NS_30_Addiction_2013 16oct.pdf

7/27/2019 NS_30_Addiction_2013 16oct.pdf

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JC3 NS30 Psychological and Cognitive Aspects of Addiction

Royal College of Surgeons in IrelandColiste Roga na Minle in irinn

Dr. Mary Clarke


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Learning Objectives

To outline the differences between substance abuse and dependence

To outline the why some individuals become addicts

To outline the mental health consequences of substance use


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Substance abuseand dependence

A major problem facing society:

Alcohol: road traffics accidents, Foetal Alcohol Syndrome, heartdisease etc.

Nicotine: lung cancer, cardiovascular disease

Cocaine: psychosis, brain damage, death, crime

Designer drugs: unknown risks, contamination, unwanted effects


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Substance abuse in Ireland

Houses of the Oireachtas Joint Committee on Health and Children Report on The Misuse of Alcohol and Other DrugsJanuary2012


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Prevalence of drug use among high risk groups

Drug use is more common among certain groups, such as:Early school leavers (ESL);Lesbian, gay, bisexual and transgender community;TravellersYoung people.


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Yes

because addiction changes the brain in fundamental ways, disturbing aperson's normal hierarchy of needs and desires and substituting newpriorities connected with procuring and using the drug.

The resulting compulsive behaviors that override the ability to control

impulses despite the consequences are similar to hallmarks of othermental illnesses.

Is drug addiction a mental illness?


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Why do some people become addicted to drugs, while others do not?


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Substance abuse and dependence:Key concepts

Acute intoxication

Substance abuse Substance dependence

Tolerance

Withdrawal Cognitive Aspects


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Factors influencing substance misuse

Availability

Peer-pressure

Deprivation

Personality disorders

Pre-existing psychopathology

Pharmacological properties


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Factors influencing substance misuse

Neurobiology:dopamine release in nucleusaccumbens

Conditioned learningPositive reinforcement

Negative reinforcement

Classical conditioning

Short-term effects vs.long-term risks


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We know that despite their many differences, virtually all abusedsubstances enhance dopamine (neurotransmitter) activity

- particularly related to pleasure, motor and cognitivefunction

Biology


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Dopamine Pathways

Functions

reward (motivation)

pleasure,euphoriamotor function

(fine tuning)

compulsion

perserveration

decision making

nucleus

accumbens

hippocampus

striatum

frontal

cortex

substantia

nigra/VTA

raphe


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Brain Changes in Addiction


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Cognitive Models of Addiction

The Biological model suggests that our genes and nervous system play abig part in addictive behaviour, BUT ..

Why dont we feel euphoric and become dependent on morphine(similar opiate to heroin) after surgery?

Other processes must be involved


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Cognition and drug addiction

Frontal cortex

decision-making;

response inhibition; planning;

memory

frontal cortex damage - impaired decision making

impaired decision making and behavioural inhibition insubstance abuse.


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Cognition and drug addiction

Impaired decision making demonstrated in two thirds of addicts (Grantet al, 2000)

Addiction involves, not only pleasure centres but also motivationalcircuits.

Cocaine addicts when watching videotapes of people using the drug,addicts' brains showed spikes in dopamine levels in the dorsal striatumregion of the brain, implicated in habit learning and initiation of action.

Has been suggested that medications to inhibit the release of dopaminein the presence of salient cues could be valuable in treating cocaineaddiction.


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Effects of frontal cortex damage

Frontal cortex effects may last long after dopaminergic effects have wornoff and may explain relapse - may make it difficult to look beyond theimmediately reinforcing and pleasurable aspects of the drug to the long

term consequences.


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Acute intoxication

Transient

Substance-induced

Alterations of:

Consciousness

Cognition

Perception

Affect

Behaviour


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Substance abuse

Maladaptive pattern of substance use leading toclinically significant impairment or distress.


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Substance abuse II

One or more of these in a 12 month period:

Recurrent substance use leading to failure to fulfil major roleobligations.

Recurrent substance use in physically hazardous situations.

Recurrent substance-related legal problems.

Continued substance use despite persistent recurring social or

interpersonal problems caused or exacerbated by thesubstance.


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Substance abuse III

The symptoms have never met the criteria for substance

dependence for this class of substance


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Substance dependence I

Maladaptive pattern of substance use leading to clinically

significant impairment or distress.


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Substance dependence II

Three or more of these occurring at any time in a 12 monthperiod:

Tolerance Withdrawal

Using larger amounts or over longer period than intended

Persistent desire and unsuccessful efforts to cut down or

control use Lot of time spent in activities needed to obtain substance

Important activities given up

Substance use continued despite knowledge of having a

problem caused by it


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Dependence

Tolerance: with continued use, increased doses required to obtain thesame effect.

Withdrawal: unpleasant physical and psychological symptoms ondiscontinuing or decreasing a heavily used substance.

Psychological dependence: Need developed through learning (e.g.reducing anxiety). Can lead to physical dependence as with alcohol.


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Withdrawal criteria: DSM-IV

Development of a substance-specific syndrome due to stopping orreducing substance use that has been heavily prolonged.

The syndrome causes clinically significant distress or impairment insocial, work or other important areas of functioning.

Symptoms not due to general medical condition and not betteraccounted for by another mental disorder


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Substance dependence III: DSM-IV

Specify if with or without physiological dependence (tolerance orwithdrawal)

Course specifiers: Early full remission

Early partial remission

Sustained full remission

Sustained partial remission

On agonist therapy

In controlled environment


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Classes of substances abused

Depressants

Opiates

Stimulants Hallucinogens

Cannabis

Solvents

Steroids


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Marijuana

Tetrahydrocannabinol

No physical dependence

Marked psychologicaldependence

Effects

euphoria

space and time distortion

relaxation; well-being

increased appetite


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Marijuana

Tetrahydrocannabinol

Effects

memory changes: consolidation, STM

transient psychoses,

apathy

lung disease

psychomotor impairment


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Alcohol abuse

safe

21 units for male

14 units for female

Alcohol abuse: regular or binge consumption sufficient tocause physical, neuro-psychiatric or social damage


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Alcohol physical signs

Intoxication ataxia, nystagmus, slurred speech, decreasedconcentration, psychological/behavioural changes, stupor.

Alcohol on breath

Red sclerae/conjunctivae

Stimata of liver disease eg jaundice, spider naevi

Tremor, sweating

Excessive face skin capillarisation


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Alcohol Dependence

compulsion to drink

preoccupation with alcohol

stereotyped drinking

inability to regulate drinking

altered tolerance

withdrawal symptoms

persistence even after attempted abstinence


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Alcohol Complications

Acute intoxication

Acute withdrawal

Medical complications

Wernickes encephalopathy

Korsakoffs psychosis

Social complications

Foetal alcohol syndrome


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Alcohol Management

Biological, psychological and social factors

Acute detoxification: nutrition, benzodiazepines;

rehydration, electrolyte balance Abstinence vs. controlled drinking

Maintenance: group psychotherapy: motivation, relapseprevention, new social routines, self-help, treatment of

anxiety and depression


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Alcohol Abuse psychiatric problems

Suicide (10-15%, similar to bipolar and schizophrenia)

Associated with 1/3 deliberate self-harm acts

Depression (40%)

Antisocial personality and violence

Anxiety disorders (25-50%)

Alcoholic hallucinations

Sexual problems

Sleep problems


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Stimulants

Nicotine

Caffeine

Amphetamines Cocaine


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Stimulants: Amphetamine

speed

Oral or intravenous

euphoria, increased concentration and energy followed bydepression, lethargy and fatigue

Chronic use: may induce schizophreniform psychoses


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Stimulants: cocaine

sniffed, chewed or injected

restlessness, increased energy, abolition of fatigue and

hunger. Visual/tactile hallucinations

Sometimes paranoid psychoses

Post-cocaine dysphoria sleeplessness and depression

Crack highly addictive


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Stimulants: MDMA

Ecstasy (MDMA)

synthetic amphetamineanalogue

Causes serotonin release andblocks reuptake

hyperactivity

dehydration

hyperpyrexia


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Hallucinogens

LSD: psychological andphysiological effects but not

dependence

Flashbacks

Schizoid psychoses

Seizures


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Opiates

Heroin, morphine,methadone

Smoked, sniffed, oral,intravenous, intra-muscular or subcutaneous


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Opiate Effects

Initial dysphoria

Buzz, rush

Histamine release

Peace, tranquillity,

Detachment

CNS depression

Rapid tolerance andwithdrawal


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Opiate Dependence

10% of users becomedependent

10% 0f these seek help and 2-

3% die annually

25% abstinent at 5 and 40%at 10 years


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Opiate Withdrawal

24-48 hours

Craving

Flu-like symptoms: (musclecramps, chills, lacrimation,rhinorrhoea); sweating,

yawning.

7-10 days

mydriasis, cramps, diarrhoea,agitation, restlessnessgooseflesh


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Many people who regularly abuse drugs are also diagnosed with mental disorders andvice versa.

people diagnosed with mood or anxiety disorders are about twice as likely to suffer alsofrom a drug use disorder (abuse or dependence)

Similarly, persons diagnosed with drug disorders are roughly twice as likely to suffer alsofrom mood and anxiety disorders

Drug use and other mental disorders

Treatment


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Treatment


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Treatment

Principles of Effective Treatment

Scientific research since the mid1970s shows that treatment canhelp patients addicted to drugs stop using, avoid relapse, andsuccessfully recover their lives. Based on this research, keyprinciples have emerged that should form the basis of any effective

treatment programs:


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Principles of Effective Treatment

Addiction is a complex but treatable disease that affects brain functionand behavior.

No single treatment is appropriate for everyone.

Effective treatment attends to multiple needs of the individual, not justhis or her drug abuse.

Remaining in treatment for an adequate period of time is critical. Counselingindividual and/or groupand other behavioral therapies

are the most commonly used forms of drug abuse treatment.

Medications are an important element of treatment for many patients,especially when combined with counseling and other behavioral

therapies. Many drugaddicted individuals also have other mental disorders.

Medically assisted detoxification is only the first stage of addictiontreatment and by itself does little to change longterm drug abuse.


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Effective Treatment Approaches

Medication and behavioral therapy, especially when combined, areimportant elements of an overall therapeutic process that often begins

with detoxification, followed by treatment and relapse prevention.

Easing withdrawal symptoms can be important in the initiation of

treatment; preventing relapse is necessary for maintaining its effects.

And sometimes, as with other chronic conditions, episodes of relapse mayrequire a return to prior treatment.

A continuum of care that includes a customized treatment regimenaddressing all aspects of an individual's life, including medical and mentalhealth servicesand followup options (e.g., community or family-based recovery support systems) can be crucial to a person's success inachieving and maintaining a drugfree lifestyle.


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Reading

BMJ article on alcoholism:http://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0

&resourcetype=HWCIT

BMJ article on drug addiction:http://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

BMJreview(2008)article:http://www.bmj.com/cgi/reprint/336/7642/496?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=30&resourcetype=HWCIT
http://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/reprint/336/7642/496?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=30&resourcetype=HWCIThttp://www.bmj.com/cgi/reprint/336/7642/496?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=30&resourcetype=HWCIThttp://www.bmj.com/cgi/reprint/336/7642/496?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=30&resourcetype=HWCIThttp://www.bmj.com/cgi/reprint/336/7642/496?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=30&resourcetype=HWCIThttp://www.bmj.com/cgi/reprint/336/7642/496?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=30&resourcetype=HWCIThttp://www.bmj.com/cgi/reprint/336/7642/496?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=30&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIThttp://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

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NS_30_Addiction_2013 16oct.pdf