PSYC251

Substance use disorders

Lecture 2

DR BRIONY LARANCE
SENIOR RESEARCH FELLOW, SCHOOL OF PSYCHOLOGY
We acknowledge the traditional
custodians of the lands on which UOW is
situated.
We pay our respects to Aboriginal
Elders past and present, who are the
knowledge holders and teachers.
We acknowledge their continued
spiritual and cultural connection to
Country. As we share knowledge,
teaching, learning and research within
the University, we also pay respect to
the knowledge embedded forever
within Aboriginal Custodianship of
Country.
From last lecture..
(oops… ran out of time)
 Heroin and other opioids
(Morphine, oxycodone, codeine, fentanyl)

Short-term effects: depressant; analgesia;

euphoria; sedation; nausea, vomiting, severe
itch; dry mouth; reduced alertness; constricted
pupils; respiratory depression/overdose risk.

Long-term effects: dependence; severe

constipation; tooth decay; irregular menstrual
cycles; injection-related injuries and diseases
such as HCV; sexual dysfunction; poor physical
health; weight loss; dependence; withdrawal
symptoms; depression; anxiety; elevated
mortality risk.
 Street Drugs Summary

 Quality, quantity & consistency may change

 Drug names reported by clients may not correspond to the

drug used

 Poly drug use (drug interactions) is common

 Drug use is often accompanied by a comorbid mental

health disorder
 Importance of language

Use person-centred
language.

Don’t define a person by

their substance use or
diagnosis —emphasise the
person first (e.g., ‘person
who injects drugs’)

Avoid terms like ‘clean’ and

‘dirty’.

Avoid expressions like ‘has a

drug habit’ or ‘suffering from
addiction’- can disempower
by trivialising or
sensationalising AOD use.

See Language Matters guide: https://www.nada.org.au/resources/language-matters/

This lecture…
 Last lecture we…
• Describe the use and effects of
alcohol and other drugs
• Examine alcohol-related harms
• Examine how hazardous
drinking is identified
• Think carefully about the
Overview language we use to describe
alcohol and other drug use and
use disorders

This lecture we will…

• Compare and contrast
international classification
systems for substance use
disorders
• Describe treatment approaches
for substance use disorders
 Models of ‘addiction’

 There is no single theory of ‘addiction’ BUT all theories of

‘addiction’ attempt to explain the processes that underpin
 onset of ‘addiction’

 maintenance of drug-taking behaviours

 mechanisms/targets for treatment

 The ways ‘addiction’ is explained and understood will have

a direct influence on treatment.
 11
Examples of ‘addiction’ theories

Theory

Moral theory Individuals have free will and choice. Those who drink or use drugs lack the
self discipline necessary to moderate drinking.
Disease/medical model Emphasis on neurobiology and genetic factors

Learning theory Patterns of substance use are learned through the complex processes of
behavioural acquisition and reinforcement. Evolved from simple classical
conditioning and operant conditioning theories to more complicated social
learning theories, that emphasise interactions between personal
dispositions and environmental situations.
Social theory Emphasis on social determinants of health and wellbeing (e.g.,
unemployment, poverty, violence, family dysfunction, gender and age
inequities).
These forces are viewed as social stressors and substance use is considered
to be an adaptation.
 Role of dopamine (the ‘Dopamine Hypothesis’)

 Dopamine gets us to repeat pleasurable activities (reinforcement), rather than

producing pleasure directly.
 Drugs can produce large surges of dopamine, powerfully reinforcing the
connection between consumption of the drug, the resulting pleasure, and all the
external cues linked to the experience.
 This "teaches" the brain to seek drugs at the expense of other, healthier goals and
activities.
 Cues in a person’s daily routine or environment become linked with drug use
through changes to the reward circuitry.
 Uncontrollable cravings can be triggered by these cues, even when the drug is not
available.
 This learned "reflex" can last a long time, even in people who haven't used drugs
in many years.
 Neural circuitry of behaviour

 Amygdala – emotional significance and learned association

 Orbotofrontal Cortext (OFT) – encodes outcome expectancies
 Anterior Cingulate Cortex (ACC) – discriminative learning and control
 Hippocampus – contextual memory
 Hypothalamic and Septal nuclei – basic drives
 Nucleus Accumbens (NAcc) – responses to pleasure
 Ventral Tegmental Area (VTA) – facilitates learning and releases dopamine
 Prefrontal Cortex (PFC) – OFT and ACC
 Dorsal Medial Thalamus – inhibits dopamine
 BUT we are more than our biology…

 Brain mechanisms underpinning the onset and maintenance of addictive

behaviours are important, but also need to place these systems in the context
of the individual and their surroundings.

 Genetics and individual differences in brain architecture do not adequately

explain why particular individuals initiate drug taking, develop addictions nor
how they respond to different interventions.

 Several psychological traits have been associated with ‘addiction’ –

impulsivity, depression, anxiety, reward sensitivity and learning capacity. Such
characteristics are the product of biology, personality and circumstance.
 Substance use and
substance use
disorders occur along
a continuum
 16
What is a substance use disorder?

 Many changes have occurred to the definitions and diagnostic criteria of

substance use disorders in DSM-5 and ICD 11 over the past 20 years.
 ICD 11 retains a diagnosis of ‘harmful patterns of substance use’, but
substance ‘dependence’ as the central diagnosis. ‘Substance dependence’ is
defined as a clinical syndrome or cluster of cognitive, behavioral, and
physiological features reflecting an ‘internal driving force’ to use the
substance.
 By contrast, DSM-5 includes a heterogeneous disorder termed substance use
disorder (mild, moderate or severe).
Hierarchy of substance use disorders
ICD-10, draft ICD-11, DSM-IV and DSM-5 classification systems

SOURCE: Saunders (2017) Substance use and addictive disorders in the DSM-5, ICD 10 and the
draft ICD 11. Current Opinion, Psychiatry
 DSM 5 substance use disorder
(substance specific – each operationalised slightly differently)

In general, 2 of the following 11 criteria within a 12-month period:

• Loss of control over drug/alcohol use

• Investing large amounts of time obtaining substances
• Cravings
• Continued use in spite of relationship conflicts
• Risk-taking, such as driving under the influence
• Continued use in the face of developing health problems
• Failed attempts to stop using
• Failing to meet obligations (work, home, school)
• Loss of interest in activities once enjoyed
• Increasing tolerance Mild: 2-3 criteria
• Withdrawal Moderate: 4-5 criteria
Severe: 6+ criteria
 Physiological features of 19
dependence (indicative of
neuroadaptation)

 Tolerance: A person's diminished response to a drug that is the

result of repeated use.
 Withdrawal: Symptoms a person experiences when not using
a substance, due to the body reacting to no longer having the
substance.

 Can be expected outcomes of treatments with some

medications.
 Alone do not constitute a substance use disorder, but may be
counted as one criteria among others
 20
DSM 5 Alcohol Use Disorder

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested
by at least two of the following, occurring within a 12-month period:

1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its
effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of alcohol.
 21
DSM 5 Alcohol Use Disorder (cont)

7. Important social, occupational, or recreational activities are given up or reduced because of

alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or desired
effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol.
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve
or avoid withdrawal symptoms.
 22
Alcohol use disorders

 Risk of AUD is twice as high in men than in women.

 Problem drinking can develop during any life period from early childhood
through old age.

 Rates of AUD vary across different cultural groups.

 Those with AUD are at significantly higher risk of having other disorders,
such as mood and anxiety disorders, personality disorders, and other
substance use disorders

 Emerging evidence that when ICD-11 criteria are operationalised in

culturally responsive ways, the prevalence of ‘alcohol dependence’ among
Indigenous Australians may be similar to that in the general population.
 23
Why do some people develop
alcohol use disorders?

 Some emphasise genetic/biochemical factors

 Others stress psychological factors
 E.g., drinking as a maladaptive pattern of adjustment to the stress of life
 Others stress sociocultural factors
 E.g. Availability of alcohol, social approval
 Some combination of all these factors is likely to influence risk
of AUD
 May be several ‘types’ of AUD
 24
Genetic risk factors for AUD

 Studies of families with and without AUD indicate as many of

one-third of people with AUD had at least one parent with
AUD (Cotton, 1979).
 The rates of AUD increase if both parents have an AUD
(Cloninger et al., 1986)
 Adoption studies: followed up with children of parents with
and without AUD who were all adopted by non-AUD families.
 The children of parents whose parents with AUD were nearly
twice as likely to have AUD by their late 20s (Goodwin et al.,
1973).
 BUT to date, no clear genetic markers have been
identified; problems replicating study findings.
 25
Psychosocial risk factors for AUD

 Parenting styles
 Adverse childhood experiences
 Comorbid mental disorders (depression, anxiety,
schizophrenia) and personality disorders
 Trauma (including intergenerational trauma)
 Expectancies (e.g. social success)
Any questions or
comments?
Treatment interventions
for substance use
disorders
 Models of ‘addiction’ and associated treatment
approaches

Underpinning theory Treatment approaches

Moral theory Emphasis on individual responsibility, e.g., law
enforcement responses
Disease/medical model Emphasis on neurobiology and genetic factors, e.g.,
AA/NA, methadone/buprenorphine
Learning theory Emphasis on reinforcement, e.g., contingency
management
Social theory Emphasis on social determinants of health and
wellbeing, e.g. reducing poverty

Each model has strengths and limitations, and they are yet to be integrated.
The biopsychosocial approach to assessment and intervention is commonly used in ‘addiction’.
 Continuum of care

Positive physical, Harmful/hazardous Substance use

mental and social substance use disorder
health

Prevention Early Treatment Continuing

intervention care/
Recovery
Addressing Intervening
Screening and
through
support
individual and detecting substance
environmental risk use problems at an pharmacotherapy,
counselling and Providing supports
factors for early stage and
other supportive to promote
substance use providing brief
services recovery, wellness
through evidence- intervention, as
and improved
based programs, needed
quality of life
policies and
strategies
Harm reduction strategies
 30
Abstinence vs. controlled drinking

 Long-standing debate.
 Research suggests that some people seeking treatment for AUD (around 1 in 6)
can learn to control their intake, although may be more successful in people
with less severe AUD.
 Despite research supporting this goal for some people, strongly-held beliefs
remain.
 Treatment approaches for SUDs

 Detailed biopsychosocial/functional assessment and care planning

 Physical health, mental health, injecting/BBV risk, cognitive functioning, relationships,
housing, income, child protection, criminal justice involvement, etc.
 Keyworker model/case management for clients with complex needs or multiagency
involvement
 Detoxification (medically supervised; a first step for some, but not ‘treatment’)
 Psychosocial/counselling interventions
 Harm reduction interventions
 Pharmacotherapies/medication
 Residential rehabilitation/therapeutic communities
 Mutual support (AA/NA, SMART Recovery)
Aim might be abstinence or reduce risky practices.
Treatment should be based on scientific evidence and evaluated through routine
outcome monitoring and research.
 Treatment approaches for SUDs

 Detailed biopsychosocial/functional assessment and care planning

 Physical health, mental health, injecting/BBV risk, cognitive functioning, relationships,
housing, income, child protection, criminal justice involvement, etc.
 Keyworker model/case management for clients with complex needs or multiagency
involvement
 Detoxification (medically supervised; a first step for some, but not ‘treatment’)
 Psychosocial/counselling interventions
 Harm reduction interventions
 Pharmacotherapies/medication
 Residential rehabilitation/therapeutic communities
 Mutual support (AA/NA, SMART Recovery)
Aim might be abstinence or reduce risky practices.
Treatment should be based on scientific evidence and evaluated through routine
outcome monitoring and research.
 Psychosocial/counselling
interventions

 Motivational Interviewing/ Motivational Enhancement Therapy

 Cognitive Behaviour Therapy
 Contingency management
 Community Reinforcement
 Continuing care/relapse prevention

Psychological therapy improves the effectiveness of pharmacotherapy

 Pharmacotherapy

Opioid agonist treatment (OAT): Other medications used in

treating substance use
• Treatment for heroin/opioid dependence
disorders:
• Long-term, patient takes daily dose of  Opioid dependence
methadone or buprenorphine (long-acting
 Methadone
opioid medicines – oral, dissolved under
 Buprenorphine+/-naloxone
the tongue or depot injection)
 Naltrexone
• Reduces mortality, injecting drug use, HIV
transmission and crime
 Alcohol dependence
 Acamprosate
 Naltrexone
Pharmacotherapy can assist with:
• Detoxification
 Nicotine dependence
• Stabilisation (e.g. OAT)  Nicotine replacement

• Relapse prevention  Varenicline

 Cytosine?
Any questions or
comments?
Hear directly from people with lived
experience…

www.livesofsubstance.org
For drug factsheets…

https://adf.org.au/drug-facts/
Methamphetamine-specific info…

www.cracksintheice.org.au
For more info on alcohol and other drug
services in NSW…
 PSYC251
Substance use disorders

THANK YOU!
DR BRIONY LARANCE
SENIOR RESEARCH FELLOW, SCHOOL OF PSYCHOLOGY