Introduction to addictions

Drug abuse is the inappropriate use of a drug. It includes the use of medicinal drugs for non-
medicinal purposes, the consumption of a drug at doses far above the normal approved
dosage in order to attain a high, and the use of illicit illegal drugs such as cocaine &
methamphetamines for a similar purpose. It also includes over consumption of drugs that
are legal & found in food stuffs, such as caffeine and alcohol. Substances of abuse are
substances that are used to rapidly experience an altered state of mind. A drug will have
higher abuse potential if:
1. It is smoked or injected rather than orally ingested → faster onset of action.
2. It has a short half-life.
3. It is fat soluble (lipophilic; influences the time it takes to reach the brain).
People in all cultures across the world have used mood- & perception-altering drugs. 25% of
adults smoke cigarettes, 90% drink alcohol and 33% have had at least one experience with
an illegal drug, mostly marijuana. There are many reasons why people take substances: a
search for a high; a search for a repeat of initial pleasurable effects; cultural norm; self-
medication for anxiety, depression, social phobia, insomnia and symptoms of psychotic
illness; and to prevent development of withdrawal symptoms.
Drugs affect an individual’s health & accomplishments. They can cause acute toxicity,
behavioural toxicity (delusions, hallucinations, illusions, etc.), toxic effects through drug
contaminants, secondary medical problems, risk of developing dependence & addictions
and reduced quality of life in social, occupational, marital and forensic matters.

Substance misuse disorders

The various substance misuse disorders are:
 Acute intoxication. This is a reversible substance-specific syndrome that results from
recent use of a substance. Most substances have pleasurable & unpleasant acute
effects. The balance between pleasure & displeasure is situation-, dose- and route-
dependent.
 At-risk use. This is a pattern of use in which the person is at increased risk of harming
their physical & mental health. This is not a discrete point, but shades into both
normal consumption and harmful use. It depends on both the quantity of drug taken
and the situation in which the patient is (e.g. taking alcohol while driving or
operating heavy machinery).
 Harmful use. This is the continued usage of a drug despite evidence of damage to an
individual’s physical or mental health, or to their social & occupational well-being.
 Dependence. This is what is called addiction by most people. It is the need to
consistently take a substance in order to avoid some withdrawal symptoms or
feeling bad. The term is used across all drug classes, although different drugs have
different dependence syndromes. Dependence can be physical or psychological:
 o Physical dependence is the physical & neuro-adaptation of a person’s body to
the use of a drug. It includes developing physical symptoms after the patient
abstains from the drug for some time.
o Psychological dependence is the behavioural adaptation of a person’s body to
the use of a drug. It includes cravings or compulsion to use.
 Tolerance. This is the physical adaptation of a person’s body to a drug such that they
cease to achieve the high they used to get with the same dose of drug.
 Withdrawal. This is a substance-specific syndrome that results from cessation or
reduction of substance use after prolonged heavy use. The symptoms of withdrawal
are often the opposites of the effects of the drugs.

Classification of substance use disorders

The essential feature of a substance use disorders is the presence of a cluster of cognitive,
behavioural and physiologic symptoms indicating that an individual continues to use the
substance despite significant substance-related problems. There are underlying brain circuit
changes that may persist beyond detoxification, particularly in individuals with severe
disorders.
Criterion A criteria appear to fit within overall groupings of impaired control (the first 4),
social impairment (criteria 5-7), risky use (criteria 8-9) and pharmacologic criteria (10 & 11).
The criteria are as follows:
1. Taking for longer or in larger amounts than planned.
2. Desire or unsuccessful efforts to cut down use.
3. Large amount of time spent to obtain, use and to recover from substance.
4. Cravings for the substance.
5. Role failure at school, work or home due to use.
6. Relationship difficulties or social problems due to/made worse by use.
7. Neglect & abandonment of important activities (including work and
social/recreational activities) due to use.
8. Use in physically hazardous situations (e.g. driving).
9. Use despite awareness that it is responsible for/aggravates medical & psychological
condition.
10. Tolerance1.
11. Withdrawal1.
The number of symptoms present determines whether one has a mild, moderate or severe
substance use disorder.
 Mild disorder: 2-3 symptoms.
 Moderate disorder: 4-5 symptoms.
 Severe disorder: 6 or more symptoms.
The criteria for intoxication, withdrawal and substance-induced mental disorders are:
1
Symptoms of tolerance & withdrawal experienced as a result of medical treatment are not counted as part of
substance use disorder criteria.
  Intoxication. This is the development of a reversible substance-specific syndrome
due to recent ingestion of a substance (criterion A). The clinically significant
physiologic & behavioural changes associated with ingestion of the substance are a
result of recognised effects of the substance on the central nervous system and
develop during or shortly after use of the substance (criterion B). The most common
changes are in perception, wakefulness, attention, thinking, judgement,
psychomotor behaviour and interpersonal behaviour (criterion C). The symptoms are
not attributable to another mental illness or medical condition (criterion D).
 Withdrawal. The essential feature is the development of a substance-specific
behavioural change with physiological & cognitive concomitants that is due to
cessation/reduction of the amount of drug ingested (criterion A). The substance-
specific syndrome causes clinically-significant stress or impairment in social,
occupational or other area of function (criterion C). The symptoms are not due to the
effects of another mental illness or medical condition (criterion D).
 Substance-induced mental disorder. The disorder represents a clinically-significant
symptomatic presentation of a relevant disorder (criterion A). There is evidence from
the history & examination that the disorder developed during or within 1 month of
substance use, intoxication or withdrawal, and the involved substance is capable of
producing the mental disorder (criterion B). The condition is not better explained by
an independent mental disorder [one that is not substance- or medication-induced]
(criterion C). The disorder does not occur exclusively during the course of a delirium
(criterion D). The disorder should also cause clinically-significant distress significant
or impairment in social, occupational and other important areas of functioning.

Development of addiction
It has been asserted that addiction is a brain disease and that the critical process that
transforms voluntary drug-using behaviour into compulsive drug use is a change in the
structure & neurochemistry of the brain. What is not known is whether these changes are
necessary & sufficient to account for drug-using behaviour.
The major neurotransmitters involved in the development of substance abuse are the
opioid, catecholamine (particularly dopamine) and GABA systems. The dopaminergic
neurons in the ventral tegmental pathway project to the cortical & limbic regions,
particularly the nucleus accumbens. This pathway is a part of the reward pathway and it
evolved as a survival mechanism to promote repetition of beneficial behaviours. It is the
most likely pathway by which substances such as cocaine & amphetamines mediate their
effects; drugs hijack this pathway but at greater magnitudes than those by which normal
natural rewards do. This is why they are so reinforcing. Opioids are believed to work
through stimulation of the locus coeruleus, which is the largest group of adrenergic neurons
in the brain.
In adolescents, circuits controlling emotion, judgement and inhibitory control develop late
and therefore adolescents focus on the present, are less concerned with future
consequences, often have a sense of invulnerability and long-term adverse effects seem less
important than short-term effects. This explains why they tend to act on impulse. For this
reason, addictions are more likely to develop when one starts taking substances in
adolescence.
There are various reasons why some people become addicted while others do not.
 Genetic factors. Genetic vulnerability is thought to contribute 40-60% in variability in
risk of addiction.
 Environmental factors. These include trauma, stress, crime, poverty, adverse life
experiences and drug availability.
 Psychological makeup. Traits such as high novelty seeking & low harm avoidance
behaviour and reward-dependent personality traits are likely to result in addictions
developing.

Prevention of substance abuse

Prevention can be divided into primary, secondary and tertiary prevention.
 Primary prevention. This involves preventing initiation of psychoactive substance
use or delaying the age of onset of use of substances such as alcohol. You can do
universal primary prevention, in which you target the whole population. This is
usually less effective. An alternative is to do selective primary prevention in which
you target at-risk groups such as adolescents and young adults. Information alone is
insufficient to stop drug use; you need to enhance protective factors and skills
training in order to divert vulnerable groups’ attention from the drugs.
 Secondary prevention. This is done during the early stages of substance use. You
screen for & identify potentially-harmful substance users prior to the onset of
problems. Also provide early brief counselling sessions. It is not appropriate for
treatment of addictions. It may, however, be used to motivate clients to engage in
treatment that is more intensive.
 Tertiary prevention. This involves both specialised substance treatment & harm
reduction strategies. It aims to end addiction or minimise the harmful sequelae
resulting from addictions. It also allows an individual to improve their levels of
functioning and health. It is appropriate for clients with mild substance use disorders
who do not respond to secondary prevention strategies and for clients with
moderate to severe substance use disorders.

Management of substance abuse

Management of substance abuse involves pharmacotherapy, psychotherapy, social
management and rehabilitation. Management is based on the stages of change model. The
model is as follows:
 Action

Pre- Contemplation
Determination Maintenance
contemplation

Relapse

1. Pre-contemplation. The user does not recognise that problematic use exists, despite
being increasingly obvious to those around them.
2. Contemplation. The user may accept that there is a problem, and begins to look at
both positive & negative aspects of drug use.
3. Determination (also called decision). At this stage, the patient has decided they are
going to attempt stopping drug use. Taking the next step, however, may take time.
4. Action. People at this stage have begun their attempts to stop taking drugs. There
are various methods of doing, including straight abstinence, taking a reducing
regimen, etc. They need help from therapists to achieve this. There is need to have
realistic goals for the patient, identify high-risk situations to avoid and develop
coping strategies to stay clear of the drug.
5. Maintenance. Change has been achieved, and now the patient needs to stay that
way. This relies on a support group, good social support base and perhaps a
maintenance regimen.
6. Relapse. Patients may fall back into addiction. Relapsed patients need to be
reassured that they can still recover from their addiction. Furthermore, relapsed
patients take a shorter time to go through the cycle than first-timers. It is important
to teach patients to pick up that they are about to relapse.
Psychotherapy
Psychotherapy of substance use disorders involves use of motivational interviewing. This is
an intervention that is used to introduce change to the patient. It makes use of skilful
reflective listening. The interviewer should express empathy and avoid arguments with the
patient; these are counterproductive and they increase resistance. You should also no label
the patient. Patients need to be shown the discrepancy between where they are (current
behaviour) and where they want to be (goals). The clinician’s job is to present arguments
supporting the intended goal, but ultimately the clients should arrive at the conclusion of
wanting to change on their own. You should roll with resistance – the patients need to
arrive at the conclusion on their own. Nonetheless, you need to remind you patient that
they are good enough and that they are able to stop taking substances completely.
Motivational interviewing is based on the transtheoretical model of change. This includes
elements that can be abbreviated by the acronym FRAMES:
 F – Feedback. Inform the patient what you find.
 R – Responsibility for change. This is an incentive that drives the patient to change.
 A – Advice. Inform the patient on the potential risks of their behaviour and the
interventions available. Make sure that the information is accurate.
 M – Menu. Include dietary & lifestyle modifications that reduce their risks. For
example you can ask an alcoholic to eat before drinking in order to delay the
development of intoxication and lower peak serum levels.
 E – Empathy. Express empathy.
 S – self-efficacy.
Pharmacotherapy
Pharmacotherapy is employed as a means of harm reduction in patients who are
experiencing withdrawal symptoms. They are not used for intoxicated individuals. Drugs
with short half-lives will give rapid but more transient withdrawals.
Detoxification is a process of managed withdrawal from drugs of dependence which can be
aided by psychosocial support, symptomatic prescribing or prescription of reducing doses of
the same/similar drugs (also called a reducing regime).
 Symptomatic prescribing. Symptomatic prescribing is the prescription of drugs to
manage symptoms of withdrawal that are not corrected by the substituting drug. For
example, antidiarrhoeal agents are given with opioid substitutes to reduce the
diarrhoea that accompanies opioid withdrawal.
 Substitute prescribing. This is the substitution of the abused drug with alternative.
This either serves as a detoxification agent or it is used for maintenance prescribing.
Substitute prescribing serves to: acutely reduce/prevent symptoms; to stabilise drug
intake and reduce secondary harm associated with drug use; to begin a process of
change in drug-taking behaviour; and to provide an incentive to continued patient
contact & involvement with treatment services.