Psychology, Physiology and Treatment of Drug Addiction

Psychology, Physiology and
Treatment of Drug Addiction
Muhammad Talha Khalid
Ph.D. (Scholar)
International Certified Addiction Professional
Presented by:

Training Content
 What is Addiction?
 Introduction to Psychoactive Substances
 Brain Communication
 Drugs and Reward-Circuit
 Consequences of Drug Addiction
 Recovery and Recovery Management
 Motivation and stages of change
 Stigma of drug addiction
 Treatment Settings
 Intensity & Duration
 The Continuum of Care
 Treatment Models and evidence based practices
 Treatment Plan
Psychology, Physiology and
Treatment of Drug Addiction

What is Addiction?
Learning Objectives
 Define Addiction
 Types of Addiction
 Addiction – The Global Problem
 Addiction – In Pakistan
 Reasons of Drug Abuse in Pakistan
 Treatment Approaches for Drug Abuse in Pakistan
 Treatment of Drug Addiction
 Bitter Facts

Small Exercise: What is Addiction?
 Share you Thoughts about Addiction

Addiction (Cont..)
Definition:
 Addiction is a chronic, relapsing brain
disease that is characterized by
compulsive substance seeking and use,
despite harmful consequences. (NIDA)

Types of Addiction
 Chemical
 Non-Chemical

Addiction - The Global Problem

Drug Addiction – In Pakistan
 Sixth most populous country in the world
 7 million drug addicts in our country
 Pakistan is considered to have the largest opioid users
within south Asian countries

 44 tons’ heroin has been consumed yearly
 110 tons of morphine and heroin trafficked all the
way from Pakistan to national and international
markets.
 Drug-related casualties are higher than those
caused by terrorism.
 Every 27th individual in Pakistan is misusing any
substance.
 Almost 25% young males are engaged in any type of
drug misuse.
 Nowadays, prescription drugs and over the counter
(OTC) drugs are very commonly abuse drugs.
Drug Addiction – In Pakistan

Reasons of drug abuse in Pakistan
 Fast growing population
 Very high poverty rate (146th/186 Countries)
 Low Literacy Rate 58% (the individuals who can
read and write)
 Financials and psychological dynamics
 Unemployment
 Historical, cultural and geographical values
 Almost No Drug Education

Reasons of drug abuse in Pakistan
 Availability
 Accessibility
 Acceptability

Treatment approaches for drug abuse
in Pakistan
 Supply reduction
 Demand reduction

Drug Addiction Treatment is Provided by,
 Hospitals
 Public sector
 Private Sector
 public-private institutions
 NGO’s
Treatment of drug abuse in Pakistan

Bitter Facts
 Unfortunately, there isn’t any uniform policy for the
treatment of drug addiction, and rehabilitation centers
 Mostly psychiatrists, Psychologists, Counselors and
other related staff have little or not trained to treat
this serious problem
 Pakistan spends only 4 rupees annually on each
substance abuser

Is There Any Hope?
What Should We Do?

Learning Objectives
 Define psychoactive substance
 Classification of drugs
 Effects of drugs on body and brain
 Main categories (classes) of psychoactive substances and
several substances within each
 Methods of administering psychoactive substances
 Discuss the levels of progression of substance use
Introduction to Psychoactive Substances

What is Drug?
In medicine: Any substance with the potential to
prevent or cure a disease or the potential to enhance
physical or mental well-being.
In Pharmacology: Any chemical agent that alters
the biochemical or physiological processes of body
tissues or organisms.
In common usage: A substance that is used for
nonmedical (e.g., recreational) reasons.

Psychoactive Substance
Definition:
 Affect the body and Central Nervous System
 Change how people behave or perceive what is
happening around them

Psychoactive Substances
Psychoactive Substances Alter;
 Mood
 Thought
 Sensory Perceptions
 Behaviors

Ref. Physiology and Pharmacology for Addiction Professionals
Drugs Classification

Others
 Cannabinoids - Marijuana/Garda/Hash
 Miraa - (Khat)
 Dissociative anesthetics - Phencyclidine (PCP)
ketamine
 Inhalants - Solvents, Gases

Legal Substances
 Just because a substance is legal
doesn’t mean it is safer than an illegal
substance

Drug Effects
 Can be Positive or Negative
 Depend on the type of Substance used

Drug Effects
 Stimulants: increase the activity of the CNS
 Depressants and opioids (also called narcotics): decrease
the activity of the CNS.
 Hallucinogens: produce a spectrum of vivid sensory
distortions and markedly alter mood and thinking.

Drug Effects
Factors Involved
A Person’s Age, the length of time a person has regularly used
the substance, and amount of a substance regularly used affect
How the body;
 Absorb Psychoactive Substance
 Metabolize them
 Eliminates them

Routes of administration
 Swallowing
 Snorting (inhaling through the nose)
 Smoking
 Inhaling fumes
 Intravenous injection (injecting the substance
into a vein)
 Intramuscular injection (injecting into a
muscle)

Routes of administration (Cont..)
 Subcutaneous injection (injecting the
substance just beneath the skin)
 Topically (applying the substance onto
the top layer of the skin)
 Sublingually (dissolving the substance
under the tongue and absorbing it
through the mouth tissue).

Speed of Action
 Smoking: 7-10 Seconds
 Intravenous injecting: 15-30 Seconds
 Injecting into muscle or under skin: 3-5 minutes
 Mucous membrane absorption (snorting, rectal): 3–5 minutes
 Swallowing: 20–30 minutes
 Absorbed through skin: Slowly over a long period

Progression of use
 Experimental/recreational use
 Circumstantial/occasional use
 Intensified/regular use
 Compulsive/addictive use

Brain Communication
Learning Objectives
 Define brain communication
 Neuron structure
 Normal brain communication
 Addicted brain
 Difference between normal and addicted brain
 Drug actions on brain

“The brain is a
communications center
consisting of billions of
neurons or nerve cells.”

Brain Communication
Definition
 Networks of neurons pass messages back and forth to
different structures within the brain, the spinal
column (the central nervous system), and the
peripheral nervous system.

Normal Brain Communication
Each nerve cell in the brain sends and receives messages
in the form of chemical impulses:
 These chemicals are called neurotransmitters.
 The brain has many different neurotransmitters.
 The sending neuron releases a neurotransmitter from its
axon terminal across a space between neurons called a
synapse or synaptic cleft.
 A neurotransmitter attaches to a specialized site on the
receiving cell called a receptor.
 Once the receiving neuron gets and processes the
message, it becomes a sender and passes the message
to other neurons.

Addicted Brain
 Psychoactive substances tap into the brain’s
communication system and mimic or disrupt with
the way nerve cells normally send, receive, and
process information.

Difference between Normal Brain
and Addicted Brain (Cont..)

Drug actions on brain
 Some psychoactive substances, like marijuana and
heroin, can activate neurons because their chemical
structure mimics that of a natural neurotransmitter.
 Other psychoactive substances, like amphetamine or
cocaine, can cause the nerve cells to release
abnormally large amounts of natural neurotransmitters
or prevent the normal reuptake of these brain
chemicals.

Brain Reward Circuit
Learning Objectives
 Brain reward circuit
 Parts of the Brain Most Affected by Substance Use
 Addiction and reward circuit
 Tolerance and Withdrawal
 Vulnerability to addiction

Brain Reward Circuit
 The way the brain communicates is the same
throughout the brain.
 Different parts of the brain are responsible for
coordinating and performing specific functions.
 Certain areas of the brain are more affected by
substance use than are others.

Parts of the Brain Most Affected by
Substance Use
 The Brain Stem
 The Cerebral Cortex
 The Limbic System

Brain Stem
 Controls functions Critical to Life such as
heart rate, breathing and sleeping.
Cerebral Cortex
 Process information from the senses;
the thinking and judgment center of
the brain.

Limbic System
 Links together a number of brain structures that
control emotional memory and regulate the ability
to feel pleasure.
 Contains The Brain Reward Circuit.

Brain Reward Circuit (Cont..)
 The brain’s reward circuit is critical to the
development of addiction.
 Our brains are wired to ensure that we repeat life-
sustaining activities by associating those activities
with pleasure or reward.

Addiction and Reward Circuit
 The overstimulation of the reward circuit produces
the euphoric effects sought by people who abuse
psychoactive substances and teaches them to repeat
the behavior.

Addiction and Reward Circuit (cont..)
 The brain adjusts to the overwhelming surges in
dopamine (and other neurotransmitters) by
producing less dopamine or by reducing the
number of receptors.

Tolerance
 Tolerance (Criterion 10) is signaled by requiring a
markedly increased dose of the substance to
achieve the desired effect or a markedly reduced
effect when the usual dose is consumed. (DSM-V)

Withdrawal
 Withdrawal (Criterion 11) is a syndrome that occurs
when blood or tissue concentrations of a substance
decline in an individual who had maintained
prolonged heavy use of the substance. (DSM-V)

Vulnerability to addiction
Why do People Start Using Substances?

No matter what a person’s reason for starting to use
psychoactive substances,
“No one Ever Plans to Become
Addicted.”

Vulnerability to addiction (cont..)
 Differs Person to Person
 The more risk factors an individual has, the greater
the chance that taking psychoactive substances will
lead to abuse and addiction.
 Biology, Environment and the Interaction between
the two.

The role of Genetics
 Between 40 and 60 percent of a
person’s vulnerability to addiction is
genetic.

What are the Environmental factors
which play a significant role in
starting and sustaining
substance use?

Learning Objectives
 Consequences of Drug Use
 Different Physiological Responses
Consequences of Drug Abuse

What can possible
outcomes of Drug Use?

Consequences of Drug Use
Individuals with addiction may suffer
a range of consequences:
 Medical
 Psychological
 Social
 Economic
 Legal
 Spiritual

Different Physiological Responses
Women:
 Develop physical problems related to
substance use sooner.
 Escalate to addiction quickly (telescoping).

What Researches Reveal?
Women:
 Are more sensitive to the consumption and long-term
effects of alcohol and drugs than are men.
 Have less water in their bodies than do men, and
they metabolize alcohol in a way that leads to higher
blood alcohol levels with comparable intake and body
weight.
 There is a similar pattern of rapid progression with
illicit drugs.

Fetal Effects
 Fetal effects generally range from low birth weight
to developmental behavioral and cognitive
deficits.
 Cocaine and Marijuana Exposure: Impaired
attention, language, and learning skills, as well as
behavioral problems.
 Methamphetamine exposure: Fetal growth
restriction, decreased arousal, and poor quality of
movement in infants.
 Heroin Exposure: Infants born addicted, low birth
weight, an important risk factor for delayed
development.

Youth
 Early use of drugs increases a young person’s
chance of more serious drug abuse and
addiction.
 Young people also are particularly vulnerable
to physical and social problems.

Recovery and Recovery Management
Learning Objectives
 Define recovery
 Abstinence in the context of recovery
 Define Recovery management
 Recovery-oriented systems of care
 Factors Affecting Treatment Outcomes

Recovery
 Recovery from drug problems is process of change
through which an individual achieves abstinence
and improved health, wellness and quality of life.
(SAMHSA)

Recovery
 A Process of Change
 Continuous growth and improved functioning
 Recovery management over a lifetime

Abstinence in the context of Recovery
 Not using Drugs
 Not using any non-prescribed Psychoactive Drugs
 Not Misusing any prescribed Psychoactive drugs

Recovery from both Mental and
Substance Use Disorders
 Recovery is a process of change whereby individuals work
to improve their own health and wellness and to live a
meaningful life in a community of their choice while
striving to achieve their full potential. (SAMHSA, 2011)

Recovery is Reality…
“It Can, Will, and Does Happen”

Recovery Management
 Shifts the focus away from discrete episodes of
treatment, or acute care, toward a long-term,
client-directed view of recovery.

Recovery-oriented Systems of Care
Seven Elements of a Comprehensive program of
Recovery Management;
 Client empowerment
 Assessment
 Recovery resource development
 Recovery education and training
 Ongoing monitoring and support
 Recovery advocacy
 Evidenced-based treatment and support services

Factors Affecting Treatment Outcomes
 The characteristics of individuals seeking treatment
 The nature and severity of their problems
 The treatment process and the services provided
 Environmental and social conditions (including
family), both during and following treatment
 The interactions among these factors

Motivation and Stages of Change
Learning Objectives
 What is change?
 What is motivation?
 Characteristics of motivation
 Stages of change

Change
 Treatment and recovery are ultimately about
change.
 Change is not always easy for people.

Personal Change
Exercise:
 What change did you make (or try to make)?
 How did you decide to make this change?
 What people, events and circumstances
influenced your decision?
 What step did you take to make the change?
 Did you level of motivation stay the same
throughout the process?

Motivation
Motivation for change affects whether a person;
 Enter treatment
 Continue in treatment
 Adhere to a specific change strategy

Motivation is Static or
Dynamic?

Motivation (Cont..)
 Fluctuate over time in relation to different
situations.
 Can go and forth between conflicting goals.
 Varies in intensity, slowing in response to doubts
and increasing as doubts are resolved.
 Varies greatly among potential behavior changes.

Internal Influences on Motivation
 Emotional states
 Life goals
 Perceptions about risks and benefits of behaviors
 Cognitive appraisals of the situation (what the
client thinks about the situation)

External Influences on Motivation
 Family and Friends
 Situations and Experiences
 Community Support (or lack of community support)

Treatment Settings and
Duration
Learning Objectives
 Different treatment settings for SUD’s
 Intensity and Duration of treatment
 How treatment is provided?
 Components of SUD’s treatment

Treatment Settings for SUD’s
 Drop-in Center
 Hospital
 Outpatient treatment
 Non-hospital residential setting

Intensity and Duration
 How often
 For how long

How Treatment is Provided
How?
 One-to-one with counselor
 In Group with peers
 Family members

Components of Treatment
 Detoxification
 Counseling
 Education
 Treatment for mental health problems
 Relapse prevention training
 Medication
 Continuing Care
 Other Services (Like Women, inmates)

Continuum of Care
Learning Objectives
 Define Continuum of Care
 Components of COC
 COC for one client
 Elements of drug treatment

Continuum of Care
Definition:
 The whole range of services a client may
receive from a treatment program or
coordinated by treatment program.

Continuum of Care
 Outreach
 Treatment
 Other services over time
 Post-treatment support

Continuum of Care for One Client

Stigma of Addiction
Learning Objectives
 Define social stigma
 Describe the possible effects of stigma related
to addiction
 Strategies for countering stigma

Social Stigma
 Severe social disapproval of personal characteristics
or beliefs that are against cultural norms.
 Social stigma often leads to status loss,
discrimination, and exclusion from meaningful
participation in society.

Social Stigma (cont..)
Stigma can interfere with effective treatment;
 A person who sees that addiction is stigmatized
may feel shame and be reluctant to seek
treatment
 Social supports for recovery may not be adequate
in a community that stigmatizes addiction

Stigma Study
Study Participants reported that:
 People treated them differently (60%)
 Others were afraid of them (46%)
 Some of their family members gave up on
them (45%)
 Some of their friends rejected them (38%)
 Employers paid them a lower wage (14%)
Ref. University of Nevada

Stigma (Cont..)
 Stigma Negatively affects recovery rates.
 The stress of hiding an SUD either out of shame or
to avoid stigmatizing responses from others can
cause other medical and social problems.

Strategies to Counter Stigma
Language: People First
 Person with a substance use disorder
 Person who injects drugs
 Person with addiction

Strategies to Counter Stigma
 Awareness Programs
 Evaluating our own attitudes and feelings

Treatment Models and evidence based
practices
Learning Objectives
 Different Treatment Models for Addiction treatment
 Define evidence-based practice
 Recommended evidence-based practices
 Discuss the applicability of these evidence-based
practices
 Ineffective treatment for SUD’s

Models of Drug Use
 Throughout history various models of drug use
have been developed;
 Moral Model: Views addiction as a sin or a moral
weakness.
 Psychodynamic Model: Asserts childhood
traumas are associated with how we cope or do
not cope as adults.
 Disease Model: Argues that the origins of
addiction lie in the individual him/herself.

Models of Drug Use (Cont..)
 Social Learning Model: Suggests that dependence
behaviors are learned, exist on a continuum and
consist of a number of behavioral and cognitive
(thought) processes.
 Public Health Model: Drug use seen as the interaction
between the drug, the individual and the
environment.
 Socio-cultural Model: Argues that substance abuse
should be examined in a wider social context and can
be linked to inequality.

What is an Evidence-based
practice?

Evidence-based Practice (EBP)
 practices for which the evidence is strongest and
most accepted—and that are most likely to have
significant impact on improving care.
(National Quality Forum, 2007)

Practices:
 Practices are set of techniques and
approaches that may include elements
from more than one counseling theory.

Evidence-based:
 Science
 Clinical and financial feasibility
 Clinical expertise

Evidence-based Practice (EBP) – Improving Care
Substandard Treatment:
 Substandard treatment for SUDs was/are common
 Defined as treatment that is not,
 Safe
 Effective
 Patient-centered
 Timely
 Efficient
 Equitable (fair)

Why do we need to know
about and care about EBP?

Recommended EBPs
 Pharmacotherapy (the use of medications to treat SUDs)
 Cognitive-behavioral therapies
 Motivational enhancement therapy
 Contingency management
 Therapeutic Community
 Marital and family therapies
 12-Step facilitation therapy
 Matrix Model

Ineffective treatments for SUDs
 Acupuncture, relaxation therapy, education, drug
testing, and detoxification as stand alone treatments.
 Individual psychodynamic therapy
 Unstructured group therapy
 Confrontation as the main approach to treatment
 Discharge from treatment in response to relapse

Treatment Plan
Learning Objectives
 Describe Treatment Structure
 Describe different components of Treatment
 Substance Use in DSM-V

Treatment Structure
 Screening
 Intake Form
 Assessment
 Narrative Summary Form
 Treatment Planning (Person-Centered)
 Progress Notes (SOAP Note)
 Continuing Care/Discharge Summary
 Waiver/ Informed Consent: Release Form/s

Addiction Severity Index (ASI) – Key points
 ASI in an Interview not a Test.
 The interview consists of seven parts, i.e. Medical,
Employment/Support, Alcohol, Drugs, Legal,
Family/Social and Psychiatric.
 Severity -defined as the need for new or additional
treatment based on the amount, duration and intensity
of symptoms within each area.
 All ratings are based on objective and subjective data
within each area.
 Can be used for in-patient and the follow-up clients
 Patient input is important.

DSM-V
 Substance-Related and Addictive Disorders
What’s New?
 Restructuring of substance use disorders
for consistency and clarity.

How to Diagnose?
 Criteria
Grouping;
 Im-paired control (1-4)
 Social impairment (5-7)
 Risky use (8-9)
 Pharmacological criteria (10-11)

Severity and Specifiers
Severity:
 Mild 2-3 Symptoms
 Moderate 4-5 Symptoms
 Severe 6 or More
Specifiers:
 In early remission min. 3 months to less than 12 months
 In sustained remission min. 12 months or more
 On maintenance therapy
 In a controlled environment

Example
Tentative Diagnosis:
According to DSM;
(F11.20) Severe Opioid Use Disorder
Current Severity: Severe
Specify with: In a controlled Environment

Person-Centered Planning—Narrative Summary Outline
Narrative Summary

Treatment Planning
Sample Treatment Plan

SOAP progress note
SOAP PROGRESS NOTE Form

Sample Discharge Summary and Continuing Care Plan
Discharge Summary and Continuing Care Plan

Form for Written Release of Information
Inter-program Consent to Release Confidential Information

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