Royal College of Surgeons in Ireland

Coliste Roga na Minle in irinn

JC3 NS30 Psychological and Cognitive Aspects of Addiction

Dr. Mary Clarke

Learning Objectives

To outline the differences between substance abuse and dependence

To outline the why some individuals become addicts

To outline the mental health consequences of substance use

Substance abuse and dependence

A major problem facing society: Alcohol: road traffics accidents, Foetal Alcohol Syndrome, heart disease etc. Nicotine: lung cancer, cardiovascular disease Cocaine: psychosis, brain damage, death, crime Designer drugs: unknown risks, contamination, unwanted effects

Substance abuse in Ireland

Houses of the Oireachtas Joint Committee on Health and Children Report on The Misuse of Alcohol and Other Drugs January2012

Substance abuse in Ireland

Prevalence of drug use among high risk groups Drug use is more common among certain groups, such as: Early school leavers (ESL); Lesbian, gay, bisexual and transgender community; Travellers Young people.

Houses of the Oireachtas Joint Committee on Health and Children Report on The Misuse of Alcohol and Other Drugs January2012

Substance abuse in Ireland

Houses of the Oireachtas Joint Committee on Health and Children Report on The Misuse of Alcohol and Other Drugs January2012

Is drug addiction a mental illness?

Yes because addiction changes the brain in fundamental ways, disturbing a person's normal hierarchy of needs and desires and substituting new priorities connected with procuring and using the drug. The resulting compulsive behaviors that override the ability to control impulses despite the consequences are similar to hallmarks of other mental illnesses.

Why do some people become addicted to drugs, while others do not?

Substance abuse and dependence: Key concepts Acute intoxication Substance abuse Substance dependence Tolerance Withdrawal Cognitive Aspects

Factors influencing substance misuse

Availability Peer-pressure Deprivation Personality disorders

Pre-existing psychopathology
Pharmacological properties

Factors influencing substance misuse Neurobiology:

dopamine release in nucleus accumbens

Conditioned learning
Positive reinforcement Negative reinforcement Classical conditioning

Short-term effects vs. long-term risks

Biology

We know that despite their many differences, virtually all abused substances enhance dopamine (neurotransmitter) activity - particularly related to pleasure, motor and cognitive function

Dopamine Pathways
striatum frontal cortex hippocampus

substantia nigra/VTA Functions reward (motivation) pleasure,euphoria motor function (fine tuning) compulsion perserveration decision making

nucleus accumbens raphe

Brain Changes in Addiction

Cognitive Models of Addiction

The Biological model suggests that our genes and nervous system play a big part in addictive behaviour, BUT .. Why dont we feel euphoric and become dependent on morphine (similar opiate to heroin) after surgery?

Other processes must be involved

Cognition and drug addiction

Frontal cortex decision-making; response inhibition; planning; memory frontal cortex damage - impaired decision making impaired decision making and behavioural inhibition in substance abuse.

Cognition and drug addiction

Impaired decision making demonstrated in two thirds of addicts (Grant et al, 2000) Addiction involves, not only pleasure centres but also motivational circuits. Cocaine addicts when watching videotapes of people using the drug, addicts' brains showed spikes in dopamine levels in the dorsal striatum region of the brain, implicated in habit learning and initiation of action. Has been suggested that medications to inhibit the release of dopamine in the presence of salient cues could be valuable in treating cocaine addiction.

Effects of frontal cortex damage

Frontal cortex effects may last long after dopaminergic effects have worn off and may explain relapse - may make it difficult to look beyond the immediately reinforcing and pleasurable aspects of the drug to the long term consequences.

Acute intoxication

Transient

Substance-induced
Alterations of: Consciousness Cognition Perception Affect Behaviour

Substance abuse

Maladaptive pattern of substance use leading to clinically significant impairment or distress.

Substance abuse II

One or more of these in a 12 month period:

Recurrent substance use leading to failure to fulfil major role obligations. Recurrent substance use in physically hazardous situations. Recurrent substance-related legal problems. Continued substance use despite persistent recurring social or interpersonal problems caused or exacerbated by the substance.

Substance abuse III

The symptoms have never met the criteria for substance dependence for this class of substance

Substance dependence I

Maladaptive pattern of substance use leading to clinically significant impairment or distress.

Substance dependence II

Three or more of these occurring at any time in a 12 month period: Tolerance Withdrawal Using larger amounts or over longer period than intended Persistent desire and unsuccessful efforts to cut down or control use Lot of time spent in activities needed to obtain substance Important activities given up Substance use continued despite knowledge of having a problem caused by it

Dependence
Tolerance: with continued use, increased doses required to obtain the same effect. Withdrawal: unpleasant physical and psychological symptoms on discontinuing or decreasing a heavily used substance.

Psychological dependence: Need developed through learning (e.g. reducing anxiety). Can lead to physical dependence as with alcohol.

Withdrawal criteria: DSM-IV

Development of a substance-specific syndrome due to stopping or reducing substance use that has been heavily prolonged. The syndrome causes clinically significant distress or impairment in social, work or other important areas of functioning. Symptoms not due to general medical condition and not better accounted for by another mental disorder

Substance dependence III: DSM-IV

Specify if with or without physiological dependence (tolerance or withdrawal)

Course specifiers: Early full remission Early partial remission Sustained full remission Sustained partial remission On agonist therapy In controlled environment

Classes of substances abused

Depressants Opiates Stimulants Hallucinogens Cannabis Solvents Steroids

Marijuana

Tetrahydrocannabinol No physical dependence Marked psychological dependence Effects euphoria space and time distortion relaxation; well-being increased appetite

Marijuana

Tetrahydrocannabinol Effects memory changes: consolidation, STM transient psychoses, apathy lung disease psychomotor impairment

Alcohol abuse

safe 21 units for male 14 units for female Alcohol abuse: regular or binge consumption sufficient to cause physical, neuro-psychiatric or social damage

Alcohol physical signs

Intoxication ataxia, nystagmus, slurred speech, decreased concentration, psychological/behavioural changes, stupor. Alcohol on breath Red sclerae/conjunctivae Stimata of liver disease eg jaundice, spider naevi Tremor, sweating Excessive face skin capillarisation

Alcohol Dependence

compulsion to drink preoccupation with alcohol stereotyped drinking inability to regulate drinking altered tolerance withdrawal symptoms persistence even after attempted abstinence

Alcohol Complications

Acute intoxication Acute withdrawal Medical complications Wernickes encephalopathy Korsakoffs psychosis Social complications Foetal alcohol syndrome

Alcohol Management

Biological, psychological and social factors Acute detoxification: nutrition, benzodiazepines; rehydration, electrolyte balance Abstinence vs. controlled drinking Maintenance: group psychotherapy: motivation, relapse prevention, new social routines, self-help, treatment of anxiety and depression

Alcohol Abuse psychiatric problems

Suicide (10-15%, similar to bipolar and schizophrenia) Associated with 1/3 deliberate self-harm acts Depression (40%) Antisocial personality and violence Anxiety disorders (25-50%) Alcoholic hallucinations Sexual problems Sleep problems

Stimulants

Nicotine Caffeine Amphetamines Cocaine

Stimulants: Amphetamine speed Oral or intravenous euphoria, increased concentration and energy followed by depression, lethargy and fatigue Chronic use: may induce schizophreniform psychoses

Stimulants: cocaine

sniffed, chewed or injected restlessness, increased energy, abolition of fatigue and hunger. Visual/tactile hallucinations Sometimes paranoid psychoses Post-cocaine dysphoria sleeplessness and depression Crack highly addictive

Stimulants: MDMA
Ecstasy (MDMA) synthetic amphetamine analogue Causes serotonin release and blocks reuptake hyperactivity dehydration hyperpyrexia

Hallucinogens

LSD: psychological and physiological effects but not dependence Flashbacks Schizoid psychoses Seizures

Opiates

Heroin, morphine, methadone Smoked, sniffed, oral, intravenous, intramuscular or subcutaneous

Opiate Effects

Initial dysphoria Buzz, rush Histamine release Peace, tranquillity, Detachment CNS depression Rapid tolerance and withdrawal

Opiate Dependence

10% of users become dependent 10% 0f these seek help and 23% die annually 25% abstinent at 5 and 40% at 10 years

Opiate Withdrawal

24-48 hours Craving Flu-like symptoms: (muscle cramps, chills, lacrimation, rhinorrhoea); sweating, yawning. 7-10 days mydriasis, cramps, diarrhoea, agitation, restlessness gooseflesh

Drug use and other mental disorders

Many people who regularly abuse drugs are also diagnosed with mental disorders and vice versa. people diagnosed with mood or anxiety disorders are about twice as likely to suffer also from a drug use disorder (abuse or dependence) Similarly, persons diagnosed with drug disorders are roughly twice as likely to suffer also from mood and anxiety disorders

Treatment

Treatment

Principles of Effective Treatment

Scientific research since the mid1970s shows that treatment can help patients addicted to drugs stop using, avoid relapse, and successfully recover their lives. Based on this research, key principles have emerged that should form the basis of any effective treatment programs:

Principles of Effective Treatment

Addiction is a complex but treatable disease that affects brain function and behavior. No single treatment is appropriate for everyone. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. Remaining in treatment for an adequate period of time is critical. Counselingindividual and/or groupand other behavioral therapies are the most commonly used forms of drug abuse treatment. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Many drugaddicted individuals also have other mental disorders. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change longterm drug abuse.

Effective Treatment Approaches

Medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic process that often begins with detoxification, followed by treatment and relapse prevention. Easing withdrawal symptoms can be important in the initiation of treatment; preventing relapse is necessary for maintaining its effects. And sometimes, as with other chronic conditions, episodes of relapse may require a return to prior treatment. A continuum of care that includes a customized treatment regimen addressing all aspects of an individual's life, including medical and mental health servicesand followup options (e.g., community or familybased recovery support systems) can be crucial to a person's success in achieving and maintaining a drugfree lifestyle.

Reading

BMJ article on alcoholism: http://www.bmj.com/cgi/content/full/315/7104/358?maxtoshow=&HITS=10& hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0 &resourcetype=HWCIT BMJ article on drug addiction: http://www.bmj.com/cgi/content/full/315/7103/297?maxtoshow=&HITS=10& hits=10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=0 &resourcetype=HWCIT BMJreview(2008)article: http://www.bmj.com/cgi/reprint/336/7642/496?maxtoshow=&HITS=10&hits =10&RESULTFORMAT=&fulltext=addiction&searchid=1&FIRSTINDEX=30&r esourcetype=HWCIT