Lesson 2: Substance Use Disorders Overview

Attention

Learning Outcomes

Upon completion of this lesson's material, students will be able

  • Understand the brain basis for addiction
  • Understand and be able to state differences and similarities among various models of SUDs
  • Be able to state differences between DSM IV and DSM V in conceptualization of SUDs

Teaching

Reading

Preface and Chapters 1 (What is Addiction), 2 (Burden of Addiction) and 3 (key Elements of Addiction)

Over the years a number of different perspectives on the nature of substace use have been developed.

Brain Basis for Addiction

  • Final common pathway for most substances in the "Pleasure Center" of the brain (The limbic system including especially the Ventral Tegmental Area and the Nucleus Accumbens)
  • So, in the beginning, pleasure is at the center of substance use
  • Some people are genetically predisposed to develop problems with substances perhaps because of issues with the limbic system
  • This genetic predisposition contributes 40 to 60% of the variance associated with substance dependence (loss of control, preoccupation with a substance and continued use despite negative consequences)
  • Generally genetic differences are more important when people have similar environments and less important when the environments are different. So for instance, two kids who both are raised in affluent families with loving parents and who are well treated at school will differ in their risk for SUDs mainly depending on their genetic inheritance. On the other hand, if one kid has a good environment and the other kid grows up poor and in a dysfunctional family and is treated badly at school, the second kid may develop a SUD even though his/her genetic predisposition isn't that strong. This is called "epigenetics" the study of how environment factors influence the development from genotype to phenotype.
  • Currently we think that genes influence both the sensitivity of the reward or pleasure center (limbic system) to dopamine with those who are likely to develop SUDs paradoxically less sensitive but therefore getting the bigger kick from dopamine releasing substances
  • Heavy use of substances generally causes changes in the central nervous system (tolerance, withdrawal, craving) that make it difficult to stop
  • These facts---genetic differences in brain sensitivity to substances and brain changes induced by heavy use of substances--- form the basis for understanding addiction (substance dependence) as a medical issue

Medical Model

  • Many medical issues (for example diabetes, heart disease, cancer) involve bad choices and lifestyle factors that need to change as part of managing the disease. For example, a person with heart disease is generally counseled to reduce salt intake, lose weight, exercise and learn to manage stress. Substance Dependence also includes the need to examine choices and make lifestyle changes.
  • Predisposing factors: impulsive/compulsive paradox (that is to say that people who develop SUDS often try new things and fly against the radar and don't have a lot of respect for authority but once they find something that turns them on, they do it too much and even when it starts to make trouble for them); lonely, depressed, alienated; youth; male gender; mental illness
  • All of these considerations are part of the "Medical Model"---that the person is sick and their objectionable behaviors are symptoms of an underlying disease. The symptoms would go away if we cured the disease.
  • An early proponent of the Medical Model was a Philadelphia physician, Benjamin Rush, who was a signer of the Declaration of Independence.
  • The Medical Model came into vogue in the 20th Century and is advocated by Alcoholics Anonymous
  • The Medical Model destigmatizes alcoholism and has been associated with the decriminalization of drunkenness
  • Before 1970, drunks could be jailed just for being intoxicated; since then they have been referred for treatment
  • Drug use, on the other hand, still carries a lot of stigma and is illegal in itself

Moral Model

  • The Moral Model is the oldest and is still in vogue for drug users. It assumes that substance use is due to weak character and lack of will power and results from an overvaluing of pleasure that is sinful in itself and also causes sin
  • Philosophy and religion have always been highly ambivalent about pleasure and see humans as needing to struggle against desire to live the good life.
  • AA is actually a combination of Medical and Moral Models. Alcoholism is a disease but the remedy is the 12 Step Program which is closely connected to the Christian Moral Rearmament renewal movement of the early 20th Century---the Oxford Group

Here is an interesting app on the history of Alchoholics Anonymous

Disability Model

  • The Disability Model (associated with psychosocial rehabilitation and with which MHRT/Cs should be thoroughly familiar). Appropriate because SUDs are physically based, chronic, progressive and sometimes terminal disorders that require skills training and location of resources for coping. There also are handicaps that may require appropriate accommodations (e.g. for people on Suboxone therapy who should be allowed to engage in normal employment even though they test positive for buprenorphine, an opiate).
  • Click HERE for a good resource regarding this model.

Psychodynamic Model

  • In the Psychodynamic Model a person is coping based on their own personality and can be helped by learning to cope better with more adaptive behavior.

Learning Model

  • Learning Model (click HERE for an excellent article on this model): Person has learned behaviors which meet some needs but results in maladaptive outcomes. Recovery is through learning more adaptive habits. Cognitive behavioral approach to therapy.

Social Model

  • Social Model: drug and alcohol abuse is the result of dyssocial environments and can be corrected by changing them. War on Drugs, DARE (learning refusal skills based on fear of breaking the law), social reform (e.g. prohibition, liquor control measures such as hours of operation or limiting places of sale)

Biopsychospiritual Model

  • Biopsychosociospiritual Model: all of the above. Humans are complex and their problems require complex solutions. E.g. Ebola which is not only a virus that could be helped with a vaccine but also spread in Liberia because of distrust in the government and health agencies.

Changes in the DSM

Changes in the conceptualization of SUDS in DSM V:primarily a movement to seeing SUDS as a continuous problem ranging from mild to severe rather than two different disorders---Abuse and Dependence with different causes and different treatment approaches.

Click HERE for a good resources on how the DMS has changed.s a good resource.

Assessment

Lesson 2 Quiz

Answer the following questions:

  1. In 500 to 1000 words, compare and contrast the first six models to one another with a paragraph for each. Finally write a paragraph or two discussing the biopsychosociospiritual model and your thoughts about the strengths and weaknesses (if any) of this model.
  2. List four differences between DSM IV and DSM V

Lesson 2 Discussion

Review the different models described in this Lesson. Pick the one that you can relate to the most and explain why.