Addiction literature week 1
CHAPTER 2 OXFORD HANDBOOK – HISTORICAL AND CULTURAL PERSPECTIVES ON
SUBSTANCE USE AND SUDS
PATTERNS OF SUBSTANCE USE
- 4 general classes of drugs subject to abuse potential: narcotics, general depressants,
stimulants and hallucinogens
- DSM 5 describes 11 drug classes: alcohol, amphetamines, caffeine, cannabis, cocaine,
hallucinogens, inhalants, opiates (heroine, morphine, codeine), phencyclidine (angel
dust PCP), sedatives/hypnotics/anxiolytics, and “other”
- drugs exert their psychoactive effects mainly in the CNS
- substances can be eaten, chewed, drunk, smoked, snorted or injected
- sometimes different routes of administration involve different chemical preparations
- fastest absorption into brain is via lungs, absorption is slow via bloodstream from
stomach and small intestine
- a problematic frequency/quantity level of use varies by professionals and by public
according to culture
- but pattern of use is more important than Q/F estimates
- many people use 2 or more psychoactive substances in combination simultaneous
polydrug use (SPU) (usually intentional to produce additive or interactive effects)
- most common combination is alcohol with tobacco
- most common illegal combination is alcohol and marijuana
- SPU is more common among adolescents and young adults
- simultaneous use of alcohol and marijuana (alcohol with other drugs too) is
associated with increased social problems
- many deaths related to alcohol/heroin overdose/oxycodone involve use of other
substances
CULTURAL VARIATION
- cultural norms are reflected in attitudes towards substance use
- the U.S. has the highest levels of both legal and illegal substance use
- individual predictors of use (high SES and male gender) are consistent across most
cultures
- regional and geographic variation in drug availability
- biological differences in acute drug effects
HISTORICAL PERSPECTIVE
Mental disorders
- syndromal diagnosis: a group of co-occurring signs and symptoms represent a
particular disease state, epitomized today
- mental disorders: clinically significant behavioral or psychological syndromes that are
associated with distress and impairment, not a reaction to an event but a
manifestation of some underlying dysfunction
- harmful dysfunction: failure of internal mechanism to perform its naturally selected
evolutionary function
,Substance problems
- discovery of the concept of addiction, and a disease called intemperance and
inebriety (for alcohol)
- Jellinek’s 4 phases of alcoholism:
o pre-alcoholic: socially motivated, relief drinking
o prodromal: social drinking becomes escape from tensions and problems, and
pathological aspects like drinking large amounts, blackouts, shame about
drinking, hangovers etc.
o crucial: some capacity of self-control, addictive drinking, loss of control,
morning drinking, rationalizing drinking, unsuccessful rules to stop drinking,
antisocial behavior, losses in family, friends and work
o chronic: self-control is destroyed, deterioration and death
- Jellinek’s subtypes:
o alpha alcoholism: problem drinking
o beta alcoholism: pathophysiologic effects of drinking without strong
dependence
o gamma alcoholism: classic alcoholism that follows the previous four phases
o delta alcoholism: similar to gamma but without devastating loss of control in
crucial and chronic phases
o epsilon alcoholism: periodic binge drinking
CRITERIA
- DSM1: alcoholism
- DSM2: alcohol and other drug problems under personality disorders
o not empirically validated
- Alcohol dependence syndrome (ADS): compulsive use patterns and incentive salience
alcohol use, with physiological features of tolerance and withdrawal
o 7 dimensions tolerance, withdrawal, use to avoid withdrawal, subjective
compulsion to use, salience of use in the person’s life, stereotyped use
patterns, rapid reinstatement of frank addiction upon return to use after a
period of abstinence
- DSM3: term “alcoholism” is dropped, separate SUDs category instead of personality
disorder, core features of ADS
- DSM3-R: substance abuse defined as hazardous use or continued use despite social
consequences, substance dependence required physiologic features
o DSM3 and DSM3-R imply that abuse than milder than dependence
- 2 broad subtypes of people with alcohol dependence (two models):
o first subtype:
no more than moderate heritability, gradual onset in maturity,
absence of gross character pathology, relatively contained
consequences, moderately abusive drinking pattern, equally common
between genders
o second subtype:
high heritability, early onset, association with antisocial traits, severely
under controlled drinking, severe psychosocial consequences, male
gender dominance
, o subtype differences based in the personality constructs reward
dependence and novelty seeking (higher in type II) and harm avoidance
(higher in type I)
o subtypes are illustrative prototypes and most people don’t fit into these and
show a mixture of clinical features
CULTURAL PERSPECTIVES ON SUD
- universalistic approach: focuses on common elements across cultures (e.g. ADS)
o advantage of cross-cultural comparisons
o a common measure can be used across cultures
- relativistic approach: emphasizes influence of culture on the manifestation and
content of illness & impact of culture in defining and shaping illness
- problems with cross cultural applicability:
o tolerance has various meanings in different cultures
o dependence criteria based on causal attribution of problems not relevant in
some cultures
o different threshold to determine the present of problematic substance use
- recommendation: cross-cultural pilot testing to maximize cross-cultural applicability
and validity
- globalization may decrease cross-cultural variation in substance use patterns
CURRENT DIAGNOSTIC SYSTEMS
- ICD 10 had two types: substance dependence and harmful use ICD 11 got updated
- DSM4: substance abuse and substance dependence mutually exclusive criterion sets
o dependence defined by either presence of tolerance or withdrawal
o limitations:
no accepted understanding of substance abuse
substance abuse and dependence overlap in concept
substance abuse does not meet standard for being a mental disorder
abuse and dependence are not empirically distinct
factor analyses indicate a single dimension of substance problems
- DSM5: single SUD for each drug class, using a combined criterion set
o criterion set includes both dependence and abuse symptoms (except legal
problems which was dropped because it’s culturally bound), and craving was
added
o threshold is 2/11 symptoms
criticism that this is far too lenient
o presence of 4/5 symptoms out of 11 is “moderate SUD”, 6 or more is “severe
SUD”
o it is important to consider noncriterion risk factors too
MODERN UNDERSTANDING OF SUBSTANCE DEPENDENCE
- repeated substance use produces neuroadaptations in the brain that hijack the
brain’s reward system and incentive salience, leading to strong drug craving
- sensitized incentive salience systems can produce strong motivation drive even if
long-term abstinence is achieved, which explains high relapse rates
CHAPTER 2 OXFORD HANDBOOK – HISTORICAL AND CULTURAL PERSPECTIVES ON
SUBSTANCE USE AND SUDS
PATTERNS OF SUBSTANCE USE
- 4 general classes of drugs subject to abuse potential: narcotics, general depressants,
stimulants and hallucinogens
- DSM 5 describes 11 drug classes: alcohol, amphetamines, caffeine, cannabis, cocaine,
hallucinogens, inhalants, opiates (heroine, morphine, codeine), phencyclidine (angel
dust PCP), sedatives/hypnotics/anxiolytics, and “other”
- drugs exert their psychoactive effects mainly in the CNS
- substances can be eaten, chewed, drunk, smoked, snorted or injected
- sometimes different routes of administration involve different chemical preparations
- fastest absorption into brain is via lungs, absorption is slow via bloodstream from
stomach and small intestine
- a problematic frequency/quantity level of use varies by professionals and by public
according to culture
- but pattern of use is more important than Q/F estimates
- many people use 2 or more psychoactive substances in combination simultaneous
polydrug use (SPU) (usually intentional to produce additive or interactive effects)
- most common combination is alcohol with tobacco
- most common illegal combination is alcohol and marijuana
- SPU is more common among adolescents and young adults
- simultaneous use of alcohol and marijuana (alcohol with other drugs too) is
associated with increased social problems
- many deaths related to alcohol/heroin overdose/oxycodone involve use of other
substances
CULTURAL VARIATION
- cultural norms are reflected in attitudes towards substance use
- the U.S. has the highest levels of both legal and illegal substance use
- individual predictors of use (high SES and male gender) are consistent across most
cultures
- regional and geographic variation in drug availability
- biological differences in acute drug effects
HISTORICAL PERSPECTIVE
Mental disorders
- syndromal diagnosis: a group of co-occurring signs and symptoms represent a
particular disease state, epitomized today
- mental disorders: clinically significant behavioral or psychological syndromes that are
associated with distress and impairment, not a reaction to an event but a
manifestation of some underlying dysfunction
- harmful dysfunction: failure of internal mechanism to perform its naturally selected
evolutionary function
,Substance problems
- discovery of the concept of addiction, and a disease called intemperance and
inebriety (for alcohol)
- Jellinek’s 4 phases of alcoholism:
o pre-alcoholic: socially motivated, relief drinking
o prodromal: social drinking becomes escape from tensions and problems, and
pathological aspects like drinking large amounts, blackouts, shame about
drinking, hangovers etc.
o crucial: some capacity of self-control, addictive drinking, loss of control,
morning drinking, rationalizing drinking, unsuccessful rules to stop drinking,
antisocial behavior, losses in family, friends and work
o chronic: self-control is destroyed, deterioration and death
- Jellinek’s subtypes:
o alpha alcoholism: problem drinking
o beta alcoholism: pathophysiologic effects of drinking without strong
dependence
o gamma alcoholism: classic alcoholism that follows the previous four phases
o delta alcoholism: similar to gamma but without devastating loss of control in
crucial and chronic phases
o epsilon alcoholism: periodic binge drinking
CRITERIA
- DSM1: alcoholism
- DSM2: alcohol and other drug problems under personality disorders
o not empirically validated
- Alcohol dependence syndrome (ADS): compulsive use patterns and incentive salience
alcohol use, with physiological features of tolerance and withdrawal
o 7 dimensions tolerance, withdrawal, use to avoid withdrawal, subjective
compulsion to use, salience of use in the person’s life, stereotyped use
patterns, rapid reinstatement of frank addiction upon return to use after a
period of abstinence
- DSM3: term “alcoholism” is dropped, separate SUDs category instead of personality
disorder, core features of ADS
- DSM3-R: substance abuse defined as hazardous use or continued use despite social
consequences, substance dependence required physiologic features
o DSM3 and DSM3-R imply that abuse than milder than dependence
- 2 broad subtypes of people with alcohol dependence (two models):
o first subtype:
no more than moderate heritability, gradual onset in maturity,
absence of gross character pathology, relatively contained
consequences, moderately abusive drinking pattern, equally common
between genders
o second subtype:
high heritability, early onset, association with antisocial traits, severely
under controlled drinking, severe psychosocial consequences, male
gender dominance
, o subtype differences based in the personality constructs reward
dependence and novelty seeking (higher in type II) and harm avoidance
(higher in type I)
o subtypes are illustrative prototypes and most people don’t fit into these and
show a mixture of clinical features
CULTURAL PERSPECTIVES ON SUD
- universalistic approach: focuses on common elements across cultures (e.g. ADS)
o advantage of cross-cultural comparisons
o a common measure can be used across cultures
- relativistic approach: emphasizes influence of culture on the manifestation and
content of illness & impact of culture in defining and shaping illness
- problems with cross cultural applicability:
o tolerance has various meanings in different cultures
o dependence criteria based on causal attribution of problems not relevant in
some cultures
o different threshold to determine the present of problematic substance use
- recommendation: cross-cultural pilot testing to maximize cross-cultural applicability
and validity
- globalization may decrease cross-cultural variation in substance use patterns
CURRENT DIAGNOSTIC SYSTEMS
- ICD 10 had two types: substance dependence and harmful use ICD 11 got updated
- DSM4: substance abuse and substance dependence mutually exclusive criterion sets
o dependence defined by either presence of tolerance or withdrawal
o limitations:
no accepted understanding of substance abuse
substance abuse and dependence overlap in concept
substance abuse does not meet standard for being a mental disorder
abuse and dependence are not empirically distinct
factor analyses indicate a single dimension of substance problems
- DSM5: single SUD for each drug class, using a combined criterion set
o criterion set includes both dependence and abuse symptoms (except legal
problems which was dropped because it’s culturally bound), and craving was
added
o threshold is 2/11 symptoms
criticism that this is far too lenient
o presence of 4/5 symptoms out of 11 is “moderate SUD”, 6 or more is “severe
SUD”
o it is important to consider noncriterion risk factors too
MODERN UNDERSTANDING OF SUBSTANCE DEPENDENCE
- repeated substance use produces neuroadaptations in the brain that hijack the
brain’s reward system and incentive salience, leading to strong drug craving
- sensitized incentive salience systems can produce strong motivation drive even if
long-term abstinence is achieved, which explains high relapse rates
