“At first drugs will take away your pain. Then it will take your joy, your freedom, your family your home, your job, your self respect. Eventually it will take away everything and you will be left with nothing BUT the pain you were trying to escape”
Changes from DSM-IV to DSM-V
Substance use disorder
- Abuse/dependence criteria scrapped to make way for Substance Use Disorder (11 criteria)
- 11 criteria grouped into 4 categories. 0-1 no diagnosis. 2-3 mild substance use disorder. 4-5 moderate substance use disorder. >6 severe substance use disorder.
1 – 4 (impaired control)
- Drug taken in large amounts or over a longer period than was intended
- Persistent desire or unsuccessful effort to cut down or control substance use
- A great deal of time is spent in activities necessary to obtain the drug, use the drug, or recover from its effects
- Craving (intense desire or urge for the drug at any time or in an environment where the drug was previously used/obtained – strong for heroin)
5- 6 (social impairment)
- Recurrent drug use resulting in a failure to fulfil major role obligations at work, school, college or home
- Recurrent drug use despite having persistent or recurrent social/interpersonal problems caused or exacerbated by effects of the drug (arguments, fights with spouse)
7-9 (risky use of substance)
- Vital social, occupation, or recreational activities are given up or reduced because of the substance (may withdraw from family activities/hobbies)
- Recurrent drug use in situations where it is physically hazardous (driving, machine operation, swimming, walking in dangerous areas)
- Drug use continued despite knowledge of having a persistent or recurrent physical/psychological problem that is likely to have been caused or worsened by the drug.
10-11 (Pharmacological criteria)
- Tolerance (need more of/ decreased effects of same quantity with continued use)
- Withdrawal (Same or related drug taken to relieve or avoid withdrawal symptoms)
Cannabis withdrawal syndrome
- A. Cessation of cannabis use that has been heavy and prolonged (usually daily or almost daily over a period of at least a few months)
- B. Three (or more) of the following signs and symptoms developing within approximately 1 week after cessation:
- Irritability, anger, or aggression
- Nervousness or anxiety
- Sleep difficulty (will have strange dreams, and nightmares)
- Decreased appetite or weight loss
- Restlessness
- Depressed mood
- At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache
- C. Causing significant distress or impairments ( negative consequences in employment, school, arrest etc.)
- D. Not attributable to another medical condition, other substances, etc.
Caffeine-withdrawal syndrome
Much easier to get caffeine withdrawal nowadays as many products (drinks) have caffeine in them
- A. Prolonged daily use of caffeine
- B. Abrupt cessation of or reduction in caffeine use, followed within 24 hours by three (or more) of the following signs or symptoms:
- Headache
- Marked fatigue or drowsiness
- Dysphoric mood, depressed mood, or irritability
- Difficulty concentrating
- Flu-like symptoms (nausea, vomiting, or muscle pain/stiffness)
- C. Cause significant distress or impairment
- D. Not attributable to another medical condition, other substance, etc.
Gambling disorder
Hence these disorders are called substance-related and addictive disorders
Substance Use Disorder
Substance use disorder is a cluster of cognitive behavioral and psychological symptoms, indicating that the individual continues using the substance despite significant substance-related problems. It is a chronic brain/physical illness (clear micro/macro changes in the brain), that manifests as compulsive behaviour (repetitive behaviours that are gratifying to the patient**)** and has **social components (**noticed by third parties). THEY ARE MENTAL DISORDERS and are classified in the DSM-V. It is preventable and treatable. Dopamine is the key neurotransmitter involved in substance use disorder, acting via the reward circuit
Definition of terms
| Term | Definition |
|---|---|
| Drug | A substance when taken into a living body alters ≥ 1 function |
| Substance | A mixture/compound of chemicals which when taken into the body through a defined mode may affect the functioning of ≥ 1 of the body functions (may create a desired or undesired change) |
| Psychoactive substance | Chemicals that produce emotional, cognitive or behavioural changes to users with adverse medical consequences and are unsanctioned |
| Substance use | Use of a drug that induces psychological, and/or behavioural change. Sounds bad, but is not necessarily bad. Use can be sanctioned or unsanctioned. |
| Sanctioned use | Substance use approved by society |
| Unsanctioned use | Substance use not approved by society |
| Harmful use | Substance use causes tissue damage or mental illness |
| Substance intoxication | The reversible set of symptoms the patient experiences due to use of a particular substance. The effect of the drug: Behavioural and psychological changes + ≥ 2 physiological changes |
| Substance tolerance | The level of adaptation a patient has to a specific drug, usually requiring the patient to use more of a substance to attain the same desired effect. “The body gets used to the drug” |
| Cross tolerance | Tolerance to one drug reduces the sensitivity to another drug. An example is an individual who has reduced sensitivity to benzodiazepines due to their tolerance for alcohol |
| Substance withdrawal | The physiologic, psychological and/or behavioural changes that result from heavy/prolonged use of a substance. “Symptoms when not having the drug” |
| Substance dependence | A maladaptive change in behaviour resulting from substance tolerance and substance withdrawal. The patient perceives a need for the substance to avoid unpleasurable feelings. “Everything in your life revolves around that drug’ |
| Monopolization (part of substance dependence) | All you think about is that drug. All your money goes into that drug |
| Loss of control (part of substance dependence) | Can’t stop yourself from using the drug, at a certain level |
| Social deterioration (part of substance dependence) | Can involve losing friends, getting into the wrong crowds, violence, rape e.t.c. |
Central circuits involved with addiction
| Pathway | Structures and function |
|---|---|
| Inhibitory pathway | the prefrontal cortex (PFC – abstract thinking, thought analysis, and regulates behaviour mediating conflicting thought and right/wrong decisions); anterior cingulate gyrus (ACG – ”brain gear shifter – makes one flexible and perceives options of life) |
| Motivation/Drive | Orbitofrontal cortex (OFC – cognitive processing of decision making, signalling expected rewards/punishments); subcallosal cortex ( SCC – rich in serotonin transporters, “Gate” that is “left open” leading to depression as 5-HT is depleted) |
| Reward circuit | Ventral Tegmental Area (VTA – DA cell bodies linked with mesocortical and mesolimbic, involved in cognition, motivation and addiction); Nucleus accumbens (NAc – roles in reward, pleasure, laughter, addiction, aggression, fear); Ventral pallidum (VP – part of limbic system associated with reward and incentive motivation) |
| Memory/Learning | 5- 7 (social impairment). Amygdala (involved in memory processing and emotional reactions); Hippocampus (part of the limbic system involved in emotions, rewards, and short/long-term consolidation of information) |
- 10 categories of drugs of abuse (DSM-V)
- Alcohol
- Caffeine (commonly included in painkillers)
- Cannabis
- Inhalants
- Opioids (heroin, codeine, meperidine, fentanyl, morphine, tramadol)
- Sedatives (benzodiazepines, barbiturates)
- Hypnotics, and anxiolytics (ketamine)
- Stimulants (cocaine, amphetamines, khat, ephedrine, pseudoephedrine)
- Tobacco
- Other (or unknown) substances
- How to tell if a patient is on a substance
- The patient tells you
- Urine tox screen returns positive
- The patient’s friends/family tell you
- There a signs of drug use in the physical exam
- What should you know about the patient?
- Drugs used: can get a good idea based on the symptoms the patient displays
- How MUCH, how OFTEN and how LONG the patient has been using the drug: relies on the patient’s history or what the companion tells you
- Route of administration: injection, drinking on an empty stomach, smoking, inhaling snout
- Duration of Symproms: most prefer short-acting ones
- Age of onset: mostly in early 20s and 20s, AUD mostly in 40s, earlier associated with conduct disorders, schooling problems, personality, other mental illnesses
- Basic info on the Hx and physical as usual
- Why is substance use disorder important?
- Substance use disorder is common
- A substance is often missed or undetected (mild effects, users do not know that they meet criteria)
- Substance use disorder impacts overall health
- Behavior changes caused by substances are reversible
- Substance use causes a heavy socioeconomic burden (for the individual, family, community and country at large)
- Why do clinicians fail to identify substance use disorders in patients?
- May make assumptions about a patient
- Stigma about drug “abuse/addiction”
- Afraid to uncover a problem
- Forgot to ask (time allocation and huge queues)
- Other categories
- Hallucinogens (LSD, PCP, mescaline, psilocybin)
- Date-rape drugs (flunitrazepam, GHB)
- Anabolic steroids
- Laxatives (abused by athletes)
- Antihistamines
Stages of change (Transtheoretical model)
| Stage | Description |
|---|---|
| Precontemplation | The patient is not considering change and is often resistant to discussing the stage. May be in denial or feel discouraged from past relapses |
| Contemplation | The patient onsiders change but remains ambivalent (fifty fifty). Focus is more on the cons of stopping than the pros |
| Preparation | The patient intends to take action in the near future. Makes clear strategies for change |
| Action | The patient implements specific observable changes |
| Maintenance | The patient maintains the desired behaviour and works to prevent relapse. May be brief (nicotine – weeks to months), moderately long (alcohol) or long (heroin – ≥ 6 months to years) |
| Relapse | Can occur at any stage. Can be due to stressors. This is part of treatment. Alcohol use disorder has 40-60% relapse rate. |
Etiology of Substance use Disorder
- Biological factors
- Genetics: parents, relatives, twins, identical/fraternal twins
- Neurotransmitters: DA, GABA, 5-HT, ACh, Opioid like endorphins
- Personality: Antisocial, Borderline, Narcissistic (Cluster B)
- Psychological factors
- Stress: major cause; imbalance between demands of life and ability to cope with them
- Experimentation/curiosity/exploration
- Social learning theory: Role modelling by parents celebs
- Parenting style: authoritarian/dictatorial breeds rebellion versus laissez-faire/carefree without direction
- Lack of love
- Instability/inconsistency: change of environment, marital conflict
- Illness or death of a significant other
- Traumatic situations: divorce, dumped, jilted, disappointments, frustrations
- Cultural shock
- Social factors
- Search for peer approval or acceptance
- Culture (muratina, mnazi, busaa, ‘naming of children’)
- Lax law enforcement (police, courts)
- Advertisements and marketing which glamorize drugs
- Easy availability and accessibility
- Extreme poverty and lack of family support
- Role of “Traditional African Woman”
- Spiritual factors
- Connect with a higher power
- To fill a void inside
- Hunger for divinity
- Cults/elders
- Rastafarians (+ cannabis)
Substance dependence
Substance dependence is a disorder on its own characterized by severe negative interference in the patient’s life with inability or lack of willingness to quit. Shows monopolization, loss of control of use, social deterioration (prominent), and symptoms of tolerance and withdrawal. Expect the patient to deny dependence. Treatment involves primary prevention and secondary prevention
- Risk factors for substance dependence
- Family history: eg. children of alcoholics are at risk
- Comorbid psychiatric illnesses: eg. depression
- Social interactions: if ur friend do heroin, you might
- Primary prevention
- Prevents substance dependence from happening in the first place
- DARE program in schools
- Ad council public service advertisments
- Prevents substance dependence from happening in the first place
- Secondary prevention
- Treats existing substance dependence (psychologic + withdrawal symptoms). Examples include:
- Alcoholics anonymous: 12 step process. Works really well. Outpatient treatment for alcoholics.
- Rehab programs specific to the drug
- Detoxification
- Naltrexone: opioid antogonst, prevent’s heroin’s lasabl ffcts. Use in pt not nwithdrwal but at risk of relapse.
- Disulfiram: “antabuse”, aldehyde dehydrogenase inhibitor. Causes severe vomiting if alcohol is consumed (Negative reinfcmnt). Explain it to the patient + its effect before prescribing.
- Methadone: Gradation therapy. Outpatient. Opiod agonist that gradually weans a patient off heroin. Reduces withdrawal symptoms
- Treats existing substance dependence (psychologic + withdrawal symptoms). Examples include:
Detection of substance use
| Substance | Direct testing |
|---|---|
| Alchoh | Blood or urine testing (more accurate than breathalyzer tests) |
| Cocaine | Urine testing positive for 2 – 4 days |
| Amphetamies | Urine testing positive for 1 – 3 days |
| Phencyclidine | Urine testing positive for 4 – 7 days. Elevated creatine phosphokinase (CPK) and aspartate aminotransferase (AST) |
| Sedative-hypnotics | Urine and blood testing. Short acting benzodiazepines for up to 5 days while long-acting benzodiazepines for up to 30 days. Short acting barbiturates for up to 24 hours while long-acting barbiturates up to 3 weeks |
| Opioids | Urine drug testing for 1 – 3 days depending on the opioids. Methadone and oxycodone are negative on a general screen and require their own separate panel. |
| Marijuana | Urine drug testing. Up to 3 days for single use while up to 4 weeks in heavy use (since THC is released from its adipose stores) |
