Substance-Related and Addictive Disorders

Alcohol Use Disorder &

Opiates

Alcohol Statistics Ireland

Theresa Lowry-LehnenRGN, BSc (Hon’s) Nursing Science, PGCC, Dip Counselling,

Dip Psychotherapy, BSc (Hon’s) Clinical Science, PGCE (QTS), H.Dip Ed, MEd, MHS accredited (Level 9) Emotional Intelligence

PhD student Health Psychology

Addiction The term "addiction" has been used in

many contexts to describe an obsession, compulsion, or excessive physical or psychological dependence, such as: drug addiction, alcoholism, compulsive overeating, gambling, etc.

In medical terminology, addiction is a state in which the body relies on a substance for normal functioning and develops a physical dependence.

DSM-5 ChangesIn the fifth edition of the Diagnostic and

Statistical Manual of Mental Disorders (DSM-5), the revised chapter of “Substance-Related and Addictive Disorders” includes substantive changes to the disorders grouped there plus changes to the criteria of certain conditions.

This presentation will focus on Alcohol Use Disorder (with DSM 5 Updates) & Opiates

Alcohol use Disorder

In the previous version of the DSM alcohol use disorders were broken down into two categories: alcohol abuse and alcohol dependence.

According to the APA, "the distinction between abuse and dependence was based on the concept of abuse as a mild or early phase, and dependence as the more severe manifestation."Instead of two separate diagnoses, the DSM-5 has a single diagnosis of alcohol use disorder which, according to the APA, will "better match the symptoms that patients experience."

Alcohol use Disorder Confusion Over 'Dependence' According to the APA, the previous diagnosis of

alcohol dependence caused confusion, because most people thought "dependence" meant "addiction."

Dependence, however, can be a normal body response to using a substance, the APA says, such as when someone becomes physiologically dependent on a medication while adhering to a prescribed regimen. Under the new manual, there will be one diagnosis of alcohol use disorder, but with the designation of mild, moderate or severe.

DSM 5 Criteria Alcohol Use Disorder

Diagnosis of “Alcohol Use Disorder” is based on whether or not the person exhibits any of 11 different symptoms.

The severity of the disorder will be graded by the number of criteria the person meets.

0 to 1, no diagnosis made.

2 to 3- diagnosis is mild. 4 to 5-diagnosis

moderate 6 or more – diagnosis

severe.

Missing work or school Drinking in 

hazardous situations Drinking despite social or

personal problems Craving for alcohol Build up of tolerance Withdrawals when trying to

quit Drinking more than intended Trying to quit without success Increased alcohol-seeking

behaviour Interference with important

activities Continued use despite 

health problems

Features of Substance Use (Alcohol and Drug)

Using more at more frequent intervals Having to use more to get the same

effect Broken promises to self and others to

control or stop using Lying to cover up the amount of useRationalising to cover up and explainDenying that drinking or drug taking

causes problems (www.rutlandcentre.ie/

alcohol_drug_rehabilitation)

Features of Substance Use (Alcohol and Drug)

Avoiding going to places where alcohol/drugs is not available

Spending excess money on alcohol/drugs Needing to drink alcohol or take drugs to

cope with worry, anxiety, stress Erratic behaviour – mood changes, short-

temper, personality change Change in personal relationships Employment problems

(www.rutlandcentre.ie/alcohol_drug_rehabilitation)

Substance DisorderCannabis, Cocaine and Methamphetamine

Cannabis, Cocaine and Methamphetamine

Schizophrenia, paranoia, Compulsive behaviour Schizophrenia, paranoia, Compulsive behaviour

StimulantsStimulants Anxiety, panic attacks, mania and sleep disorder

Anxiety, panic attacks, mania and sleep disorderLSD, Ecstasy &

psychedelicsLSD, Ecstasy & psychedelics

Delusions and hallucinationsDelusions and hallucinations

Alcohol, sedatives, sleeping tablets & narcoticsAlcohol, sedatives, sleeping tablets & narcotics

Depression and mood disturbancesDepression and mood disturbances

PCP & KetaminePCP & Ketamine Antisocial behaviourAntisocial behaviour

DRUG ADDICTION IS A COMPLEX ILLNESS

Addiction is a state in which

the body relies on a substance for

normal functioning and develops a physical dependence

www.drugabuse.gov

Physiology of Addiction

Dopamine -master molecule of addiction Addictive substance enhances amount of

dopamine in the nervous system Increased dopamine results in increased feelings

of pleasure Nervous system responds by reducing the

number of dopamine receptors Addict must take more of the substance to

produce the same effect “high” “So while addicts begin by taking alcohol/drugs to

feel good “high”, they end up taking them in order not to feel low.”

AetiologyGenetic factors: Twin studies and adoption

studies have shown genetic factors may influence the risk.

Evidence of a genetic vulnerability.

Adoption studies suggest the potential for an addictive personality rather than for alcohol addiction.

Biological: Alcohol influences mood

through an impact on levels of GABA and dopamine (neurotransmitters).

(Bennett 2007)

Socio cultural factors: Including ease of access, peer

influence and advertising, influence levels of consumption.

Men are more likely to drink heavily than women.

Blue collar workers are more likely than white collar drinkers to report drinking problems.

Binge drinking is most frequent amongst the young, male, lower income and lower educated groups.

Psychological explanations : Operant and classical

conditioning experiences and cognitions that support consumption.

(Bennett 2007)

AetiologyPsychological factors: Conditioning The pleasure of taking the

substance/ alcohol establishes an operant conditioning process in which the individual is ‘rewarded’ for taking the substance/ alcohol by the pleasant effects, reduction in tension associated with its use, and the avoidance of withdrawal symptoms.

Classical conditioning triggers cravings for alcohol when a user encounters conditions similar to its previous use.

(Bennett 2007)

Effects – Alcohol Use Disorder

The physical health effects associated with alcohol consumption may include

Cirrhosis of the liver Pancreatitis Epilepsy Alcoholic dementia Heart disease Increased risk of cancer Nutritional deficiencies Sexual dysfunction Death. Life expectancy is about 12

years shorter

(www.nhsdirect.co.uk)

Psychological health effects: Psychological disorders are

common in alcoholics, especially panic, anxiety and depressive disorders, with as many as 25% of alcoholics presenting with severe psychological disturbances.

Over 37% of alcohol abusers suffer from at least one co-existing psychological disorder (Lapham, Smith, et al, 2001)

Social effects: loss of employment domestic violence marital conflict/divorce (www.nhsdirect.co.uk)

Prevention &TreatmentPrevention: Preventative approaches attempt to change the context or rules

surrounding consumption; Drink driving laws Advertising EducationTreatment Initial treatment involves a period of withdrawal – aided by the use of

sedatives to moderate the severity of withdrawal symptoms. Drug therapy 12 step approach (AA treatment programme) Cognitive behavioural approaches Social skill training- interpersonal and assertive skills to help

participants cope with stressful situations, refuse drinks and so on. Relapse prevention programmes – strategies to challenge addictive

beliefs and cope with cravings CBT Counselling (Bennett 2007)

Alcohol and Costs. Facts Ireland

Alcohol-related problems cost Ireland an estimated €3.7 billion in 2007 – that’s a cost of €3,318 on each person paying income tax.

Treating alcohol-related injuries and diseases cost the healthcare system an estimated €1.2 billion – around 8.5% of the total annual healthcare budget.

Every night, 2,000 hospital beds are occupied for alcohol-related reasons

10% of all general in-patient hospital costs, 7% of GP costs and up to 30% of emergency department costs are alcohol-related

An estimated €1.2 billion of tax payers’ money is spent on dealing with alcohol-related crime, including violence and vandalism.

An estimated €527 million is lost on alcohol-related absenteeism and accidents in the work place.

In 2007, alcohol-related road collisions cost an estimated €526 million. A 30% reduction in alcohol-related harm would save taxpayers an

estimated €1 billion a year, according to the Chief Medical Officer of Ireland –

http://alcoholireland.ie/facts/alcohol-and-costs

Alcohol and Crime. Facts Ireland

Links between alcohol and crime are well established. Intoxication of both perpetrator and victims has been noted

in a high percentage of instances of homicide and sexual assault .

76% of all rape defendants had been drinking at the time of the alleged offence.

Alcohol has been identified as a contributory factor in 97% of public order offenses as recorded under the Garda PULSE system.

One in eleven, or approximately 318,000 of the full adult population, said that they or a family member were assaulted by someone under the influence of alcohol in the past year.

Almost half of the perpetrators of homicide were intoxicated when the crime was committed

http://alcoholireland.ie/facts

Effects on Children. Facts Ireland

One in eleven children in Ireland say parental alcohol use has a negative effect on their lives - that is about 109,684 children.

16% of child abuse and neglect cases are associated with adult alcohol problems

Alcohol in the home was named as a key child welfare issue in the Report of the Independent Child Death Review Group.

It was the second most prevalent issue after neglect and twice as prevalent as drugs in the home

http://alcoholireland.ie/facts

Alcohol and Health. Facts Ireland

In Ireland it is estimated that one in ten people are alcoholics, and that alcoholism in one person, directly affects the lives of at least 4-5 others.  

88 deaths every month in Ireland are directly attributable to alcohol There are almost twice as many deaths due to alcohol in Ireland as

due to all other drugs combined Alcohol is a factor in up to one third of all deaths by unnatural causes. Chronic alcohol-related conditions are becoming increasingly common

among young age groups. Between 2005 and 2008, 4,129 people aged under 30 were discharged from hospital with chronic diseases or conditions of the type normally seen in older people

Alcoholic liver disease deaths almost trebled (188% increase) between 1995 and 2009

One in 10 cancers in men and one in 33 in women are caused by drinking

http://alcoholireland.ie/facts

Alcohol and Health. Ireland Facts

Alcohol-related admissions to acute hospitals doubled between 1995 and 2008

Alcohol-related deaths also increased during the same period, from 3.8 deaths per 100,000 to 7.1 deaths per 100,000

St Vincent’s Hospital in Dublin figures show a 335pc increase in admissions with alcoholic liver disease between 1995 and 2010

Over 14,000 people were admitted to the liver unit in St Vincent’s Hospital for the treatment of alcohol dependence in 2011.

http://alcoholireland.ie/facts

Alcohol and Health. Facts Ireland

Alcohol increases the risk of developing more than 60 diseases and medical conditions, even at low levels of consumption.

Alcohol is the third leading risk factor for death and disability in the EU after tobacco and high blood pressure.

A more than 3% increase in unemployment in the EU is associated with a staggering 28% increase in deaths from alcohol use disorders, according to the WHO.

http://alcoholireland.ie/facts

Alcohol and Injuries. Facts Ireland

More than one in four of those attending accident and emergency departments have alcohol related injuries, almost half of which occurred to people aged under 30 years.

Alcohol is a factor in one in four traumatic brain injuries.

Alcohol is a factor in 80% of cases of assaulted patients admitted to neurosurgery units

http://alcoholireland.ie/facts

Alcohol- Children and Young People

Harmful drinking in Ireland is highest among 18-24 year old age group at 75%.

Dependent drinking in Ireland is highest among 18-24 year old age group at 15%.

Irish children reported drinking more per drinking occasion than most other European children of the same age.

9% of girls surveyed and 13% of the boys said they first got drunk at or before the age of 13.

Irish 16 to 17-year-olds spend an average of €20·09+ per week on alcohol. This amounts to an illegal alcohol market of €145m in this country. Just under half of all 6th year students and over 60% of young adults report

excessive drinking, according to a survey of mental health and young people. The average age of first alcohol use for children born in 1990 was 14 – in

1980, it was 15 64% of men and 51% of women started drinking before the legal age of 18. Because the brain in still developing, drinking in adolescence has the

potential to cause detrimental long-term effects http://alcoholireland.ie/facts

Alcohol. Women & Men Ireland

WOMEN A higher proportion of Irish women

drink compared with women in other European countries (77% compared to 68%)

Four out of ten Irish woman drinkers report harmful drinking patterns – they are drinking at a level damaging to their health

Since 1995, Irish teenage girls have been drinking as much and sometimes more than their male counterparts.

Women account for a quarter of all alcohol-related hospital discharges, but among those aged 17 and under, the proportion of discharges from hospital is almost half, at 47%

MEN Seven in ten men in Ireland who

drink are drinking in a way which is already causing damage to their health .

One in four deaths of young men aged 15-39 in Ireland is due to alcohol.

One in five men aged 18-23 said they had been pushed, hit or assaulted in the past year as a result of someone else’s drinking.

The link between alcohol and suicide has been well established – four times the number of men as women die by suicide.

Alcohol is the world’s leading risk factor for death among males aged 15-59, according to the World Health Organisation

Alcohol and Suicide. Facts Ireland

A recent study of suicide in Ireland found that half of those who took their own lives had abused alcohol in the previous 12 months .

Suicide is the leading cause of death among young Irish men aged 15-24. The World Health Organisation has estimated that the risk of suicide when a person is currently abusing alcohol is eight times greater than if they were not abusing alcohol.

Alcohol-related disorders were the third most common reason for admission to Irish psychiatric hospitals between 1996 and 2005.

Alcohol-related disorders accounted for 1 in 10 first admissions to Irish psychiatric hospitals in 2011.

Alcohol was a factor in 40% of all cases of self-harm in 2010 http://alcoholireland.ie/facts

Opiate Use Opiates are a group of drugs derived from the poppy

plant. They include opium, morphine and heroin. The most widely used is heroin.

Taking heroin results in feelings of warmth, relaxation and euphoria. Worries, fears and concerns are forgotten and self confidence increases.

Results in euphoric spasm for 60 seconds, followed by a high with lethargy .Generally it takes 30 days or so of continual use (varies among individuals) to become addicted and larger amounts are needed to create the same ‘hit’

Effects last between 4 and 6 hours . From 1960’s – 90’s heroin was more likely to be

injected. Now it is more likely to be smoked which speeds up and increases the drugs effect. The quicker a drugs action the more addictive it is.

Opiate Use Once dependant on the drug, withdrawal symptoms

begin about 8 hrs after last use and result in muscle pain, sweats, sneezing and uncontrollable yawning, runny nose, teary eyes, perspiration, restlessness, increased respiration, intense need for the drug.

After 36 hours the symptoms become increasingly severe and include flushing, excessive perspiration, vomiting, diarrhoea, abdominal cramps, pains, headache, tremors and insomnia, uncontrollable muscle twitching, cramps, chills, sweats and increased heart rate.

These symptoms last for 72 hours and then gradually reduce over a period of 5 – 10 days.

(Bennett 2007)

Brain Before and After Heroin

Normal

Heroin Abuser (after 10 days abstinence)

Heroin Abuser (after 100 days abstinence)

Aetiology & RisksGenetic: Evidence of a genetic

vulnerability/ predisposition.

Adoption studies suggest the potential for an addictive personality rather than for opiate addiction.

Biological: Opiates exert their

action through neurotransmitters- dopamine and endorphins.

Socio-cultural factors: Social pressure Means of reducing stress

(Vietnamese war – 40% American soldiers used heroin)

Progression from the use of other drugs

Sharing needles - infections Expensive Loss of employment/

financial Crime / prostitution

(Bennett 2007)

AetiologyPsychological factors: Conditioning Psychological factors associated with

opiate use are similar to those involved in alcohol use.

That is the pleasure of taking the drug establishes an operant conditioning process in which the individual is ‘rewarded’ for taking the drug by the pleasant effects and reduction in tension associated with its use, and then the avoidance of withdrawal symptoms.

Classical conditioning triggers cravings for heroin when a user encounters conditions similar to its previous use.

(Bennett 2007)

Physiology of Addiction

Dopamine -master molecule of addiction Addictive substance/ heroin enhances amount of

dopamine in the synapses Increased dopamine results in increased feelings

of pleasure Nervous system responds by reducing the

number of dopamine receptor sites Addict must take more drug to produce the same

“high” “So while addicts begin by taking drugs to feel

high, they end up taking them in order not to feel low.”

Heroin Withdrawal And Treatment

Withdrawal- Physiological response to lack of drug effects.

Withdrawal effects will be intense at first, especially if the user quits abruptly

With successful treatment/ therapy and abstinence-the body’s physiology eventually returns to normal, and the person will stop craving the drug.

Heroin addicts are put on methadone to wean them off heroin

Methadone replaces the

heroin without giving the “rush”

If the addict tries to take heroin, the methadone blocks the euphoric effects of it

Eventually the addict’s neurotransmitter production returns to normal if they can avoid taking heroin

Treatment Socio-cultural

approach - Harm minimisation approaches: they reduce the harm associated with the continued use of drugs either by substitution or reducing use of infection. They include;

Methadone programmes

Needle exchange programmes

Psychological approaches include operant programmes (tokens/ rewards) CBT and couples therapy

Behavioural therapy and social approaches can be effective in the treatment of opiate dependence: couples therapy may be the most effective intervention where appropriate.

(Bennett 2007)

Hyperlink-Video’s- Heroin Addiction

http://www.youtube.com/watch?v=-5GIonSHa8c

http://www.youtube.com/watch?v=kOPOK24g9Cc

Addiction Services

Anna Liffey Drug Project, 13 Lower Abbey Street, Dublin 1, 01- 8786899

Arbour House Treatment Centre, St Finbarr's Hospital, Cork, 021-968933

Aisling Group and Bradan Foundation, Dowdstown, Navan, Meath, 046-75979

Coaim, Nelson Mandela House, 44 Lwr Gardiner St, Dublin 1, 01-8338033

Coolmine House, 19 Lord Edward St, Dublin 2, 01-6794822 Cuan Mhuire Centres, Cardington, Athy, Kildare, 045-31493 Drug Treatment Centre Board, Trinity Court, 30-31 Pearse St,

Dublin 2, 01-6771122 Hanly Centre, The Mews, Eblana Avenue, Dun Laoghaire, Dublin,

2809795 Merchant's Quay Project, Dublin 8, 01-6790044 Rutland Centre, Knocklyon House, Knocklyon Road, Dublin 16 - a

private residential treatment centre, 01-4946358

References American Psychiatric Association (APA) (2013), Diagnostic and

statistical manual of mental disorders, 5th Edition, Washington, DC: American Psychiatric Publishing.

American Psychiatric Association (APA) (2000), Diagnostic and statistical manual of mental disorders, 4th Edition, text revision (DSM-IV-TR) Washington, DC: American Psychiatric Publishing.

Bennett, P (2007) Abnormal Clinical Psychology; An Introductory Textbook (Second edition). Maidenhead: Open University Press

Central Statistics Office www.alcoholireland.ie/facts (2014) www.irishhealth.com/ www.nhsdirect.co.uk www.rutlandcentre.ie/alcohol_drug_rehabilitation