Foundation of Addiction Medicine 2019

Cycle

Psychosocial
factors

Substance Abuse

301

PROBLEM AREAS (AYTACLAR, ERKIRAN,
KIRISCI & TARTER, 2013)

◈ Physical
◈ Psychological
◈ Familial, Financial
◈ Social
◈ Academic
◈ Legal

302

PSYCHOLOGICAL

◈ Psychosis, depression, anxiety, and other mental illness
◈ Suicide
◈ Any underlying MI is generally aggravated by substance

use

303

FAMILIAL AND FINANCIAL

◈ Minimal parental involvement with their children
◈ Dearth of affectionate, supportive parent-child

interactions
◈ Emotional Burden
◈ Economic Burden
◈ Relationship distress

304

SOCIAL

◈ Disability
◈ Increase burden to treat these productive members
◈ Deaths due to accidents/ substance use
◈ Criminal behaviour
◈ High risk behaviour
◈ Unemployment

305

LEGAL

◈ Substance users are in conflict with law
◈ High risk behaviour: vandalism, rash driving

306

Treatment must address the whole person

◈ Addiction is a multifaceted disease
◈ “Biobehavioral disorder,”
◈ Has profound effects on a person’s

■ Physical health
■ Emotional health
■ Mental health
■ Family
■ Colleagues
■ Neighbors, and
■ Community.

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Cycle

Psychosocial
factors

Substance Abuse

308

Substance Abuse Severity and Level of Care

Adapted from the SAMHSA (1999) and

Institute of Medicine (1990)

None Substance

Mild Abuse Severity

Moderate

Severe

Primary Specialized
Prevention Treatment
Brief
Intervention

309

Psychosocial Individual BI, MI, RP, Contingency,
Interventions Group Network Therapy
Family
Psycho-education
Community Skill development
Support group
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Brief strategic FT
CRA

Supported Employment
Workplace Prevention
Program

Interventions and Indications

Intervention Basic Approach Evidence for effectiveness
Brief Intervention
Motivation Enhancement Therapy FRAMES Harmful users
Relapse Prevention
Network Therapy Motivational Interviewing All type of substance users

Community Reinforcement Cognitive Behavior approach All substances especially in
Approach maintenance program
Multisystemic Therapy
Matrix Model Social Network/Social Treatment non seekers and
support/peer support enhancing compliance
Self Help Approach approach

Behavioral approach Adolescent solvent users,
cannabis and cocaine users

Social Cognitive approach Adolescent (especially
solvent users)

Combination of cognitive Used in stimulant, alcohol
behavioral, empowerment and opiate users
education, social learning,
social network approaches

Social networks/ social Alcohol and opiate users
support / peer support

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Pre requisite competencies of the counselor

◈ Knowledge of subject matter

◈ Knowledge of ethics of counseling

◈ Competence

◈ Consent Unconditional
◈ Confidentiality Positive Regards
◈ Dual relationships

◈ Cultural sensitivity

Empathy Genuineness

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5- A strategy

(making it a mandatory clinical practice)

◈ Asking every patient about the use of substances (just as

we ask for a history of diabetes or hypertension)

◈ Assessing the pattern of use and resulting problems

(establishing a link between substance use and presenting problem)

Advice◈ (clear strong advice to stop or cut down)
◈ Assisting (in the form of specific interventions)
Arranging◈ (by making appropriate referrals when required)

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Components of Brief Interventions
(Miller and Sanchez, 1994)

F◈ eedback: About personal risk and impairment.
R◈ esponsibility: Emphasis on personal responsibility for change.
A◈ dvice: To cut down, abstain if indicated because of severe dependence

or harm.

M◈ enu: Menu of alternative options for changing drinking pattern and,
jointly with the patient, setting a target; intermediate goals of reduction
can be a start.

◈ Empathic interviewing: Listening reflectively without cajoling or
confronting; exploring with patients the reasons for change as they see
their situation.

S◈ elf-efficacy: An interviewing style which enhances people's belief in
their ability to change

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Remember DARES...

◈ Develop Discrepancy – facilitate client to identify the discrepancy

between current behaviour and future goals.

◈ Avoid Argumentation – It’s counterproductive. Look for

inconsistencies and consequences that conflict with important goals.

◈ Roll with Resistance – Be empathetic and non-judgmental and

encourage client to develop their own solutions and examine new
perspectives.

◈ Express Empathy – see the world through client’s eyes. Be

non-judgmental; leave aside one’s own views and values.

◈ Support Self-Efficacy – Belief in the possibility of change is a good

motivator and previous efforts and successes can be elicited to build
self-confidence.

315

◈ 40 users and 40 non-users
◈ Aged 15-24 years
◈ Users had initiated substance abuse during 15-18 years of age,

with peer influence, curiosity and sense of growing being the
major reasons.
◈ Feel good and socialization were the main reasons for
maintenance
◈ Non-users never gave into substances because of personal values,
awareness of the impact on health and family values

316

◈ 221 participants diagnosed with SUDs
◈ Result: more psychosocial problems in early

onset users in the areas of behavioural pattern,
psychiatric disorder, family and peer relation,
work adjustment

317

◈ Decline in academic performance: Low grade, falling
behind, poor attendance

◈ In order to sustain substance use behaviour, many
users are forced to indulge in illegal activities like
stealing, robbing, peddling

318

◈ Purpose - To describe the relationship among the most common
risk factors among a clinical sample (n=214) and to determine the
collective importance of these risk factors on problems with
substance use

◈ Risk factors were most effective in explaining alcohol use, binge
drinking and marijuana use

◈ Antisocial peers and delinquent behavior were the strongest
predictors of substance use.

◈ ◈Reviews of the psychosocial highest risk factors of adolescent

with alcohol and drug use were summarized as :

a. Psychosocial functioning
b. Family environment
c. Peer relationships
d. Stressful life events

◈ 319

◈ Patients who had relapsed (n=30)were significantly more likely

a. To have a positive family history of substance use and higher
number of previous relapses

b. To be using maladaptive coping strategies
c. To have been exposed to a higher total number of ‘high risk’

situation
d. Have experienced a higher number of undesirable life events’

◈ Those who had remained abstinent (n=30) tended to

a. use significantly more number of coping strategies, principally
adaptive ones and

b. scored significantly higher on all measures of self efficacy.

◈ Factors influencing relapse appeared to be largely similar among
patients with alcohol and opioid dependence.

320

◈ Family history of dependence and the number of previous relapses are
consistently associated with alcohol relapse

◈ Coping behavior of the patient to adverse situations had the highest
association with relapse, followed by high-risk situations

◈ Lesser positive thinking and avoidance coping strategies had higher
association in the individual domain analysis of coping behaviors.

◈ Undesirable life events in the past year and general self-efficacy had
significant association with relapse

◈ Relapse rates are higher among those who are not capable to use coping
skills effectively in stressful events (family conflict, peer pressure,
financial difficulties, or temptations).

321

◈ Study examined the association between demographic variables,
clinical parameters, and psychosocial factors that predict the
vulnerability to relapse in cases of alcohol dependence syndrome
(n=100)

RESULTS:

◈ Patients who had relapsed were found to have significantly more

positive family history of substance use

◈ Past history of alcohol-related comorbidity

◈ Experienced a higher number of undesirable life events

◈ Higher negative mood states

◈ Social anxiety and dysfunction in social, vocational, personal,

family, and cognitive spheres compared to patients who had

remained abstinent. 322

Summary

Psychosocial factors if addressed can
help people to:

◈ Participate or remain in drug treatment
◈ Examine options and make healthier

choices
◈ Cope with stressors and/or drug cravings

which often lead to relapse
◈ Learn to improve communication,

relationships, and parenting skills

323

International Day against Drug Abuse and Illicit Trafficking
June 26th

THANK YOU

324

Alcohol & Its Physiological
Effects

Presenter: Dr Sumit Kumar D
Moderator: Dr Prabhat Chand

Note: These slides can be reproduced as a whole with the
acknowledgement to the author/presenter and NIMHANS

ECHO.
For any modifications please contact the author/presenter

for due permission by email.
Email: [email protected] Mobile No. 9480829844

325

Objectives of presentation

• What is Alcohol?
• Absorption/Metabolism
• Physiological effects
• Long term adverse effects

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Introduction

• Chemical name - Ethanol, is a psychoactive
substance(CH3CH2OH)

• Compared with other drugs, large amounts of
alcohol are required for physiological effects,
resulting in its consumption more as a food than a
drug.

• Chronic Alcohol intake

– Profound neurotoxic and neuroadaptive
consequences on neurotransmitter systems and brain
circuitries that are strongly involved in learning and
memory

327

Alcohol Beverages – one standard
drink

328

Absorption

Rate of absorption

• Quickest while empty
stomach

• Higher the concentration,
faster the absorption

• Adding “Soda” makes faster
absorption

• Carbohydrate food retards
Alcohol absorption

ABC of alcohol-Alex Paton ,bmj.com

329

Distribution

• Heart/Brain/Muscle: Same
alcohol concentration as
Blood

• The exception is the liver,
where exposure is greater
because blood is received

direct from the stomach and
small bowel via the portal
vein

ABC of alcohol-Alex Paton ,bmj.com

330

Metabolism

ABC of alcohol-Alex Paton ,bmj.com 331

• More than 90% of alcohol is eliminated by the liver; 2-5% is
excreted unchanged in urine, sweat, or breath

• The first step in metabolism is oxidation by alcohol
dehydrogenases to acetaldehyde of which at least four
isoenzymes exist.

• Acetaldehyde is a highly reactive and toxic substance, and
in healthy people it is oxidised rapidly by aldehyde
dehydrogenases to harmless acetate.

• Under normal circumstances, acetate is oxidised in the
liver and peripheral tissues to carbon dioxide and water

332

• Several isoenzymes of aldehyde dehyrdrogenase
exist

• One of which is missing in about 50% of Japanese
people and possibly other south Asian people (but
rarely in white people).

• Headache,nausea,flushing,and tachycardia are
experienced by people who lack aldehyde
dehydrogenases and who drink( because of
accumulation of acetaldehyde)

333

• On an empty stomach,blood •,
alcohol concentration peaks
about one hour after ABC of alcohol-Alex Paton ,bmj.com 334
consumption

• Alcohol is removed from the
blood at a rate of about 3.3
mmol/hour (15 mg/100
ml/hour)

Heavy drinkers

• Two mechanisms dispose of excess
alcohol in heavy drinkers and account
for “tolerance”in established drinkers.

• Firstly, normal metabolism
increases,as shown by high blood
concentrations of acetate.

• Secondly,the microsomal ethanol
oxidising system is brought into play

• This process is called enzyme
induction,and the effect is also
produced by other drugs that are
metabolised by the liver and by
smoking

ABC of alcohol-Alex Paton ,bmj.com 335

Impact of Ethanol on Key
Neurochemical Systems

GABA-A GABA release, ↑ receptor density
NMDA Inhibition of postsynaptic NMDA receptors; with chronic use,
upregulation
DA
↑ Synaptic DA, ↑ effects on ventral tegmentum/nucleus
ACTH accumbens reward
Opioids
5-HT ↑ CNS and blood levels of ACTH
Cannabinoid Release of endorphins, activation of μ receptors
↑ in 5-HT synaptic space
↑ CB1 activity → changes in DA, GABA, glutamate activity

336

Behavioral effects

• Activate the pleasure or reward – dopamine

• Physiological changes such as flushing, sweating, tachycardia,
and increases in blood pressure

• The kidneys secrete more urine, not only because of the fluid
drunk but also because of the osmotic effect of alcohol and
inhibition of secretion of antidiuretic hormone

• Anti-anxiety actions and produce behavioral disinhibition

337

Risk of Accidents

ABC of alcohol-Alex Paton ,bmj.com 338

Risks associated with concentrations of
alcohol in the blood

ABC of alcohol-Alex Paton ,bmj.com 339

CNS-Sleep

• Low dose: disturbances in sleep architecture, with frequent
awakenings and restless sleep.

• High doses: vivid and disturbing dreams (suppression of REM
stage)

• Hangover (“next morning”): syndrome of headache, thirst,
nausea, and cognitive impairment

340

CHRONIC ETHANOL USE

• Tolerance is defined as a reduced behavioral or
physiological response to the same dose of ethanol

• Physical dependence-withdrawal syndrome when
alcohol consumption is terminated

• Psychological dependence-craving and drug seeking
behaviour

• Delirium tremens-hallucinations, delirium, fever, and
tachycardia. Two or more days after withdrawal.

341

Long Term Adverse Effects

• Deficits in cognitive functioning and judgment
– Shrinkage of the brain (Frontal lobes are particularly
sensitive)

• Malnutrition or vitamin deficiencies-
Wernicke’s encephalopathy and Korsakoff’s psychosis

• Large doses, interfere with encoding of
memories-anterograde amnesias (alcoholic blackouts)

342

Cardiovascular System

• Ethanol intake greater than three standard drinks per day
elevates the risk for heart attacks and bleeding-related
strokes (Hvidtfeldt et al., 2008).

• 6-fold increased risk for CADs, a heightened risk for
cardiac arrhythmias, and an elevated rate of CHF.

• Hypertension. Heavy alcohol use can raise DBP & SBP.
Above 30 g alcohol per day (> 2 standard drinks) is
associated with a 1.5-2.3 mm Hg rise.

343

Gastrointestinal System

• Esophagus. esophageal reflux, Barrett’s esophagus, traumatic
rupture of the esophagus, Mallory-Weiss tears, and esophageal
cancer.

• Stomach. Heavy alcohol use can disrupt the gastric mucosal
barrier and cause acute and chronic gastritis. Not thought to play
a role in the pathogenesis of peptic ulcer disease.

• Intestines. Many alcoholics have chronic diarrhea as a result of
malabsorption in the small intestine. Rectal fissures and pruritus
ani.

• Pancreas. Heavy alcohol use is the most common cause of both
acute and chronic pancreatitis.

344

• Liver. The primary effects are fatty infiltration of the
liver, hepatitis, and cirrhosis.

• Fibrosis, resulting from tissue necrosis and chronic
inflammation, is the underlying cause of alcoholic
cirrhosis.

• Histological hallmark-formation of Mallory bodies

345

“Alcohol-induced” psychiatric syndromes

(Schuckit, 2006a).

• Increases risk of alcohol induced mood and
anxiety disorders

• Increases risk of alcohol induced psychotic
disorders

• Temporary auditory hallucinations and
paranoid delusions-3%

346

Sexual Function

• Despite the widespread belief that alcohol can enhance
sexual activities, the opposite effect is generally noted.

• Many drugs of abuse, including alcohol, have
disinhibiting effects that may lead initially to increased
libido.

• Both acute and chronic alcohol use can lead to
impotence in men.

347

• Many female alcoholics complain of decreased libido,
decreased vaginal lubrication, and menstrual cycle
abnormalities.

• Their ovaries often are small and without follicular
development.

348

Teratogenic Effects: FAS

Teratogenic Effects: FAS

– a cluster of craniofacial
abnormalities

– CNS dysfunction
– pre- and/or postnatal

stunting of growth

349

REFERENCES

1.ABC of alcohol-Alex Paton ,bmj.com
2.Kaplan and Sadock- comprehensive textbook of
psychiatry

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