Substance Use Disorder

– by Timothy Lyons

A Definition, Signs and Symptoms of Substance Use Disorder

Substance use disorder is a complex behavioral disorder. Persons who do not understand this disorder often relegate its complexity to a lack of willpower or morals. The mistake that occurs with this thinking is the belief that someone can just stop using substances of abuse simply by choice (NIDA, 2016). The truth is that once a person has made the choice to engage in use of a substance with addiction potential, physiological changes in the brain can occur. Once this disorder has taken hold, those changes can make it difficult for the addicted person to maintain self-control or resist cravings for drugs. It will take more than willpower to overcome this problem.

The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), (American Psychiatric Association, 2013) defines substance use disorder. The main attributes of this disorder are complex interwoven symptoms of thoughts, behaviors and physiological changes that include use of the substance of abuse even though there are substantial problems created by its use. In many instances the understanding of this disorder is characterized and informed by the biopsychosocial model (Borrell-Carrió, Suchman, & Epstein, 2004). This would include biological social and psychological components that are the backbone of this DSM 5 definition.

A main attribute in this disease of substance use disorder is the physiological change that occurs in the systems of the brain that are directly affected by these substances.  In a chapter from (Purves D, Augustine, & Fitzpatrick, 2001) these changes are considered long term potentiation which is a strengthening of synaptic transmissions in the storage of memory. These changes persist even after detoxification, the length of which is positively correlated with the severity of the disorder. The behavioral components of these changes are intense cravings for the substance when there are external stimuli presented that are in some way related to the drug, and repeated relapse into use once the person attempts use cessation (American Psychiatric Association, 2013). An overarching theme in the diagnosis is the pathological behavior patterns as a result of this disorder.

If you would like to read more about behaviors that make up the disorder, please go to the next page

Behaviors that Make up the Disorder

The behaviors that define substance use disorder are separated into 11 categories or criterion. The first four categories relate to impaired control. The first category is that the individual ingests the substance for longer and in greater quantities than they had planned. Next the person reports the desire to cease use but is unsuccessful in either stopping or cutting down. Third, the amount of time spent acquiring using and recovering from the substance is assessed, and fourth the individual craves the substance almost any time but specifically in concert with environmental queues that have been associated with previous use. This last criterion is measured by asking whether the person was unable to think of anything else when they had the obsession and it can be a yardstick as to the likelihood of relapse when measured during treatment (American Psychiatric Association, 2013).

The next set of markers in substance use disorder is that of pathological behaviors, numbers 5 through 7 are those that impair social functioning. First, the person is unable to satisfy commitments at work or school. Next the person, although experiencing major crises with relationships or in social situations, continues to use despite the problems. And last the sufferer chooses substance use over important activities that include work, social engagements or recreational undertakings (American Psychiatric Association, 2013).

In criterion 8 and 9 the identifier is risky use. The individual undertakes use in the face of persistent problems and at great risk especially when it is a hazard. Next there may be use even though there are physical or psychological problems that are exacerbated by the use. This is identified when the person fails to discontinue use despite knowledge of the problem (American Psychiatric Association, 2013).

The Last criterion for substance use disorder in (American Psychiatric Association, 2013), 10 and 11, fall under the parameter of pharmacology. First, the individual shows tolerance for the substance. This occurs when the dose of the substance must be increased to achieve the same effect. There are issues with tolerance determination that include a person’s sensitivity to the initial substance use. In some cases a person might be able to tolerate more than another. However, testing of the levels of a substance in the blood juxtaposed against the level of functionality while intoxicated can indicate the presence of tolerance.

Criterion 11 involves withdrawal. In this area, the subject discontinues use and concentrations of the substance decrease. This precipitates withdrawal symptoms. Not all substances cause withdrawal symptoms. In the case of those drugs that do cause symptoms of withdrawal, the symptoms may include an increase production of histamines, anxiety, nausea, cramps and even pain (MedlinePlus Medical Encyclopedia, 2017). It should be noted that due to the fact that some substances do not cause these symptoms, neither tolerance nor withdrawal have to be noted for a diagnosis of substance use disorder, but can be used to consider severity.

The final aspect of the definition for substance use disorder has to do with severity and specifications. The DSM 5 uses continuums to diagnose mental illness. In the case of substance use disorder the levels are from mild, moderate to severe. This corresponds with the number of criteria that are met during assessment. Mild diagnosis would be 2 or three symptoms. Moderate would be four or five symptoms and severe for a diagnosis would occur when the subject reports six or more of the earlier criteria.  The severity can also change over time with regard to the number of symptoms.

The specifiers used in substance use disorder are as follows:  “in early remission,” in most cases this would specify that the person has been free from the earlier symptoms for at least 3 months but less than 12 months; “in sustained remission,” This would occur if the symptoms have not been met for more than 12 months; “on maintenance therapy,” not all substances would include this specifier but it would appear if the individual were taking continuous maintenance medication such as an opiate agonist, partial agonist, agonist/antagonist or full antagonist with the requirement that none of the symptoms for substance use disorder have been met for that medication; and “in a controlled environment,” which is used to note that the individual is in an environment where the substance of abuse is not available. Each of these specifiers is dependent upon the type of substance and is explained within the criteria for that substance (American Psychiatric Association, 2013).

If you would like to read more about important components of substance use disorder, please go to the next page

Important Components of Substance Use Disorder

The scope of this paper in regard to physiology of brain mechanisms will detail changes that occur as a result of the use of substances of abuse in substance use disorder. In addition, some studies point to genetic and social influences that may play a role in the use of substances of abuse.

In a 2009 study by (Bevilacqua & Goldman, 2009) genetic components of substance use disorder were studied. The results showed that although there is some type of genetic component and that substance use disorder were moderate to highly heritable, there was also a social component that could not be ruled out. The issue at hand is that in twin studies for heritability, many of the populations shared similar social and environmental factors that also played a role in the use of substances. The likelihood that a substance was available was a factor in the use of the substance. It appears that this plays a role in earlier use but the genetic factor plays a greater role in later use. The exact mechanism in genetic factors could not be determined but the highest heritability occurred under specific social conditions so that the genetic component of the disorder became relevant.  It was determined that a combination of environment and genes played a role in initial use and with the development of a substance use disorder.

There have been many studies regarding the changes that occur in the brain as a result of substance use. The hypothesis in this case is that changes begin from the initial voluntary intake of a substance and move the brain through a series of changes that impair cognitive function and bring the user to a state of persistent and irresistible drug use (Everitt & Robbins, 2013). The discovery of long term synaptic potentiation, a type of strengthening of synaptic transmission, was first described in the early 1970’s. These changes are physiological changes in the brain that occur as a result of input from external sources. In this way it is believed that memories are formed (Purves D, Augustine, & Fitzpatrick, 2001; Volkow, Wang, Fowler, Tomasi, & Telang, 2011).

The idea that these known changes might be the basis for alterations in other areas of the brain paved the way for studies directly related to transformations that occur as a result of substance use. In (Volkow, Wang, Fowler, Tomasi, & Telang, 2011) we can see that all synapses in the brain have the ability to change from sensory and chemical input. This is known as neural plasticity.

In the case of substances of abuse there is a clear path that leads to these changes. The idea that many drugs of abuse directly influence the production of dopamine in the dopamine rich neural pathways of the mesolimbic cortex is well studied (Daglish et al., 2008). In some cases this is likened to hijacking. Part of this disorders process is like that of storing memories. Synaptic changes occur in the ventral tegmental area (VTA) and in the nucleus accumbens (NAc) directly from the continuous use of substances of abuse (Volkow, Wang, Fowler, Tomasi, & Telang, 2011).

The process of substance use disorder does not happen instantaneously. These changes happen in some type of order and begin in the VTA. Dopamine weakens the VTA and begins to create initial behavioral changes in response to introduction of drugs of abuse (Volkow, Wang, Fowler, Tomasi, & Telang, 2011).  This is a type of stimulus–reward learning attributable to dopamine (Flagel et al., 2011). The initial reaction to the drug is the increased production of dopamine which is so powerful that the person is motivated to take it again. This would make it appear that the addiction is an immediate response. This does not begin to explain the continued use after pathological problems start to occur (APA, 2015).

If you would like to learn more about why people continue to use even after problems occur, please go to the next page

Continued Use After Pathological Problems

The initial response in the VTA continues with downstream long term potentiation in the NAc. This area forms associations with the substances of abuse and creates a link between them and the internal and external social and psychological cues that become associated with the intake of the substances. These cues are the conditioned stimulus that are now indicators of the drugs of abuse (APA, 2015; Flagel et al., 2011; Volkow, Wang, Fowler, Tomasi, & Telang, 2011).

The synapses in the brain react to the intake of the substance and lessen the production of dopamine in those areas after repeated use. When persons who do not take drugs regularly are compared to persons who are abusing substances, we can see that in those persons regularly ingesting drugs, the response to the actual drug begins to produce less of an effect in the dopamine pathways in the VTA. This was the reward for taking the drug in the first place. The response rate is reduced. However in that reduced response the environmental and behavioral cues become much more important (APA, 2015).

From (APA, 2015; Volkow, Wang, Fowler, Tomasi, & Telang, 2011) we learn that the dopamine pathways in the NAc now begin the production of the dopamine in response to cues from the environment. This dopamine response encourages the behavior of taking the drug again (Everitt & Robbins, 2013). The brain was designed for survival. In the case of intake of food or engaging in sex, the initial response of the brain is to produce dopamine to move the individual to seek that biological behavior. In other words, to ensure survival, the brain must make certain that the individual engages in the behavior. The new responses to the environmental cues such as drug paraphernalia, the drug dealer’s house or even the routine in drug use in the NAc create an anticipatory dopaminergic response.

The response to the conditioned stimuli is overwhelming. The dopamine begins the anticipation that there is a reward upcoming which is the drug itself (Flagel et al., 2011). The conditioning from this guarantees that the person with the disorder will procure the drug just as they would procure food for their survival. In a sense these two behaviors are the same. The drugs however have hijacked the same reward systems and even though the drugs are not necessary for survival the strong connections now in place make it seem as if they are necessary (APA, 2015) .

The changes from the use of substances in dopamine systems continues its path through the brain. The substances activate the production of dopamine and also make the pathways less sensitive to the normal survival stimuli such as sex or food. These areas then become less sensitive to the drug itself and also reduce natural production of dopamine. The reduction in dopamine sensitivity and production now complicate matters in the prefrontal cortex (APA, 2015).

This area is known as the executive function center. It is a necessary component to inhibit compulsive behavior. This area helps with self-control, emotion regulation, memory, making decisions and in judgement. A reduction in dopamine in the prefrontal cortex also contributes to the actions of ADHD with regard to response to obsessions and compulsions (APA, 2015; Voeller, 2004). The reduced dopamine in the prefrontal cortex then prevents the person with the substance use disorder from being able to make rational decisions or from enacting self-control mechanisms.

One of the issues with prefrontal cortex inhibition is to create thoughts that are in defense of the disorder through justification and rationalization. The thought patterns that are learned and used as a result of lessened ability to remain rational are considered the psychological basis for substance use disorders. At some point in the 1950’s Albert Ellis theorized that thoughts and perceptions were the driving force behind mental disorders (Patterson, 2015). This theory informs the psychology behind substance use disorder today and is a mainstay in cognitive behavioral therapy.

The idea is that the substance abuser engages in faulty logic, a lens through which the world is viewed. This type of thinking can keep the substance use going because the thinking supports continued use. Some of the thinking patterns might include ideas such as, “I am not hurting anyone,” or “I must take this to feel normal.” These thoughts fit nicely with the idea that those areas of the brain that might normally perform the executive function of decision making and judgment have been compromised.

To further complicate matters, ingesting these substances affects the limbic areas of the brain. The amygdala and hippocampus help in processing emotions and control our reactions to stressful triggers. The brain no longer reacts properly to these triggers. The use of the substance then becomes of paramount importance as a behavior in controlling these emotions. The substance user then begins to think and act in ways that can only make sense in light of an understanding of this disease. Even in the face of the fact that the drug no longer is a pleasure because it does not produce the dopamine that it once did, the person will take it because the alternative, which is to face the stressor without it, is unbearable (APA, 2015).

If you would like to learn about treatments for substance use disorder, please go to the next page

Treatments for Substance Use Disorder

The importance of these earlier findings can inform the type of interventions that are used to treat the disease of substance use disorder. The knowledge that specific brain systems have been hijacked can help inform others about these issues. For instance if we are to tell someone that they suffer from a disease called alcoholism, it does not ease or assist in their understanding the battle they now face. This is similar to telling someone that the reason their loved one is in a coma is because they have diabetes. It explains nothing. If however we understand the process of the disease we can then be informative and help someone know more about their problem.

By informing a substance abusers family that the person with the disorder has a problem with the production of a chemical in their brain that keeps them using the drugs they use despite the consequences is far more illuminating. The fact that we can now address aspects of the disorder with specific treatments can then make sense and allow for informed decisions in mental health care. This may reduce stigma and improve outcomes. It may assist in the use and access of evidenced based treatments within the scope of acceptable treatments. It may pave the way for insurance companies and care providers to come together in the best interest of those persons who suffer mental illness (APA, 2015).

The treatment for substance use disorder has not really come far in comparison to the amount of knowledge that has been obtained in regard to this problem from the physiological perspective. The fact is that most of the treatment today involves some form of moral therapy that includes a twelve step component (Dodes & Dodes, 2014). Even the insurance companies ask for proof that a patient is attending some type of fellowship group and if they have a sponsor which is a component of the twelve step process. This is a type of treatment that started in the 1930’s long before the neural correlates that involve addiction were understood. But there is hope in that even the most hardened 12 step based treatment programs are adopting evidenced based treatments.

Today’s standard treatment should entail some type of evidenced based practice that is informed by scientific study of the components of addiction based on the biological, psychological, social, and physiological components of substance use disorder. There are many therapies that work with this disorder that can be found on the Substance Abuse and Mental Health Services Administration (SAMHSA) website (SAMHSA, 2015). These therapies can include individual and group counseling, inpatient treatment, intensive outpatient and partial hospitalization program and even twelve step recovery fellowships. The most comprehensive list of scientifically studied therapeutic techniques can be found at the National Registry of Evidenced Based Program and Practices provided by SAMHSA (SAMHSA, 2015).

For most treatments there is some type of group or individual psychotherapy which is sometimes combined with medically assisted treatment (MAT). Medications used would depend upon the substance that was the user’s drug of choice and other mental health factors that can only be determined by a qualified physician or psychiatrist. MAT is considered most effective when combined with psychotherapy. Some of the categories of medication include anti-depressants, anxiolytics, mood stabilizers, and antipsychotic medications (NIMH, 2015; SAMHSA, 2015).

If you would like to learn about medications in the treatment of substance use disorder, please go to the next page

Medications in the Treatment of Substance Use Disorder

There are types of medications that are often used in treatment settings that have been designed to work for the specific use disorders. From (SAMHSA, 2015) we can see the different types of medications. For alcohol use disorders, Acamprosate can be used to help reduce cravings and for general maintenance. Naltrexone, an opioid antagonist is used to reduce cravings. Disulfiram is used to change the way in which alcohol is metabolized which provides an upsetting experience if the user ingests alcohol. Medications for Tobacco use disorders can include nicotine replacement through nicotine gum, transdermal patches and lozenges which contain small amounts of nicotine to reduce withdrawal symptoms. There are also nicotine inhalants that are fact acting. There is Varenicline which is a nicotine agonist that helps in cessation and Bupropion, a type of antidepressant that has been found to be useful in this treatment. Drugs for opioid use disorder have been extensively.  Methadone is a type of synthetic opiate which is used in maintenance of the disorder. Buprenorphine is another type of opiate that is also used but when combined with an opiate antagonist, the resultant medication known as suboxone has been shown to be effective in craving reduction. .

In addition to these components, many clinical settings offer case management services to address the social component of the disorder such as coordination of behavioral health services with housing, employment, and even education, This is provided because in most cases the person with the disorder is involved with multiple mental health care systems and it is preferable that they have one point of contact to assist in the recovery process (SAMHSA, 2015).

Many of the evidenced based treatment modalities that are used in today’s treatment are some form of cognitive behavior therapy or behavior therapy. The cognitive behavioral therapies address issues of irrational thinking through cognitive disputation, deal in psychoeducation about biological and non-biological aspects of the disease and teach a relapse prevention model (NIDA, 2012).  Behavior therapies such as third-wave behavioral techniques including Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT) utilize mindfulness based techniques and values definition to help clients to change behaviors so that there is a decrease in pathological behaviors with a corresponding increase in healthy prosocial behaviors that move the person in the direction of the things they most value (Hayes, Strosahl, & Wilson, 2012; Koerner, 2012). These behavior models also assist the user with emotion dysregulation and help in dealing with cognitive distortions but do so in a way that is counter to the CBT models in that the irrational thoughts and feelings are not disputed directly.

If you would like to read about alternative treatments for substance use disorder, please go to the next page

Alternative Treatments for Substance Use Disorder

Some alternative therapies are also used in treatment settings. From (Schuon, 2016) we can see that some of the therapies that are not evidenced based are considered to be holistic in nature and are referred to as complementary and alternative. These therapies can include equine therapy with the use of horses, yoga, and art therapy such as the use of coloring mandalas and painting to relieve stress and anxiety. In addition, experiential adventure-based therapy that uses outdoor activities as metaphor and bio and neurofeedback to help with self-regulation are included in many of the alternative models.

The combination of therapies and medications that are possible are quite numerous and are beyond the scope of this paper. The idea here is that this disorder has a well-informed physiological aspect in additional to psychological and behavioral components. The knowledge of these components should be used to inform treatment so that outcomes can be statistically significant over non treatment. The effects of this disease are devastating and costly (NIDA, 2012). The monetary cost of this disorder is estimated to cost over $600 billion per year. The personal cost is devastating.

 

 

 

 

References For Substance Use Disorder

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Bevilacqua, L., & Goldman, D. (2009). Genes and Addictions. Clinical Pharmacology and Therapeutics, 85(4), 359-361. doi:10.1038/clpt.2009.6

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