THE NATURE OF SUBSTANCE MISUSE

1
THE NATURE OF SUBSTANCE MISUSE

W. De La Haye, M.D., M.P.H., D.M. Department of
Community Health and Psychiatry University of the
West Indies Mona

2
OBJECTIVES

• Definition of addiction
• Addiction as a biobehavioural disorder
• Triangulation model of addiction
• Substance use disorders
• Substance induced disorders
• Risk and protective factors in addiction
• Exposure opportunity to substances of abuse

3
Substance abuse A health
nightmare
4
Types of addiction

• Sex
• Gambling
• Computer and cyberspace
• Food
• Drugs

5
Drug addiction

• World Health Organization 1964
• Recommended a new standard that replaces both
  the term drug addiction and the term drug
  habituation with the term drug dependence
• Attempt to differentiate the physical or
  psychological components of dependence

6
Drug abuse

• Use of a substance with such frequency that it
  impairs your
• - Physical functioning
• - Social functioning
• - Occupational functioning

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Drug dependence

• A state arising from
• - the repeated administration of a drug
• - on a periodic or continual basis
• - being of a particular type
• - Its characteristics will vary with the
  agent
• involved

8
Syndrome of Dependence

• Use of drugs assumes a much higher priority than
  other behaviour that once had a higher value
• Components of dependence syndrome
• - feeling of compulsion to take drugs
• - desire to stop taking drugs
• - relatively stereotyped pattern of drug
  taking
• - signs of neuroadaptation
• - salience relative to other priorities

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DSM IV criteria for drug abuse

• Chemical (drug) abuse
• I. A maladaptive pattern of drug use
  leading to
• impairment or distress, presenting as
  1 or more of the
• following in a 12-month period
• 1. Recurrent use leading to failure to
  fulfill major
• obligations
• 2. Recurrent use that is physically
  hazardous
• 3. Recurrent drug-related legal problems
• 4. Continued use despite social or
  interpersonal
• problems
• II. The symptoms have never met the criteria
  for
• chemical dependency.

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DSM IV criteria for dependency

• Chemical (drug) dependency
• I. A maladaptive pattern of drug use,
  leading to impairment or
• distress, presenting as 3 or more of the
  following in a 12-month period
• 1. Tolerance to the drug's actions
• 2. Withdrawal
• 3. More-than-intended use of drug
• 4. Inability to control drug use
• 5. Expenditure of effort to obtain the drug
• 6. Replacement of important activities by
  drug use
• 7. Continued drug use despite negative
  consequences
• II. Two types of dependency can occur
• 1. With physiologic dependency (including
  either items 1 or 2)
• 2. Without physiologic dependency (including
  neither items 1 nor 2)

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Substance Misuse

• Pervasive throughout the world
• Enormous burden on health care systems
• Deaths, illnesses and disabilities more than seen
  from any other preventable health condition

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Substance Misuse

• Relationship between illicit drug use and crime
• Relationship between drug use and the
  transmission of STIs (HIV/AIDS)
• Disadvantaged groups disproportionately affected

13
Substance Misuse

• Substance use and abuse among adolescents of
  particular concern
• Chronic relapsing disorder
• Characterized by a pattern of use, abstinence and
  relapse
• (relapse is often the rule not the exception)

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Common substances of abuse

• Legal
• - alcohol
• - tobacco
• - prescription drugs
• Illegal / illicit
• ATOD / ATID

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Common substances of abuse

• Stimulants caffeine, nicotine,
  cocaine,
• 
  amphetamines (speed, ecstasy)
• Sedatives alcohol, benzodiazepines,
• 
  barbiturates, cannabis
• Narcotics opioid class morphine,
• 
  codeine, cocaine, heroin
• Hallucinogens lsd, pcp(angel dust),
  cannabis,
• 
  psylocybin (mushrooms),
• 
  mescaline(cacti)

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Methods of substance misuse

• Oral (tablets, liquids, powder)
• Intranasal/snorting/sniffing
• (cocaine powder, heroin powder)
• Vaginal
• Smoking (cannabis, opium)
• Inhalation (chasing the dragon, glue)
• Injection (i.m., i.v., sub cut.)

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Important information in history

• Substances
• Quality
• Quantity
• Route
• Duration of use
• Amount () per day

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Important information in history

• Last use
• Longest period of abstinence
• Previous treatment
• Drug of onset
• Drug of impact
• Drug of choice

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Biobehavioural Disorder

• Biology
• Behavior Social
  context
• 
  

20
Triangulation model in infectious diseases

• Host
• Agent Vector
• 
  

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Triangulation model in substance misuse

• User
• Drug
  Environment
• 
  

Substance misuse
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Substance-related disorders

• Substance use disorders
• Substance-induced disorders

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Substance Induced disorders

• Substance intoxication
• Substance withdrawal
• Psychotic disorder
• Mood disorder
• Sexual dysfunction
• Sleep disorder

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Substance Use Disorders

• Substance abuse
• Substance dependence

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Substance Misuse

• Substance
• abuse
• 
  Substance Misuse
• Substance
• dependence

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Risk factors

• Greater potential for drug use
• - Ineffective parenting
• - Unstable home environment
• - Poor nurturing in childhood
• - Poor social coping skills
• - Affiliation with deviant groups
• - Drug trafficking
• - Availability

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Protective factors

• Reduced potential for drug use
• - Strong family bond
• - Schools
• - Religious organizations
• - Parental monitoring of children
• - Knowledge of conventional norms about
• drug use
• - Awareness of personal and community
• hazards of drug use

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Impact of risk and protective factors

• Function of stage of psychological and social
  development of an individual
• Exposure, initial drug use, regular use and
  subsequently dependence

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Exposure opportunity

• Users of A/T are more likely than nonusers to
  have an opportunity to try marijuana
• (x 3)
• Users of A/T are more likely to use marijuana
  with a marijuana exposure opportunity
• (x 7)
• Opportunity to use cocaine is associated with
  prior marijuana smoking
• (x 1.9, 4.6, 7.6)
• Users of marijuana are more likely to use cocaine
  with cocaine exposure opportunity
• (x 15)

Anthony J, 2002. Into the World of Illegal Drug
Use, American Journal of Epidemiology, Vol. 155,
No. 10 918 925
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Risk and protective factors

• The presence of risk factors and absence of
  protective factors in adolescents lead to
  increased EXPOSURE OPPORTUNITY to substances of
  abuse
• Early initiation of alcohol, tobacco and illicit
  drug use among adolescents is a strong predictor
  of subsequent drug dependence

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Problems with substance misuse

• Personal
• (morbidity, mortality, theft, trafficking,
  prostitution)
• Public health (prostitution, multiple partners,
  sti)
• Family
• Social (theft, trafficking, assaults, homicide)
• Economic

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Cost of substance misuse

• Adolescents at highest risk
• Narcotics trafficking closely associated
• with the epidemic of gang/political warfare
• Deaths from swallowing (o.d. or murder)
• High admission rates to hospitals

33
Cost of substance misuse

• The impacts of alcohol and other drugs can
  present as trauma cases at UHWI.
• In a study done by McDonald et al at UHWI in 1999
  it was found that 32 of 111 patients presenting
  at AE for trauma in a 3 month period had
  significant levels of alcohol in their blood(71
  gt80mg/dl).
• Note that metabolites of cannabis was found in
  46 of those patients

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Motivated Behavior Model of addiction

• - biological drive
• - conditioned learning
• - free will

Addicted behavior
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Motivated Behavior Model

• Biological drive
• Biological mechanisms drive all motivated
  behaviors (eating, sleeping, sex).
• BIOLOGICAL REWARD SYSTEM

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Motivated Behavior Model

• Conditioned learning
• Shapes behavior by way of psychological and
  environmental variables. Stereotypical and
  compulsive behavior pattern.

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Motivated Behavior Model

• Free will
• To initiate and continue using drugs.
• Choice becomes narrower as addiction
  progresses.
• It is by choice that individuals enter
  treatment resulting in a lifestyle change

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Motivated Behavior Model

• Addiction
• Results when biological mechanisms and
  environmental conditioning combine to produce a
  new drive or hunger to use drugs without the
  normal checks and balances that keep natural
  drives under control

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Sequence of events

• Exposure
• Use/Experimentation
• Abuse
• Craving, compulsion, impaired control
• Dependence

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Consequences of repeated drug use

• Change in brain structure and function
• Neuroadaptive changes
• New memory connections
• Distortion of cognitive and emotional functioning
• - compulsion to use drugs
• - drug use the sole motivational priority

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Consequences of early substance misuse

• Early initiation of alcohol, tobacco and illicit
  drug use among adolescents is a strong predictor
  of subsequent drug dependence
• Young users - much greater network and behavior
  risk for sexually transmitted diseases and have
  more sex partners

Wagner, F. A., Anthony J. C. 2001 American
Journal of Epidemiology 155(10)918-925.
Blum, R.W., Center for Adolescent Health,
University of Minnesota
42
Consequences of substance misuse

• Substance abuse reduces inhibitions and
  encourages engagement in high risk sexual
  behaviours
• ¹Substance abusers are disproportionately
  affected by the AIDS epidemic

¹Sorensen et al., July 2002. Science and Practice
Perspectives, NIDA 1(1) 4-11
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Role of conditioning

• Environmental cues surrounding drug use become
  conditioned
• Through classical conditioning, take on
  conditioned stimulus properties
• Cue-induced craving relapse
• Even after long periods of abstinence

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Globus pallidus
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Positron Emission Tomography (PET)
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Your Brain on Drugs
1-2 Min
3-4
5-6
6-7
7-8
8-9
9-10
10-20
20-30
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Your Brain After Drugs
Normal
Cocaine Abuser (10 da)
Cocaine Abuser (100 da)
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The Memory of Drugs
Amygdalanot lit up
Amygdalaactivated
Front of Brain
Back of Brain
Nature Video
Cocaine Video
49
Non user
Cocaine user
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Responsibility and Choice

• Very important that providers are aware of
  their own views on the role of
• Personal responsibility
• Societal responsibility
• in the onset and progression of and recovery
  from substance abuse

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Responsibility of the substance abuser

• Free will to initiate and continue using drugs
• Choice becomes narrower as addiction
• progresses
• It is by choice that individuals enter
• treatment resulting in a lifestyle change

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Public health implications

• Substance abusers are potentially harmful not
  only to themselves but also to others
• Some substance abusers lack the environmental or
  personal resources necessary to modify their
  behavior
• Society must become involved to protect itself

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Substance Abuse

• Chronic relapsing disorder
• Characterized by a pattern of use, abstinence and
  relapse

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Role of abstinence

• Relapse is often the rule not the exception
• Relapse is likely unless a person sustains very
  long periods of abstinence
• This could be as long as 5 years and even longer

Hser, Y., Hoffman, V., Grella, C., Anglin, D.
(2001). A 33-year follow-up of narcotic addicts.
Archives of General psychiatry, 58, 503-508.
Vaillant, G. E. (1996). A long-term follow-up of
male alcohol abuse. Archives of general
psychiatry, 53, 243-249.
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Relapse and Recycling

• Not a problem of drug abuse but one of inability
  to sustain behaviour change.

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Treatment patterns

• Many patients have had multiple treatment
  episodes
• More than half of the patients in drug abuse
  treatment have had at least one prior treatment
  episode
• These studies report a 40-60 relapse rate within
  a year of discharge.

Simpson, D., Joe, G., Fletcher, B., Hubbard, R.,
Anglin, M. (1999). A national evaluation of
treatment outcomes for cocaine dependence.
Archives of General Psychiatry, 56, 507-514.
57
Treatment Programs

• Initiate abstinence
• Sustain that abstinence over a long period
• of time
• One of the most effective means of promoting
  abstinence in drug-dependent individuals is
  reinforcement of drug abstinence.

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Primary goals of SAclinical evaluation

• Accurate diagnostic assessment, incl. DD
• Planning and initiating effective intervention
• Motivational enhancement
• - aimed at increasing readiness for
• treatment and compliance with treatment
• recommendations

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Transtheoretical model of intentional behaviour
change (DiClemente, Porchaska, 1992)

• 1. Precontemplation
• 2. Contemplation
• 3. Preparation
• 4. Action
• 5. Maintenance
• 6. Relapse/Recycling
• 7. Termination

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Stages of change
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Stages

• 1. Precontemplation not ready to change
• 2. Contemplation thinking about change
• 3. Preparation getting ready to change
• 4. Action making the change
• 5. Maintenance sustaining change
• 6. Relapse/Recycling slipping back and
• reentering the cycle
• 7. Termination leaving the cycle

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Algorhythm of DiClemente et al

• I do not intend to quit in the next 6/12
• - precontemplation
• I intend to quit in the next 6/12
  contemplation
• I intend to quit in the next 30 days
• preparation
• I quit lt 6/12 ago action
• I quit gt 6/12 ago maintenance

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Process of change

• Change engines that enable movement through the
  stages of change
• Cognitive/behavioural processes during early
  stages
• Behavioural process in later stages

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Aim of education

• Provide students, teachers and families with
  accurate information about drug abuse, addiction
  and association with high risk sexual behaviour
• Reduce exposure opportunities
• Break the chain of experimentation, regular use,
  abuse and dependence

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Outcome

• Stops drug use before it starts
• Reduces violence associated with drug
• use / distribution
• Reduces load on treatment system
• Reduces load on criminal justice system
• Reduces lost productivity
• Reduces acquisition and transmission of
• STIs (HIV/AIDS)

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Role of exposure

• Parents, paediatricians and GPs must ask
• kids about chances to try illegal drugs
• Kids more likely to talk about their chances
• to try than their use
• Once there is a chance, it should raise a
• RED FLAG!

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Role of prevention

• Drug abuse is a preventable behaviour
• Drug addiction is a preventable disease
• Substance abusers are more likely to engage
• in high-risk sexual activities
• Substance abuse prevention in adolescents
• is HIV prevention

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Role of prevention

• The presence of risk factors and absence of
  protective factors in adolescents lead to
  increased Exposure Opportunity to substances of
  abuse
• Prevention programs must focus on reducing
  Exposure Opportunities to substances of abuse
  in Jamaican adolescents
• Implement prevention programs as early as
  kindergarten!!!

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Summary

• Substance abuse prevention is HIV prevention
• Reducing the gap between substance abusers
  needing treatment and prevention and those
  getting help
• Reduce the risk of risky sexual behaviour
  associated with substance abuse

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Caution

• Use of any mood altering substance (including
  legal ones) can result in risky sexual behaviour
• One does not need to be chemically dependent to
  have risk associated with their drug use!

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• Our fight against drug use is a fight for our
  childrens future!!!