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David-Willey-substance use disorders-V-ppt.pptx
- 1. SUBSTANCE USE DISORDERS: DIAGNOSISAND TREATMENT David Willey MD Substance Use Unit Director Cottonwood Springs Hospital Multiple Slides Courtesy of: Ronald W. Kanwischer LCPC, CADC Professor Emeritus Department of Psychiatry SIU School of Medicine
- 2. Objectives. At theend of this talk you should be able to: • Describe the changes in the concept of addiction as it applies to diagnostic criteria • Identify changes in DSM V as it pertains to substance use and addictive disorders • Identify the diagnostic criteria for substance use disorders • Describe the etiology and epidemiology of substance use disorders • Describe treatment options including potential settings, pharmacotherapy and therapeutic interventions
- 3. The Evolution ofthe Concepts of Addiction
- 4. The Evolution ofthe Concepts of Addiction
- 5. The Evolution ofthe Concepts of Addiction
- 6. The Evolution ofthe Concepts of Addiction
- 7. The Evolution ofthe Concepts of Addiction
- 8. The Evolution ofthe Concepts of Addiction
- 9. The Evolution ofthe Concepts of Addiction
- 10. The Evolution ofthe Concepts of Addiction
- 11. Substance -Related andAddictive Disorder Changes
- 12. Substance -Related andAddictive Disorder Changes
- 13. Substance -Related andAddictive Disorder Changes
- 14. Substance -Related andAddictive Disorder Changes
- 15. DSM V Criteriafor Substance Use Disorders •A problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12 month period:
- 16. Substance Use Disorders ImpairedControl: • Using larger amounts or for longer time than intended • Persistent desire or unsuccessful attempts to cut down or control use • Great deal of time obtaining, using, or recovering • Craving or strong desire or urge to use
- 17. Substance Use Disorders SocialImpairment: • Fail to fulfill major roles (work, school, home) • Persistent social or interpersonal problems caused by substance use • Important social, occupational, recreational activities given up or reduced • Risky Use of the Substance: • Use in physically hazardous situations • Use despite physical or psychological problems caused by use
- 18. Substance Use Disorders •Pharmacological Criteria: Tolerance as defined by either of the following: • Need to use an increased amount of a substance in order to achieve the desired effect OR • Markedly diminished effect with continued use of the same amount of the substance Withdrawal as manifested by either of the following: The characteristic withdrawal syndrome of the substance OR The substance is taken to relieve or avoid withdrawal symptoms
- 19.
- 20. Substance Classes Alcohol Caffeine Cannabis Hallucinogens PCP others Inhalants Gambling Opioids Sedatives, hypnotics,and anxiolytics Stimulants Tobacco Other
- 21. Substance-Related Disorders • 2Groups: • Substance Use Disorders • Previously split into abuse or dependence • Involves: impaired control, social impairment, risky use, and pharmacological criteria • Substance-Induced Disorders
- 22. Substance-Induced Disorders • Intoxication •Withdrawal • Psychotic Disorder • Bipolar Disorder • Depressive Disorder • Anxiety Disorder • Sleep Disorder • Delirium • Neurocognitive • Sexual Dysfunction
- 23. Intoxication • Reversible substance-specificsyndrome due to recent ingestion of a substance • Behavioral/psychological changes due to effects on CNS developing after ingestion: • ex. Disturbances of perception, wakefulness, attention, thinking, judgement, psychomotor behavior and interpersonal behavior • Not due to another medical condition or mental disorder • Does not apply to tobacco
- 24. Clinical picture ofintoxication depends on: • Substance • Dose • Route of Administration • Duration/chronicity • Individual degree of tolerance • Time since last dose • Person’s expectations of substance effect • Contextual variables
- 25. Withdrawal • Substance-specific syndromeproblematic behavioral change due to stopping or reducing prolonged use • Physiological & cognitive components • Significant distress in social, occupational or other important areas of functioning • Not due to another medical condition or mental disorder • No withdrawal: PCP; other hallucinogens; inhalants
- 26. Neuroadaptation: • Refers tounderlying CNS changes that occur following repeated use such that person develops tolerance and/or withdrawal • Pharmacokinetic – adaptation of metabolizing system • Pharmacodynamic – ability of CNS to function despite high blood levels
- 27. Tolerance • Need touse an increased amount of a substance in order to achieve the desired effect OR • Markedly diminished effect with continued use of the same amount of the substance
- 28. Substance-Induced Mental Disorder •Potentially severe, usually temporary, but sometimes persisting CNS syndromes • Context of substances of abuse, medications, or toxins • Can be any of the 10 classes of substances
- 29. Substance-Induced Mental Disorder •Clinically significant presentation of a mental disorder • Evidence (Hx, PE, labs) • During or within 1 month of use • Capable of producing mental disorder seen • Not an independent mental disorder • Preceded onset of use • Persists for substantial time after use (which would not expect)
- 30. Epidemiology: Prevalence • NIDA’04: 22.5M > 12yo – substance-related d/o 15M – Alcohol Dependence or Abuse • Start at earlier age (<15yo), more likely to become addicted – ex. alcohol: 18% vs. 4% (if start at 18yo or older) • Rates of abuse vary by age: 1% (12yo) - 25% (21yo) - 1% (65yo) • Men; American Indian; whites; unemployed; large metro areas; parolees
- 31. Epidemiology (cont.) • ETOH- $300 billion/year • 13 million require treatment for alcohol • 5.5 million require treatment for drug use • 2.5% population reported using Rx meds nonmedically within past month
- 32. Epidemiology (cont.) • 40%of hospital admission have alcohol or drugs associated • 25% of all hospital deaths • 100,000 deaths/year • Intoxication is associated with 50% of all MVAs, 50% of all DV cases and 50% of all murders
- 33. ER Visits (NIDA‘09) • 1.2M: non-medical use of pharmaceuticals • 660K: alcohol • 425K: cocaine • 380K: marijuana • 210K: heroin • 93K: stimulants
- 34. Etiology • Multiple interactingfactors influence using behavior and loss of decisional flexibility • Not all who become dependent experience it same way or motivated by same factors • Different factors may be more or less important at different stages (drug availability, social acceptance, peer pressure VS personality and biology)
- 35. Etiology • “Brain Disease”– changes in structure and neurochemistry transform voluntary drug-using compulsive • Changes proven but necessary/sufficient? (drug- dependent person changes behavior in response to positive reinforcers) • Psychodynamic: disturbed ego function (inability to deal with reality)
- 36. Etiology • Self-medication • EtOH- panic; opioids -anger; amphetamine - depression • Genetic (well-established with alcohol) • Conditioning: behavior maintained by its consequences • Terminate aversive state (pain, anxiety, w/d) • Special status • Euphoria • Secondary reinforcers (ex. Paraphernalia)
- 37. Etiology • Receptors Toolittle endogenous opioid activity (ie low endorphins) or too much endogenous opioid antagonist activity = increased risk of dependence. Normal endogenous receptor but long-term use modulates, so need exogenous substance to maintain homeostasis. • Neurotransmitters o Opioid o Catecholamines o GABA o Serotonin Pathways
- 38. Learning and PhysiologicalBasis for Dependence • After using drugs or when stop – leads to a depleted state resulting in dysphoria and/or cravings to use, reinforcing the use of more drug. • Response of brain cells is to downregulate receptors and/or decrease production of neurotransmitters that are in excess of normal levels.
- 39. Typical Presentation andCourse: • Present in acute intoxication, acute/chronic withdrawal or substance induced mood, cognitive disorder or medical complications • Abstinence depends on several factors: social, environmental, internal factors (presence of other comorbid psychiatric illnesses) • Remission and relapses are the rule (just like any other chronic medical illness) • Frequency, intensity and duration of treatment predicts outcome • 70 % eventually able to abstain or decrease use to not meet criteria
- 40. Options for whereto treat • Hospitalization- -Due to drug OD, risk of severe withdrawal, medical comorbidities, requires restricted access to drugs, psychiatric illness with suicidal ideation • Residential treatment unit -No intensive medical/psychiatric monitoring needs -Require a restricted environment -Partial hospitalization • Outpatient Program -No risk of med/psych morbidity and highly motivated patient
- 41. Treatment • Manage Intoxication& Withdrawal • Intoxication • Ranges: euphoria to life-threatening emergency • Detoxification • outpatient: "social detox” program • inpatient: close medical care • preparation for ongoing treatment
- 42. Treatment • Behavioral Interventions(target internal and external reinforcers) Motivation to change (MI) Group Therapy Individual Therapy Contingency Management Self-Help Recovery Groups (AA) Therapeutic Communities Aversion Therapies Family Involvement/Therapy Twelve-Step Facilitation Relapse Prevention
- 43. Treatment • Pharmacologic Intervention •Treat Co-Occurring Psychiatric Disorders • 50% will have another psychiatric disorder • Treat Associated Medical Conditions cardiovascular, cancer, endocrine, hepatic, hematologic, infectious, neurologic, nutritional, GI, pulmonary, renal, musculoskeletal