Substance Abuse
- Substance use – use of a substance in a socially acceptable manner (ie glass of wine at dinner)
- Drug misuse – doc using drugs not for medical use (prescribing drugs w.out seeing pts at a $50 charge)
- Abuse – a maladaptive pattern related to a drug you are using leading to clinically significant impairment or distress as manifested by one or more of the following occuring at any time during the same 12-mo period:
1. Recurrent substant abuse resulting in a failure to fulfill major role obligations at work, school, or home
2. Recurrent substance abuse in situations in which it is physically hazardous – your life or the life of others (ie “I can drive”)
3. Recurrent substance-related legal problems (DWI, PI, etc.)
4. Continued substance use despite having persistent or recurrent social or intepersonal problems
The DSM-IV diagnostic criteria for abuse require evidence of repeated occurences within a 12 month period of possible social, legal, or interpersonal trouble related to the substance.
I. Dependence
- aka “habituation” or “compulsive use”
- Psychological dependence- “I need whisky to speak in front of a crowd” or “I need X medication to sleep at night”
- Tolerance
Metabolic tolerance- liver metabolizes the drug quicker
Pharmacodynamic tolerance- adaptation of cells to drugs
Behavioral tolerance- don’t get the same behavioral response after prolonged use
1. Start drinking – lose inhibitions
2. Continue drinking for a year – need twice the alcohol to lose inhibitions
- Withdrawal or an abstinence syndrome is the appearance of physiological symptoms when the drug is stopped too quickly; usually the manifestations are opposite those of the drug
Ex. Cocaine euphoria, no sleep, no eat, ↑ sex; withdrawal ↑sleeping, eating,
depression, and ↓ sex
- Like tolerance, withdrawal is not an all or none phenomenon and usually consists of a syndrome comprising a wide variety of possbile symptoms, with patterns that are different for opiods, depressants, and stimulants
II. Factors that influence recreational drug use and patterns of use
Factors:
1. The physical reward potential
Feel like you have ↑ power (cowboys losing and the player walks on his broken ankle
Boxer is a young guy with many fractures but keep fighting and tolerate the pain
2. Peer pressure
3. Pleasurable effects
4. Social-learning component of drug use
You drink for the first time and throw up all night; your friends tell you that next time they will teach you how to drink.
5. Individual expectations as a component of drug use
Effects the indiv expects to gain from using the drug (relaxing from pot or halucinations from hallucinogenic drugs)
If they are getting the desired effects they will keep taking it
6. Family dysfunction (emotional, neglect, physical, and sexual abuse) leads to
unhealthy coping mechanisms
Patterns of Use:
- Regular daily intake of large amounts
- Regular heavy drinking limited to weekends- pt goes straight to drinking every fri
- Long periods of sobriety followed by drinking binges
III. Alcohol dependence
Primary vs. Secondary alcoholism
70% are primary (people without psychiatric problems to complicate the drinking prob)
30% are secondary (↑ anti-social personality, personality d/o, and MOOD d/o **TQ**
15-20% of female alcoholics and 5% of males have shown primary mood disorders and secondary alcoholsim
20% of male alcoholics and 5% of female alcoholics have shown anti-social personality disorders and secondary alcoholism; the opposite for females
Less than 10% of alcoholics demonstrate schizophrenia or other psychiatric disorder (Brisque’s hysteria) and anxiety disorders
There are an estimated 16 million people who are diagnosed as alcoholics
Prevalence of Alcohol dependance
- The prevalence of drinking is higher and abstention is lowest in the 21-34 year old range
- From 5-13% of the adult population in the USA will demonstrate alcoholism at some time in their lives
- It is important to recognize that alcoholism is a problem of all ages, all religions, all countries, and both sexes
- Higher rates of alcoholism are associated with….
1. Armed services
2. Lower socioeconomic strata
3. Lower income and education
4. Among Catholics
5. Among French and Irish
** don’t believe this 100%**
IV. Etiology
1. Psychological Theories
2. Pleasure theory- you feel great, powerful, euphoric
3. Defense mechanisms
- Denial- I am just a social drinker
- Projections- my wife brought me here but I don’t know why. Why didn’t she brin gher father…he drinks like a fish
- Rationalization – Yes, I drink, but I have to in order to survive at my stressful job
- Fragmentation – Form of denial. I am not an alcoholic…I have been sober for a week
- Minimization- I drink only a couple of drinks (means ½ bottle of whisky and ½ bourbon / night
V. Sociocultural theory – “you are probably an alcoholic because you have not been properly introduced to drinking (ex. Jewish are formally introduced to alcohol, but the Ashkenazies drink less)
- Biological Theory
- Acetaldehyde forms condensation products with biogenic amines
- Acetaldehyde + NE = TIQ (tetrahydroisoquinoline)
- Acetaldehyde + Dopamine = THP (tetrahydropapaveroline)
- Acvetaldehyde + 5HT = tetrahydro-beta-carbolines
- The TIQ Hypothesis
- Suggests that chronic alcohol use significantly reduces the brain’s production of the endorphins, the enkephalins, and the dynorphins
- TIQ was capable of binding opiate-like receptor sites within the brain’s pleasure center causing the individual to experience a sense of well-being
- TIQ’s effects were thought to be short-lived, forcing the individual to drink more alcohol in order to regain or maintain the initial feeling of euphoria achieved through the use of alcohol
VI. Genetic Factors
- Alcoholism runs in families
- On average about 40% of alcoholics have an alcoholic parent
- 2/3 of the studies reviewed, at least 25% probands have fathers who were alcoholics
- As many as 62% of one set of alcoholics had 1 or more relatives in the preceding 2 generations who had “problems with alcohol”
- Women seem to be more vulnerable than men to the impact of familial alcoholism
- Alcoholism was found more frequently than any other forms of mental illness in relatives of alcoholics
Adoption Studies
Tags: Alcohol dependence, Behavioral tolerance, Defense mechanisms, euphoria, Metabolic tolerance, Pharmacodynamic tolerance, Pleasure theory
