SUBSTANCE-RELATED AND ADDICTIVE DISORDERS
Carolyn A. Baird
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Discuss addictive disorders
2. Describe the historical perspective and epidemiology of substance use and addictive disorders (SUDs)
3. Distinguish among the characteristic behaviors for disorders involving alteration of mood SUDs
4. Discuss current issues and other problems related to substance use
Substance use disorder
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) departs from previous versions in deleting a category of substance abuse and dependency. The category is substance-related disorders, which include substance use disorders and substance-induced disorders that result from the activation of the reward pathways in the brain and behavioral SUDs for certain repetitive actions. The substances that are capable of producing activation of the reward pathways are encompassed within a set of 10 classes, one of which is an all others class. A substance use disorder is diagnosed when the ingestion of one of these substances results in specific cognitive, behavioral or physiological symptoms. Substance use disorders are diagnosed as mild when 2 to 3 symptoms are present, moderate for 4 to 5 symptoms, and severe for 6 or more out of the 11 possible. It is further suggested by the DSM-5 that individuals are predisposed to substance use disorders by having lower levels of self-control. Substance-induced disorders include INTOXICATION (stupefaction or excitement due to the action of a chemical), withdrawal, and any mental disorder determined to be the result of ingesting a substance or medication (APA, 2013).
Activation of the reward pathways in the brain is part of a neurobiological brain system, the mesolimbic dopamine system, that identifies pleasurable activities and sets in motion a system of reward and motivation to sustain life. Some primary activities for sustaining life are eating, sexual activity, and feeling good. Looking at substances pharmacologically shows that activation of these same reward pathways in the brain can occur from any use of psychoactive licit and illicit substances. Identical neurological responses have been identified with certain behaviors. Stimulation of the reward pathway results in the same responses regardless of the brain stimulated. What differs is the extent to the response. This is mediated by the physiological and psychological characteristics of the individual (National Institute on Drug Abuse [NIDA], 2010). Professionals in the substance use treatment field see SUDs to be brain disorders rather than an issue of self-control. Symptoms for a substance use or addictive disorder follow the criteria of DSM-5 (American Society of Addiction Medicine [ASAM], 2011; NIDA, 2010).
The 10th edition of the International Classification of Diseases (ICD-10) from the World Health Organization has been clinically modified for use in the United States. All health care entities covered by the Health Information Portability and Accountability Act (HIPAA) are required to use these diagnostic codes. The substance use category in the ICD-10-CM code is mental and behavioral disorders due to psychoactive substance use and includes a continuum of use versus abuse versus dependency. The diagnostic symptomatology classifications closely follow those of the DSM-5, ASAM, and NIDA (World Health Organization, 1995). Because of the issues associated with these multiple sources for diagnostic presentation, this chapter looks at SUDs from a clinical aspect using ASAM and NIDA resources.
SUBSTANCE USE AND ADDICTIVE DISORDERS refer to the “chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences” (NIDA, National Institutes of Health [NIH], and U.S. Department of Health and Human Services [DHHS], 2012; NIDA, Public Information and Liaison Branch, Office of Science Policy and Communications, 2014). Initially, a person voluntarily makes the choice to use a drug. However, over time, the person’s ability to voluntarily choose not to use the drug becomes impaired. As a result, the person’s self-control is compromised, leading to compulsive behavior to seek out and use the drug. The explanation is that substance use and addictive disorders affect the brain circuitry, causing changes in specific areas such as those involved in reward and motivation, learning and memory, and inhibitory control over behavior (NIDA, NIH, and DHHS, 2012; NIDA, Public Information and Liaison Branch, Office of Science Policy and Communications, 2014). In 2011, the ASAM adopted the definition, “Substance use and addictive disorders is a primary, chronic disease of brain reward, motivation, memory and related circuitry,” which continues to be used today.
Substance use and addictive disorders involve a spectrum of disorders of substance use and dependence, as well as substance-induced disorders including intoxication and withdrawal. Substance use and addictive disorders in populations present many challenges for society in general as well as health care providers.
This chapter addresses the historical perspectives and epidemiology of addictive disorders followed by a detailed description of these disorders as defined by the NIDA and the ASAM. Specific scientific theories focusing on the disease SUDs are described along with current trends and common treatment options. Application of the nursing process from an interpersonal perspective is presented, including a plan of care for a patient with an addictive disorder.
Compulsive drug seeking and use that leads to harmful consequences is termed an addictive disorder.
Any substance has the potential to become a drug of abuse, not just alcohol or illegal drugs. The U.S. Drug Enforcement Administration (DEA) statistics state that more than 7 million Americans are abusing prescription drugs (Palladini, 2011). Over the past centuries, society has viewed the use of alcohol, tobacco, and other drugs in varying ways. Initially, substances were viewed from a cultural perspective and were accepted. Additionally, when individuals overindulged and their intoxicated behavior became a problem, alcohol and drug use was dealt with as a criminal offense. Thus, the theory of SUDs was based on a more social model. Gradually, the view changed as the addictive nature of substances was identified. This led to SUDs being viewed through a medical or disease model. For example, notable instances of general use of a now known addictive substance are opium in paregoric and cannabis in many patent medications.
The American Medical Association (AMA) first took the position in 1958 that alcoholism was a disease. Identifying similarities in the action of various substances to produce the same dysfunction in the neurotransmitters of the brain led to a broader understanding of SUDs. The introduction of the first Controlled Substances Act in 1970 came as a result of the acknowledgment of SUDs as a disease of the neurotransmitters of the brain. Since that time, researchers have identified the specific neurotransmitters, areas of the brain, and response pathways that are implicated in SUDs. It has been observed that abusive relationships with objects and behaviors may affect the same areas of the brain. The resulting disorder is now considered a process addiction.
Over time, a number of substance and process addictions have been noted. Each generation appears to have its own primary SUDs. Consider these examples. Individuals born before 1943, termed the Traditional or Silent Generation, were more likely to experience alcoholism and prescription drug abuse and less likely to use illicit substances. This changed with the Baby Boomer generation, those born between 1944 and 1964. They experienced the social issues involving the Vietnam War, antiwar demonstrations, Flower Children, and Woodstock. As a result, illicit substances were brought into the forefront in the form of cannabis and lysergic acid diethylamide (LSD). Individuals of Generation X, those born from 1964 to 1978, appear to have started with cannabis, used LSD and mescaline, graduated to cocaine and methamphetamine, and then expanded into heroin (Furek, 2008). Generation Y or Millennials, those born from 1979 to 2000 and known for their preoccupation with technology, have been noted for the use of club drugs.
Substance use disorder refers to a disease affecting the brain and its chemistry. Both substances and behavioral or process addictions activate the same neurotransmitters and use the same reward pathways.
The Substance Abuse and Mental Health Services Administration (SAMHSA) funds an annual National Survey on Drug Use and Health (NSDUH). The 2014 report reveals that the number of Americans 12 years or older who engaged in the use of an illicit drug was estimated at 24.6 million or approximately 9.4% of the population in 2013. Additionally, an estimated 21.6 million persons aged 12 years and older were classified as having substance dependence or substance abuse in the past year. Of these, approximately 2.6 million persons abused or were dependent on alcohol and illicit drugs, 4.3 million persons were dependent on or abused illicit drugs alone, and 14.7 million were dependent on or abused alcohol alone (SAMHSA, 2014). Treatment also was addressed in this report. According to SAMHSA (2014), 22.7 million persons or 8.6% (aged 12 years and older) needed treatment for an illicit drug or alcohol use problem. Out of this group, only 2.5 million received treatment at a specialty facility, with the remaining 20.2 million with a problem not receiving treatment.
Many reasons exist for this large discrepancy in the numbers receiving treatment. One reason may be that the secrecy and confusion surrounding this disease make it difficult to diagnose. Also, many individuals who are using substances deny that their use is a problem. Only about 5% feel they need treatment. The most frequent reason given by those wanting treatment but not receiving it is they lack insurance or the financial resources to pay for it (SAMHSA, 2014). Formal standardized definitions, terminology, and/or criteria are being developed (ASAM, 2015; NIDA, NIH, and DHHS, 2012, 2014); however, confusion still exists around the terms substance use, abuse, and dependence. They are often used interchangeably even though they are separate terms referring to discrete patterns of behavior. Substance use, addictive disorders, and substance-induced disorders are common categories under SUDs. All of these relate to a maladaptive pattern of substance use.
There are a variety of reasons why individuals use substances. When illegal or illicit drugs are being used or legal drugs are being used inappropriately, it is referred to as ABUSE. There may be repeated use to produce pleasure or alleviate stress, or there may be an attempt to alter or avoid reality. Prescription drug abuse refers to using drugs that are prescribed for you in ways other than as prescribed or by taking medication prescribed for someone else (ASAM, 2014; NIDA, Public Information and Liaison Branch, Office of Science Policy and Communications, 2014). During this initial stage there may be intermittent use that leads to failure to meet obligations, allows the individual to be put in hazardous situations, causes legal problems, or results in social, interpersonal, or professional problems (Doweiko, 2006). DEPENDENCY is a term that may be used in two ways. Individuals may develop a physical dependence on a substance without having the disease of SUDs. Any substance taken into the body on a regular (daily or almost daily) basis triggers the body’s adaptive mechanism. Whether the substance is legal or illegal, taken as prescribed or abused, adaptation will cause TOLERANCE to develop and larger amounts of the substance will be needed to receive the same result. This adaptation also triggers symptoms, often referred to as WITHDRAWAL, when the substance is removed (NIDA, Public Information and Liaison Branch, Office of Science Policy and Communications, 2014). It can be confusing because dependence that is referred to as a SUBSTANCE USE DISORDER has tolerance and withdrawal as part of the criteria for diagnosis. However, there are additional criteria that need to be met. Addictive drugs are psychoactive. They affect the brain’s natural inhibition and reward centers. The individual is unable to control the impulse to use. Negative consequences will occur but the individual will continue to crave the substance (ASAM, 2014; NIDA, Public Information and Liaison Branch, Office of Science Policy and Communications, 2014). This dependency is said to be the final stage; here, dependency refers to a maladaptive pattern of behavior characterized by progression, tolerance, withdrawal, and preoccupation with the behavior regardless of any consequences. It has the potential to be fatal (Doweiko, 2006). Current use of diagnostic terminology combines substance abuse and substance dependence under the phrase substance-related and addictive disorders (APA, 2013).
Substance use and addictive disorders refers to a disease that can occur at any time across the life span, manifesting as chronic with remissions and exacerbations, or as an isolated episode (Antai-Otong, 2006). Many presenting core symptoms are the same across SUDs while others are descriptive of the particular type of substance use (Box 15-1). The quest for knowledge about SUDs has led to the understanding that individuals may be addicted to a substance, prescribed or illicit; liquid, vapor, or solid; or they may be addicted to a particular course of action, thoughts, feelings, or behaviors, known as a process addiction. Between 50% and 75% of individuals diagnosed with a substance use disorder have a co-occurring mental health disorder.
ASAM (2014) discusses the neurobiological adaptation, the interactive nature of genetic predisposition and environmental stressors, and its characteristic bio-psycho-social-spiritual factors. Substance use and addictive disorders may manifest behaviorally, cognitively, and emotionally. Increasingly, recognition is being given to certain behavioral activities as process addictions. In the past, consideration was given to an individual’s legal situation. That recognition has been dropped as substance-related and addictive disorders are being viewed more globally (APA, 2013).
Behavioral manifestations can include the following:
1. Excessive use and/or engaging in addictive behaviors, often more frequently than intended, using more than intended, or unsuccessful attempts to stop using
2. Excessive time lost using or recovering from use, neglect of responsibilities with adverse effects on social or professional functioning, and relationship problems (at home, school, or work);
3. Continued use and/or engagement in addictive behaviors, despite persistent or recurrent physical or psychological problems which may be the result of substance use and/or related addictive behaviors
4. A narrowing of interest to only rewards that are part of SUDs
5. An apparent lack of ability and/or readiness to quit despite admitting use is a problem
Cognitive changes can include the following:
1. Preoccupation with substance use
2. Altered perception of the benefits and detriments associated with drugs or reward behaviors
3. The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of SUDs
Emotional changes can include the following:
1. Increased anxiety, dysphoria, and emotional pain
2. Increased sensitivity to stressors
3. Difficulty in identifying feelings, identifying bodily sensations of emotional arousal, and describing the same (www.asam.org/for-the-public/definition-of-addiction)
BOX 15-1: FIVE FEATURES OF SUBSTANCE USE AND ADDICTIVE DISORDERS
Reduced to five features, SUDs can be said to be
1. An inability to consistently Abstain
2. An impairment in Behavioral control
3. A Craving; or increased “hunger” for drugs or rewarding experiences
4. A Diminished recognition of significant problems with one’s behaviors and interpersonal relationships
5. A dysfunctional Emotional response (ASAM, 2014).
Some of the categories of psychoactive substances are:
• Amphetamines and similar acting drugs (amphetamine, dextroamphetamine, methamphetamine [“speed”])
• Cannabis (marijuana, bhang, hashish)
• Cathinones (bath salts, flakka, etc.)
• Hallucinogens (LSD, morning glory seeds, phenylalkylamines [mescaline, “STP”], MDMA [ecstasy])
• Inhalants (hydrocarbons such as those found in gasoline, paint thinners, glue, and spray paints)
• Opioids (morphine, heroin, codeine, hydromorphone, methadone, oxycodone, meperidine, and fentanyl)
• Phencyclidine (PCP) and similar acting drugs (such as ketamine)
• Sedatives, hypnotics, or anxiolytics (benzodiazepines, barbiturates)
Many models have been used to explain the theoretical basis of SUDs. Research has focused on a wide range of areas including the spiritual, systems, moral, characterological, behavioral, educational, temperance, dispositional, and medical or disease models (Doweiko, 2006; Konrad, 2005). Many of these models are based on the individual lacking knowledge or control of behavior. These are all part of what may be considered the social model and their focus is on blaming the individual for choosing bad behavior or for lacking sufficient character or a strong moral compass. For example, the spiritual model is the basis for Alcoholics Anonymous (AA) and other 12-step recovery programs. Following the program necessitates the individual declaring powerlessness and finding a higher power. All of the models based on individual choice support the idea that all the individual with an SUD has to do is stop using the substance or engaging in the activity. Medication is not usually a part of the treatment protocol.
Although the medical or disease model is the most widely accepted within the substance abuse field, many laypeople and professionals continue to question the presence of biological markers (Doweiko, 2006). Doweiko defines the disease model of SUDs as a primary medical disorder with the potential to affect an individual’s social, psychological, spiritual, and economic life. Yet he also admits that “a universally accepted comprehensive theory of substance use and addictive disorders has yet to be developed” (Doweiko, 2006, p. 20). To really understand SUDs, it is important to acknowledge the role of the central nervous system, neurotransmitters, and the brain’s reward pathways.
In pursuit of a comprehensive theory based on the medical or disease model, research has been conducted in a variety of areas (Koob, 2006; Shaffer et al., 2004). Evidence is emerging that suggests that SUDs must be viewed or conceptualized in a much broader fashion to capture the nature, origin, and processes that comprise SUDs (Satel & Lilienfeld, 2013; Shaffer et al., 2004). In reviewing the evidence, Shaffer et al. (2004) identified a number of interacting biopsychosocial antecedents. This study is highlighted in Evidence-Based Practice 15-1. In 2014, Satel and Lilienfeld conducted research intended to debunk the idea of SUDs as a brain disease. Their argument paralleled the work of Shaffer et al. (2004). Substance use and addictive disorders are more than the sum of neurotransmitters and brain reward pathways. Shared neurobiological antecedents include the central nervous system circuitry, neurotransmitters, and reward pathways along with the genetic vulnerability factors that make up the biological antecedents. Social and psychological risk factors make up the shared psychological antecedents. The last set of antecedents are shared experiences with shared manifestations and sequelae, parallel natural histories, object nonspecificity, concurrent manifestations, and treatment nonspecificity (Shaffer et al., 2004). For example, not everyone who uses a substance or engages in a behavior develops the disease, but everyone who develops a substance use or addictive disorder displays the same symptomatology, has the same genetic vulnerability, and shares a similar life history regardless of the substance or behavior. Thus, these shared antecedents support the idea that there are common risk factors for SUDs that reflect a shared origin or etiology. For these reasons, SUDs can be identified as a syndrome disorder.
EVIDENCE-BASED PRACTICE 15-1:
MODEL OF SUDs
Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review Psychiatry, 12, 367–374. Retrieved from www.expressionsofaddiction.com/docs/shafferetalsyndrome.pdf
The authors challenge the current view of the disease referred to as SUDs. Instead of relying on just the physiological action of the substances as the causal factor, they state that there is strong evidence of both neurobiological and psychosocial antecedents. This suggests a syndrome model of SUDs that simultaneously covers multiple expressions and common etiology. Proposals for the understanding of SUDs as a syndrome have their basis in the co-occurrence of various chemical and behavioral expressions stemming from an underlying commonality of genetic and psychosocial susceptibility.
APPLICATION TO PRACTICE
At the present time, more emphasis is put on self-report as the key to diagnosis. Using a syndrome approach to the treatment of SUDs engages the clinician in an ongoing evaluation of the relationships among the various antecedents, manifestations, and consequences and the course of the illness. Rethinking the philosophy of SUDs will lead to more objective diagnostic criteria, strengthen treatment approaches, and improve treatment outcomes.
QUESTIONS TO PONDER
1. How does viewing SUDs as a syndrome challenge your current understanding of the disease?
2. What implications can you see for changing treatment approaches?
Viewing this disease as a syndrome may be helpful in understanding the process that the individual undergoes in relationship to a substance or a behavior. It may also explain why only some of the individuals displaying this relationship become dependent while others do not. The ability to assess the shared manifestations allows for adjusting the diagnosis and treatment to fit the course of the illness and the potential for relapse (Shaffer et al., 2004). This is important for all health care professionals, especially psychiatric-mental health nurses. Psychiatric-mental health nurses must gain an understanding of SUDs as a disease process with clearly defined characteristics and manifestations due to the increased presence of comorbid psychopathology in the abusing and dependent population. This psychopathology takes the form of generalized anxiety, major depression, and posttraumatic stress disorder (Shaffer et al., 2004).
There is a great deal of research being conducted in an attempt to understand the genetic and neurobiological components of SUDs. It is known that some individuals appear to be more genetically vulnerable and researchers have been attempting to identify the specific genes that may predispose individuals to become addicted to specific substances. It should be acknowledged that all individuals who use an addictive substance have the potential to become addicted. Genetic vulnerability may decide what substances or processes an individual is most at risk of or the extent of the cognitive damage that may occur as a result of the alteration in the neurotransmitter function. The only protection from becoming addicted is to never use the substance. This is true even for individuals with genetic vulnerability. Having a positive life history, good coping and stress management skills, and a supportive environment are also protective factors.
In the late 1940s and early 1950s, Jellinek (n.d.) conducted some of the earliest research on substance use disorders using a population of male alcoholics. These results were then used to develop a male model of care that was used through much of the 20th century. This gender bias was not considered a problem because substance abusing men were offered treatment, while substance abusing women were often hidden, protected, or abandoned (Doweiko, 2006). It is still difficult to compare gender rates because most statistics do not identify a male-to-female ratio. Statistics do reveal that 4.4 million women abuse or are dependent on alcohol, one of every three individuals dependent on alcohol is female, and that two million women abuse or are dependent on illicit drugs. This is important because of the biological differences between males and females. They experience SUDs and comorbid conditions differently and enter treatment through different pathways and for different reasons. Men frequently are referred to treatment by employers or the law. They also have lower incidences of depression and their substance diagnosis is primary. On the other hand, women seek treatment on their own, frequently from a mental health provider, due to a preexisting depression, anxiety, or posttraumatic stress disorder (Doweiko, 2006).
Factors Related to Substance Use and Addictive Disorders and Substance Abuse
As stated previously, there is currently no one theory that explains the cause of SUDs. However, several factors have been identified that increase a person’s vulnerability to developing a substance use problem. These factors do not occur in isolation, that is, no one single factor is responsible for substance use. Rather, it is the interplay or sharing among these factors that increases a person’s vulnerability.
Substance use disorders often occur in individuals with other mental health disorders. Although estimates vary depending on the population being surveyed, statistics from the SAMHSA (Center for Substance Abuse Treatment [CSAT], Tip 42, 2005b) set the number of individuals who admit to any mental health or substance use disorder at 52 million (30%) and those with both substance dependence and a severe mental illness (major depression, generalized anxiety, or posttraumatic stress disorder) at 8 million (5%). Another proposed explanation for a shared vulnerability is the prevalence of comorbid psychiatric and addictive disorders. Substance use disorders often occur as a secondary illness in those with mental health disorders; and mental health disorders are increasing in frequency with increasing rates for substance abuse. Thus, health care professionals need to understand that the interaction of mental health and substance use disorders is an expectation rather than an exception (Minkoff, 2005).
Also common to this at-risk population are a variety of sociodemographic factors. Poverty, geography, family, and peer groups have been shown to influence the onset and course of various disorders, as do subclinical risk factors, such as impulsivity, delinquency, and impaired parenting skills (Shaffer et al., 2004). Additionally, researchers are beginning to examine the prevalence of addictive and mental health disorders in certain groups of individuals to identify additional risk factors. For example, the military came under scrutiny after the Vietnam War due to the large numbers of returning veterans who were addicted and met criteria for comorbid mental health disorders such as major depression and posttraumatic stress disorder. Military service has continued to attract interest as a risk factor. A history of trauma, domestic violence, and criminal justice involvement also appear to be risk factors for developing mental health and substance use disorders (Koola et al., 2013).
Not all members of at-risk populations or individuals with risk factors develop a mental health or substance use disorder. However, being under stress, experiencing traumatic events, having poor coping skills, or having a particular genetic makeup may make individuals vulnerable to the onset of the neuroadaptive response if they are also exposed to potential objects of SUDs, such as chemicals or behaviors (ASAM, 2014; Shaffer et al., 2004). No particular personality traits have been identified as predictive; however, once abuse and dependency are present, common traits such as dysthmia, deceit, shame, or guilt have been identified.
A natural history appears to exist within the experience of SUDs that begins with risk factors and exposure, spreads an addictive pattern across chemical and behavioral expressions, and ends with an identifiable pattern of compulsion, tolerance, withdrawal, craving, and relapse. For example, the individual grows up in a home with an alcoholic, drug-addicted, or abusive parent, conferring genetic and psychological risk factors. The peer group they belong to likes to party on the weekends. They binge drink or use drugs each weekend, then start drinking or using during the week. They find it takes more for them to relax and have fun. Soon they are drinking or using during the day, or they drink or use and drive. They are on report at work or get a driving-under-the-influence (DUI) charge. They attend treatment as ordered but return to drinking or using drugs as soon as they are out of treatment.
The SUD syndrome presentation is the same regardless of the substance or behavioral process of SUDs. Both processes and substances of SUDs are frequently interchangeable. These shared manifestations of compulsion, tolerance, withdrawal, craving, and relapse serve as the definitive evidence for diagnosis (ASAM, 2014; Shaffer et al., 2004).
Substance use and addictive disorders are known to be a chronically relapsing disorder presenting with compulsive use of a substance or behavior, loss of control, and withdrawal symptoms, such as dysphoria, anxiety, or irritability (Koob, 2006). Individuals experience the use of drugs with the potential for dependence in different ways; therefore, there is current neurobiological research being conducted in an attempt to understand if there are neuropharmacological and neuroadaptive mechanisms that control this (Koob, 2006). One of the neuroadaptive mechanisms that have offered the best understanding of the addictive process is the brain reward system (Koob, 2006; NIDA, 2009a, 2009b, 2014; Shaffer et al., 2004).
Using functional magnetic resonance imaging, researchers have been able to track the neurobiological reward activity associated with the neurotransmitter dopamine (Koob, 2006; Shaffer et al., 2004). The dopamine reward system provides positive reinforcement for all natural rewards such as food, water, sex, and nurturing. These activities are rewarded with feelings of pleasure. Research has revealed that the use of psychoactive drugs has the ability to stimulate the same neurobiological pathways. Certain behaviors are capable of stimulating the same dopamine reward pathways, resulting in addictive disorders that are known as process or behavioral addictions (Shaffer et al., 2004). Other pathways and neurobiological mechanisms such as the learning and memory functions of the hippocampus and the role of the amygdala in emotional regulation have been implicated as playing a role in substance abuse.
Although it is not possible to use imaging techniques to follow all the changes in the brain and predict the addictive process, researchers have used their knowledge of the brain’s neurobiology to develop generalized theories of the addictive process. As SUDs develop, changes occur in the neural circuits associated with the amygdala and in the function of various neurotransmitters and neuromodulators that recruit the brain stress system and reinforce dependence. The resulting dysregulation in these systems is implicated in decreases in orbitofrontal/prefrontal cortex matter and function and brain dopamine D2 receptors (Fortier et al., 2014; Koob, 2006). These changes are thought to explain the difficulty dependent individuals have with abstinence motivation, recurrent cravings, and frequent relapse. Shaffer et al. (2004, p. 369) have proposed that “the neurobiological circuitry of the central nervous system is the ultimate common pathway for addictive behaviors.”
As a companion to the study of the neurobiological antecedents for SUDs, researchers have also examined the possibility of genetic markers as links and predictors to specific addictive behaviors. The evidence appears to support that a familial vulnerability transmission link for dependency is present, but that this risk is general rather than specific. This has raised the potential for the existence of a genetic link to a general increased risk for SUDs (Koob, 2006; Shaffer et al., 2004). What remains to be examined is the outcome of an individual having any of these associated markers. It is known that some affected individuals will never develop an addictive disorder. Other family members may display a variety of individual processes or substance disorders or multiple disorders.
One suggested explanation for these differences in the expression of SUDs is the impact of varying environmental, psychosocial, ethnic, and cultural factors. Although international research into alcohol use is impacted by variations in the size and strength of drinks and the methods used to measure alcohol consumption, survey data have provided insight into rates of consumption and abstinence. Once the comparability difficulties have been resolved, additional studies may provide information on alcohol-related outcomes and differences within and across countries (Bloomfield, Stockwell, Gmel, & Rehn, 2003). Researchers have found that it is easier to study some of these differences within the population of the United States, as many races, cultures, and ethnic groups are represented. Although race is primarily representative of physiological responses, Straussner (2001) proposed that culture and ethnicity represent “worldviews, life patterns, institutions, languages, religious ideals, artistic expressions, and relationships shared by their group’s members” (as cited in National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2005, p. 3). For these reasons, trends and patterns of alcohol consumption and drug use differ significantly across various groups and manifest symptomatology according to the underlying physiological status of the individual.
Psychological, environmental, and neurobiological influences and shared experiences play a role in whether or not a person develops substance use and addictive disorders.
CURRENT TRENDS: PRESCRIPTION DRUG EPIDEMIC
From 2006 until 2010 there was an approximately 20% increase in prescription drug-associated overdose deaths. In 2010, 16,000 deaths were attributed to overdosing on prescription pain medication. Individuals were able to obtain 70% of that medication from friends and family. That same year around 3,000 individuals died as a result of a heroin overdose. As a result, in 2011 the Executive Office of the President of the United States identified prescription drug abuse as a national epidemic and a plan was developed to begin addressing it.
The plan was formed on a collaborative effort of policy, programming, and community and agency initiatives. The approaches used were developed using best advice, as evidence-based best practice was not available. A four-pronged plan using education, tracking and monitoring, proper medication disposal, and enforcement resulted in an immediate and effective response with the number of individuals abusing in 2011 and 2012 dropping by 12% (Executive Office of the President of the United States, 2011; National Center for Injury Control and Prevention, 2014; Trust for America’s Health, 2013).
According to statistics from the NIH and NIDA, at the same time that opioid prescription overdose deaths were decreasing, deaths from heroin overdoses increased fivefold (www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates). Drug poisoning or overdose is now the number one cause for injury-related deaths. Statistics from the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) show heroin overdose deaths doubled between 2012 and 2013. There is some concern that these deaths may be underreported because heroin breaks down into morphine metabolites.
Regardless of the opioid involved, 46 individuals die each day as a result of opioid drug poisoning (Hedegaard, Chen, & Warner, 2015).
Reducing the availability of opioid pain medications and heroin is not enough. There is medication that reverses the overdose. Narcan or naloxone is a pure opioid antagonist. It can be used to partially reverse opioid depression until medical attention can be obtained. Until recently, its use was highly controlled, making it difficult to obtain and unavailable to the individuals who would need to administer it. The existence of laws that criminalize the use of Narcan, the actions of individuals calling for help, and those overdosing punished everyone trying to help. At this time, 28 states have adopted Good Samaritan Laws that make naloxone available and protect individuals using it (Baird, 2014; Davis, 2015; SAMHSA, 2013).
EMERGING TRENDS: NEW PSYCHOACTIVE SUBSTANCES/SYNTHETICS (NPS)
More commonly known as designer drugs, the NPS are synthetic analogs of controlled illicit substances. They are manufactured so they can be distributed to evade current drug laws. There is a growing concern internationally due to the drugs’ acute toxicity and severe physical and psychological effects. Many serious side effects and deaths have been reported. Young adults are the primary users and they seldom come in contact with health care providers. When they do present for treatment, it is often with severe neuropsychiatric symptoms (Weaver, Hopper, & Gunderson, 2015).
These drugs fall into three categories: synthetic cathinones (bath salts, flakka), synthetic cannabinoids (spice), and synthetic hallucinogens (N-bomb). Synthetic cathinones are stimulants and taken orally or injected. They appear to facilitate the release of the neurotransmitters dopamine, norepinephrine, and serotonin, causing effects of increased alertness, tachycardia, and psychosis similar to stimulants such as amphetamines and cocaine (Weaver et al., 2015).
Synthetic cannabinoids (SCs) mirror delta-9-tetrahy-drocannabinol (THC), the psychoactive portion of cannabis. The chemical is usually put on vegetable matter and smoked. Because they are much stronger than naturally occurring THC, they affect the cannabinoid receptors in the central nervous system to a greater extent. The potential effects may include anxiety, trouble thinking clearly, agitation, paranoia, and delusions. They have been identified as provoking acute psychosis. Individuals with familiar genetic vulnerabilities are at high risk and psychotic symptoms have been known to persist for any period of time from 1 week to 5 months (Weaver et al., 2015).
Synthetic hallucinogens are based on phenethylamine. They can be liquid or powder and have many potential routes of administration. Effects can be felt from as little as a few grains. In addition to visual and auditory hallucinations, the user can experience delirium, agitation, aggression, violence, paranoia, dysphoria, severe confusion, and self-harm. As these are serotonin hallucinogens, it is possible to have serotonin toxicity or even an “excited delirium” with severe agitation, aggression, and violence (Weaver et al., 2015).
Regardless of the origin of the substance use or addictive disorder, the gender of the individual, or the presence of comorbid conditions, the treatment options are much the same. Substance use treatment is delivered in a variety of settings and across a broad continuum of care according to the severity of the symptoms the patient is experiencing. Patient placement criteria have been developed in order to ensure that clinical needs are matched with the correct care setting. The best known is the criteria published by the ASAM.
Treatment usually consists of a mix of therapies including self-help programs, psychopharmacology, and psychotherapy such as cognitive behavioral therapy and insight-oriented psychotherapy. For example, the compulsive nature of addictive behavior often responds better to selective serotonin reuptake inhibitors (SSRIs) than to insight-oriented therapy. In addition, specific treatment of associated physiological disorders may be required. Another part of the treatment process often involves participation in a self-help program such as 12-step groups. Many variations on the original 12-step group have come into existence as a way of addressing the various substance use- and process-related addictive disorders.
Treatment begins with screening, followed when indicated by a complete assessment to evaluate the presenting signs and symptoms reported by an individual as a basis of formulating a diagnosis. In October of 2003, the CSAT, part of SAMHSA, awarded seven national Screening, Brief Intervention, Referral and Treatment (SBIRT) grants. The intention was the development of a continuum for the activities of screening, intervention, and referral within medical and community settings that act as entry to treatment. This work was further supported by the 2007 National Quality Forum consensus report, National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. This report broadened the responsibility for screening, brief intervention, and referral for treatment to all medical and mental health settings.
Treatment options for individuals with comorbid psychiatric and substance use disorders are many and varied. Best practice is to address both/all disorders simultaneously in an integrated treatment program rather than in parallel or sequential treatment episodes. During the assessment phase, the severity of the disorders is determined and initial placement is made based on the ASAM criteria or on criteria determined by the state where treatment is being delivered. Individuals at risk of withdrawal symptoms need to be admitted to an inpatient medically managed detoxification program. The intensity of treatment steps down from there to inpatient rehabilitation, halfway house, partial hospital programming (minimum of 10 hours a week), intensive outpatient (between 5 and 9 hours a week), and outpatient (at most 5 hours a week).
Within each level of care, a patient-centered treatment plan is developed. Many facilities use a multidisciplinary plan of care, better known as a care pathway. Care pathways are one way that evidence-based best practices can be introduced and implemented in the provision of care. The format also assists in tracking and evaluating the quality of care and the accomplishment of patient goals (Rayner, 2005). The care provided is threefold with therapy, interpersonal relationships, and neurobiological approaches. A number of modalities may be used simultaneously and treatment plans are individualized based on the specific mix of modalities and approaches. Although not considered treatment, 12-step groups and activities are included.
Founded in 1930, AA is the oldest and best known of the 12-step fellowships. Everyone is welcome; all that is needed is a desire to quit drinking. Using the support of other members and the 12 steps, individuals learn how to be sober one day at a time. Attendance begins during treatment and is based on complete confidentiality and anonymity. Members choose a home group and a sponsor that best fit them. Meetings are available worldwide and around the clock, including online. Sponsors serve as their guide to completing the tasks associated with the 12 steps. Although AA meetings are open to individuals who have problems with substances other than alcohol and with process addictions, programs are also available for their significant others, family members, or support persons. The 12-step movement has expanded to include meetings for most substance and process addictions, as well as for individuals experiencing pain from a loved one’s SUDs.
Links for the most common ones, such as Alcoholics Anonymous (aa.org), Narcotics Anonymous (naranon.org), Gamblers Anonymous (gamblersanonymous.org), Overeaters Anonymous (oa.org), Rational Recovery (rational.org), and Dual Recovery Anonymous (draonline.org), as well as similar organizations can be found on the websites of most treatment facilities or through the use of a search engine. Significant others and family members can attend Al-Anon, Alateen, and Nar-Anon. Unless the information about the meeting identifies it as closed, most meetings welcome health care providers who have an interest in understanding the role of the 12-step process in recovery. In addition, many resources are available online from the SAMHSA at www.samhsa.gov, Hazelden Treatment Center at www.hazelden.org, Enter Health at www.enterhealth.com, and the National Alliance on Mental Illness at www.nami.org, to list a few.
Alcoholics Anonymous (AA) is the oldest and most notable of the 12-step programs. Confidentiality, anonymity, and a desire to remain sober are key components of AA.
Given that dependency and many psychiatric disorders result from neurobiological changes in the brain, there has been a great deal of research into psychoactive medications that would reverse or ameliorate the changes and offer some restoration of function. Medications are specific to the psychiatric disorder and the substance of abuse. They are used to manage symptoms during periods of acute withdrawal, to assist with detoxification, and to support abstinence in early recovery and during maintenance. Some medications have shown to be effective with behaviors associated with abuse and dependence while other medications are available as substitutes to reduce harm. Harm reduction is also practiced by encouraging controlled use at a lower level. Research is ongoing into medications and genetics in an effort to offer additional resources to treat these disorders (Cicero & Ellis, 2015). Drug Summary 15-1 highlights specific agents used for substance use and induced disorders.
Medications are prescribed according to the specific symptomatology and medical need. Some drugs of abuse produce severe symptoms during detoxification. For example, alcohol withdrawal may precipitate seizures and can be treated with a variety of medications from barbiturates such as phenobarbital, benzodiazepines such as diazepam (Valium) or chlordiazepoxide (Librium), or anticonvulsants such as carbamazepine (Tegretol). Heroin is another drug with severe withdrawal symptoms. Patients may need symptom-specific medications like clonidine (Catapres) to control hypertension that may develop during withdrawal. Once the patient is past the initial withdrawal of the substance, he or she may need pharmacological support for continued abstinence. For example, acamprosate calcium (Campral), naltrexone (Revia, Vivitrol), disulfiram (Antabuse), or quetiapine (Seroquel) may be prescribed to manage alcohol cravings. Full opioid agonist methadone, partial opioid agonist buprenorphine (Suboxone), and the antagonist naltrexone (Vivitrol) may be used to detoxify and maintain abstinence from opiates (Bart, 2012).