Lecture 4: Addiction

What topics are discussed?

Classification psychoactive substances
There are three classifications of psychoactive substances. First, there are sedatives. Examples of these are opiates, barbiturates, GHB, alcohol and laughing gas. They give a relaxed and euphoric feeling. They are very strong and therefore an overdose is a high risk. Stimulants can be for example cocaine, oat, nicotine and caffeine. Cocaine when snorted has a different effect than when it is smoked (crack). Hallucinogens are psychedelic drugs and when snorted in a high dose it can have a dissociative effect. People become energetic, euphoric and empathetic when using hallucinogens. They can also be psilocybin (changes in perceptions). Hallucinogens make you ‘high’ or ‘stoned’ and mostly give a relaxing effect. Examples of hallucinogens are LSD, ketamine, XTC, mushrooms and cannabis.

DSM IV criteria abuse and dependence
The DSM IV made a distinction between abuse and dependence and these were criteria to be diagnosed with a substance use disorder.

Abuse is described as a maladaptive pattern of use, with significant impairment or distress, as manifested by at least one criterion within a 12 month period:
- Failure to fulfil major role obligations as a result of use
- Recurrent use in physically hazardous situations
- Recurrent use-related legal problems
- Continued use despite persistent social problems caused by use

Dependence is describe as a maladaptive pattern of use, with significant impairment or distress, as manifested by at least three criteria within a 12 month period:
- Tolerance (having to use more every time to get the same effect(s))
- Withdrawal / use to avoid withdrawal
- Use in larger amounts / over longer period than intended
- Persistent desire / failed efforts to cut down or control use
- Much time spent in activities to obtain, use, or recover from effects of use
- Important social or occupational activities given up or reduced because of use
- Continued use despite physical or psychological problems caused by use

This distinction was used in the DSM IV until 2013.

‘Abuse’ is considered to be a mild form or preliminary stage of dependence, but the distinction is insufficiently valid. Dependence is often not preceded by abuse. Besides, many dependent individuals do not meet the criteria for abuse (diagnostic orphans). Many abuse diagnoses are based on one criterion: use-related legal problems, like drunk driving. Psychometric research strongly suggest one-dimensional structure of combined abuse and dependence criteria.

In the transition to DSM V the distinction between abuse and dependence has been removed. The abuse-criterion concern legal problem has been removed too and craving has been added as a criterion. In the DSM V there are 11 criteria, with a diagnostic threshold of at least two criteria.

Substance use and treatment in the Netherlands
Half of all people who seek treatment/help are related to alcohol use. Most of the people who are addicted to heroin are in treatment, about 80%. When someone is addicted to benzo’s, there is no craving but there is dependence. The use of cocaine and heroin is decreasing.

Mortality due to alcohol
Alcohol addiction is a serious public health problem. It causes 3.8% of all mortality worldwide. In Europe it causes 6.5% of all mortality (11% for men, 1.8% for women). Russia is included in these data, as it is the number 1 producer in home-made alcohol. For men between 15 and 60 years old alcohol is the most important risk factor for dying worldwide.

Deaths related to alcohol happens as a result of unintended injuries (30%, e.g. traffic incidents), cancer (22%), liver cirrhosis (17%), cardiovascular disease and diabetes (14%) or intentional injuries (12%, e.g. fights, domestic violence).

In the Netherlands, alcohol is responsible for 4.5% of the total burden of disease.

When it comes to mortality related to drug use: most drug overdose deaths involve opioids. Fentanyl, a substance in heroin, causes many deaths and it is 50 to 100 times as potent as morphine.

Course of addiction
The course of addiction differs by person, the type of problems, and the setting (population setting vs. treatment setting), just like in any psychiatric disorder. Prior to the first treatment episode, there are often many years of alcohol- or drug-related problems. It often takes 7-8 years for someone with problems with alcohol addiction to seek treatment. Among many treatment-seekers, their addiction can already be characterised as a chronic relapsing disorder.

Progression towards chronicity is apparent in the rate of treatment re-admissions:

• Alcholics: 80% re-admissions
• Opiate addicts: 98% re-admissions
• Cocaine addicts: 84% re-admissions
• Cannabis addicts: 70% re-admissions

Progression towards chronicity is comparable with other psychiatric disorders.

40-70% of patients in addiction care have also been diagnosed with other psychiatric disorders. Most have a depressive disorder or an anxiety disorder. Other comorbid disorders are ADHD, a serious mental health illness, antisocial personality disorder, and borderline personality disorder.

Factors that contribute to chronicity are genetic vulnerability, progressive and persistent changes in the brain, and powerful learning processes, like operant conditioning, classical conditioning and social learning.

It depends on the substances indicated, but about 40% of the contributing factors can be attributed to genetic factors.

Incentive-sensitisation theory of addiction
This theory suggest that addiction occurs due to incentive sensitization. The reason why incentive salience occurs with addiction is because the brain of the individual has become sensitized to the substance. Individuals can develop hypersensitization if they are repeatedly exposed to addictive substances. In the future the drug will stimulate neurobehavioural systems at a great intensity. The individual will get an increased level of pleasure from their drug use. This leads to incentive salience and the symptoms associated with addiction. The individual will have a strong desire for the drug that goes way beyond liking it. This will result in the repetition of the behaviour. At the same time, the unconscious forces that drive addiction will become conscious desires for using the drug. Initially it is about ‘liking’ the drug, but addiction process will gradually be dominated by stress, negative reinforcement and compulsive ‘wanting’.

Craving
Craving/cue reactivity are anticipatory compensatory responses, resulting from conditioning responses. Organisms are directed towards maintaining an internal balance, called homeostasis. Drug-intake causes imbalance in that process. Organisms try to minimise drug-effects to maintain homeostasis by generating opponent process. Gradually, the opposite effect occurs prior to the drug intake. This is only possible if the organism ‘expects’ the drug intake and its effect. This is due to classical conditioning. For example: someone who uses cocaine knows it will increase their heart rate. Then before the person takes the cocaine, their heart rate will drop. According to Siegel, the strength of this compensatory response increases as the drug use progresses, a process called tolerance.

I-RISA model of addiction (Volkow)
I-RISA stands for Impaired Response Inhibition and Salience Attribution. It proposes that impairments of response inhibition and salience attribution contribute to the cycle of addiction across a broad range of substances of abuse. Drug addiction is not only about the rewards, but it is also about inhibitory control which works through memory associations. There are four processes described in the I-RISA model, which all influence one another in a vicious cycle.

Craving (drug expectation and attention bias) → intoxication (impaired self-awareness) → bingeing (loss of control) → withdrawal (motivation and anhedonia) → craving → …

Conditioning
Both operant conditioning and classical conditioning play a role in addiction. Operant conditioning can be described as behaviour X → positive or negative consequences → increased or decreased frequency. An example is intake of cocaine → positive effects (feeling relaxed, feeling happy) → increased frequency.

Classical conditioning can be described as follows: neutral stimulus → conditioned response → drug approach → pleasurable effect.

The neutral stimulus could be a specific environment or mood, which leads to a conditioned response, e.g. subjective craving or physiological cue reactivity, which leads to drug intake and then a pleasurable effect.

What important is after all is whether the person has the coping mechanisms to perform control, e.g. social learning.

Goals of treatment

• To treat intoxication and withdrawal
• To reduce drug-related harm
• To prevent/reduce relapse, by
  
  • Blocking drug effect
  • Reducing craving
  • Aversion
  • Changing habitual behaviour, improving social/coping skills
• to treat psychiatric and somatic comorbidity
• To foster social and personal recovery

Good medical practice
The principles of good medical practice and its hierarchy are fundamental in the treatment of all disorders.

If the treatment of the disorder is necessary, it must be directed towards resolving acute, (life) threatening situations, e.g. when someone has overdosed or when someone is severely intoxicated.

If treatment and the disorder is possible, it must be directed towards curing the disease and preventing relapse by achieving stable, long-lasting abstinence.

If a cure is not possible, the treatment must be aimed towards stabilisation and symptom reduction.

40-60% of the patients in addiction treatment relapse within one year post-treatment. after one single treatment, in less than 25% there is a stable, enduring abstinence. Addiction is not an acute condition, and therefore it shouldn’t be treated as such.

Heroin experiment
In the 1990s most people addicted to heroin were in methadone treatment and most of them benefitted from it. Yet, there would still be people using heroin and they were involved in criminal activity. As a last resort treatment, the patients were offered heroin assistant treatment, including pure heroin, prescribed on a medical basis. Patients received heroin for a year, either injectable or inhalable heroin. There was a significant effect for those who were medically prescribed heroin. Also, heroin treatment was cheaper than methadone treatment.

There is no substance treatment for cocaine, however, dexamfetamine reduces cocaine use by 66%.

Prevention and early intervention
Universal prevention and early intervention is aimed at the broad population, regardless of the risk status. Generally it has little effect. Selective prevention and early intervention is aimed at those with an increased biological/psychosocial risk. Indicated prevention and early intervention is aimed at individuals with at-risk/excessive substance use but no substance use disorder.

There is increasing evidence for the important role of parents. They show role model behaviour and they set norms, values and rules when it comes to alcohol and smoking.

Patient-treatment matching: adolescents with cannabis use disorder
It is important to provide the treatment to an individual which fits best. For young adolescents (13-16 years old) with psychiatric comorbidity it is recommended to provided family based therapy. For older adolescents (17-18 years old) without psychiatric comorbidity cognitive behavioural therapy is recommended.

What topics are discussed which aren’t discussed in the literature?
The sections about prevention and early intervention, and the experiments discusses in the lecture, the I-RISA model are not discussed in the literature. Topics which are discussed in the literature but which aren’t discussed in the lectures are the effects of specific drugs, the new criteria for addiction (DSM V), addiction to tobacco, psychological theories, and synthetic theories.

How has this topic developed over the past few years?

Like described in the previous lectures, the transition from DSM IV to DSM V has resulted in changes in the criteria for substance use disorders.

What comments are made with regard to the exam?

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What questions are being asked which could be asked on the exam? What is the answer?

How many criteria must be met to meet the diagnosis for substance use disorder?

At least two.

Psychoactive drugs are drugs that…

A. Have little effect or no effect on mood or behaviour
B. Alter only behaviour
C. Alter only mood
D. Alter behaviour or mood

Which of the following is a common side effect of sniffing/snorting a drug?
A. Elevated chance of overdose
B. Increased chance of infection
C. Vein scarring
D. Damage to the nasal membrane lining

Which of the following is a psychoactive drug?
A. Opium
B. Malathion
C. Birth control pills
D. Ketamine