Chung-Deh College: October 2011

Substance use disorders

Substance use disorders include substance abuse and substance dependence. In DSM-IV, the conditions are formally diagnosed as one or the other, but it has been proposed that DSM-5 combine the two into a single condition called "Substance-use disorder".

Terminology and usage:

Although the term substance can refer to any physical matter, "substance abuse" has come to refer to the overindulgence in and dependence of a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others.

The disorder is characterized by a pattern of continued pathological use of a medication, non-medically indicated drug or toxin, which results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. There are on-going debates as to the exact distinctions between substance abuse and substance dependence, but current practice standard distinguishes between the two by defining substance dependence in terms of physiological and behavioral symptoms of substance use, and substance abuse in terms of the social consequences of substance use.

In the United States, physical dependence, abuse of, and withdrawal from drugs and other substances is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR). It does not use the word 'addiction' at all. It has instead a section about Substance dependence:

"Substance dependence When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders..."[17]

Addiction is now narrowly defined as "uncontrolled, compulsive use"; if there is no harm being suffered by, or damage done to, the patient or another party, then clinically it may be considered compulsive, but to the definition of some it is not categorized as 'addiction'. In practice, the two kinds of addiction are not always easy to distinguish. Addictions often have both physical and psychological components.

There is also a lesser known situation called pseudo-addiction.[18] A patient will exhibit drug-seeking behavior reminiscent of psychological addiction, but they tend to have genuine pain or other symptoms that have been under-treated. Unlike true psychological addiction, these behaviors tend to stop when the pain is adequately treated.

Physical dependency:

Physical dependence on a substance is defined by the appearance of characteristic withdrawal symptoms when the substance is suddenly discontinued. Opiates, benzodiazepines, barbiturates, alcohol and nicotine induce physical dependence. On the other hand, some categories of substances share this property and are still not considered addictive: cortisone, beta blockers and most antidepressants are examples. So, while physical dependency can be a major factor in the psychology of addiction and most often becomes a primary motivator in the continuation of an addiction, the initial primary attribution of an addictive substance is usually its ability to induce pleasure, although with continued use the goal is not so much to induce pleasure as it is to relieve the anxiety caused by the absence of a given addictive substance, causing it to become used compulsively.

Psychological dependency:

In the now outdated conceptualization of the problem, psychological dependency leads to psychological withdrawal symptoms (such as cravings, irritability, insomnia, depression, anorexia, etc). Addiction can in theory be derived from any rewarding behaviour, and is believed to be strongly associated with the dopaminergic system of the brain's reward system (as in the case of cocaine and amphetamines). Some claim that it is a habitual means to avoid undesired activity, but typically it is only so to a clinical level in individuals who have emotional, social, or psychological dysfunctions (psychological addiction is defined as such), replacing normal positive stimuli not otherwise attained.

A person who is physically dependent, but not psychologically dependent can have their dose slowly dropped until they are no longer physically dependent. However, if that person is psychologically dependent, they are still at serious risk for relapse into abuse and subsequent physical dependence.

Psychological dependence does not have to be limited only to substances; even activities and behavioural patterns can be considered addictions, if they become uncontrollable, e.g. problem gambling, Internet addiction, computer addiction, sexual addiction / pornography addiction, overeating, self-injury, compulsive buying, or work addiction.

Causes:

Psycho-social:

1. free-will model (proposed by Thomas Szasz and later refined by Jeffrey Schaler)

Free-will model theorists argue that addiction cannot be a disease, because drug-taking is a behavior, and all behaviors are choices.

Free-will model theorists believe that individuals are capable of deliberate action in pursuit of chosen goals, and that physiology alone can never determine whether a person will take a drug, or how often they will take it.

2. Pleasure model (proposed by professor Nils Bejerot)

Addiction "is an emotional fixation (sentiment) acquired through learning, which intermittently or continually expresses itself in purposeful, stereotyped behavior with the character and force of a natural drive, aiming at a specific pleasure or the avoidance of a specific discomfort." "The pleasure mechanism may be stimulated in a number of ways and give rise to a strong fixation on repetitive behavior. Stimulation with drugs is only one of many ways, but one of the simplest, strongest,and often also the most destructive" "If the pleasure stimulation becomes so strong that it captivates an individual with the compulsion and force characteristic of natural drives, then there exists...an addiction" The pleasure model is used as one of the reason for zero tolerance for use of illicit drugs.

3. Experiential model (devised by Stanton Peele)

argues that addictions occur with regard to experiences generated by various involvements, whether drug-induced or not. This model is in opposition to the disease, genetic, and neurobiological approaches. Among other things, it proposes that addiction is both more temporary or situational than the disease model claims, and is often outgrown through natural processes.

4. Opponent-process model (generated by Richard Soloman)

for every psychological event A will be followed by its opposite psychological event B. For example, the pleasure one experiences from heroin is followed by an opponent process of withdrawal, or the terror of jumping out of an airplane is rewarded with intense pleasure when the parachute opens. This model is related to the opponent process color theory. If you look at the color red then quickly look at a gray area you will see green. There are many examples of opponent processes in the nervous system including taste, motor movement, touch, vision, and hearing. Opponent-processes occurring at the sensory level may translate "down-stream" into addictive or habit-forming behavior.

5. Cutural model

recognizes that the influence of culture is a strong determinant of whether or not individuals fall prey to certain addictions. For example, alcoholism is rare among Saudi Arabians, where obtaining alcohol is difficult and using alcohol is prohibited. In North America, on the other hand, the incidence of gambling addictions soared in the last two decades of the 20th century, mirroring the growth of the gaming industry. Half of all patients diagnosed as alcoholic are born into families where alcohol is used heavily, suggesting that familiar influence, genetic factors, or more likely both, play a role in the development of addiction. What also needs to be noted is that when people don't gain a sense of moderation through their development they can be just as likely, if not more, to abuse substances than people born into alcoholic families

6. Moral model

states that addictions are the result of human weakness, and are defects of character. Those who advance this model do not accept that there is any biological basis for addiction. They often have scant sympathy for people with serious addictions, believing either that a person with greater moral strength could have the force of will to break an addiction, or that the addict demonstrated a great moral failure in the first place by starting the addiction. The moral model is widely applied to dependency on illegal substances, perhaps purely for social or political reasons, but is no longer widely considered to have any therapeutic value. Elements of the moral model, especially a focus on individual choices, have found enduring roles in other approaches to the treatment of dependencies.

7. Chemical model

Nearly all drugs, directly or indirectly, target the brain’s reward system by flooding the circuit with dopamine.[28] As a person continues to overstimulating the “reward circuit”, the brain adapts to the overwhelming surges in dopamine by producing less of the hormones or by reducing the number of receptors in the reward circuit. As a result, the chemical’s impact on the reward circuit is lessened, reducing the abuser’s ability to enjoy the things that previously brought pleasure.[28] This decrease compels those addicted to dopamine to increase the drug consumption in order to attempt to bring their "feel-good" hormone level back to normal —an effect known as tolerance. Development of dopamine tolerance can eventually lead to profound changes in neurons and brain circuits, with the potential to severely compromise the long-term health of the brain.[29] Modern antipsychotics are designed to block dopamine function. Unfortunately, this blocking can also cause relapses in depression, and can increase addictive behaviors.[30]

Misuse:

It is not uncommon for those dependent or addicted to substances to enter or remain in a state of polypharmacy misuse. One of the best examples includes those who chronically or acutely binge on amphetamines or other psychostimulants (particularly those with long half lives such as the amphetamines and methylphenidate). Because these agents have the effect of reducing or eliminating sleep for long periods of time, when sleep is finally desired or in an effort to reduce the "crash," hypnotics such as benzodiazepines, sometimes opiates, and less frequently barbiturates are used to induce sleep and/or hypnosis. Another classic example of concurrent polypharmacy misuse is the "speedball," a solution of typically cocaine and heroin in the same syringe which is injected together. Other combinations like amphetamines, methylphenidate and morphine, oxycodone, hydrocodone etc are also used and sometimes taken orally. The classic combination of cocaine and heroin injection has resulted in numerous high profile deaths as the stimulant effect of cocaine (which has a notably short half life) last much shorter than the depressant effects of opiates, which can then induce respiratory depression, respiratory arrest, and death.

Polypharmacy is the use of multiple medications by a patient, especially when too many forms of medication are used by a patient, when more drugs are prescribed than is clinically warranted,[1] or even when all prescribed medications are clinically indicated but there are too many pills to take (pill burden). Furthermore, a portion of the treatments may not be evidence-based. The most common results of polypharmacy are increased adverse drug reactions, drug-drug interactions and higher costs.[2] Polypharmacy is most common in the elderly but is also widespread in the general population.[3]

Polypharmacy is most common in people with multiple medical conditions. Combination therapy is the use of multiple drugs specifically to treat a single medical condition; monotherapy is the use of a single drug.

ill burden is a term that refers to the number of tablets, capsules or other dosage forms that a patient takes on a regular basis.

High pill burden decreases compliance with drug therapy, resulting from the need to take a large quantity of pills or other forms of medication on a regular basis. It also increases the possibility of adverse medication reactions (side effects) and drug-drug interactions. High pill burden has also been associated with an increased risk of hospitalization, medication errors, and increased costs for both the pharmaceuticals themselves and for the treatment of adverse events. Finally, pill burden is a source of dissatisfaction for many patients.

Celebrities with substance-abuse issues:

1. Marilyn Monroe – She is known as a famous actress, model, and American sex symbol. She was born as Norma Jean Mortenson and was married 3 times, all of which ended in divorce. Today, Monroe is the only woman listed on Forbes list of top earning dead celebrities. At the age of 36, Marilyn died in her sleep of barbiturate poisoning (an overdose of sleeping pills). To this day, no one knows for sure whether her death was a suicide or homicide.

2. Billie Holiday – Billie was a famous female jazz singer. She was originally named Eleanora Fagan. This singer used hard drugs (primarily heroin) and was involved in unhealthy relationships where abuse took place. Eventually she developed heart disease and liver complications. She died at the age of 44 from cirrhosis of the liver, a problem which arose from long-term drug and alcohol abuse.

3. Anna Nicole Smith – Smith was an actress and model. In fact, she was named Playmate of the Year in 1993. She was married three times during her lifetime, the most famous of which was to J. Howard Marshall. This oil executive was a billionaire and 63 years older than Smith. Anna Nicole Smith died at the age of 39 from accidental overdose of chloral hydrate and other prescription drugs.

4. Jim Morrison – He is most famous for being a singer, but he also wrote a number of poems, directed films, and wrote his own songs. Morrison was a lead singer for the famous band, The Doors. Throughout his life, the singer struggled with both drug and alcohol abuse. He died at the age of 27. Although several stories have circulated regarding his death, the general consensus is that he died of a heart attack triggered by accidental heroin overdose.

5. Whitney Houston (Cocaine, Marijuana) - In April 2000, airport security discovered Marijuana in Whitney’s luggage. Whitney has been in and out of rehab, and also has admitted to abusing Alcohol, Marijuana, Cocaine and Pills. In 2006 the National Enquirer published photographs of what was reportedly Houston’s private bathroom. The counters were covered with empty beer bottles, rolling papers, pipes and powder-covered spoons and lighters. Whitney’s sister-in-law claimed that she is addicted to Crack and has nearly overdosed several times. She also claimed that Whitney often punches and bites herself until she is black and blue, thinking that the devil is attacking her.

6. Robert Downey Jr. (Alcohol , Cocaine, Heroin, Valium) - Robert Downey Jr.’s addiction to drugs started with Marijuana when he was only 6 years old. He was surrounded by drugs, and that was the type of home he grew up in. By the age of 22 he had developed a serious drug problem. He went through his first rehab in 1987, and in 1996 was arrested three times on drug and weapons charges. For the next few years, Downey went in and out of prison and rehab. He continued to use Crack Cocaine and Heroin. Despite this he continued to act and even won an award on the TV series Ally McBeal all while living in a residential treatment facility. A few months later came another arrest for felony drug possession. Before this even came to trial he was arrested yet again. Despite being sober for over five years now, Robert Downey Jr. still gets stopped by police officers who think he might be under the influence.

7. Elvis Presley - "Drug use was heavily implicated" in Presley's death, writes Guralnick. "No one ruled out the possibility of anaphylactic shock brought on by the codeine pills ... to which he was known to have had a mild allergy." A pair of lab reports filed two months later each strongly suggested that polypharmacy was the primary cause of death; one reported "fourteen drugs in Elvis' system, ten in significant quantity."[298] Forensic historian and pathologist Michael Baden views the situation as complicated: "Elvis had had an enlarged heart for a long time. That, together with his drug habit, caused his death. But he was difficult to diagnose; it was a judgment call."[299]

While Presley's main physician, Dr. Nichopoulos, was exonerated of criminal liability for the singer's death, the facts were startling: "In the first eight months of 1977 alone, he had [prescribed] more than 10,000 doses of sedatives, amphetamines and narcotics: all in Elvis's name." His license was suspended for three months. It was permanently revoked in the 1990s after the Tennessee Medical Board brought new charges of over-prescription.

Elvis began declining in his last 3 to 4 years. He had difficulty performing; received unfavorable reviews; and experienced anger and depression, colon problems, weight gain and bloating, and bizarre behavior.

He was now becoming increasingly unwell. Twice during the year he overdosed on barbiturates, spending three days in a coma in his hotel suite after the first incident.

(Barbiturates are drugs that act as central nervous system depressants,)

In 1994, the Presley autopsy was reopened. Coroner Dr. Joseph Davis declared, "There is nothing in any of the data that supports a death from drugs. In fact, everything points to a sudden, violent heart attack."[219] Whether or not combined drug intoxication was in fact the cause, there is little doubt that polypharmacy contributed significantly to Presley's premature death

The common denominator in all these young celebrity deaths is substance abuse, a disease that can result in depression, insomnia, personality changes, impaired judgment, and poor relationships. In some of these cases, medical care was somewhat questionable and inadequate, and self-medication was frequent. The deaths in many cases were shrouded in mystery due to cover-up attempts.

Celebrity patients frequently practice polypharmacy using multiple physicians, multiple drug stores, and multiple aliases to obtain medications. Denial increases as dependency worsens.

Prescription drugs, especially the opioid analgesics, now cause more deaths than heroin and cocaine. All of these drugs can cause central nervous system and respiratory depression. They form deadly combinations with barbiturates and other sedatives and with alcohol.

Cure?

Is cure or prevention the best answer to drug and alcohol abuse? It probably seems a pretty obvious answer to most of us. Most of us would rather prevent abuse of any substance than have to try and come up with a cure for it but unfortunately the fact is that a massive amount of people become dependent on drugs or alcohol and there is no known cure for either. That is to say, there is no tablet you can take, there's no medicine the doctor can give sufferers.

Firstly, we must remember that alcohol or drug addiction is a disease which can not be treated in the traditional medicinal sense of the word. Strong will and stubbornness are the most important factors in recovering from addiction as well as having invaluable support from friends, family and loved ones.

An alcohol treatment center can offer support for both sufferers and their families but it really is down to the individual to help themselves through the rehabilitation process.

The first step to prevention is identification. If we can identify that someone may have or will have a problem with drug and alcohol abuse the first thing we should do is remove temptation. Unfortunately, it isn't always that easy. Many alcoholics or drug users conceal their addiction and are very good at it. Of course, unless we suspect someone it is highly unlikely that we will be looking for any of the signs of drug and alcohol abuse and that is why many cases often go undetected until it is too late.

10 best movies about Substance-abuse

1. Altered states – Ken Russell, 1980

2. Reefer Madness – Louis J. Gasnier, 1934

3. The Boost – Harold Becker, 1988

4. Trainspotting – Danny Boyle, 1996

5. The Man with the Golden Arm – Otto Preminger, 1955

6. Gridlock'd – Vondie Curtis Hall, 1997

7. Drugstore Cowboy – Gus van Sant, 1989

8. Leaving Las Vegas – Mike Figgis, 1995

9. Days of Wine and Roses – Blake Edwards, 1962

10. Requiem for a Dream – Darren Aronofsky, 2000

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