Brain diseases: Substance abuse and co-occurring disorders

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Brain diseases Substance abuse and co-occurring
disorders

• Mark Publicker, MD FASAM

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Addiction

• A chronic but treatable brain disease
  characterized by
• Loss of control
• Compulsive use
• Use despite known harm
• Relapse
• The emergence of a negative affect state

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Questions

• Does mental illness cause substance abuse?
• Does substance abuse cause mental illness?

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Questions

• Are there differences in populations
• Primarily psychiatric
• Primarily substance dependent

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Comorbid substance abuse

• Common problem in psychiatric patients
• Contributes to treatment failure and
  non-compliance
• Increased health care costs

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Neurobiology

• Same neurotransmitter systems
• Dopamine
• Serotonin
• GABA
• Glutamate
• Endogenous opioids

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Neurobiology

• Drugs of abuse interact and alter neural
  substrates of psychiatric disorders
• More neuro-psychological impairment

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Rand Survey 2001

• 3 US population has co-occuring disorders
• Of these
• 72 received no treatment in previous 12 months
• Only 8 received both mental and substance abuse
  treatment
• Only 23 of those in treatment received
  appropriate treatment

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Current situation in US treatment systems

• Comorbid rates are high
• Different services are provided according to
  entry portal

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Co-morbid psychiatric disorders

• Depression
• Anxiety disorders
• Bipolar disorder
• Schizophrenia

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Co-morbid psychiatric disorders

• Attention deficit hyperactivity disorder
• Post traumatic stress disorder
• Antisocial personality disorder

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Epidemiology substance abuse disorders

• 50 lifetime prevalence for psychiatric patients
• Among individuals with alcohol use disorders,
  about 22 will also have a drug use disorder
• Among individuals with a drug use disorder,
  almost half (47) will have an alcohol use
  disorder
• Schizophrenia 70prevalence rates
• Earlier onset of symptoms

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Epidemiology

• Affective disorders are very common. Up to 67 of
  alcohol-dependent patients, 53 of
  cocaine-dependent patients, and 75 of
  opiate-dependent patients have comorbid affective
  disorders
• Approximately 25-50 of alcohol dependent
  individuals meet criteria for an anxiety disorder
• Approximately 30-60 of patients with an SUD have
  comorbid Antisocial Personality Disorder

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Order of Onset

• Mental disorders typically emerge before comorbid
  substance use disorders
• This pattern is somewhat stronger for women than
  men
• Data from a large epidemiologic study found that
  the median age of onset of mental disorders was
  11 yrs old as compared to 21 yrs old for
  substance disorder

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Diagnostic Difficulties

• Substance intoxication and withdrawal can mimic
  nearly any psychiatric disorder
• Stimulants/hallucinogens/cannabinoids mania and
  schizophrenia
• Alcohol/opiate/sedative-hypnotic withdrawal
• depressive and anxiety disorder

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Diagnostic Difficulties

• Assess which disorder developed first
• Ask about symptoms during periods of abstinence.
  Minimum acceptable period of abstinence necessary
  for diagnostic clarity will differ by diagnosis
• Anxiety/depression most symptom overlap, 2-4
  weeks important.
• Psychosis/mania 2-4 days sufficient in most
  cases.
• Ask about family history
• Consult multiple sources of information

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Substance Use and Suicide

• Substance induced depression
• May resolve quickly with treatment but is still
  very dangerous
• Increased suicidal thoughts, ideation
• High risk group Diagnosis of major depression
  alcohol or drug abuse/dependence
• Rates are 20-120X the general population

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Epidemiology

• Schizophrenia substance abuse associated with
  higher rates of homelessness, non-compliance,
  medical illness and violence
• Bipolar disorder rates estimated to be 50-70
• Associated with worse prognosis

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Epidemiology

• Unipolar depression 30-50
• Associated with treatment resistance and greater
  severity
• Worsens alcohol dependence treatment outcomes

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Epidemiology

• ADHD 50 of substance abuse patients
• Increases risk of substance abuse
• Effective childhood treatment reduces risk

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Epidemiology

• PTSD increased risk of substance abuse
• Hypothalamic and noradrenergic mechanisms
• Substance abuse increases PTSD symptoms which in
  turn intensify substance abuse

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Post traumatic stress disorder

• Withdrawal symptoms overlap with arousal symptoms
• Increased stress sensitizes the Locus Ceruleus

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Post traumatic stress disorder

• Increased noradrenaline increases stress
• Increased fear responses in amygdala

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Epidemiology - Nicotine

• Nicotine-dependent patients with comorbid
  disorders 7.1 US population consume 34.2 of
  all cigarettes smoked

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Self-medication hypothesis

• Nicotine decreases stress reactivity
• Schizophrenia nicotine used to deal with
  negative symptoms
• Sleepiness
• Dysphoria
• Antipsychotic adverse effects
• Improve cognitive function

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Cannabis

• Heavy adolescent use increases psychiatric risk
• Depression
• Anxiety disorders
• Schizophrenia

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Summary

• High rates of comorbidity
• Each increases the risk of the other and
  complicates their management
• Concurrent treatment yields best results