Causes and Treatment of Substance Use Disorders

1
Causes and Treatment of Substance Use Disorders

• Chapter 11

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The Spectrum of Use

• Use Noncompulsive and nonconsequential use
• Misuse Periodic negative consueqnces
• Abuse A pattern of misuse
• Dependence Compulisve use with significant
  consequences often w/physiological dependence

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Moving Through the Spectrum

• Depends on numerous issues
• The drug itself (The Agent)
• The person (The Host)
• The persons environment (The Environment)
• With some drugs it is difficult to maintain the
  line between use, misuse, abuse and dependence

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DSM IV CriteriaSubstance Abuse

• A maladaptive pattern of substance use occurring
  within a 12 month period
• Impairment/Distress
• One of the following
• Failure to fulfill major role obligation
• Use in physically hazardous situations
• Recurrent legal problems
• Continued use despite recurrent psychosocial
  problems

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DSM-IV Substance Dependence

• A maladaptive pattern of substance use occurring
  within a 12 month period
• Three of the following
• Tolerance (increased drinking to achieve same
  effect)
• Withdrawal
• Drinking more than intended
• Unsuccessful attempts to cut down on use
• Excessive time related to obtaining, using and or
  recovering from
• Impaired social or work activities due to alcohol
  
• Use despite physical or psychological
  consequences

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Causes - Multidimensional

• Abuse/Dependence is an interaction between
• Pharmacological
• Biological/Genetic
• Psychological/Behavioral
• Social/Environmental

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Pharmacologic

• Drugs differ in terms of the potential for
  physiological addiction.
• Nicotine High
• Heroin High
• Cocaine High
• Alcohol Moderate
• Marijuana Low
• Hallucinogens - Low

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Biologic/Genetic

• Substance Abuse and Dependence runs in families.
• Diathesis for certain types of alcohol
  dependence. Mechanism seems to tolerance
• Diathesis for other drugs is less clear.
  Probably through a temperamental characteristic,
  psychopathology and/or dopamine NT system
  sensitivity

9
Psychological/Behavioral

• Alcohol/Drug use is functional and is
  reinforcing. Use is subject to the laws of
  behavioral reinforcement (positive and negative).
• Self-regulation/Coping
• Certain personality characteristics are
  predictive.

10
Social/Environmental

• Certain developmental insults
• Access
• Social norms
• Using peers

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Substance Abuse Treatment

• Three main philosophies/modalities
• Mutual-help
• Psychosocial
• Pharmacological
• In the past there has been much conflict between
  these philosophies. Not so much now.

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Mutual Help Philosophy

• Twelve Step Fellowship
• Alcoholics Anonymous
• Narcotics Anonymous
• Spiritual Disease Model
• Mechanisms
• Acceptance of loss of control and higher power
• Working the steps
• Most probably powerful social support and
  behavioral management

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Psychosocial Treatment

• Psychological Treatments
• Motivational Interviewing/MET
• Empathy
• Rolling with resistance
• Develop Discrepancy
• Community Reinforcement Approach
• Rearrange reinforcement contingencies
• CBT
• Skills training and cognitive restructuring
• Psychotherapy and Educational alone are
  ineffective

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Project MATCH

• Mulitsite clinical trial of psychosocial
  treatments
• Three alcohol dependence treatments treatments
• MET
• CBT
• 12 Step Facilitation
• Results
• TSF marginally better. AA meetings
• MET as good over time with less treatment.
  Better for those high in anger
• Behavioral treatments work

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Pharmacotherapy

• Alcohol
• Antabuse Become ill if one drinks
• Naltrexone Opiate antagonist
• Heroin/Opiates
• Methadone An agonist. Opiate replacement
• Buprinorphine A partial agonist.
• Naltrexone Blocks opiate action
• Cocaine
• Havent found one yet
• Overall not many meds work. Compliance is the
  ultimate issue.

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Treatment Integration

• Combine treatment philosophies/modalities
• Motivation Enhancement
• Increase readiness
• CRA/CBT
• Active treatment
• Rearrange reinforcement structure
• Teach coping skills
• Address psychopathology
• Pharmacotherapy
• Mutual-help groups
• Social Support
• Maintenance

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Project COMBINE

• Multisite clinical trial addressing the
  combination of drugs and psychosocial treatments
• Acamprosate (a benzo) and/or Naltrexone
• Medication management or Psychosocial Treatment
• Psychosocial Treatment is a combo of MET and CRA