Causes and Treatment of Substance Use Disorders

Chapter 11

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

Moving Through the Spectrum

• Depends on numerous issues– The drug itself (The Agent)– The person (The Host)– The person’s environment (The Environment)

• With some drugs it is difficult to maintain the line between use, misuse, abuse and dependence

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

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

Causes - Multidimensional

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

Pharmacologic

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

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

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.

Social/Environmental

• Certain developmental insults

• Access

• Social norms

• Using peers

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.

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

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

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

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– Haven’t found one yet

• Overall not many meds work. Compliance is the ultimate issue.

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

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