Substance Abuse and Mental Health

I’ve decided to make this section because even though drugs and alcohol affect millions if you’re basically sheltered and not directly involved, it may feel like jumping into a volcano. It can be a HAWT mess.

And it’s not your fault. Most people in the medical field can barely have any type of charge or a problem let alone a substance abuse issue. But as you are aware, addictions do not discriminate.

Since my clinic is designated to treat substance use disorders (SUD), I’ve been compelled to try to put something together to help other providers. I also imagine drugs and ETOH are worsening due to COVID so I’ll try to keep this area updated on the latest information about anything substance abuse-related. I’m still editing and organizing this section, thank you for your patience : )) 

Introduction

How do you deal with this population? I simply think about things I have overcome, granted I’m still dealing with issues but it’s a way to empathize with the patient. We don’t do the same things we did 5, 10, 15+ years ago…

Use those lessons to relate with patients about the necessity to overcome their battle and how it’s possible. Always instill HOPE.

Science Stuff. Addiction is all about DOPAMINE (DA). It is our reward hormone and drugs horribly dysregulate the system in multiple ways, it’s also a primary neurotransmitter for (motor) balance so if that’s off, everything can seem off. DA is also why your medications become scheduled, regulated, and addictive.

We get reasonable surges of DA with food, love, a new job, and stuff. However, with drugs such as cocaine, that DA is surging into another galaxy, and then you get serious problems.  It’s this explosion of DA that leads to risky behaviors, strokes, deaths, etc. 

If someone says, it’s not a big deal they’re simply WRONG, with drugs you are dancing with the devil and it’s a slippery slope that can easily destroy a person’s life. (So don’t listen to this professor doing heroin). Learn from people or professionals who want solutions that don’t include destroying yourself.  

With addictions, you’ll find plenty of people masking or self-medicating issues, socially and financially unstable, and if you add medical problems, etc. it significantly increases the risk of suicidal thoughts or the worst outcomes.

SUD is also in the category of impulse disorders. You may frequently see people with one main addiction and +/- others. It’s a vicious cycle of trying to overcompensate and deal with this huge void of lacking DA that is normally filled with drugs or other addictions, thus being prone to chronic relapses.  

For example, a person may smoke crack to fight off alcohol cravings. What’s interesting is how patients get cautious about medications but had no problem doing every other street drug.

You’ll see all types of dysfunctions but that’s just one of the many effects that drugs have on a person’s psyche. I ultimately see the guilt and shame on the patient’s face like a child getting scolded. So like a kid, you just have to be patient because you’re truly dealing with a broken person. 

I attended this seminar that suggested something similar to retraining/treating an addicted person’s brain as if they’re rationalizing like a toddler. Drugs basically inhibit the thought process so decisions are based on impulses, emotions, and other primitive behaviors.

It’s the only thing that stuck out years later from that seminar because it made so much sense. Working in rehab, you see many people who are agitated for no clear reason. It really feels like you’re dealing with a moody teenager since the person is definitely not at full potential. But with time and with the right care management, the brain can regenerate and heal. A person may take a long time to recover or be permanently affected, but the idea is NOT to cause further damage. 

Treat the Mood or SUD first? According to most literature, treat the SUD first or the mood if it’s suicidal, psychotic, or something serious. In other words, stabilize or treat the biggest problem first and then address the next problem. You’re talking to a brick wall if someone is psychotic, drunk, and/or stoned so make sure the person is sober then start focusing on the treatment and their mental health. Once the mood or the person is stabilized, you can focus on the substance abuse treatment (the following links below are coming soon):

Quick Definitions

  • Aberrant Behavior: Medication-related behavior that departs from adherence to the prescription plan.
  • Addiction: Chronic neurobiological disease characterized by impaired control over drug use, compulsive use, and continued use despite harm and/or craving.
  • Abuse: Use of a drug/medication for non-medical purposes 
  • Dependence: Pharmacological adaptation characterized by drug class-specific withdrawal 
  • Tolerance: State of adaptation in which exposure to a given dose of a drug induces biological changes that result in the drug’s diminished effects over time; often leads to escalation

Substance Use Disorder

The DSM-5 has helped change how we think about addictions by not overly focusing on withdrawal. “The essential feature of substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.” There are 3 Basic Substance-Related Categories:

  1. Substance Use Disorder: The user has taken a substance frequently enough to produce clinically significant distress and/or impaired functioning.
  2. Substance Intoxication: This is an acute condition resulting from a recent overuse of a substance.
  3. Substance Withdrawal: The user experiences a collection of symptoms that occur when the user has frequently used a substance and discontinues or markedly reduces the amount used.

Drug craving has been added to the list, and problems with law enforcement have been eliminated due to cultural considerations that make the criteria difficult to apply internationally. The DSM-5 uses ten groupings of individual disorders. The ten specific disorders are 1. Alcohol 2. Caffeine 3. Cannabis 4. Hallucinogen Related Disorders 5. Inhalant Related Disorders 6. Opioid-Related Disorders 7. Sedative, Hypnotic, or Anxiolytic Disorders 8. Stimulant Related Disorders 9. Tobacco-Related Disorders 10. Other (or Unknown) Substance-Related Disorders, Generally speaking, the substance-related categories are the same for the majority of the categories.

Nearly all substances are diagnosed based on the same overarching criteria. In this overarching categorization of substance abuse disorders, the criteria have not only been combined but strengthened. Whereas a diagnosis of substance abuse previously required only one symptom, mild substance use disorder in DSM-5 requires two to three symptoms from a list of eleven. Regardless of the particular substance, the diagnosis of a substance use disorder is based upon a pathological set of behaviors related to the use of that substance. These behaviors fall into four main categories:

  • Impaired control: (1)Using for longer periods of time than intended, or using larger amounts than intended; (2) Wanting to reduce use, yet being unsuccessful in doing so; (3) Spending excessive time getting/using/recovering from the drug use; (4) Cravings that are so intense it is difficult to think about anything else.
  • Social impairment: (5) People may continue to use despite problems with work, school, or family/social obligations. This might include repeated work absences, poor school performance, neglect of children, or failure to meet household responsibilities. (6) Addiction may also be indicated when someone continues substance use despite having interpersonal problems because of the substance use. This could include arguments with family members about the substance use; or, losing important friendships because of continued use. (7) Important and meaningful social and recreational activities may be given up or reduced because of substance use. A person may spend less time with their family, or they may stop playing golf with their friends.
  • Risky Use: The key issue of this criterion is the failure to refrain from using the substance despite the harm it causes. (8) Addiction may be indicated when someone repeatedly uses substances in physically dangerous situations. For instance, using alcohol or other drugs while operating machinery or driving a car. (9) Some people continue to use addictive substances even though they are aware it is causing or worsening physical and psychological problems. An example is a person who continues to smoke cigarettes despite having a respiratory disorder such as asthma or COPD.
  • Pharmacological indicators (tolerance and withdrawal): (10) Tolerance occurs when people need to increase the amount of a substance to achieve the same desired effect. Stated differently, it is when someone experiences less of an effect using the same amount. The “desired effect” might be the desire to avoid withdrawal symptoms. On the other hand, it may be the desire to get high. People experience tolerance differently; i.e., people vary in their sensitivities to different substances. Specific drugs will vary in terms of how quickly tolerance develops and the dose needed for tolerance to develop. (11) Withdrawal is the body’s response to the abrupt cessation of a drug, once the body has developed a tolerance to it. The resulting cluster of (very unpleasant and sometimes fatal) symptoms is specific to each drug. We discuss these specific symptoms in each substance category. Although withdrawal is very unpleasant, it does not usually require medical assistance. However, withdrawal from some drugs can be fatal. Therefore, consult with a medical professional before attempting to stop drug use after a period of heavy and continuous use. This will ensure that quitting is as safe and comfortable as possible.

–Mental Help

The Severity of Substance Use Disorders
The DSM 5 allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified. Two or three symptoms indicate a mild substance use disorder;1 four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. –Very Well Mind  & Addiction Policy Forum also has a nice graphic.

Also Read: New Diagnostic Codes for Substance Use Disorders to reflect stages of use and remission, etc. –Psychiatric Times 

Specific Addictions & Medication Management

Mental Health and Alcohol (ETOH): I sort of ramble with ETOH because it’s so different from the drug/other addictions but afterward it’s less wordy and pretty straightforward: 

Other (Substance Abuse Topics)

Recovery and Maintenance

Blog Posts and Pages about Substance Abuse

General Resources of Substance Abuse & Treatment

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