Substance-Related and Addictive Disorders

1. Substance-Related andAddictive Disorders Chapter 12

2. Substance Use Disorders • Substance: A chemical that alters a person’s mood or behavior when it is smoked, injected, drunk, inhaled, or swallowed in pill form. • Substance abuse: Maladaptive pattern of substance use occurring within a 12-month period that leads to significant impairment or distress evidence by: • Failure to meet obligations • Repeated use of substances in physically hazardous situations • Legal problems • Interpersonal problems. • Substance dependence: Maladaptive pattern of use manifested by cognitive, behavioral, and physiological symptoms during a 12-month period and caused by continued use of substance.

3. Substance Use Disorders • Withdrawal: Physiological and psychological changes that occur when an individual stops taking a substance. • Tolerance: Extent to which the individual requires larger and larger amounts of a substance in order to achieve its desired effects, or the extent to which the individual feels less of its effects after using the same amount of the substance. • Substance intoxication: The temporary maladaptive experience of behavioral or psychological changes that are due to the accumulation of a substance in the body.

4. substance use disorder • A cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using a substance even though it causes significant problems in his or her life. • Clinicians diagnose substance use disorders by assessing the individual in four categories of symptoms: • impaired control, • social impairment, • risky use • pharmacological changes. • New diagnostic term has fewer negative connotations than the term “addiction”

5. Opioid epidemic in the us

6. Understanding the Epidemic (CDC) • Drug overdose deaths continue to increase in the United States. • In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999. • On average, 130 Americans die every day from an opioid overdose.

7. How did this happen? • In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers. • Healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive • (1995) Introduction of OxyContin: • Increase in Overdose deaths • Increase in neonatal abstinence syndrome • Increase in Hep C and HIV

9. CDC – Reverse Overdose to Prevent Death • Expand access to and use of naloxone – a non-addictive, life-saving drug that can reverse the effects of an opioid overdose when administered in time. • Naloxone is a medication approved by the Food and Drug Administration (FDA) to prevent overdose by opioids such as heroin, morphine, and oxycodone. • It blocks opioid receptor sites, reversing the toxic effects of the overdose • Access to naloxone can be expanded through: • Standing orders at pharmacies • Distribution through local, community-based organizations • Access and use by law enforcement officials • Training for basic emergency medical service staff on how to administer the drug

10. Alcohol Use Disorder

12. Alcohol Effects • Alcohol is a depressant • A psychoactive substance that causes the depression of central nervous system activity. • Excessive drinking affects vital functions and can be fatal. • Immediate effects • Sedating • In small amounts, alcohol has sedating effects leading users to feel relaxed. • In larger amounts, alcohol may lead drinkers to feel more outgoing, self-confident, and uninhibited. • As drinking continues, alcohol’s effects as a central nervous system depressant become more apparent, as sleepiness, uncoordination, dysphoria, and irritability set in. • Potentially fatal in excess • Potentiation: • Combination of the effects of two or more psychoactive substances such that the total effect is greater than the effect of either substance alone.

13. DSM 5 – Alcohol Use Disorder(National Institute on alcohol abuse and alcoholism Anyone meeting any two of the 11 criteria during the same 12-month period receives a diagnosis of AUD. The severity of AUD—mild, moderate, or severe—is based on the number of criteria met. To assess whether you or loved one may have AUD, here are some questions to ask.  In the past year, have you: • Had times when you ended up drinking more, or longer than you intended? • More than once wanted to cut down or stop drinking, or tried to, but couldn’t? • Spent a lot of time drinking? Or being sick or getting over the aftereffects? • Experienced craving — a strong need, or urge, to drink? • Found that drinking — or being sick from drinking — often interfered with taking care of your home or family? Or caused job troubles? Or school problems? • Continued to drink even though it was causing trouble with your family or friends?

14. Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? • More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? • Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? • (TOLERANCE) Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before? • (DT’s – Delirium Tremens)Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating? Or sensed things that were not there? If you have any of these symptoms, your drinking may already be a cause for concern. The more symptoms you have, the more urgent the need for change Most people with AUD can benefit from treatment. Unfortunately, less than 10 percent of them receive any treatment.  Ultimately, receiving treatment can improve an individual’s chances of success in overcoming AUD.

15. What are the stages of alcohol use disorder? • Five stages of alcohol and drug use disorders have been identified. • The first stage: is described as having access to alcohol rather than use of alcohol. In that stage, minimizing the risk factors that make a person more vulnerable to using alcohol are an issue. • The second stage: use ranges from experimentation or occasional use to regular weekly use of alcohol. This or any of the more severe stages of alcoholism may involve binge drinking. • The third stage is characterized by individuals further increasing the frequency of alcohol use and/or using the substance on a regular basis. This stage may also include either buying or stealing to get alcohol. • Fourth stage of alcohol use, users have established regular alcohol consumption, have become preoccupied with getting intoxicated ("high") and have developed problems in their social, educational, vocational, or family life as a result of using the substance. • Fifth and final stage: and most serious. Alcohol use is defined by the person only feeling normal when they are using alcohol. During this stage, risk-taking behaviors like stealing, engaging in physical fights, or driving while intoxicated increase, and they become most vulnerable to having suicidal thoughts.

16. Binge drinking has serious risks (CDC). • Binge drinking is associated with many health problems, including the following: • Unintentional injuries such as car accidents, falls, burns, and alcohol poisoning. • Violence including homicide, suicide, intimate partner violence, and sexual assault. • Sexually transmitted diseases. • Unintended pregnancy and poor pregnancy outcomes, including miscarriage and stillbirth. • Fetal Alcohol Spectrum Disorders • Sudden infant death syndrome. • Chronic diseases such as high blood pressure, stroke, heart disease, and liver disease. • Cancer of the breast, mouth, throat, esophagus, liver, and colon. • Memory and learning problems. • Alcohol dependence.

17. BINGE DRINKING • National Institute on Alcohol/ Alcoholism (NIAAA) defines binge drinking as • A pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. • Drinking 5 or more alcoholic drinks for males or 4 or more alcoholic drinks for females on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past month.

18. Alcohol poisoning • Life-threatening signs of alcohol poisoning include: • Inability to wake up • Vomiting • Slow breathing (fewer than 8 breaths per minute) • Irregular breathing (10 seconds or more between breaths) • Seizures • Hypothermia (low body temperature), bluish skin color, paleness

19. What to do in case of alcohol poisoning In the event a person suffers from alcohol poisoning, immediately call 911. Stay with the individual to prevent accidental self-harm or to prevent the person from choking on their own vomit if unconscious. It is vitally important to get emergency medical help as soon as possible, even if the person is conscious and speaking After calling 911 for emergency medical help, there are other steps to take to help a person who is experiencing alcohol poisoning. These include: • Keep the person awake if possible. • Keep the person informed. Let the person know if you are going to touch them or perform any action on them, as some individuals may become aggressive. • Keep the person sitting. • If the person is conscious and able to swallow, try to get them to slowly drink water. • If the person is unconscious and lying down, carefully roll them onto their side with their arms over their head so they will not choke on their own vomit. • Get a warm blanket for the person, as alcohol poisoning will likely make them feel cold.

20. Things NOT To Do for Someone Experiencing Alcohol Poisoning • Do not give the person coffee, because caffeine can cause further dehydration. • Do not attempt to feed the person, because they may choke on the food due to a lack of gag reflex or ability to swallow. • Do not give the person any other medications, because mixing drugs and alcohol will likely make the alcohol poisoning worse. • Do not make the person throw up to get alcohol out of the stomach, because their gag reflex will likely not work and they could choke. • Do not walk the person around, in an attempt to “walk it off,” because their reduced physical coordination could lead to falls or other accidental harm. • Do not put the person in a cold shower, because that could increase hypothermia. • Do not let the person “sleep it off,” because alcohol is likely still digesting into their bloodstream and their symptoms could get much worse. • Do not leave the person alone. • Do not allow the person to drink more alcohol

21. Long term effects of alcohol use • Long-term effects Permanent brain damage: Dementia *Wernicke’s disease Form of aphasia in which the individual is able to produce language but has lost the ability to comprehend, so that these verbal productions have no meaning. *Korsakoff’s Syndrome Permanent form of dementia associated with long-term alcohol use in which the individual develops retrograde and anterograde amnesia, leading to an inability to remember recent events or learn new information. Retrograde amnesia: Amnesia involving loss of memory for past events. Anterograde amnesia: Amnesia involving the inability to remember new information. Harmful changes in the liver, gastrointestinal system, bone density, muscles, and immune system

22. Alcoholics Anonymous (AA) and Alternatives http://www.aaventuracounty.org/ Ventura County AA • Alcoholics Anonymous (AA): Worldwide self-help organization composed of recovering alcoholics; emphasizes admitting powerlessness over alcohol usage and wanting to recover • Spiritual component • Free; around for over 70 years! • Rational Recovery, and Secular Organizations for Sobriety (SOS): Non-spiritual AA Alternatives

23. Life with the Alcoholichttp://www.alanonventura.org/ Al-Anon/Al-Ateen Ventura County • Alcoholism affects the entire family • There is strong, scientific evidence that alcoholism tends to run in families. • Alcohol is associated with a substantial proportion of human violence • A relationship between parental alcoholism and child abuse is indicated in a large proportion of child abuse cases • Children of alcoholics exhibit symptoms of depression and anxiety more than children of non-alcoholics, they often have difficulties in school as well

24. Effects of Alcohol on the Family(Satir- Black) “survival mechanisms” • In a home where one or both parents are alcoholic family life tends to be: inconsistent, unpredictable, arbitrary, and chaotic.(i.e. Walking on eggshells) (I.e., What is true one day may change the next day) (I.e., You do not who will greet you when you get home: a sober or drunken parent) (i.e. Unable to agree on rules for their children). • Diffused boundaries (Enmeshment): There may be a Role Reversal: Child parents the parent. • Authoritarian or Permissive Parenting: More prone to abuse. • Feelings are ignored/ridiculed (Don’t talk; Don’t feel; Don’t tell). • Poor Communication (i.e. triangulation: child becomes the mediator between mom and dad). • Possibly live in fear, do not trust their world or themselves. • Feel out of control. • Feelings of abandonment and disappointment are very common.

25. Roles Played by Adult Children of Alcoholics • The Responsible Child: Motto: In the midst of chaos, I’ll do it and I’ll take care of it. (i.e. May take care of other children and parents; as they grow older they are perfect children, A students, etc..) • The Adjuster: This child will adjust/adapt easily. Motto: In the midst of chaos I’ll ignore it.They feel that they have no control over what is happening and thus no power to change anything in their environment. • The Placater: These children fix e/one’s feelings, worries, troubles. They typically diffuse any tension/crisis. Excellent conflict negotiators. Work hard at taking care of everybody else’s needs, EXCEPT THEIR OWN. Motto: In the midst of chaos I’ll fix it and make it better. They please, please, please, and are always apologetic. (i.e. If mom has been drinking, dad comes home s/he will guide him to dinner and tell him e/thing has been taking care of; I am sorry, mom is asleep because she is sick, DON’T WORRY ABOUT ANYTHING).

26. The Clown: These children make light of everything; they try to diffuse conflict by making everyone laugh or by “clowning around”. They grow up having difficulty being serious, and often their humor is sarcastic as if their anger and pain was just below the surface. Motto: In the midst of chaos I’ll make a fool of myself and make everyone feel better at my expense. The Rebel: These children become the Scapegoats or the “Black Sheep” of the family. They usually get into trouble, and sometimes do so to pull away the attention from the alcoholic and the problems associated with his/her drinking. They are usually in the “out group” and have had numerous problems at school, work, etc. Motto: In the midst of chaos I’ll “act out” the family dysfunction; I’ll get into trouble to veer the attention away from the alcoholic

27. Do’s and Don’ts for children of Alcoholics • DO talk about how you feel • DO try to get involved in doing enjoyable things at school or near where you live • DO remember that feeling afraid and alone is a normal way to feel when you live with alcoholic parents. • DO remember to have fun • Don't ride in a car when the driver has been drinking • Don't think that because your parent is an alcoholic you will be one too • Don't think that your alcoholic parent has stopped loving you

28. Fetal Alcohol Syndrome • Signs may include: • Distinctive facial features: small eyelid openings, a sunken nasal bridge, thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip • Heart defects • Deformities of joints, limbs and fingers • Slow physical growth • Vision difficulties including nearsightedness (myopia) • Small head circumference and brain size (microcephaly) • Mental retardation and delayed development • Abnormal behavior such as a short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety

29. Non-Substance-Related Disorders

30. Gambling Disorder • A non-substance-related disorder involving the persistent urge to gamble. • This disorder is included with substance use disorders as it is now conceptualized as showing many of the same behaviors, such as: • Cravings • Increasing needs to engage in the behavior • Negative social consequences. • People with gambling disorder also have high rates comorbidity: • Nicotine dependence • Dependence on other substances • Mood disorder • Anxiety disorder • Mood and anxiety disorders are more likely to precede, rather than follow, the onset of gambling disorder