SUBSTANCE USE AND ADDICTIVE DISORDERS

Wamcie M. Chua, M.D.

DEFINITION OF TERMS DENIAL

HALLMARKS OF SUBSTANCE USE DISORDERS  Often behave as if the substance use that is causing
Behavioral, physical, and psychological dependence are the obvious problems were not really a problem
hallmark of substance use disorders  Unwilling to accept the notion that outside
 Most patients will experience all 3 intervention is needed
Behavioral dependence Substance-seeking activities o Common lines of enablers in a co-dependent
and related evidence of relationship with the substance user is “Sige
pathological use patterns lang, Doc, wag muna natin iparehab.
are emphasized Gagaling din yan. Kaya naman daw niya
Physical dependence Physical effects of multiple itigil kapag gusto niya.”
episodes of substance use o However, the thing with substance abuse is
Includes intoxication and there comes a time when the neurons have
withdrawal already adapted and it would be very
Psychological dependence AKA Habituation difficult to stop using the substance on your
Continuous or intermittent own and you’ll need outside intervention
craving for the substance to o The thing with substance use is… When you
avoid a dysphoric state can stop, you don’t want to stop yet. When
you want to stop already, you can’t stop
ENABLING anymore.
 Because of the social pressure for protecting and  Denial allows the abusing/dependent individual to
supporting family members or because of continue his/her activity despite its detrimental
pathological interdependencies, or both effects
o Usually, the enablers are the relatives
o They help propagate or perpetuate the SUBSTANCE VS. DRUG
patient’s substance using behavior  “Drug” is not a scientific term
 Enabling behavior often resists modification  Substance is the term recommended by DSM-5
o As much as it is difficult to ask the patient to o Alters brain functions/activities
discontinue or change the substance using o May occur naturally (e.g. opium) or
behavior, relatives who are also enablers… manufactured chemically
it’s very difficult to point out their enabling o May not be indicated for human
behavior and to develop insight into these consumption (e.g. wood glue, solvents)
relatives
 Results in feelings of anger, rejection, and failure ADDICTION
 Family members may feel guilty and depressed  “Addiction” is not a scientific term (WHO, 1964)
because addicts, in an effort to deny loss of control  Terms in DSM-V:
over drugs and to shift the focus of concern away o Substance intoxication
from their use, often try to place the responsibility o Substance dependence
for such use on other family members, who often o Substance withdrawal
seem willing to accept some or all of it o Substance induced mental disorder
o “Ugaling adik”: blaming everybody else but  SI mood d/o, SI psychosis, etc
themselves (e.g. “I’m taking drugs because  Diagnosed only if the patient’s
my mother argued with me yesterday”) symptoms disappear when the
effects of the substance wears off
CO-ADDICTION / CO-DEPENDENCE  A state in which an organism engages in compulsive
 2 or more persons have a relationship that maintains behavior
substance use behavior in at least one of the persons o The behavior is reinforcing (rewarding or
 Relationship develops due to enabling behaviors and pleasurable)
denial of situation o Loss of control in limiting intake

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TOLERANCE SUBSTANCES THAT CAN INDUCE INTOXICATION
 A given dose of drug produces a decreased effect Alcohol Inhalants Hallucinogens
 Increasingly large doses must be administered to Amphetamines Opiates Residual category
obtain the effect observed Caffeine Sedatives / (steroids, nitrous
o The substance user will need greater Cannabis hypnotics / oxide)
amounts of the drug or greater frequency of Cocaine anxiolytics
use to achieve the same effect The phenomenon of intoxication is not just limited to illicit
substances. It can also occur in substances that we use in
INTOXICATION the medical practice. For psychiatrists, what is of concern
 A specific syndrome of maladaptive behavioral or to us usually are the effects of sedatives/hypnotics/
psychological changes due to the recent ingestion anxiolytics.
or of exposure to a substance that acts on the CNS
o Syndrome: group of signs and symptoms WITHDRAWAL
 Effects of using drugs and alcohol  CRITERION A: The essential feature is the
 Involves the toxic results of introducing a poison into development of a substance-specific problematic,
the body behavioral change, with physiological and cognitive
 Alcohol and most drugs are actually poisons concomitants, that is due to the cessation of, or
 The essential feature is the development of a reduction in, heavy and prolonged substance use
reversible substance-specific syndrome due to the  CRITERION C: The substance-specific syndrome
recent ingestion of a substance causes clinically significant distress or impairment in
social, occupational, or other important areas of
WITHDRAWAL functioning
 Maladaptive behavioral change with physiological  CRITERION D: The symptoms are not due to another
and cognitive effect medical condition and are not better explained by
 When concentration of a substance declines in the another mental disorder
body
Withdrawal is usually, but not always, associated with a
Both intoxication and withdrawal produce substance- substance use disorder
specific symptoms and behavioral changes, the diff is:
 Intoxication: after recent ingestion or exposure Most individuals with withdrawal have an urge to re-
 Withdrawal: when amount of substance in the body administer the substance to reduce the symptoms
declines
CLINICAL PICTURE
PHENOMENOLOGY Invidual
Duration /
INTOXICATION Chronicity
degree of
tolerance
MOST COMMON CHANGES IN INTOXICATION INVOLVE Time since
DISTURBANCES OF: Dose
last dose
Perception Thinking Judgment
Wakefulness Psychomotor Interpersonal
Attention behavior behavior
Persons's

Substance
Clinical expectations as
to the
 CRITERION A: The essential feature is the picture substance's
effect
development of a reversible substance-specific
syndrome due to the recent ingestion of a substance
 CRITERION B: The clinically significant problematic
behavior or psychological changes associated with The patient’s intoxication and withdrawal is dependent on
intoxication are attributable to the physiological type and dose of the substance ingested, duration/
effects of the substance on the central nervous chronicity of use, individual degree of tolerance, time since
system and develop during or shortly after use of the the last dose, and the person’s expectations as to the
substance substance’s effect of the substance.
 CRITERION D: The symptoms are not attributable to
another medical condition and are not better These are the things that you have to obtain and include in
explained by another mental disorder your history when you are talking to a patient with a
known history of substance abuse.

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EPIDEMIOLOGY Note that polysubstance use (or abuse of drugs one after the
 In 1972, there were only 20,000 drug users in the PH other or in combination with other intoxicating substances) is
 In 2004, this figure has climbed to 6.7 million common among drug abusers
 Methamphetamine hydrochloride or “shabu” and  It is the norm, rather than the expectation
marijuana are the illegal drugs preferred by one in  Significance: with all the other information that you
every 29 Filipinos aged 10 to 44 years will get regarding intoxication, you also have to ask
 Those who started to use illicit substances, or check for other substances the patient is using
particularly at an earlier age, are more likely to aside from whatever it is that they volunteer.
become addicted
ETIOLOGY
Alcohol related disorders  Result of a process in which multiple interacting
 There is little data, available on the extent of factors influence drug-using behavior and loss of
alcoholism or alcohol abuse in the Philippines judgment
 In a 2001 survey of persons aged 15-74, the rate of o Is there one factor that is responsible for the
regular drinking was 11.1% (13% males, 5.9% patient’s substance use? NO.
females)  Not assumed that all people who become
 Among drinkers, 4.8% were heavy drinkers (6.6% dependent on the same drug experience its effects
males, 1.3% females) in the same way or are motivated by the same set
of factors
Regular drinker One who drinks 4x or more per week  Different factors may be more or less important at
Heavy drinking Having more than 12 drinks on an different stages of the process
average drinking day  Major determinants of initial experimentation with a
drug:
PROFILE OF A FILIPINO SUBSTANCE ABUSER o Drug availability
Based on reported 4,703 cases admitted in the different o Social acceptability
treatment and rehabilitation centers, both residential and o Peer pressures
out-patient facilities in 2006 (Source: Department of Health’s  Personality and individual biology are important in
Dangerous Drugs Abuse Prevention and Treatment Program) how the effects of a given drug are perceived and
the degree to which repeated drug use produces
FILIPINO SUBSTANCE ABUSER (MUST KNOW!) changes in the central nervous system
Mean age 26 years old
Sex ratio 9 males: 1 female QUICK QUIZ! Write A if it is a Personality
Civil status Single (57.77%) determinant of initial Peer pressure
Occupation Employed (35.81%) experimentation (before onset Social acceptability
Educational attainment High school level (29.79%) of substance use) and B if it is a Individual biology
Economic status P13,706 average monthly determinant of effects (after Drug availability
family income onset of substance use)
Place of residence Urban, specifically Metro
Manila (58.32%)  Addiction is a “brain disease”
Duration of drug abuse More than 6 years  Critical processes that transform voluntary drug-
using behavior into compulsive drug use are
TOP 10 DRUGS / SUBTANCES OF ABUSE changes in the structure and neurochemistry of the
brain of the drug user
Rank Substance %
o That’s why after some, even if they want to
1 Methamphetamine HCl (Shabu) 69
change their substance using behavior
2 Cannabis (Marijuana) 38
already, it is very difficult to do so without
3 Contact cement (e.g. Rugby) 11.4
outside intervention
4 Benzodiazepines 3.8
 Use of the drug initiates a sequence of consequences
5 Cough/cold preparations 2.7 that can be rewarding or aversive and which,
6 Methylenedioxymethampethamine 1.5 through a process of learning, can result in a greater
(MDMA) or lesser likelihood that the drug-using behavior will
7 Cocaine 1.1 be repeated
8 Nalbuphine hydrochloride 0.6
9 Psilocybin (Magic mushroom) 0.5
10 Solvents (acetone, thinner) 0.3

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BIOPSYCHOSOCIAL THEORIES COGNITIVE MODEL OF ABUSE AND DEPENDENCE
LEARNING THEORY Core belief
 Behavior as over-learned habit (Marlatt & Gordon, 1985) I am a weakling in the office
o Growing up, what you see in the people
around you and how they behave tend to Anticipatory beliefs
make you learn that and pattern your When I take alcohol, I can get through a day of stress
behavior after what you see around you
Craving
 Adaptation to the environment Therefore, I need alcohol to get through a day of stress
 Substances as positive reinforcers
o For patients who are shy and find out that Permissive belief
use of illicit substances lower they anxiety Today is full of stress. Therefore, I can take all the alcohol I want
and help them be more sociable tend to use
it again
Abuse / dependence
Alcohol, alcohol, alcohol
o Same with coffee: if you see that whenever
you drink coffee, you have more energy to
finish all the chapters that you need to read PSYCHODYNAMIC THEORIES
for your psychiatry class, you’ll think “Next  Substance abuse is a masturbatory equivalent
time I’ll drink coffee, too!” o The rush that they feel regarding the use of
the illicit substance is equivalent to a sexual
LEARNING AND CONDITIONING THEORIES orgasm
 Behavior maintained by its consequences (usually  A defense against anxious impulses
positive consequences)  A manifestation of oral aggression
 Evokes rapid positive reinforcement, either as a o A sign of dependency
result of the rush, alleviation of disturbed affects,  Use as a reflection of disturbed ego functions
alleviation of withdrawal symptoms, or any o Some patients who are unable to deal with
combination of these effects reality or who are experiencing psychosis
 Eventually, the paraphernalia (needles, bottles, also use illicit substances
cigarette packs) and behaviors associated with  As a form of self-medication…
substance use can become secondary reinforcers as o Alcohol may be used to control panic
well as cues signaling availability of the substance, o Opioids to control anger
and in their presence, craving or a desire to o Amphetamines to alleviated depression
experience the effects increases  Some addicts have great difficulty recognizing their
 The most intense craving is elicited by condition inner emotional states, a condition called
associated with the availability or use of the alexithymia (i.e. being unable to find words to
substance describe their feelings)
o Such as watching someone else use heroin  Drugs as transitional object
or light a cigarette or being offered some o Inability to internalize soothing self-objects
drug by a friend o In a very chaotic home environment with no
 This why we always advise or instruct patients that stability, there is a lack of soothing self-
after they undergo rehabilitation, as much as objects. The parents are always fighting so
possible and if they can do it, they move to a the child uses the substance as an internal
different environment soothing object.
 If, after rehabilitation, they go back to the same o Transcriber’s note: it’s like the drug is used
environment, they’ll see the same people and they like a teddy bear or blanket to soothe
will offer them illicit substances and they’ll see them themselves
using. It will induce cravings and they will be
tempted again to use the illicit substance. SOCIOCULTURAL FACTORS
 Social setting may lead to abuse or dependence
SOCIAL LEARNING THEORY o If you grow up seeing you parent’s use illicit
 What you think affects how you learn substances and it’s no big deal for them,
 Cognitions: anticipation, planning, expectancies, you’ll think that using illicit substances is OK
attributions, self-efficacy, and decision-making  Habits in the family
 Disturbed familial and societal relationships

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BIOLOGICAL FACTORS  Substance use is also a major precipitating factor
GENETIC FACTORS for suicide
 Strong evidence from studies of twins, adoptees, o 20x more likely to die by suicide than the
and sibling brought up separately indicates that the general population
cause of alcohol abuse has a genetic component o 15% of the persons with alcohol abuse or
 Many less conclusive data show that other types of alcohol dependence have been reported to
substance abuse of substance dependence have a commit suicide
genetic pattern in their development o 2nd only to the frequency in patients with
major depressive disorder
ANATOMICAL CORRELATES  DSM-5
 Reward circuit: nucleus accumbens and ventral o Substance use disorder
tegmental area -> thalamus o Substance intoxication
o If there is a pleasurable experience from the o Substance withdrawal
use of the illicit substance, it will distort the o Substance-induced mental disorder
memory and eventually, there is the
development of compulsive behavior and it Transcriber’s note: This is where the lecture ended.
becomes routine… the person will keep on
looking for the turning on of that reward I just really wanted to get this out to the batch ASAP
circuit so this is just based on pictures of the slides that I typed up
and my audio recording of the lecture.
Dopaminergic mesolimbic system
 Increased levels of dopamine in nucleus accumbens The powerpoint, as of 10 April 11:19PM, is not yet available.
mediates rewarding effects or positive
reinforcement of drugs (Koob and Le Moal, 2002) Please see ppt/handout, when it comes out,
for the rest of the topic 
Cocaine dopamine reuptake blockade in nucleus
accumbens END OF TRANSCRIPTION
Amphetamine blockade combines with dopamine
release from terminals
Alcohol, increased dopaminergic neuronal firing
I will remember those who have been forgotten.
opiates through disinhibition in VTA
-Edgedancer, Arcanum Unbounded by Brandon Sanderson
COMORBIDITY
 A high prevalence of additional psychiatric Transcription Team 2019
disorders is found among persons seeking Transcribed by: Sharmaine Tablada,
RPm
treatment for alcohol, cocaine, or opioid
Edited by:
dependence
References: Lecture ppt, recording
 Up to 50% have a comorbid psychiatric disorder
Remarks: Doc’s other notes in
 A range of 35 to 60% of patients with substance
italics
abuse or substance dependence also meet the
diagnostic criteria for antisocial personality disorder
o Among the different personality disorders,
the top comorbid PD for substance users is
antisocial personality disorder
 Patients with substance abuse or substance
dependence diagnoses who have antisocial
personality disorder:
o Use more illegal substances
o Have more psychopathology
o Less satisfied with their lives
o More impulsive, isolated, and depressed
 1/3 to ½ of all those with opioid abuse or opioid
dependence also have psychiatric comorbidity
 40% of those with alcohol abuse or alcohol
dependence have psychiatric comorbidity

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