PSY 320 - Ch 18 - Treatment
PSY 320 - Ch 18 - Treatment PSY 320
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This 8 page Class Notes was uploaded by Elliana on Monday April 18, 2016. The Class Notes belongs to PSY 320 at University of Miami taught by Dr. Marc Gellman in Spring 2015. Since its upload, it has received 11 views. For similar materials see Drugs & Behavior in Psychlogy at University of Miami.
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Date Created: 04/18/16
PSY 320 Drugs & Behavior Chapter 18 Treatment Burden of Substance Abuse • Substance abuse (including smoking/illegal drugs/alcohol) costs the na▯on over $500 billion/ year • Illicit drug use alone accounts for ~ $161 billion • Alcohol, tobacco, prescrip▯on drugs account for the rest • Drug abuse linked w/: ◦ Infec▯ous diseases, crime, accidents, teen pregnancies • ~ 1/2 of individuals suﬀering an addic▯on also suﬀer a chronic psychiatric disorder Treatment Overview in the U S • 96% of treatment: l ohoc◦l A sd i o i O ◦ Cocaine ◦ S▯mulants (primarily methamphetamine) • Average age of those admi▯ed is 34 ◦ Early 30s due to chronic disorder • Sites of treatment ◦ 57% treated as outpa▯ents ◦ 20% treated as hospital inpa▯ents (detoxiﬁca▯on) ◦ 17% treated in a residen▯al se▯ng ◦ 6% treated in medica▯on-assisted opioid programs • Substance abuse treatment development should focus on: ◦ More eﬀec▯ve interven▯ons for commonly abused drugs ◦ Treatment delivery on an outpa▯ent basis • Eﬀec▯ve outpa▯ent behavioral/psychosocial interven▯ons are needed to improve overall treatment success • Substance dependence is a chronic illness: ◦ Treatment doesn't work for every individual every ▯me ◦ Condi▯on may require con▯nuing care throughout life • Studies show treatment is cost-eﬀec▯ve by reducing crime & increasing employment • Treatment also saves lives in the long term Drug Addic▯on • Deﬁni▯on: A chronic, relapsing disorder in which compulsive drug-seeking & drug-taking behavior persists despite serious nega▯ve consequences • Drug Abuse - Characterized by recurrent/clinically signiﬁcant adverse consequences related to repeated use, causing the individual to no longer fulﬁll obliga▯ons of life ◦ Puts them in situa▯ons that are legally/socially/physically harmful • Addic▯ve substances induce pleasant states ◦ Euphoria in the ini▯a▯on phase ◦ Or relieve stress • Con▯nued use induces adap▯ve changes in CNS PSY 320 Drugs & Behavior ◦ Tolerance ◦ Physical dependence no▯ a z▯ i sn ◦e S gn i va◦r C ◦ Relapse • Use o▯en con▯nues to avoid withdrawal symptoms Key Terms • Psychological dependence - (Cravings); Intense desire to re-experience the eﬀects of a psychoac▯ve substance • Craving - The cause of relapse a▯er long periods of abs▯nence • Physiological dependence - Refers to physical tolerance & withdrawal syndrome • Priming - Refers to a new exposure to a formerly abused substance ◦ Exposure can precipitate rapid resump▯on of abuse at previous or higher levels • Relapse - Resump▯on of drug-seeking or drug-taking behavior a▯er a period of abs▯nence ◦ Priming, environmental cues, ppl, places, things associated w/ past use may trigger intense cravings & cause relapse • Reward - S▯mulus the brain interprets as intrinsically posi▯ve or something to be obtained • Sensi▯za▯on - Increase in the expected eﬀect of a drug a▯er repeated administra▯on ◦ Also refers to persistent hypersensi▯vity to the eﬀect of a drug in a person w/ history of exposure ◦ One of the neurobiological mechanisms involved in craving & relapse Substance Abuse Criteria • Characterized by recurrent and clinically signiﬁcant adverse consequences related to the repeated use of substances, such as failing to fulﬁll major role obliga▯ons, use of drugs in situa▯ons in which it is physically hazardous, occurrence of substance-related legal problems, and con▯nued drug use despite the presence of persistent or recurrent social or interpersonal problems ◦ Pa▯ern leads to impairment at work, school, etc. ◦ Increased hazards in daily situa▯ons ◦ Legal problems ◦ Con▯nued use despite expressing abuse factors • Substance Dependence - Cluster of cogni▯ve, behavioral, & physiological symptoms indica▯ng a person is con▯nuing to use a substance despite having clinically signiﬁcant substance-related problems • Included in the DSM-5 • Criteria: ◦ At least 3 of: • Symptoms of tolerance • Symptoms of withdrawal • Use of a substance in larger amounts or for longer periods than intended • Persistent desire or unsuccessful a▯empts to reduce or control use • Spending considerable ▯me/eﬀort to obtain the substance • Reduc▯on in important social/occupa▯onal/recrea▯onal ac▯vi▯es b/c of drug use • Con▯nued use of a substance despite a▯endant health/social/economic problems • DSM-5's Changes: PSY 320 Drugs & Behavior ◦ Major change has been removal of dis▯nc▯on btwn "abuse" & "dependence" ◦ Moved "Gambling Disorder" into a behavioral addic▯on • Demonstrates similarity btwn gambling & abuse disorders in their eﬀects on the reward system ◦ Criteria provided for substance use, intoxica▯on, withdrawal, substance/medica▯on- induced disorders, & unspeciﬁed substance-induced disorders ◦ Criteria changes for substance disorder: • Recurrent legal problems deleted • New criterion for cravings/strong desires added ◦ Threshold for Substance Use Disorder diagnosis set at 2+ criteria ◦ Cannabis & caﬀeine withdrawal are new ◦ Criteria for tobacco use disorder the same as other substance abuse disorders, no separate category ◦ Severity of substance use disorders based on # of criteria endorsed: • 2 -3 = mild disorder • 4 - 5 = moderate disorder • 6 + = severe disorder Treatmen t • Hundreds of thousands of Americans undergo treatment for substance abuse/dependence each year • Variety of treatment approaches o▯en used in combina▯on: ◦ Behavioral/psychosocial treatments ◦ Pharmacotherapies • Diﬀerent approaches reﬂect: ◦ Diﬀerent substance abuse problems ◦ Diﬀerent theories about substance abuse NIDA's Principles of Eﬀec▯ve Treatment 1. Addic▯on is a complex but treatable disease/disorder that aﬀects brain func▯on & behavior 2. No single treatment is appropriate for everyone 3. Treatment needs to be readily available/aﬀordable 4. Eﬀec▯ve treatment a▯ends to mul▯ple needs of the individual beyond drug abuse (employment, ﬁnancial ﬁtness, etc.) 5. Remaining in treatment for an adequate period of ▯me is cri▯cal 6. Counseling & other behavioral therapies are the most commonly used treatment Treatment Goal s • Inﬂuenced by the underlying theore▯cal view of substance abuse Alcohol: • Biological disease that someone either has or doesn't have ◦ Only acceptable treatment goal is abs▯nence • Dependence represents one end of a con▯nuum of drinking ◦ Possible treatment goal is controlled social drinking • Cannot have homogeneous goal for en▯re popula▯on Opioids • Dependence undermines physical & mental health of individuals ◦ Only acceptable treatment goal is abs▯nence • Dependence on legal methadone is preferable to dependence on illegal heroin PSY 320 Drugs & Behavior ◦ Preferable to be addicted to manufactured medica▯ons than cut/illicit drugs w/ unknown ingredients ◦ Goal of treatment changed from elimina▯ng opioid use to elimina▯ng heroin use Tobacco • Complete abs▯nence most common goal • Vs. cu▯ng down on smoking or switching to cigare▯es w/ lower tar/nico▯ne Evalua▯ng Treatmen t • Researchers beginning to develop cost/beneﬁt analyses ◦ Cost of treatment vs. cost savings from: • Increased employment • Decreased crime a▯er treatment Alcoholics Anonymous • Founded in 1935 - loose aﬃlia▯on of local groups adhering to common methods • Based on disease model of dependence ◦ Alcoholics are biologically diﬀerent • Abs▯nence the only appropriate goal ◦ Disease takes away individuals' control over drinking behavior • Removes blame for the problem from the alcoholic, but not the responsibility for dealing w/ it • Major approaches include group support/buddy system • Developed by ppl who've personally decided to stop drinking & want to aﬃliate w/ others making the same decision • Formal evalua▯ons not very posi▯ve ◦ Tho studying individuals w/ court-ordered AA referrals may not be an appropriate evalua▯on method ◦ More appropriate evalua▯on may be to determine which types of drinkers beneﬁt most from AA ◦ Evalua▯on important b/c many treatment models follow 12-step model • Cocaine Anonymous, Narco▯cs Anonymous, Gamblers Anonymous PSY 320 Drugs & Behavior Mo▯va▯onal Enhancement Therapy • A▯empts to shi▯ focus away from denial & toward mo▯va▯on to change • Mo▯va▯onal interviewing ◦ Used to boost mo▯va▯on to change an ambivalent/less ready substance abuser ◦ Non-confronta▯onal process of determining abuser's current stage of change & helping them move forward • Goals of mo▯va▯onal interviewers: ◦ Help client focus on problem behaviors ◦ Help the client move forward to the next stage of change • Best conceptualized as prepara▯on for other therapies rather than stand-alone treatment Transtheore▯cal Model of Behavior Change • Assesses individual's readiness to act on a new healthier behavior • Assesses someone's readiness to enter a treatment program • Provides strategies/processes of change to guide individual thru stages of: ◦ Change -> Ac▯on -> Maintenance • Stages of Change Model: ◦ Precontempla▯on - Individual doesn't recognize a problem exists ◦ Contempla▯on - Individual recognizes a problem & begins considering possibility of changing behavior ◦ Prepara▯on - Individual decides to change/make plans to change ◦ Ac▯on - Individual takes ac▯ve steps toward change ◦ Maintenance - Individual engages in ac▯vi▯es intended to maintain change Cogni▯ve Behavioral Therapy/Relapse Preven▯on • Approach combining cogni▯ve therapy techniques w/ behavioral skills training ◦ Individuals learn to iden▯fy/change behaviors that could lead to relapse ◦ Teaching life skills such as choosing healthier environments/suppor▯ve friend groups • Shown to be more eﬀec▯ve than most therapies • Limita▯ons: ◦ Challenging b/c it places signiﬁcant demands on pa▯ents who may have drug-related cogni▯ve deﬁcits ◦ Tho recent evidence suggests this concern is unwarranted gn im u snoc em ◦i T • CBT remains one of the most widely used treatments • More eﬀec▯ve than medica▯ng Con▯ngency Management • Approach in which individuals receive immediate rewards for providing drug-free urine samples ◦ Value of rewards increases w/ consecu▯ve drug-free samples ◦ Clients par▯cipate in weekly skill-building counseling sessions • Produced consistent reduc▯on in use • Clients also par▯cipate in weekly counseling sessions • Limita▯ons: ◦ Cost of rewards ◦ May be unfair to reward users for not using • May be more beneﬁcial to reward pa▯ents w/ prac▯ce of employment skills, rather than material rewards Detoxiﬁca▯on PSY 320 Drugs & Behavior • Ini▯al & immediate phase • Medica▯ons administered to alleviate unpleasant/dangerous withdrawal symptoms • Convulsions may be a concern in certain withdrawal processes Maintenance Therapy • Longer-term strategy used to help dependent individuals avoid relapse • 3 general categories of pharmacotherapy for maintenance: ◦ Agonist or subs▯tu▯on therapy • Used to induce cross-tolerance to abused drug • Methadone for heroin, nico▯ne replacement for tobacco • Typically have safer routes of administra▯on/diminished psychoac▯ve eﬀects compared to original drug • Allows user to be stabilized on agonist & then slowly tapered oﬀ to avoid abs▯nence symptoms ◦ Antagonist therapy • Used to prevent user from experiencing reinforcing eﬀects of abused drug • I.E. Naltrexone blocking opioid eﬀects ◦ Punishment therapy • Produces aversive reac▯on following inges▯on of the abused drug • I.E. Disulﬁram for alcohol dependence ▪ Antabuse ▪ Causes severe nausea/sickness when drinking • *Necessary to oversee administra▯on for compliance Pharmacotherapies • Many experts believe drugs alone won't cure chronic/relapsing/behavioral disorders • Pharmacotherapies can provide a window of opportunity for behavioral/psychosocial treatments by relieving withdrawal symptoms • Some pa▯ents have suﬀered enough brain damage that CBT may be ineﬀec▯ve • For Alcohol: ◦ Detoxiﬁca▯on phase - pharmacological therapies important due to eﬀects of acute alcohol withdrawal syndrome ◦ Medical risks o▯en require inpa▯ent se▯ng for detox ◦ Benzodiazepines typically used • Reduce autonomic hyperac▯vity/prevent seizures • Best choices are those w/ slow onset of ac▯vity ◦ Disulﬁram (Antabuse) - causes unpleasant symptoms (headache, vomi▯ng, breathing diﬃcul▯es) if alcohol is consumed • Inhibits aldehyde dehydrogenase, increases acetaldehyde • Not very eﬀec▯ve since most ppl don't take medica▯on ◦ Naltrexone - reduces alcohol cravings, days/week of drinking, & rate of relapse • Tho doesn't have large impact on overall treatment success • Unclear mechanism of ac▯on ◦ Acamprosate - compound structurally similar to GABA • Normalizes basal GABA concentra▯ons • Blocks glutamate increase during alcohol withdrawal • Recently approved, eﬀec▯veness not yet determined • For Nico▯ne: PSY 320 Drugs & Behavior ◦ Withdrawal symptoms occur in most smokers who stop (anxiety, depression, insomnia cravings) ◦ 5 replacement products FDA approved: • Transdermal patch, gum, nasal spray, vapor inhaler, lozenge ◦ Smokers should stop smoking before using replacements to avoid nico▯ne toxicity ◦ Use of replacement products shown to increase quit rates in controlled clinical studies • Success rates probably lower in real world se▯ngs ◦ Buproprion (Zyban) - non-nico▯ne pharmacotherapy for smoking cessa▯on • FDA approved in 1997 • Used in treatment of depression • Mechanisms of ac▯on not deﬁni▯vely determined • Shown to gradually decrease cigare▯e craving/use ◦ Varenicline • FDA approved in 2006 • Par▯al nico▯ne-receptor antagonist • Even at large doses, doesn't produce full response of nico▯ne • Reduces withdrawal symptoms & cravings • Blocks nico▯ne eﬀects during relapse • Found more eﬀec▯ve than placebo or buproprion • For Opioids: ◦ An▯cholinergic drugs like Belladonna typically used: • To produce a state of delirium for several days so the dependent person would avoid experiencing withdrawal ◦ More recent version is "rapid opioid detoxiﬁca▯on:" • Dependent person anesthe▯zed & given opioid antagonist that causes immediate withdrawal • Person released a▯er 24 hrs & enters period of counseling while con▯nuing to take antagonist : sn o▯a t im◦ i L • Medical risks of rapid withdrawal process • Behavioral psychosocial a▯ercare is o▯en deemphasized : no▯a cﬁ i xo t◦e D • Medica▯ons given to reduce withdrawal symptoms (nausea, vomi▯ng, diarrhea, aches, pain) • Methadone - long-ac▯ng opioid • Buprenorphine - par▯al opioid antagonist w/ long dura▯on of ac▯on ◦ Maintenance: • Methadone maintenance the most common form of treatment for opioid dependence ▪ May con▯nue for months or years • Less data available on more recently approved buprenorphine maintenance ◦ Naloxone - short-ac▯ng opioid antagonist, used to treat OD ◦ Naltrexone - long-ac▯ng opioid antagonist, approved for trea▯ng dependence • Shown to be eﬀec▯ve • Appropriate only for highly mo▯vated individuals • Once-per-month form being studied • For Cocaine: PSY 320 Drugs & Behavior ◦ Withdrawal symptoms can include depression, nervousness, anhedonia, fa▯gue, irritability, sleep disturbances, cravings ◦ Risk of relapse may be greatest during withdrawal period ◦ No current medica▯on to treat symptoms • Reduced dopamine/serotonin ac▯vity may underlie withdrawal symptoms • Medica▯ons that increase dopamine/serotonin ac▯vity have been tested but have not been found useful in trea▯ng withdrawal/dependence • Currently no approved pharmacotherapy for cocaine dependence • Cannabis ◦ Withdrawal symptoms include irritability, anxiety, sleep disrup▯on, aches ◦ Many medica▯ons have been tested for relief of cannabis withdrawal symptoms • Dronabinol found eﬀec▯ve ◦ Currently no approved pharmacotherapy for cannabis dependence - tho is it necessary? • Oﬀ-label - Use of prescrip▯on drug to treat a condi▯on for which the drug has not received US FDA approval
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