
Minimal for occasional use, greater for longer-term heavy use
Respiratory system: hot irritating smoke ® all the effects of cigarette smoke (inflammation, mucus, thickened basement membrane, squamous cell metaplasia, destruction of cilia)
CNS: enhanced feelings of well being, disputed dose-dependent effects – reduction in energy, drive and motivation, psychosis, ¯learning and attention, dependence with associated social and psychological dysfunction, acute adverse reactions (eg anxiety/panic attacks)
Treatment of Substance Abuse
Treatment Rationale
Treatment must be for underlying addictive disorder, not just detoxification and withdrawal
Addiction is a chronic not acute illness. Requires long term follow-up and behaviour modification (as with diabetes and hypertension)
Often unsympathetic response because addiction is perceived as self-afflicted: but there are numerous involuntary components in the addictive process. Loss of voluntary control turns a drug misuser into drug addicted. There is a compulsive, often overwhelming, involuntary component
Involves genetic, biological, behavioural and environmental components
Success rate for treatment depends on type of drug and variables inherent in the population being treated (e.g. better for professionals than for poorly educated). Nicotine has the poorest success rate. Success rates are comparable with other chronic diseases
Treatment is cost-effective
Issues In Treatment
Compliance with treatment. Those who comply with treatment have best prognosis – as with other chronic diseases
Who should be involved: multidisciplinary approach
Managing the environment: peer pressure, money, job, supports, triggers to former behaviour, family relationships (can they be helped, education about illness)
The most significant predictor of treatment success is an empathic, hopeful, continuous treatment relationship
Must also treat any co-morbid diagnosis simultaneously
A&D counselling: motivational interviewing, strategies for change, relapse prevention
Psychotherapy: CBT, psycho-education
Self-help groups
Addressing specific issues: grief, anxiety, childhood sexual abuse, sexual assault, anger, relationship problems, parenting issues, financial, housing, employment issues, etc
Readiness to Change/Motivational Interviewing
See Topic: Behavioural Change
Services for dependency
Detox: Kenepuru (inpatient)
AA
Narcotics anonymous
Queen Mary – Hamner: uses 12 step process
Odyssey House (Auckland)
Alcohol and drug service
Making the change
Takes a long time
Involves changing lifestyles, supports, habits
GP can assist with motivation for change:
Methadone Treatment
For opiate addiction
Methadone is highly addictive, but is regular, long acting (a dose a day holds for 24 – 46 hours), free ( ¯crime), legal, more effective taken orally than other opiates, no risks from injection
Doesn‟t give a high – just stops „hanging out‟ (withdrawal)
Has to be taken every day
Can cause high mood, drowsiness, ¯pain, small pupils, constipation, histamine release (sweating, itching, etc), ¯saliva tooth decay, ¯libido – it is a powerful drug
It doesn‟t affect senses, or damage body organs, shouldn‟t affect pregnancy or breast-feeding
Is dangerous in conjunction with tranquillisers and/or alcohol overdose situation (eg vomit and choke while sedated)
Is taken as part of a planned programme, including counselling, to build a life away from opiate abuse – can concentrate on sorting out debt, relationships, etc
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