Substance Use Substance Use DisordersDisorders

Substance Use DisordersSubstance Use Disorders A maladaptive pattern of substance use A maladaptive pattern of substance use

leading to clinically significant social, leading to clinically significant social, emotional, or occupational impairment or emotional, or occupational impairment or distressdistress

Substance DependenceSubstance Dependence Tolerance, as evidenced by eitherTolerance, as evidenced by either

A need for more of the substance to achieve A need for more of the substance to achieve intoxication or the desired effectintoxication or the desired effect

Diminished effect with continued use of the same Diminished effect with continued use of the same amountamount

Withdrawal, as evidenced by eitherWithdrawal, as evidenced by either Characteristic withdrawal symptoms for the Characteristic withdrawal symptoms for the

substancesubstance The same or a different substance is taken to The same or a different substance is taken to

relieve or avoid withdrawal symptomsrelieve or avoid withdrawal symptoms

Substance DependenceSubstance Dependence

Must meet 3+ symptoms during a 12 month periodMust meet 3+ symptoms during a 12 month period

ToleranceTolerance

WithdrawalWithdrawal

Substance is taken in larger amounts or for longer periods Substance is taken in larger amounts or for longer periods than intendedthan intended

Persistent desire and unsuccessful efforts to cut downPersistent desire and unsuccessful efforts to cut down

A lot of time is spent getting, using or recovering from useA lot of time is spent getting, using or recovering from use

Important social, occupational or other activities are given Important social, occupational or other activities are given up because of useup because of use

Use is continued despite significant negative consequencesUse is continued despite significant negative consequences

Robert Downey, Jr.Robert Downey, Jr. It’s like I’ve got a gun in my mouth, It’s like I’ve got a gun in my mouth,

and my hand on the trigger and I like and my hand on the trigger and I like the taste of the gunmetalthe taste of the gunmetal

Substance AbuseSubstance Abuse

Must meet one or more symptoms during a 1 year Must meet one or more symptoms during a 1 year periodperiod

Recurrent use resulting in a failure to meet major role Recurrent use resulting in a failure to meet major role obligations at work, school, or homeobligations at work, school, or home

Recurrent use in situations where it is physically hazardousRecurrent use in situations where it is physically hazardous

Recurrent substance-related legal problemsRecurrent substance-related legal problems

Continued use despite having persistent or recurrent social Continued use despite having persistent or recurrent social or interpersonal problemsor interpersonal problems

CausesCauses Genetics (Marc Schuckitt)Genetics (Marc Schuckitt)

227 sons of alcoholics & 227 matched controls at 227 sons of alcoholics & 227 matched controls at age 20age 20

Administered alcoholAdministered alcohol Sensitivity to alcohol assessedSensitivity to alcohol assessed

Subjective rating: How High are You?Subjective rating: How High are You? Objective measure: Body SwayObjective measure: Body Sway

Interviewed 10 years later re: symptoms of alcohol Interviewed 10 years later re: symptoms of alcohol dependencedependence

GeneticsGenetics% of men who met criteria

for alcohol abuse or dependence

34%

13%

0%

10%

20%

30%

40%

Family History+ for

Alcoholism

Family History- for

Alcoholism

% of men who met criteria for alcohol abuse

or dependence43%

11%

0%

10%

20%

30%

40%

50%

20% withthe LowestResponse

20% withthe HighestResponse

CausesCauses BiologicalBiological

Areas associated with drug rewardAreas associated with drug reward Ventral Tegmental Area (VTA) in the Ventral Tegmental Area (VTA) in the

brainstem brainstem Nucleus Accumbens (NA) in the Nucleus Accumbens (NA) in the

midbrainmidbrain

VTA projects to the the NAVTA projects to the the NA

CausesCauses Drugs of Abuse produce their rewarding Drugs of Abuse produce their rewarding

effects by increasing dopamine in the effects by increasing dopamine in the Nucleus Accumbens, either byNucleus Accumbens, either by

Stimulating the VTA to release dopamine onto Stimulating the VTA to release dopamine onto the cells of the NAthe cells of the NA

Directly exciting the receptors in the NA Directly exciting the receptors in the NA

Blocking reuptake of Dopamine in the NABlocking reuptake of Dopamine in the NA

CausesCauses Social LearningSocial Learning

Vicarious Learning Vicarious Learning Learn Learn about the consequencesabout the consequences of a behavior by of a behavior by

observing a model engage in the behavior and observing a model engage in the behavior and experience consequencesexperience consequences

Outcome ExpectanciesOutcome Expectancies Learned association between a specific behavior Learned association between a specific behavior

and a specific consequence ORand a specific consequence OR Belief about the consequences of a behaviorBelief about the consequences of a behavior

CausesCauses Positive ExpectanciesPositive Expectancies

Belief that substance use will result in positive Belief that substance use will result in positive outcomes outcomes Increased or continued substance use Increased or continued substance use

Negative ExpectanciesNegative Expectancies Belief that substance use will result in negative Belief that substance use will result in negative

outcomes outcomes decreased or discontinued substance decreased or discontinued substance useuse

CausesCauses Operant ConditioningOperant Conditioning

Behaviors that are followed by reinforcement are Behaviors that are followed by reinforcement are repeatedrepeated

Initial substance use is reinforced by its effectsInitial substance use is reinforced by its effects HighHigh RelaxationRelaxation Social disinhibitionSocial disinhibition Elevated moodElevated mood

CausesCauses Drugs are powerful reinforcersDrugs are powerful reinforcers

Role model uses drugs Role model uses drugs gets high; less stressed gets high; less stressed + + expectancy developedexpectancy developed

Opportunity arises Opportunity arises Use drug Use drug get high; reduce get high; reduce stress stress + expectancies reinforced + expectancies reinforced repeat behavior repeat behavior

CausesCauses Classical ConditioningClassical Conditioning

Substance use becomes associated with internal Substance use becomes associated with internal and environmental cuesand environmental cues

E.G., People, Places, Things, Thoughts, & FeelingsE.G., People, Places, Things, Thoughts, & Feelings More frequent pairing results in a stronger More frequent pairing results in a stronger

associationassociation Exposure to these cues triggers thoughts about Exposure to these cues triggers thoughts about

using and cravingusing and craving Opiates, Alcohol, Nicotine Opiates, Alcohol, Nicotine compensatory response compensatory response Cocaine Cocaine anticipatory response anticipatory response

TreatmentTreatment

MedicationMedication AlcoholAlcohol

Disulfiram (antabuse) Disulfiram (antabuse) Naltrexone Naltrexone Acamprosate (campral) Acamprosate (campral)

NicotineNicotine Nicotine ReplacementNicotine Replacement BupropionBupropion

MedicationMedication OpiatesOpiates

MethadoneMethadone Buprenorphine/NaloxoneBuprenorphine/Naloxone

CocaineCocaine No effective medicationsNo effective medications

MarijuanaMarijuana No effective medicationsNo effective medications

BehavioralBehavioral Self-HelpSelf-Help

AA/NAAA/NA Rational RecoveryRational Recovery

Contingency ManagementContingency Management Offer rewards that compete with the reinforcing Offer rewards that compete with the reinforcing

effects of the drugeffects of the drug

BehavioralBehavioral Cognitive Behavioral TherapyCognitive Behavioral Therapy

Substance Use represents maladaptive coping Substance Use represents maladaptive coping strategystrategy

Treatment involvesTreatment involves Identifying High Risk Situations Identifying High Risk Situations Teaching skills for coping with those High Risk Teaching skills for coping with those High Risk

SituationsSituations Differentiating Slips/Lapses from RelapsesDifferentiating Slips/Lapses from Relapses

High Risk

Situation

Cope Don’t Use IncreaseSelf-Efficacy

Risk of Relapse

Decreases

Don’tCope

Pos. Expectancies

of Use triggered

LapseOr Slip

AbstinenceViolation

Effect

Risk of Relapse Increases