BEHAVIORAL SCIENCE UNIT:SUBSTANCE ABUSE

Part A: Alcoholism as a detailed example

Part B: Other Categories of Drug Abuse

Prepared with the Assistance of:

James E. Black, MD PhDDepartment of PsychiatryWasatch Canyons CenterSalt Lake City, UT 84123

BIO-PSYCHO-SOCIAL PERSPECTIVE ON SUBSTANCE ABUSE:

BIO: some people are genetically vulnerable, drugs vary in their addictive potential, and health risks to users vary substantially.

PSYCHO: comorbid psychiatric disorders, elevated stress, or impaired cognition are all risk factors for addiction.

SOCIAL: all drug abuse is socially defined, such that a “bad” drug may be a “good” drug in another culture or time.(Cocaine was once a component of a popular soft drink)

Casual or “Recreational” Substance Use

This pattern of use typically does not cause major problems. However, naïve users may unwittingly overdose or get into legal problems.

“Gateway” drugs also may introduce drugs to individuals that are at genetic risk of addiction. Similarly, recreational use can lower cultural barriers to substance abuse or addiction (e.g., seeing parents drink beer makes it easier for teenagers to try it themselves).

On the other hand, cultures that endorse “responsible” drinking and stigmatize drunkenness (e.g., Italian or French drinking of wine with dinner) can model low-risk behaviors for young people, perhaps lowering the incidence of addiction.

DSM-IV Definition of Substance Abuse

"A maladaptive pattern of substance use leading to ... distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home...(2) recurrent substance use in situations in which it is physically hazardous(3) recurrent substance-related legal problems...(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the ... substance..."

Substance DependenceA maladaptive pattern of substance use manifested by three or more of the following:1) tolerance – a need for increasing amounts of drug to get the desired effects;2) withdrawal – either the characteristic withdrawal syndrome for a substance, or using a substance to avoid withdrawal symptoms (e.g., “hair of the dog…”)3) increased use - the substance is progressively taken in larger amounts or for longer periods than intended (e.g., a coke run that is only stopped when the money runs out).4) loss of control - There is a persistent desire or unsuccessful attempts to cut back or control drug use (the addiction has become painful, but the patient is now stuck)5) obsessing about using - A great deal of time is spent on planning how to obtain the substance (e.g., finding the money, planning the buy), using the substance (e.g., drinking round the clock through a weekend), or on recovering from the hangover (e.g., calling in sick on Monday).6) other parts of life become unimportant - The patient sacrifices important activities in order to keep using (e.g., not going to your kid’s baseball games; breaking dates; not completing work assignments).7) using becomes irrational - The patient keeps using with the full knowledge that this will result in physical, psychological, or legal problems (e.g., continued drinking after a diagnosis of liver cirrhosis). This is the “insanity” of addiction.

Alcohol and Substance Use

* Up to 90% of adult Americans use at least some alcohol

* Caffeine - 80%; Tobacco - 25%

* Illicit drugs - 37% of population over age 12

* Issues from a medical (and societal) perspective are use to excess, lack of control, situations not socially approved, deleterious effects on health

* Comorbidity of substance abuse and Psychiatric disturbance is common

COSTS OF DRUG ABUSE TO SOCIETYImpairment costs:

lost productivity (e.g., calling in sick, hangovers, intoxication at work)

actual damages (e.g., DUI damages, crime to feed a habit),

medical costs (e.g., deaths to cirrhosis, spread of HIV, emphysema)

indirect costs (e.g., stress on family, shame)

social costs (e.g., cost of law enforcement, prisons, money laundering)

COSTS OF DRUG ABUSE TO SOCIETY

alcohol $ 99 billion, 1/3 lost productivity

illegal drugs $ 67 billion, 3/4 social costs

smoking $ 91 billion, 1/2 early death, much of remainder is medical

Note that smoking involves little crime or lost productivity, so most of the cost is health related. Note that illegal drugs often involve crime to pay for drugs or involve law enforcement to punish users, thus very high social costs.

Recognition and Treatment of Alcohol or Substance Abuse by the Physician

* Knowledge of characteristics of alcohol or substance abuse, pharmacology of substances

* Recognize substance abuse/dependency in patient, despite efforts to conceal or deny

* Knowledge of acute management procedures

* Knowledge of long-term treatment/rehabilitation options

*Awareness of own biases

ALCOHOL IN THE USAalcoholism is one of the most common psychiatric disorders, with life-time prevalence of about 13% (NIMH ECA study)

other psychiatric disorders increase the risk of alcoholism (e.g., by self-medicating depression or anxiety).

mean consumption is 3 gallons of pure ethanol a year

70% of adults drink just occasionally, 12% drink heavily (i.e., drinking daily or getting drunk more than 3 times a month)

the 30% heaviest drinkers consume 4/5 of all alcohol in USA

the10% heaviest drinkers consume half of all alcohol in USA (clearly alcoholism)

GENETICS OF ALCOHOLISM*1960 Swedish study found concordances of 71% for identical twins, 32% fraternal twins; many other studies have confirmed high heritability. This is clinically useful when the family history is postive for alcoholism; the patient should be educated about their vulnerability.*the specifics of heritability have been difficult to find. Claims that it caused by dopamine receptor mutations or by “personality” features have been debunked.*distinguishing two patterns of alcoholism may be clinically useful:

Type 1: late onset of drinking (sometimes as late as retirement, these patients feel guilty about drinking, often related depression or anxiety symptoms (i.e., self-medicating), generally do not break the law. The daughters of Type 1 patients are at risk of depression, suggesting a link between substance abuse and mood disorders.

Type 2: early onset of drinking (often before puberty), show an addictive pattern with high tolerance, often show disregard for consequences, engage in criminal behavior. Less motivated to seek treatment, but court-ordered rehab can be helpful.

ALCOHOL PHARMACOLOGY *is a CNS depressant, but suppresses anxiety (e.g., shyness) and social norms (e.g., date rape) before motor impairment and stupor

*legal intoxication in Illinois is 80 mg/dl (.08%), but cognitive and motor impairments occur below that

*coma can occur at 300 mg/dl, but with tolerance alcoholics can be awake at up to 600 mg/dl. Inexperienced drinkers can drink fatal overdoses of alcohol on a dare or for a party trick.

*synergism with other CNS depressants, resulting in many accidental or intentional overdoses (especially common factor in suicides)

*causes release of endorphins, resulting in euphoria and later craving

*withdrawal includes autonomic hyperactivity: tachycardia, sweating, hypertension

*CNS withdrawal is manifested by irritability, tremor, and seizures. The seizures can occur days after the last drink. Delerium tremens is extreme cardiovascular instability, can be fatal, needs hospital admission.

WERNICKE’S ENCEPHALOPATHY: easily preventable cause of brain damage

*primarily caused by thiamine deficiency, not direct alcohol damage to brain

*manifests with nystagmus, diplopia, truncal ataxia, apathy, confusion, memory impairment

*if untreated, can cause disability or death

*doctors easily confuse it with intoxication or head injury

*be conservative: give thiamine injections early and often in ER. It’s cheap and safe.

ALCOHOLISM IN THE ELDERLY: a hidden epidemic

*as many as 3 million older Americans are affected by problem drinking (about 8% in community, 20% in hospital)

*elderly are hospitalized as often for alcohol complications as for heart attacks

*elderly are more vulnerable to complications (depression, suicide, falls, malnutrition, heart disease, medication interactions)

*typical doctors only recognize 1 in 3 elderly with alcohol problems

SUBSTANCE ABUSE AMONG CHILDREN: another hidden epidemic

(1995 high school seniors) % smoking cigarettes daily: 21.6% % using cocaine daily over last year: 4.0% % using crack daily over last year: 2.1% % using marijuana daily over last year: 34.7% % having 5 or more drinks at one time in last 2 weeks: 29.8%

(from the American Health Foundation, 1996)

ALCOHOLISM: making a diagnosis

* patients are often in denial or ashamed, so you need to be open and supportive

** take a good history: * think about what might explain family or job problems, vagueness, odd injuries

** physical exam: * poor hygiene, spider angiomas, flushed nose/palms, tremor or stagger

ALCOHOLISM: making a diagnosis

CAGE QUESTIONAIRE: a quick and easy probeHave you ever...1. thought about CUTTING down?2. felt ANNOYED when others criticize your drinking?3. felt GUILTY about drinking?4. used alcohol as an EYE-OPENER?

TREATMENT OF ALCOHOLISM:

most effective approach is integrated, multimodal, and long-term

bio: Antabuse, Revia, SSRIs, but avoid cross-addiction

psycho: confront denial, address psychiatric comorbidity, relapse prevention, support MD-pt alliance

social: AA (forgiveness, modeling, peer support) and family, community support for rehab efforts, laws directed at supporting recovery

MEDICATIONS FOR ALCOHOLISM

disulfiram (Antabuse) simply punishes the drinker, requires cooperation, and can be dangerous

naltrexone (Revia), an opiate antagonist, decreases craving and blocks “rush”

comorbid disorders can be relapse triggers, so prescribe for issues of depression, anxiety, pain, ADHD

“helping” can cause relapse, so be careful with prescribing benzos or narcotics

there is no magic bullet: meds can only help within a full program

PSYCHOLOGICAL ISSUES

psychotherapy can address issues of childhood trauma, interpersonal problems, or personality

family members are central: source of enabling, aggravation of guilt or stress, possible victims, potentially invaluable support

group therapy is uniquely valuable for resolving guilt, modeling success, managing relapse, and providing social support

ALCOHOLICS ANONYMOUS:a valuable ally for health professionals

the first “12 step” program, old and very popular

independence makes it more trusted and basically free group therapy

repeatedly confronts denial and reinforces accepting help from others

models successful ways to stay sober & its rewards

offers relief from guilt, finding meaning in life

“serenity prayer” fosters acceptance, problem solves, helps manage stress

SUBSTANCE ABUSE CATEGORIES OTHER THAN ALCOHOL

* stimulants (e.g., cocaine, amphetamines, Ritalin)* sedative-hypnotics (e.g., barbiturates, benzos)* narcotics (e.g., heroin, opium, prescription narcotics)* hallucinogens (e.g., marijuana, LSD, peyote)* nicotine (now in DSM-IV)* inhalants (gasoline, paint, etc. mostly young people: brain damaging)* anabolic steroids & growth hormone (?addictive, but dangerous)

THE DOCTOR’S ROLE IN TREATING ADDICTION

Be knowledgeable aboutaddiction and its treatmentcommunity resources and allies

For the patient, provide:basic informationmedical authorityalliance with the support system or familymonitor and follow-upcultivate doctor-patient relationship