ADDICTION –SUBSTANCE ABUSE An overview AHMED ALBEHAIRY, M.DPSYCHIATRY CONSULTANT, MOH
Essence of Addiction“Compulsive drug seeking behavior, and use, in the face of negative consequences”“Physical dependence is not that important” Drug Abuse and Addiction Research The Sixth Triennial Report to Congress from the Secretary of Health and Human Services 1999, p.2.
Complex Illness Chronic use and abuse Relapsing condition Compulsive seeking and using Loss of control Changes in values Changes in lifestyle Problems in accountability Dishonesty Ambivalence
Biological aspects of addiction- Reward circuits : DA mesolimbic pathway.- Neurotransmitters of reward circuits: DA, CB1,2, U ENK,BZD-A, GABA, NMDA, m- Glu, Ach, 5HT, NA.- VTA, NA, Amygdala, thalamus, DLPF, OFC.- Bottom up, and Top down.- Molecular Mechanisms of Neuroadaptation
Neurobiology of addiction andseeking , motivational ,learning , related memory .
Addiction: Dysregulation in the Motive Circuit Stage 1: Acute Drug Effects Stage 2: Transition to Addiction Stage 3: End-Stage Addiction
The Neurobiologyof Adaptive Behavior Dopamine can be seen as serving two functions in the circuit: 1) to alert the organism to the appearance of novel salient stimuli, and thereby promote neuroplasticity (learning), and 2) to alert the organism to the pending appearance of a familiar motivationally relevant event, on the basis of learned associations made with environmental stimuli predicting the event.( cues).
The orbitofrontal cortex and the anterior cingulate gyrus, which are regions neuroanatomically connected with limbic structures, are the frontal cortical areas most frequently implicated in drug addiction.These regions are also involved in higher-order cognitive and motivational functions, such as the ability to track, update, and modulate the salience of a reinforcer as a function of context and expectation and the ability to control and inhibit prepotent responses.
These results imply that addiction connotes cortically regulated cognitive and emotional processes, which result in the overvaluing of drug reinforcers, the undervaluing of alternative reinforcers, and deficits in inhibitory control for drug responses. These changes in addiction, which the authors call I- RISA (impaired response inhibition and salience attribution), expand the traditional concepts of drug dependence that emphasize limbic-regulated responses to pleasure and reward. (Am J Psychiatry 2002; 159:1642–
The Neural Basis of Addiction: A Pathology of Motivation and Choice Cellular adaptations in prefrontal glutamatergic innervation of the accumbens promote the compulsive character ofdrug seeking in addicts by decreasing the value of natural rewards, diminishing cognitive control (choice), andenhancing glutamatergic drive in response.
The AmygdalaThe Amygdala is especially critical inestablishing learned associations betweenmotivationally relevant events and otherwise
A Hijacking of Neural SystemsRelated to the Pursuit of Rewards An explanation of addiction - long-term memories persist for many years or even a lifetime . From this point of view, sensitized dopamine responses to drugs and drug cues might lead to enhanced consolidation of drug- related associative memories, but the persistence of addiction would seem to be based on the remodeling of synapses and circuits that are thought to be characteristic of long-term associative memory .
PotentialPsychotherapeutic Targets These include drugs that 1) decrease the motivational value of the drug, 2) increase the salience and motivational value of nondrug reinforcers, or 3) inhibit conditioned responses to stimuli predicting drug availability.
Addiction as a BrainDiseaseAm J Psychiatry 155:6, June 1998EDITORIAL, THOMAS R. KOSTEN, M.D.Will these demonstrations that addictive disorders are genetically influenced brain diseases persuade our leaders and fellow citizens that these patients deserve the same level of compassion and treatment as is provided to other medical patients? Not without our help in educating them.
Management of AddictionAssessment . Bio psycho socialIntervention bio psycho socialFollow up and maintenance
Implications for TreatmentMust restore Medical integrity Personal integrity Social integrity
PsychopharmacologicalTreatment of patients- Symptomatic detox treatment . Physical, psychological- Anticraving.- Antagonist.- Partial agonist.- Agonist or replacement.
Alcohol- Benzodiazepine, chlordiazepoxide 5-20 mg three or four times daily. - Antiepileptic ;carbamezapine . - vitamin B, thiamine , wernick’s encephalopathy respectively.
Alcohol-Naltrexone .At night , after meal, liver-Acomprosate. Campral333mg, 2-1-1, renal , diarrhea, headach-Disulfram.500mg for 1st wk then 250mg, nausea, metronidazole-Topramate.
Tools of managing self efficacy inaddict- Individual psychotherapy .- Group .- Team work.- Motivational skills.- Ex addict .- Family involvement.- Relapse and lapse investigations.
Self efficacy and solveproblem- Psycho education- Anticipation of risky situations .- Discussion ??????- Training , motivation.- List of problems- Prioritize the problems .- Analysis of the problems.( cognitive errors and other related psychosocial issues).
Problem solving- Alternative solutions.- Choose the suitable solution ( with, against, and key persons).- Test the solution .- Approve the solution or choose other alternative.- Recycle and repeat.
Types of problems to besolved- cues.- Craving- Psychiatric disorders.- Medical disorders.- Legal problem.- Family .- financial.
Self efficacy and problem solvingmeanContinous motivation for change of- Attitude .- Thoughts .- Mood .- Behavior .
The Stages of Changeare: Precontemplation (Not yet acknowledging that there is a problem behavior that needs to be changed) Contemplation (Acknowledging that there is a problem but not yet ready or sure of wanting to make a change) Preparation/Determination (Getting ready to change) Action/Willpower (Changing behavior) Maintenance (Maintaining the behavior change) and Relapse (Returning to older behaviors and abandoning the new changes)
Possibility of relapse in addiction therapy Relapse prevention
Key Themes in RelapsePrevention1- identify risk relapse factors and develop strategies to deal with.2- understand relapse as a process and as an event.3- understand and deal with cues and cravings.4- understand and deal with social pressures to use substance.5- develop and enhance a supportive social network.
Key Themes in RelapsePrevention6- develop methods of coping with negative emotional states.7- assess the pt. for co morbid psychiatric disorder.8- help and learn the pt. methods to cope with cognitive distortions.
Cognitive behavioral model of the relapse process Decreased Coping Increased Probability response Self efficacy Of relapseHigh risksituations AVE disonance No Initial use Increased Decreased conflicts Coping Of Probability Self efficacy Of response substance Self relapse attribution
Family intervention in addiction treatment- F Counseling- Enabling, coping with relapse and craving.- F therapy
Family Therapy confessions and confrontations. Parenting skills. Discussions skills. Solving problem skills. Anger management in the family. Family firmness. Therapeutic alliance ( patient , family and therapists).