Pharmacological Treatment for Substance Related Disorders

1
Pharmacological Treatment for Substance Related
Disorders

• Claudia Flato
• Texas AM University

2
Overview

• Brief history and definitions of
  Substance-Related Disorders
• Summary of the DSM-IV criteria for
  Substance-Related Disorders
• Reported trends and facts related to substance
  use
• Description of specific substances, and current
  pharmacological treatments
• Alcohol
• Cocaine
• Hallucinogens

3
Substance Abuse and Dependence

• DSM IV Definition of Substance Abuse
• Brief history
• the transition of Substance Abuse Diagnosis
  across the DSMs
• Substance abuse vs. substance dependence
• The validity of Substance Dependence
• The validity of Substance Abuse
• DSM IV Substance-related Disorders
• Substance Use Disorders
• Substance abuse
• misuse of a substance followed by social or
  occupational consequences but without
  physiological processes (withdrawal, tolerance
  and compulsive use)
• Substance dependence
• compulsive use of the substance with or without
  physiological consequences
• Substance Induced Disorders

(Diagnostic and Statistical Manual of Mental
Disorders IV-TR., 2000)
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Substance Abuse and Dependence

• Substance Abuse
• A maladaptive pattern of substance use
• failure to fulfill major obligations
• continued use under hazardous conditions
• multiple legal problems
• recurring social and interpersonal problems.
• Sans tolerance, withdrawal or a pattern of
  compulsive use of the substance
• Symptoms have never met criteria for dependence
• Substance abuse does not apply to nicotine and
  caffeine.

(Diagnostic and Statistical Manual of Mental
Disorders IV-TR., 2000)
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Substance Abuse and Dependence

• Substance Dependence
• Addiction to a substance except caffeine
• Cognitive, behavioral and physiological symptoms
• Three of the 7 criteria specified must have
  occurred within the same 12 months
• Criteria for this disorder include tolerance,
  withdrawal, reduced involvement in pleasurable
  activities, and compulsive use of the substance
• Does not apply to caffeine
• Specify With or Without Physiological Dependence

(Diagnostic and Statistical Manual of Mental
Disorders IV-TR., 2000)
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Substance-Induced Disorders(Differential
Diagnosis)

• The Substance Induced Disorders
• Intoxication
• Reversible, maladaptive, and not due to a GMC (NA
  for nicotine)
• Withdrawal
• Problems after cessation or reduction of a
  substance
• NA for caffeine, cannabis, hallucinogens,
  inhalants, and PCP
• Substance Induce Disorders that share
  phenomenology with other mental disorders
• Substance-Induced
• Delirium
• Persisting Dementia
• Persisting Amnestic Disorder
• Psychotic Disorder
• Mood Disorder
• Anxiety Disorder
• Sexual Dysfunction
• Sleep Disorder

(Diagnostic and Statistical Manual of Mental
Disorders IV-TR., 2000)
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Substance Abuse Factsand Treatment Trends

• In 2003 approximately 1.7 million Americans were
  admitted to a publicly funded substance abuse
  program

By Race/Ethnicity 61.8 White 23.6 African
American 13.3 Hispanic 2.3 American
Indian/Alaskan 1.1 Asian/Pacific Islander
By Drug 23.2 Alcohol 18.7 Alcohol other
drug 15.4 Marijuana 14.4 Heroin 9.9 Smoked
cocaine 7.7 Amphetamines 3.5 Other than Smoked
cocaine (i.e. powder) 2.9 Opiates (other than
heroin)
By Age 15.6 36-40 years 14.2 41-45 13.6
31-35 13.3 21-25 8.5 12-17
(Nida www.nida.nih.gov/Drug Pages/Treatment.html
)
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Substance Abuse Factsand Treatment Trends

• Treatment modalities for Substance Dependence
• Self-help Groups (12-step)
• Motivational Enhancement Therapy
• Relapse Prevention
• Contingency Contracting
• Interpersonal, Couple, and Family Therapies
• Pharmacotherapies

(Tapert, S.F., Tate, S. R., Brown, S.A. 2001)
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Alcohol (Ethanol)

• Background

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Alcohol (Ethanol)
Current, Binge, and Heavy Alcohol Use, by Age
NSDUH 2004

• About 50 of Americans (12 years or older)
  reported current drinking
• About 23 participated in binge drinking at least
  once in the 30 days prior to the survey
• About 7 reported heavy drinking

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Drug mechanisms

• Alcohol
• Metabolism

(Swift, R., Davidson, D.,1998)
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Drug mechanisms
NMDA Receptor
GABAA Receptor
(Carlson, N. R., 2004 Johnson and Ait-Daoud,
1999)
13
Alcohol and Treatment
(Preston et al., 2004 Tapert, et al., 2001)
14
Cocaine

• Background
• CNS Stimulant
• Dopaminergic system
• Binds to dopamine transporter
• Short term effects of abuse
• Increased dopamine leads to euphoria, increased
  energy, hyperexcitability, sleeplessness,
  decreased hunger
• Long term effects of abuse
• Addiction, irritability, mood disturbances,
  restlessness, paranoia, and auditory
  hallucinations
• Crack - Possibly the most effective reinforcer
  of all drugs

(www.nida.nih.gov/ResearchReports/Cocaine/cocainec
over.gif Preston et al., 2004)
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Cocaine
Past Year Cocaine Use among Persons Aged 12 or
Older, by Age 1972-2004
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Drug mechanism

• Cocaine
• Mechanism
• Cocaine attaches to
• dopamine transporter
• causing dopamine to
• build-up in the synapse.

(www.nida.nih.gov/ResearchReports/Cocaine/cocainec
over.gif)
17
3-D Images of Cocaine in the Brain Brookhaven
National Laboratory

Dorsal view
Lateral view
http//www.bnl.gov/CTN/GVG/Cscans3D.asp
18
Cocaine and Treatment
19
Images of Cocaine and Lorazepam in the Brain
Brookhaven National Laboratory
Side-by-side comparison of two PET scans from two
subjects before and after taking a dose of
lorazepam. Top two scans non-drug user's brain
Bottom two scans cocaine addict.

http//www.bnl.gov/bnlweb/pubaf/pr/1998/bnlpr02099
8.htmlimage
20
Hallucinogens

• Background
• Hallucinogens produce transient psychotic states
• LSD, PCP, Ketamine, Dextromethorphan
• Known to affect the serotonin system
• Mescaline, psilocybin, and ibogaine
• Often used in religious and cultural rituals
• In natural form (peyote) availability is
  limited
• LSD synthetic compound
• No unique criteria for Hallucinogen Dependence
  and Abuse in DSM-IV
• No withdrawal syndrome

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Drug mechanism

• Hallucinogens
• Similarities between Serotonin and Hallucinogens

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Hallucinogens and Treatment
Medications Used to Treat Phases of
Hallucinogens State Medications Intoxication
Benzodiazepines, (agitation, prominent
hallucinations) Antipsychotics There is no
withdrawal syndrome
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Websites

• http//www.nida.nih.gov/NIDAHome.html
• http//www.samhsa.gov/
• http//www.niaaa.nih.gov/
• http//nhsn.med.miami.edu/
• http//www.bnl.gov

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References

• American Psychiatric Association (1994).
  Diagnostic and statistical manual of mental
  disorders (4th Ed). Washington, DC Author
• Johnson, B., Ait-Daoud, N. (1999). Medications
  to treat alcoholism. Alcohol Research Health,
  (23), 99 -106. www.niaaa.nih.gov
• Moras, K. (1997). Outcome measurement
  considerations Pharmachological treatments for
  substance abuse. Nida Research Monograph, (175),
  118 -136
• Preston, J.D., ONeal, J.H., Talaga, M.C.
  (2004). Handbook of clinical psychopharmachology
  for therapists (4th ed.). Oakland, CA New
  Harbinger Publications
• Swift, R., Davidson, D. (1998). Alcohol
  hangover Mechanisms and mediators. Alcohol
  Research Health, (22), 54 - 60.
  www.niaaa.nih.gov
• Tapert, S.F., Tate, S. R., Brown, S.A. (2001).
  Substance abuse An overview. In P. B. Sutker,
  H. E. Adams (Eds.), Comprehensive handbook of
  psychopathology (3rd ed.). New York, NY Kluwer
  Academic/Plenum.
• Carlson, N. R. (2004). Physiology of behavior
  (8th ed.). Boston, MA Allyn and Bacon.