Clinical psychology
Chapter 10
Substance use disorders

Clinical descriptions, prevalence, and effects of substance use disorders

Prevalence adolescents: 9,3 to 10 percent.

Addiction: a more severe substance use disorder that is characterized by having more symptoms, tolerance, and withdrawal, by using more of the substance than intended, by trying unsuccessfully to stop, by having physical or psychological problems made worse by the drug, and by experiencing problems at work or with friends.

Tolerance: indicated by either:

• Larger doses of the substance being needed to produce the desired effect
• The effects of the drug becoming markedly less if the usual amount is taken.

Withdrawal: the negative physical and psychological effects that develop when a person stops taking the substance or reduces the amount.

DSM-5 criteria for substance use disorder

• Problematic pattern of use that impairs functioning. Two or more symptoms within a 1-year period:
  • Failure to meet obligations
  • Repeated use in situations where it is physically dangerous
  • Repeated relationship problems
  • Continued use despite problems caused by the substance
  • Tolerance
  • Withdrawal
  • Substance taken for a longer time or in greater amounts than intended
  • Efforts to reduce or control use do not work
  • Much time spent trying to obtain the substance
  • Social, hobbies, or work activities given up or reduced
  • Craving to use the substance is strong

Alcohol use disorder

Delirium tremens (DTs): when the level of alcohol in the blood drops suddenly.

Liver enzymes that metabolize alcohol can account to a small extent for tolerance. The central nervous system is responsible as well.
Tolerance results from changes in the number or sensitivity of GABA or glutamate receptors. Withdrawal may result because some neural pathways increase their activation to compensate for alcohol’s inhibitory effects in the brain.

Alcohol use disorder is often part of polydurg abuse.
Polydrug abuse: abusing ore than one drug at a time.

Alcohol and nicotine are cross-tolerant; nicotine can induce tolerance for the rewarding effects of alcohol and vice versa.
Consumption of both drugs may be increased to maintain their rewarding effects.

Prevalence and cost of alcohol abuse and dependence

No yet prevalence estimates.
Especially frequent among college-age adults.

Binge drinking: having five drinks in a short period of time
Heavy-use drinking: having five drinks on the same occasion five or mire times in a 30-day period.
Among college students, binge drinking and heavy-use prevalence rates are 43,5 and 16 percent.

Binge drinking can have serious consequences

• Alcohol related incidents
• Assaults

More men than women have problems with alcohol, though the gender difference has decreased.
Prevalence of alcohol problems differs by ethnicity and education.

Alcohol use disorders are comorbid with

• Several personality disorders
• Mood disorders
• Schizophrenia
• Anxiety disorder
• Other drug use

21,3 percent of people suffering from alcohol or drug dependence or abuse also have at least one other mental disorder.

Short-term effects of alcohol

Absorption of alcohol can be very quick. But removal is always slow.
The effects of alcohol vary with its concentration in the blood-stream. Levels in the bloodstream depend on the amount of ingested in a particular period of time, the presence of the food in the stomach, the weight and body fat of the person drinking, and the efficiency of the liver.
Women achieve higher blood alcohol concentrations. Perhaps due to differences in body water content between men and women.

The alcohol content of the particular beverage is what matters.

Alcohol produces its effects through its interactions with several neural systems in the brain.
It stimulates GABA receptors, which may account for its ability to reduce tension.
Alcohol also increases the level of serotonin and dopamine, which may be the source of its ability to produce pleasurable effects.
Alcohol inhibits glutamate receptors, which may cause the cognitive effects of alcohol intoxication.

Long-term effects of prolonged alcohol abuse

Almost every tissue and organ of the body is adversely affected by prolonged consumption of alcohol.

• Alcohol provides so many calories, that drinkers often reduce their intake of food. But those calories do not supply to the nutrients essential for health. → severe malnutrition.
• Impairing digestion of food and absorption of vitamins
• Severe loss of memory for both recent and long-past events. Often filled in by reporting imaginary events (confabulation)
• Contributes to the development of cirrhosis of the liver.
• Damage to the endocrine glands and pancreas
• Heart failure
• Erectile dysfunction
• Hypertension
• Stroke
• Capillary hemorrhages
• damage to many areas of the brain

Heavy alcohol consumption by a woman during pregnancy is the leading known cause of intellectual developmental disorder among children.

• Fetal alcohol syndrome (FAS): the growth of the fetus is slowed, and cranial, facial, and limb abnormalities can be produced.
• Even moderate drinking can produce undesirable, if less severe, effects on the fetus.

Growth deficits associated with prenatal alcohol exposure can be mitigated if the children are raised in a more stable and healthy environment, indicating that the biological effects of early alcohol exposure are sensitive to environmental conditions.

But
Light drinking has been related to lower risk for coronary heart disease and stroke.

Tobacco use disorder

Nicotine: the addicting agent of tobacco.
The neural pathways that become activated stimulate the dopamine neurons in the mesolimbic area that seem to be involved in producing the reinforcing effects of most drugs.

Prevalence and health consequences of smoking

The single most preventable cause of premature death.

Among the other problems associated with, and almost certainly caused or exacerbated by, long-term cigarette smoking are:

• Ephysema: cancers of the larynx and of the esophagus, pancreas, bladder, cervix, and stomach
• Complications during pregnancy, sudden infant death syndrome
• Periodontitis
• A number of cardiovascular disorders

The most probable harmful components in the smoke of burning tobacco are:

• Nicotine
• Carbon monoxide
• Tar

In general, smoking is more prevalent among men than women.

Health consequences of secondhand smoke

Secondhand smoke: the smoke coming from the burning end of a cigarette.
Contains higher concentrations of ammonia, carbon monoxide, nicotine, and tar than does the smoke actually inhalated by the smoker.

The best form of prevention for exposure to secondhand smoke is to promote smoke-free environments as there is really no safe level of exposure to secondhand smoke.

Marijuana

Marijuana: consists of the dried and crushed leaves and flowering tops of the hemp plant, cannabis sativa.

Prevalence of marijuana use

Most frequently used illicit drug.
Most common drug across all age groups.
Higher among men than women.

Effects of marijuana

Psychological effects
The intoxicating effects of marijuana, like those of most drugs, depend in part on its potency and the size of the dose.

• Relaxed and sociable
• Large doses bring rapid shifts in emotion, dull attention, to fragment thoughts, to impair memory, and to give the sense that time is moving slowly.
• Extremely heavy doses have sometimes been found to induce hallucinations and other effects similar to these of LSD, including extreme panic, sometimes arising from the belief that a frightening experience will never end.

Marijuana can interfere with a wide range of cognitive functions.

• Impact on short-term memory.

Being high on marijuana impairs complex psychomotor skills.

Long-term users may exhibit a slight impairment in learning and memory.

Physical consequences

• Short term: bloodshot and itchy eyes, dry mouth and throat, increased appetite, reduced pressure within the eye, and somewhat raised blood pressure.
• Long term: seriously impairs lung structure and function. Short-term memory problems.
  Increased blood flow to regions in the brain often associated with emotion. Decreased blood flow in regions associated with auditory attention.

Might be addictive.

Therapeutic effects

THC and related drugs could reduce the nausea and loss of appetite that accompany chemotherapy for some people with cancer.
An effective treatment for the discomfort of AIDS, chronic pain, muscle spasms, and seizures.

Opiates

Opiates: opium and its derivatives morphine, heroin, and codeine.

The opiates are a group of addictive drugs that in moderate doses relieve pain and induce sleep.

Psychological and physical effects

Opiates produce euphoria, drowsiness, ans sometimes lack of coordination.
Herion and OxyContin also produce a ‘rush’, a feeling of warm, suffusing ecstasy immediately after an intravenous injection.
The user sheds worries and fears and has great self-confidence for 4 to 6 hours. However, the user then experiences a severe letdown, bordering on stupor.

Opiates produce their effects by stimulating neural receptors of the body’s own opioid system.

Opiates are clearly addicting.

People who abuse opiates face serious problems.

• Death
• The drug itself and the process of obtaining it become the center of the person’s existence, governing all activities and social relationships.
• Additional problem associated with intravenous drug use is exposure, through sharing needles, to infectious agents such as HIV.

Stimulants

Stimulants act on the brain and the sympathetic nervous system to increase alertness and motor activity.
Amphetamines: synthetic stimulants.

Amphetamines

Produce their effects by causing the release of norepinephrine and dopamine and blocking the reuptake of these neurotransmitters.
Taken orally or intravenously and can be addicting.

Methamphetamine
Men use methamphetamine more often than women in contrast with abuse of other amphetamines, where few gender differences occur.
Physiological dependence on methamphetamine often includes both tolerance and withdrawal.
Chronic use causes damage to the brain, affecting both dopamine and serotonin systems.

Cocaine

Crack: a form of cocaine.
Use of crack is declining.
Men use cocaine and crack more often than women do.

Cocaine reduces pain.

• Acts rapidly on the brain, blocking the reuptake of dopamine in mesolimbic areas.
  Can increase sexual desire and produce feelings of self-confidence, well-being, and indefatigability.
  An overdose may bring on chills, nausea, and insomnia, as well as strong paranoid feelings and terrifying hallucinations of insects crawling beneath the skin.
  Chronic use can lead o heightened irritability, impaired social relationships, paranoid thinking, and disturbances in eating and sleeping.

Some develop tolerance to cocaine.
Others may become more sensitive to cocaine’s effects.
Stopping cocaine use appears to cause severe withdrawal symptoms.

Cocaine is a vasoconstrictor, causing the blood vessels to narrow.

Hallucinogens, ecstacsy, and PCP

LSD and other hallucinogens

In addition to hallucinations, LSD can alter a person’s sense of time.
A person using LSD may have sharp mood swings but can also experience an expanded consciousness such that he or she seems to appreciate sights and sounds like never before.

The effects of hallucinogens depend on a number of psychological variables in addition to the dose self.

• A person’s set (attitudes, expectancies, and motivations in regard to taking the drugs)
• The context in which the drug is experienced

Many users experience intense anxiety after taking LSD

• Flashbacks may come to haunt people for weeks and months after they have taken the drug

Ecstasy and PCP

Ecstacy acts primarily by contributing to both the release and the subsequent reuptake of serotonin.

Ecstasy enhances intimacy and insight, improves interpersonal relationships, elevates mood and self-confidence, and promotes aesthetic awareness.
Can cause muscle tension, rapid eye movements, jaw clenching, nausea, faintness, chills or sweating, anxiety, depression, depersonalization, and confusion.

Etiology of substance use disorders

The factors that contribute to the substance use disorder may depend on the point in the process that is being considered.

Genetic factors

Genetic and shared environmental risk factors for illicit drug use disorders may be rather nonspecific.
They appear to be the same no matter what the drug, this is true for men and women.

Peers and parent appear to be particularly important environmental variables.

The ability to tolerate large quantities of alcohol may be inherited for alcohol use disorder.
Nicotine appears to stimulate dopamine release and inhibit its reuptake. People how are more sensitive to this effects of nicotine are more likely to become regular smokers.

Gene polymorphism

Neurobiological factors

Drugs use typically results in rewarding or pleasurable feelings, and it is via the dopamine system that these feelings are produced.
Nearly all drugs stimulate the dopamine systems in the brain, particularly the mesolimbic pathway.

People who take drugs also feel less sad.
And people continue to take drugs to avoid the bad feelings associated with withdrawal.

Incentive-sensation theory
The dopamine system is linked to pleasure, or linking, becomes supersensitive not just to the direct effects of drugs, but also to the cues associated with drugs.
This sensitivity to cues induces craving, or wanting, and people go to extreme lengths to seek out and obtain drugs.
Over time, liking of drugs decreases, but the wantings remain very intense.

Cues for drugs activate the reward and pleasure areas of the brain implicated in drug use.

Psychological factors

Mood alteration

Drug is used because it enhanced positive moods or diminishes negative ones.
If tension reduction works, it does so only in certain context for certain people.
Substances can reduce more than just tension.

• Lessens negative emotions, but it also lessens positive emotions in response to anxiety-provoking situations.

People experience a greater reduction of tension and negative affect more when starting to smoke than when regularly smoking or in relapse of treatment.
The situation is important.
The effects of inhalating, whether there was nicotine or not, had the greatest association with reducing negative affect.

Alcohol may reduce tension by altering cognition and perception.

• Alcohol impairs cognitive processing and narrows attention to the most immediately available cues, resulting in ‘alcohol myopia’.
  The intoxicated person has less cognitive capacity and tends to use that capacity to focus on an immediate distraction, if available, rather than on tension-producing thoughts, with a resultant decrease in anxiety.

But, alcohol and nicotine may increase tension when no distractors are present.

Tension reduction is only one aspect of the possible effects of drugs on mood.

• Some people may take drugs to reduce negative affect
• Some people may use drugs to increase positive affect when they are bored.

Expectancies about alcohol and drug effects

People who expect alcohol to reduce stress and anxiety are those likely to be frequent users.
Drinking amount and positive expectancies about alcohol appear to influence each other.

Expectancies about drug effects predict drug use in general.
Cognitions can have a powerful effect on behavior. Reciprocal relation.

The extent to which a person believes a drug is harmful and the perceived prevalence of use by others are also factors related to use.
The greater the perceived risk of a drug, the less likely it will be used.
Alcohol and tobacco are used more frequently among people who overestimate the frequency with which these substances are used by others.

Personality factors

Important in predicting the later onset of substance use disorders:

• High levels of negative affect (negative emotionality)
• A persistent desire for arousal along with increased positive affect
• Constraint: cautious behavior, harm avoidance, and conservative moral standard

Sociocultural factors

Sociocultural factors play a widely varying role in substance use disorders.
People’s interest in and access to drugs are influenced by peers, parents, the media, and cultural norms about acceptable behavior.

Men consume more alcohol than women.
Cultural prescriptions about drinking by men and women are important.

• Ready availability of the substance is also a factor.
• Family factors
• The social setting in which a person operates
• Media

Treatment of substance use disorders

Substance use disorders are typically chronic, and relapse occurs often.

The first step in treatment is admitting there is a problem.

Treatment of alcohol use disorder

Inpatient hospital treatment

Detoxification: withdrawal from substances.
Often the first step in treatment. Can be difficult, physically and psychologically.

The therapeutic results of hospital treatment are not superior to those of outpatient treatment.
In addition, short stays (less than 8 days) in detoxification hospitals may be as effective as longer stays.

Inpatient treatment is probably necessary for people with few sources of social support who are living in environments that encourage the abuse of alcohol, especially people with serious psychological problems in addition to their alcohol problems.

Alcoholics anonymous

The group provides emotional support, understanding, and close counseling as well as a social network.

Couples therapy

Behaviorally oriented marital or couples therapy has been found to achieve more reductions in problem drinking, even a year after treatment has stopped, as well as some improvement in couples’ distress generally.

Cognitive and behavioral treatments

Contingency management therapy is a cognitive behavior treatment for alcohol and drug use disorders that involves teaching people and those close to them to reinforce behaviors inconsistent with drinking.
Vouchers are provided for not using a substance.
This therapy also includes teaching job-hunting and social skills, as well as assertiveness training for refusing drinks.
For socially isolated people, assistance and encouragement are provided to establish contacts with other people who are not associated with drinking.

Relapse prevention is another cognitive behavioral treatment that has been effective with alcohol and drug use disorders.
Can be a stand-alone treatment or a part of other interventions.

Motivational interventions

Two parts

• A comprehensive assessment that included the timeline flow back (TLFB) interview which carefully assesses drinking in the past 3 months
• A brief motivational treatment that included individualized feedback about a person’s drinking in relation to community and national averages, education about the effects of alcohol, and tips for reducing harm and moderating drinking.

Moderation in drinking

Controlled drinking: a pattern of alcohol consumption that is moderate, avoiding the extremes of total abstinence an inebriation.
People with less severe alcohol problems can learn to control their drinking and improve other aspects of their lives as well.

Guided self-change
People have more potential to control over their immoderate drinking than they typically believe and heightened awareness of the costs of drinking to excess as well as of the benefits of abstaining or cutting down can be material of help.

Medications

Disulfiram or antabuse: a drug that discourages drinking by causing violent vomiting if alcohol is ingested.
For it to be effective, a person must already by strongly committed to change.
High dropout rates!

Opiate antagonist naltrexone for alcohol use disorder.
Blocks the activity of endorphines that are stimulated by alcohol, thus reducing the craving for it.
Add to overall treatment effectiveness when combined with cognitive behavioral therapy.

Acamprosate
Impacts the gluatamate and GABA neurotransmitter systems and thereby reduces the cravins associated with withdrawal.
Highly effective.

Treatments for smoking

People are more likely to quit smoking if other people around them quit.

Psychological treatments

Probably the most widespread psychological treatment consists of a physician telling the person to stop smoking.

Scheduled smoking.
Reduce nicotine intake gradually over a period of a few weeks by getting smokers to agree to increase the time between cigarettes.
The cigarettes would be smoked on a schedule provided by the treatment team, not when the smoker feels and intense craving.

Cognitive behavior therapy focus on problem solving and coping skills.

Nicotine replacement treatments and medications

Reducing a smoker’s craving for nicotine by providing it in a different way is the goal of nicotine replacement treatments.
Nicotine may be supplied in gum, patches, inhalers, or electronic cigarettes. The idea is to help smokers endure the nicotine withdrawal that accompanies any effort to stop smoking.

Treatment of drug use disorders

Central is detoxification.

Enabling the drug user to function without drugs after detoxification is extremely difficult.
The cravins often remain.

Psychological treatments

Desipramine was better for people with a low degree of dependence on cocaine. CBT was better for people with a high degree of dependence.

Contingency management with vouchers has shown a promise for cocaine, heroin, and marijuana use disorders.
Vouchers appear to work in the short term, but CBT appears to be an effective component of treatment for marijuana use disorder in the long term with respect to maintaining abstinence after treatment is over.

Motivational interviewing (or enhancement) has shown great promise.
A combination of CBT techniques and techniques associated with helping clients generate solutions that work for themselves.
Effective for both alcohol and drug use disorders.

Self-help residental homes are another psychological approach to treating heroin and other types of drug abuse and dependence.

• Separation of people from previous social contacts, on the assumption that these relationships have been instrumental in maintaining the drug use disorder
• A comprehensive environment in which drugs are not available and continuing support is offered to ease the transition from regular drug use to a drug-fee existence
• The presence of charismatic role models, people formerly dependent on drugs who appear to be meeting life’s challenges without drugs.
• Direct, often intense, confrontation in group therapy, in which people are goaded into accepting responsibility for their problems and for their drug habits and are urged to take charge of their lives.
• A setting in which people are respected as human beings rather than stigmatized as failures or criminals.

Drug replacement treatments and medications

Two widely used programs for heroin use disorder involve

• The administration of heroin substitutes: drugs chemically similar to heroin that can replace he body’s craving for it.
  These drugs are themselves addicting, but withdrawal from these drugs is less severe.
• Opiate antagonists: drugs that prevent the user from experiencing the heroin high.
  First, people are gradually weaned from heroin. Then they receive increasing dosages of naltrexone, which prevents them from experiencing any high should they later take heroin.

Drug replacement does not appear to be an effective treatment for cocaine abuse and dependence.

Prevention of substance use disorders

Self-esteem enhancement has not been shown to be effective.
Social skills training and resistance training have shown some positive results, particularly by girls.

Brief family interventions show promise.
May have preventative effects.

• Peer pressure resistance training.
• Correction of beliefs and expectations
• Inoculation against mass media messages
• Peer leadership