Historical Perspective (DSM 1-3)
- Temperance Mvnt => First anti-alcohol mvnt which turned to alcohol prohibition
- Alcohol being good vs war on drugs
DSM:
Early DSMs largely conceptualized substance use as manifestation of underlying psychopathology
DSM-I: A symptom of “sociopathic personality disorder”, Alcoholism and drug dependence, No classes of drugs specified, No specific criteria
DSM-II: Still a personality disorder, Alcoholism and drug dependence,Barbiturates, cannabis, cocaine, hallucinogens, opioids; Some criteria specified
- “… the inability of the patient to go one day without drinking”
- “… habitual use or a clear sense of need for the drug”
DSM-III: “Substance use disorders” separated from
personality disorders, Each class of substance recognized, Sets of diagnostic criteria established, Distinguish between abuse vs. dependence
Levels of Involvement (DSM 4-5)
Use and Intoxication => “Normal” vs Abuse and Dependence => “Abnormal”
DSM-IV: Substance Abuse
- A maladaptive pattern of substance use leading to distress or impairment
One or more of:
- Failure to fulfill role obligations
- Physically hazardous situations
- Legal/social problems
- No history of dependence => If dependence, then only get dx of dependence
DSM-IV: Substance Dependence
- A maladaptive pattern of substance use leading to distress or impairment
Three or more of:
- Tolerance
- Withdrawal
- More than intended
- Failure to cut down
- Time spent
- Other activities given up
- Physical or psychological problems
Distinction made to indicate severity => Dependence thought to be more severe than abuse (now recognize not always true)
DSM-5
- No longer recognizes a distinction between “abuse” and “dependence”
- Now a single dx => With mild, moderate, and severe sub- classifications
DSM-5 Dx
10 classes of substances:
Alcohol, Caffeine, Cannabis, Hallucinogens, Inhalants, Opioids, Sedatives/hypnotics/anxiolytics, Stimulants, Tobacco, Other or unknown
Problematic pattern of substance use leading to impairment or distress over 12 months
Need two or more:
- Taken in larger amounts than intended (Impair Cont)
- Desire or unsuccessful efforts to cut down (Impair Cont)
- Time spent (Impair Cont)
- Craving (Impair Cont)
- Failure to fulfill roles/obligations (Soc Impair)
- Social/interpersonal problems (Soc Impair)
- Use in physically hazardous situations (Risky Use)
- Physical/psychological problems (Risky Use)
- Tolerance (Pharmaco Depend)
- Withdrawal (Pharmaco Depend)
*Could technically have up to 10 dx
Epidemio
Prevalence
Lifetime prevalence: 30%
One-year prevalence: 15%
=> But, drinking in general VERY common with over 50% of adults over the age of 18 are “regular drinkers”
- Survey of Canadians aged 15 and older by Health Canada (2016): 77% reported drinking alcohol in past 12 months
Gender/Ethnic
- In men, rates have traditionally been 2-5 times highe => Western societies, now see less of a difference between men and women
- Rates typically higher in White and First Nations pop
- Lower in Black and Hispanic populations => Varies by study
- East Asian and Jewish populations tend to have lower rates => Genetic polymorphism (alcohol dehydrogenase aka feeling sick) and rates of abuse of other substances similar or higher
Comorbidity
- ~35-40% also meet criteria for another dx => Bipolar dx, schizophrenia, and antisocial personality dx show markedly increased rates of AUD
- Also, anxiety and depressive disorders
Why comorbidity?
- Common risk factors contribute to both
- Mental dx causes substance use or Substance use causes mental dx?
Course
Onset typically in late adolescence/ early adulthood => Median age of onset: 21
- Though more common in men, women typically deteriorate more quickly
Study: Chronic course? Study of 724 men, all originally recruited as healthy controls for other studies during the late 1930s and early 1940s => Of the 724, 181 (25%) eventually diagnosed with AUD
- But, decrease in rates with age
- By age 70: ~50% had chronic course, Between 25-30% recovered, 10% had controlled drinking (not impairing anything)
- If abstinent for 5 years, unlikely to relapse
Course/Risk:
Heavy drinking associated with increased rates of:
- Vulnerability to injury
- Marital discord
- Intimate partner violence
- Illness (ex: diabetes, cirrhosis of the liver)
- Neurocognitive impairments (ex: brain shrinkage)
Decreased lifespan: As much as 12-year decrease and Increased suicide risk
Students and Cultural Norms and Gateway Hypothesis
- 86% of students at Canadian universities have drank alcohol in past 12 months
- More likely to “binge drink” => 18.5% report drinking 5+ drinks 2x/ month or more
- Males > females
- Living alone or in residence > living at home
Consequences? Academic, Social
- ~13% of student binge drinkers meet criteria for AUD
Gateway Hypothesis
- Alcohol, marijuana, and nicotine are “gateway drugs” => Increases the likelihood of use of other illicit drugs
- Use does correlate with harder drug use => And often see use of these drugs prior to use of other illicit drugs
=> Not necessarily causal link
- Doesn’t rule out general tendency towards subs abuse
- Alcohol and marijuana are just easier to get
- Also, evidence that abuse of prescription meds can increase alcohol and marijuana use – can anything be a gateway drug?
Biological Factors
Family History
- Child’s risk increases with number of parents who have AUD (ex: one or two parents)
- Lifetime risk of alcoholism in relatives of alcoholics is 30% compared to 14% in controls
- Relatives of alcoholics also had higher rates of abuse of other subs
- Also increased risk for almost all other mental dx
- General liability for psychopathology? => Slight inclination toward externalizing
Adoption Studies: Ind whose biological parent(s) were alcoholics but adopted by non-alcoholic non-relatives => Look at the freq of alcoholism in ind in adulthood
- Increased probability of alcoholism => Suggests a bio predisposition *But, biology is not deterministic
Tolerance
If you have to drink more, then you’re slower to recognize the effects aka Drink more, Build up tolerance, Drink more, spiral
- Sons of alcoholics: balance and coordination after drinking better than in sons of controls
- May start out less sensitive to the effects of alcohol (subjective and physiological)
Biological - Twins Studies
Twin Studies:
- Group 1: Offspring of all twins (Mz and Dz) with dx of AUD => High genetic risk, high environmental risk (Genes and env are imp)
- Group 2: Offspring of Mz twins who do NOT meet criteria for AUD but co- twin does => High genetic risk, low environmental risk (x)
- Group 3: Offspring of Dz twins who do NOT meet criteria for AUD but co- twin does => Moderate genetic risk (bcz 50% of genes), low environmental risk (x)
- Group 4: Offspring of twins (Mz and Dz) who do not meet criteria for AUD => Low genetic risk, low environmental risk (control)
Physiological Effects
Both a stimulant and a depressant
While drinking: stimulant
- Drinkers report increases in elation, excitement, extraversion
- Decreases in fatigue, restlessness, depression, tension
After drinking: depressant
- Decrease in energy
- Increase in fatigue, relaxation, confusion, and depression
=> Stimulation:
- Increases in Norepinephrine => Responsible for arousal
- Increased Norepinephrine associated with increased impulsivity
=> Brain areas affected with decreased activation: PFC, Cerebellum, Hippocampus
=> Alcohol-Induced Heart Rate (Psychomotor stimulant theory of addiction)
- Sensitivity to rewarding properties of alcohol = risk factor for AUD
- Measured by increased alcohol-induced heart rate
- Men with relatives who have AUD show larger increases in heart rate => Those with greatest increases in heart rate more inclined to drink alcohol regularly
Psychological Factors
Positive Alcohol Expectancies
Expectancy that alcohol will positively transform social, physical, and emotional experiences
- Arises through direct learning and social learning
- AUD more likely to believe that alcohol use will
result in positive outcomes - Priming positive alcohol expectancies increases subsequent alcohol consumption in heavy drinkers
Social-Enhancement Motives (Why do men show such higher rates of alcohol-related problems?)
- Some evidence that the effects of alcohol are more rewarding for males (inconsistent evidence)
- Many men report that majority of their bonding with other males occurs in the context of drinking
- Social processes may explain gender differences => Not as socially appropriate for men to have intimacy, affiliation, self-disclosure
Social Contagion Study: Male and female participants (N=720) drink socially in the lab
- Both M & F show positive effects of alcohol on mood
- BUT men experienced an increase in reciprocal smiling when drinking (vs. control)
- Duration of men’s smiles increased => Making contagion more likely
- More interpersonally rewarding for men
- Women in placebo group shared same number of social smiles
Psychological - Reinforcement
Reinforcement and Learning
- Alcohol dependence develops through reinforcement
- Positive reinforcement: It feels great to BE drinking
Positive Affect Regulation Theory => For many people, drinking increases positive affect (feel more confident, happier) and some evidence that people who are high on reward-seeking or sensation-seeking, more vulnerable to AUD
Negative reinforcement
- For many, it feels bad to not drink
- Drink to avoid withdrawal sx
Negative Affect Regulation Theory => Self-medication theories of AUD, Decreases anxiety, sadness, self-consciousness, forgot your worries and some evidence that people with more trait negative affect (ex: depression, anxiety) vulnerable to AUD
=> For many, both positive and negative reinforcement paths leads to increased alcohol consumption
Personality Characteristics (3)
Beh disinhibition
- Correlates with severity of alcohol abuse
- Predates onset on alcohol problems
Negative emotionality
- One study showed negative emotionality was linked with more rapid escalation of problems following onset of drinking in adolescents
- Consequence or risk factor?
Deviance proneness
- General deviant pattern of beh
- Roots in childhood, attributable to deficient socialization
Addictive Subs
5 main cat: Depressants, Stimulants, Hallucinogens, Opiates, Others
- Craving for substance
- Despite serious consequences ex: cancer
- Desire for it even after years of abstinence
=> Non-Substance Addictive Disorders
In DSM-V, a change from “Substances Disorders” to “Substance-Related and Addictive Disorders”
- Addictive disorders now include Gambling Disorder
- Internet Gaming Disorder included as category for future consideration
- Hypothesized to be similar in terms of clinical expression, neural origins, comorbidity, physiology, and treatment
Prevalence Rates
Use of any illicit drug:
- 14% for 8th graders
- 27% for 10th graders
- 37% for 12th graders
- 35% for college students
- 34% for 19- to 28-year olds
Polysubstance use is more common than not => 80% of problem drinkers also smoke, 50% of cocaine users dependent on alcohol
*Neurobiology of Addiction: Mesocorticolimbic pathway (PFC, nucleus accumbens, ventral tegmental area) and dopamine
Opioids
Opiate – Natural chemical in opium poppy => Narcotic effects (pain relief)
=> Opioids – Broader term that refers to a class of natural and synthetic substances with narcotic effects ex: heroin, opium, codeine, morphine
- Activates endogenous opioid receptors => Endorphins
- Morphine developed as treatment for pain but too addictive so developed heroin
- Low doses: euphoria, drowsiness, slurred speech, memory impairment, slowed breathing (High can be sustained 4-6 hours)
- High doses can result in death *respiratory issues
- Withdrawal symptoms can be lasting (1 week) and severe
- Less than 1% of Canadians report having ever tried heroin
- Prescription opioids more prevalent
- 8% of adults use codeine, morphine, or Demerol => Current “opioid epidemic”
Stimulants
Amphetamines (Speed)
- Low doses: increases alertness and attention (tx ADHD)
- High doses: exhilaration, confidence, elation, vigor,
reduce fatigue - Similar to the effects of adrenaline => Followed by a “crash” and chronic use can lead to fatigue, sadness, intense anger
- Enhances the release of dopamine and norepinephrine, while blocking reuptake
- Repeated high doses can cause psychotic symptoms (toxic psychosis)
- High risk of dependency and withdrawal
- 6% of Canadians aged 15+ report lifetime usage
=> Methamphetamines (“crystal meth”) – often amphetamine of choice for poorer people
Cocaine
- Used to be legal and viewed as harmless
- Short lived sensation of elation, energy, reduced
fatigue - Effects result from blocking reuptake of dopamine
- Highly addictive, but addiction develops slowly (after 2-5 years)
- Withdrawal (boredom, paranoia), tolerance
- Prevalence: 2% of Canadians in 2019
=> Crack: crystallized form of cocaine that is
smoked, acts faster, also more often consumed by poorer people
Hallucinogens
Also: psychedelics ex: LSD, psilocybin, mescaline, PCP, ecstasy (Mild: marijuana)
- Change the way the user perceives the world => Delusions, paranoia, hallucinations, and altered sensory perception, Synesthesia
- 11% report lifetime use of hallucinogens => Less than 1% report recent usage, Prevalence peaked in the 60s
LSD *Most common
- Tolerance tends to be rapid, however, sensitivity returns
- Withdrawal symptoms uncertain
- Psychotic delusional and hallucinatory sx can be problematic
- Unclear exactly how they affect the brain
- Flashbacks
- Not viewed as very addictive
MDMA aka ecstasy
- Unlike other drugs, almost uniformly universal
pleasure - First developed as “diet pill”
- Tested in middle of last century as a potential treatment for PTSD, phobias, depression, drug addiction, marital conflict
- Outlawed, but some limited research still being done => Produces a sense of profound well-being initially (serotonin), “Hangover” associated with a profound decrement (serotonin)
Other Hallucinogens as Therapeutics
- Ketamine: Treatment resistant depression
- Psilocybin: Trials in which administered to cancer patients in an effort to relieve their anxiety and “existential distress”
=> All focus on delivering carefully controlled doses (In medical env, with trained clinicians)
=> All this research is relatively recent (last 5 years) but need more long-term follow-up
Safer Injection Sites (SIS)
Also: Supervised Consumption Services
Injection drug use associated with harmful outcomes: Physical health (ex: infections, death), Social environment (ex: crime, drug-related litter)
=> SIS introduced as a harm reduction approach with safe, clean drug equipment (ex: needles), drug checking, emergency medical care, access to mental health professionals, referrals, and social services
*Very common in Vancouver and Sydney, Australia
Lots of critics => Concern that SIS will foster 1) more drug use, and 2) increase drug-related consequences (ex: crime)
Study: Meta-analysis of 75 studies (Mostly research done in Vancouver and Sydney)
- Reduction in harm among users (ex: less overdoses, less syringe sharing)
- Attracts the most marginalized individuals
- Increases referrals to psychological services (ex: detox programs, addictions treatment)
- Improvements in public spaces => less syringes dropped, less injection-related litter
- No increase in number of drug users
- No increase in drug-related crime
Treatments - Pharmaco/AA/Controlled
Pharmaco Tx
- Agonist substitution => Replace drug with a safer substance ex: methadone, nicotine gum/patch
- Antagonists: Blocks the positive effect of the drug, Doesn’t block the withdrawal, Requires high degree of motivation ex: Naltrexone
- Aversive treatment => Make the drug unpleasant ex: Antabuse (disulfiram) *Noncompliance
AA or Narcotics Anonymous (NA) => 12 step programs
- Based on disease model
- Total abstinence => Once an alcoholic, always an alcoholic (Faith in a higher power => Believe they are powerless over their drinking)
- Key mechanisms: Social support, Structure *Limited research on effectiveness
Controlled drinking => Evidence that some individuals with AUD can learn techniques to drink moderately
Fare better if:
- Younger
- Better social and psychological stability
- Employed
- Female
- Less severe alcohol dependence
- Stronger belief in one’s ability to moderate drinking
=> If someone is very resistant to abstinence (even if severe AUD), can focus on harm reduction
Treatments - CBT/MI/Personality
CBT
- Contingency management => Identify antecedents to drinking and high-risk situations, Arrange contingencies to reward sobriety
- Restructuring thoughts about drinking ex: positive expectancies
- Relapse prevention => Identify possible triggers, View it as lapse, not total failure
*Already assumed they’re motivated (might do MI before)
Motivational Interviewing
- People will have varying degrees of readiness for change
- Ambivalence: stuck between simultaneously wanting to change and not wanting to change
- MI: Non-confrontational, accepting, person- centered approach => Explore pros and cons of alcohol use, Foster intrinsic motivation to change
- Demonstrated efficacy among adults
Personality-Targeted Interventions
Four personality-specific motivational pathways to risky drinking in adolescence
- Hopelessness
- Anxiety sensitivity
- Impulsivity
- Sensation seeking
=> Developed school-based interventions to target each process and Effective at reducing problem drinking sx (lasting effect at 6 month follow up)
Brief MI Interventions Study
A brief intervention in a medical setting may represent a “teachable moment” for adolescents. Can MI be effective?
Methods: 94 adolescents (aged 18-19), All admitted to ER following alcohol-related incident and randomly assigned to MI or “standard care” => Follow-up interviews 3 and 6 months later
Key results:
- Drinking was reduced in both groups at follow-
up, no difference in treatment - Risky behaviors were lower in MI gr => Drinking and driving, Alcohol-related injuries, Driving violations (per DMV report)
- Reduced alcohol-related problems with family, friends, partners, and at school
Conclusion: MI represents a brief, low-cost intervention that may directly reduce functional impairment from drinking
