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

Transcription

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

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

3 Substances In the DSM-IV-TR, the term substance can refer to: a medication a toxin a drug of abuse

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

5 Toxins Toxic 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

6 Toxins Volatile 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

7 Substances of Abuse These are grouped in 11 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

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

9 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

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

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

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

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

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

15 Withdrawal A maladaptive behavioral change, with physiological and cognitive 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

16 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

17 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:

18 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

19 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

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

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

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

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

24 Agonist medication Agonist m. 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.

25 Agonist medication Partial agonist m. 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

26 Antagonist medication Antagonist 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

27 Psychoactive substances CNS Stimulants CNS Depressants Hallucinogens Inhalants

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

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

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

31 Amphetamines Street 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: orally, sniffed, or diluted & injected into the bloodstream

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

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

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

35 Cocaine Street 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: sniffed (snorting it is inefficient), smoked (crack crystals or mixed with other drugs) or IV - smoke or IV injections are preferred by users

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

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

38 Crack Pattern of use: Instant rush (after 30 min.) High lasts for min. Heavy users 1x or 2x/week 2/3 of crack users use daily

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

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

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

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

43 Depressants ( downers ) Types of depressants (continued): Tranquilizers: Minor (Librium) Major (Thorazine, Stelazine)

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

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

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

47 Synthetic Opiate - Methadone Synthetic opiate was developed by the Nazis initially used as analgesic Street names: dollies, done, biscuits Mode of 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

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

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

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

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