Your strength, the ultimate

antidote to Substance use

Disorder
Understanding, Overcoming
Dr Mariam Naz
and Thriving
MBBS,MD PSYCH,CHPE,CFMH,CGMH
Head of Psychiatry Department
Gujranwala Medical College
Psychology, Physiology and
Treatment of Drug
Addiction
Training Content

 What is Addiction?
 Introduction to Psychoactive Substances
 Brain Communication
 Drugs and Reward-Circuit
 Consequences of Drug Addiction
 Recovery and Recovery Management
 Motivation and stages of change
 Stigma of drug addiction
 Treatment Settings
 Intensity & Duration
 The Continuum of Care
 Treatment Models and evidence based
practices
 Treatment Plan
What is Addiction?

Learning Objectives

 Define Addiction
 Types of Addiction
 Addiction – The Global Problem
 Addiction – In Pakistan
 Reasons of Drug Abuse in Pakistan
 Treatment Approaches for Drug Abuse in
Pakistan
 Treatment of Drug Addiction
 Bitter Facts
Small Exercise: What is
Addiction?

 Share you Thoughts about Addiction

Addiction
Addiction (Cont..)
Definition:

 Addiction is a chronic, relapsing

brain disease that is characterized
by compulsive substance seeking
and use, despite harmful
consequences. (NIDA)
Types of Addiction

 Chemical
 Non-Chemical
Addiction - The Global Problem
Addiction - The Global Problem
Addiction - The Global Problem
Drug Addiction – In
Pakistan
 Sixth most populous country in the world
 7 million drug addicts in our country
 Pakistan is considered to have the largest opioid
users within south Asian countries
In Pakistan
According to 2013 UNODC
 6.7million people use substance with a rise
of 40000 per year and 2.9 millions are in
Punjab.
 4.25 million are drug dependant.
 3.6% population use cannabis
 0.8% population use opioids.
 Injectabledrug use is around 500,000 linked
to high prevalence of hep c and HIV.
Drug Addiction – In
Pakistan
 44 tons’ heroin has been consumed yearly
 110 tons of morphine and heroin trafficked all
the way from Pakistan to national and
international markets.
 Drug-related casualties are higher than those
caused by terrorism.
 Every 27th individual in Pakistan is misusing
any substance.
 Almost 25% young males are engaged in any
type of drug misuse.
 Nowadays, prescription drugs and over the
counter (OTC) drugs are very commonly abuse
drugs.
Vulnerability to
addiction

Why do People Start Using

Substances?
Vulnerability to addiction (cont..)

 Differs Person to Person

 The more risk factors an individual has, the
greater the chance that taking psychoactive
substances will lead to abuse and addiction.
 Biology, Environment and the Interaction
between the two.
The role of Genetics

 Between 40 and 60 percent of a

person’s vulnerability to addiction is
genetic.
Reasons of drug abuse in
Pakistan
 Fast growing population
 Very high poverty rate (146th/186 Countries)
 Low Literacy Rate 58% (the individuals who
can read and write)
 Financials and psychological dynamics
 Unemployment
 Historical, cultural and geographical values
 Almost No Drug Education
Reasons of drug abuse in
Pakistan
 Availability
 Accessibility
 Acceptability
No matter what a person’s reason for starting to use
psychoactive substances,

“No one Ever Plans to Become

Addicted.”
Models of Drug Use
 Throughout history various models of drug
use have been developed;
 Moral Model: Views addiction as a sin or a
moral weakness.
 Psychodynamic Model: Asserts childhood
traumas are associated with how we cope
or do not cope as adults.
 Disease Model: Argues that the origins of
addiction lie in the individual him/herself.
Models of Drug Use (Cont..)

 Social Learning Model: Suggests that

dependence behaviors are learned, exist on a
continuum and consist of a number of
behavioral and cognitive (thought) processes.
 Public Health Model: Drug use seen as the
interaction between the drug, the individual and
the environment.
 Socio-cultural Model: Argues that substance
abuse should be examined in a wider social
context and can be linked to inequality.
Treatment approaches for
drug abuse in Pakistan
 Supply reduction
 Demand reduction
Treatment of drug abuse in
Pakistan
Drug Addiction Treatment is Provided
by,

 Hospitals
 Public sector
 Private Sector
 public-private institutions
 NGO’s
Bitter Facts
 Unfortunately, there isn’t any uniform policy for
the treatment of drug addiction, and
rehabilitation centers
 Mostly psychiatrists, Psychologists, Counselors
and other related staff have little or not trained
to treat this serious problem
 Pakistan spends only 4 rupees annually on each
substance abuser
Is There Any Hope?
What Should We Do?
Introduction to Psychoactive
Substances
Learning Objectives

 Define psychoactive substance

 Classification of drugs
 Effects of drugs on body and brain
 Main categories (classes) of psychoactive
substances and several substances within each
 Methods of administering psychoactive substances
 Discuss the levels of progression of substance use
What is Drug?
In medicine: Any substance with the potential
to prevent or cure a disease or the potential to
enhance physical or mental well-being.

In Pharmacology: Any chemical agent that

alters the biochemical or physiological
processes of body tissues or organisms.

In common usage: A substance that is

used for nonmedical (e.g., recreational)
reasons.
Psychoactive Substance
Definition:
 Affect the body and Central Nervous
System
 Change how people behave or perceive
what is happening around them
CNS
Psychoactive Substances

Psychoactive Substances Alter;

 Mood
 Thought
 Sensory Perceptions
 Behaviors
Drugs
Classification

Ref. Physiology and Pharmacology for Addiction Professionals

Others
 Cannabinoids - Marijuana/Garda/Hash
 Miraa - (Khat)
 Dissociative anesthetics - Phencyclidine
(PCP) ketamine
 Inhalants - Solvents, Gases
Legal Substances
 Just because a substance is legal
doesn’t mean it is safer than an
illegal substance
Drug Effects

 Can be Positive or Negative

 Depend on the type of Substance
used
Drug Effects

 Stimulants: increase the activity of the CNS

 Depressants and opioids (also called narcotics):
decrease the activity of the CNS.
 Hallucinogens: produce a spectrum of vivid
sensory distortions and markedly alter mood and
thinking.
Drug Effects
Factors Involved

A Person’s Age, the length of time a person has regularly

used the substance, and amount of a substance regularly
used affect
How the body;
 Absorb Psychoactive Substance
 Metabolize them
 Eliminates them
Routes of administration

 Swallowing
 Snorting (inhaling through the nose)
 Smoking
 Inhaling fumes
 Intravenous injection (injecting the
substance into a vein)
 Intramuscular injection (injecting into a
muscle)
Routes of administration
(Cont..)

 Subcutaneous injection (injecting

the substance just beneath the skin)
 Topically (applying the substance
onto the top layer of the skin)
 Sublingually (dissolving the
substance under the tongue and
absorbing it through the mouth
tissue).
Speed of Action
 Smoking: 7-10 Seconds
 Intravenous injecting: 15-30 Seconds
 Injecting into muscle or under skin: 3-5 minutes
 Mucous membrane absorption (snorting, rectal): 3–5
minutes
 Swallowing: 20–30 minutes
 Absorbed through skin: Slowly over a long period
Progression of use

 Experimental/recreational
use
 Circumstantial/occasional
use
 Intensified/regular use
 Compulsive/addictive use
Brain Communication

Learning Objectives

 Define brain communication

 Neuron structure
 Normal brain communication
 Addicted brain
 Difference between normal and addicted
brain
 Drug actions on brain
“The brain is a
communications center
consisting of billions of
neurons or nerve cells.”
Brain Communication
Definition

 Networks of neurons pass messages back and

forth to different structures within the brain, the
spinal column (the central nervous system), and
the peripheral nervous system.
Neuron Structure
Normal Brain Communication

Each nerve cell in the brain sends and receives

messages in the form of chemical impulses:
 These chemicals are called neurotransmitters.
 The brain has many different neurotransmitters.
 The sending neuron releases a neurotransmitter
from its axon terminal across a space between
neurons called a synapse or synaptic cleft.
 A neurotransmitter attaches to a specialized site
on the receiving cell called a receptor.
 Once the receiving neuron gets and processes the
message, it becomes a sender and passes the
message to other neurons.
Normal Brain Communication
Addicted Brain

 Psychoactive substances tap into the brain’s

communication system and mimic or disrupt
with the way nerve cells normally send,
receive, and process information.
Difference between Normal
Brain and Addicted Brain
(Cont..)
Difference between Normal
Brain and Addicted Brain
(Cont..)
Difference between Normal
Brain and Addicted Brain
(Cont..)
Difference between Normal
Brain and Addicted Brain
(Cont..)
Drug actions on brain

 Some psychoactive substances, like marijuana

and heroin, can activate neurons because their
chemical structure mimics that of a natural
neurotransmitter.
 Other psychoactive substances, like
amphetamine or cocaine, can cause the nerve
cells to release abnormally large amounts of
natural neurotransmitters or prevent the normal
reuptake of these brain chemicals.
Brain Reward Circuit

Learning Objectives

 Brain reward circuit

 Parts of the Brain Most Affected by Substance
Use
 Addiction and reward circuit
 Tolerance and Withdrawal
 Vulnerability to addiction
Brain Reward Circuit
 The way the brain communicates is the same
throughout the brain.
 Different parts of the brain are responsible for
coordinating and performing specific functions.
 Certain areas of the brain are more affected by
substance use than are others.
Parts of the Brain Most
Affected by Substance Use
 The Brain Stem
 The Cerebral Cortex
 The Limbic System
Brain Stem

 Controls functions Critical to Life

such as heart rate, breathing and
sleeping.
Cerebral Cortex

 Process information from the

senses; the thinking and
judgment center of the brain.
Limbic System

 Links together a number of brain structures

that control emotional memory and regulate
the ability to feel pleasure.
 Contains The Brain Reward Circuit.
Brain Reward Circuit (Cont..)

 The brain’s reward circuit is critical to the

development of addiction.
 Our brains are wired to ensure that we repeat
life-sustaining activities by associating those
activities with pleasure or reward.
Brain Reward Circuit (Cont..)
Addiction and Reward Circuit

 The overstimulation of the reward circuit

produces the euphoric effects sought by people
who abuse psychoactive substances and
teaches them to repeat the behavior.
Addiction and Reward Circuit
(cont..)

 The brain adjusts to the overwhelming

surges in dopamine (and other
neurotransmitters) by producing less
dopamine or by reducing the number of
receptors.
Tolerance

 Tolerance (Criterion 10) is signaled by

requiring a markedly increased dose of the
substance to achieve the desired effect or a
markedly reduced effect when the usual dose
is consumed. (DSM-V)
Withdrawal

 Withdrawal (Criterion 11) is a syndrome that

occurs when blood or tissue concentrations of
a substance decline in an individual who had
maintained prolonged heavy use of the
substance. (DSM-V)
Consequences of Drug
Abuse

Learning Objectives

 Consequences of Drug Use

 Different Physiological
Responses
What can possible
outcomes of Drug
Use?
Consequences of Drug Abuse
Consequences of Drug
Use

Individuals with addiction may

suffer a range of consequences:

 Medical
 Psychological
 Social
 Economic
 Legal
 Spiritual
Different Physiological
Responses
Women:

 Develop physical problems related to

substance use sooner.
 Escalate to addiction quickly
(telescoping).
What Researches Reveal?
Women:

 Are more sensitive to the consumption and

long-term effects of alcohol and drugs than are
men.
 Have less water in their bodies than do men,
and they metabolize alcohol in a way that leads
to higher blood alcohol levels with comparable
intake and body weight.
 There is a similar pattern of rapid progression
with illicit drugs.
Fetal Effects

 Fetal effects generally range from low birth

weight to developmental behavioral and
cognitive deficits.
 Cocaine and Marijuana Exposure:
Impaired attention, language, and learning
skills, as well as behavioral problems.
 Methamphetamine exposure: Fetal
growth restriction, decreased arousal, and
poor quality of movement in infants.
 Heroin Exposure: Infants born addicted,
low birth weight, an important risk factor for
delayed development.
Youth

 Early use of drugs increases a young

person’s chance of more serious drug
abuse and addiction.
 Young people also are particularly
vulnerable to physical and social
problems.
Recovery and Recovery
Management

Learning Objectives

 Define recovery
 Abstinence in the context of recovery
 Define Recovery management
 Recovery-oriented systems of care
 Factors Affecting Treatment Outcomes
Recovery

 Recovery from drug problems is process of

change through which an individual achieves
abstinence and improved health, wellness
and quality of life. (SAMHSA)
Recovery

 A Process of Change
 Continuous growth and improved
functioning
 Recovery management over a lifetime
Abstinence in the context of
Recovery

 Not using Drugs

 Not using any non-prescribed Psychoactive
Drugs
 Not Misusing any prescribed Psychoactive
drugs
Recovery from both Mental and
Substance Use Disorders

 Recovery is a process of change whereby individuals

work to improve their own health and wellness and
to live a meaningful life in a community of their
choice while striving to achieve their full potential.
(SAMHSA, 2011)
Recovery is Reality…

“It Can, Will, and Does

Happen”
Recovery Management

 Shifts the focus away from discrete

episodes of treatment, or acute care,
toward a long-term, client-directed view of
recovery.
Recovery-oriented Systems
of Care
Seven Elements of a Comprehensive program of
Recovery Management;

 Client empowerment
 Assessment
 Recovery resource development
 Recovery education and training
 Ongoing monitoring and support
 Recovery advocacy
 Evidenced-based treatment and support
services
Factors Affecting Treatment
Outcomes

 The characteristics of individuals seeking

treatment
 The nature and severity of their problems
 The treatment process and the services
provided
 Environmental and social conditions (including
family), both during and following treatment
 The interactions among these factors
Motivation and Stages of Change

Learning Objectives

 What is change?
 What is motivation?
 Characteristics of motivation
 Stages of change
Change

 Treatment and recovery are ultimately

about change.
 Change is not always easy for people.
Personal Change
Exercise:

 What change did you make (or try to

make)?
 How did you decide to make this change?
 What people, events and circumstances
influenced your decision?
 What step did you take to make the
change?
 Did your level of motivation stay the
same throughout the process?
Motivation
Motivation for change affects whether a
person;

 Enter treatment
 Continue in treatment
 Adhere to a specific change strategy
Motivation is
Static or
Dynamic?
Motivation (Cont..)

 Fluctuate over time in relation to different

situations.
 Can go and forth between conflicting goals.
 Varies in intensity, slowing in response to
doubts and increasing as doubts are
resolved.
 Varies greatly among potential behavior
changes.
Internal Influences on Motivation
 Emotional states
 Life goals
 Perceptions about risks and benefits of
behaviors
 Cognitive appraisals of the situation (what the
client thinks about the situation)
External Influences on Motivation
 Family and Friends
 Situations and Experiences
 Community Support (or lack of community
support)
Stages of
Change
Treatment Settings and
Duration
Learning Objectives

 Different treatment settings for

SUD’s
 Intensity and Duration of
treatment
 How treatment is provided?
 Components of SUD’s treatment
Treatment Settings for
SUD’s
 Drop-in Center
 Hospital
 Outpatient treatment
 Non-hospital residential setting
Intensity and Duration
 How often
 For how long
How Treatment is Provided
How?

 One-to-one with counselor

 In Group with peers
 Family members
Components of Treatment
 Detoxification
 Counseling
 Education
 Treatment for mental health
problems
 Relapse prevention training
 Medication
 Continuing Care
 Other Services (Like Women,
inmates)
Continuum of Care

Learning Objectives

 Define Continuum of Care

 Components of COC
 COC for one client
 Elements of drug treatment
Continuum of Care
Definition:

 The whole range of services a client may

receive from a treatment program or
coordinated by treatment program.
Continuum of Care
 Outreach
 Treatment
 Other services over time
 Post-treatment support
Continuum of Care for One
Client
Elements of Drug
Treatment
Stigma of Addiction
Learning Objectives

 Define social stigma

 Describe the possible effects of stigma
related to addiction
 Strategies for countering stigma
Social Stigma
 Severe social disapproval of personal
characteristics or beliefs that are against
cultural norms.
 Social stigma often leads to status loss,
discrimination, and exclusion from meaningful
participation in society.
Why Addicts Face
Stigma?
Social Stigma (cont..)

Stigma can interfere with effective treatment;

 A person who sees that addiction is

stigmatized may feel shame and be
reluctant to seek treatment
 Social supports for recovery may not be
adequate in a community that stigmatizes
addiction
Stigma Study
Study Participants reported that:
 People treated them differently (60%)
 Others were afraid of them (46%)
 Some of their family members gave up
on them (45%)
 Some of their friends rejected them
(38%)
 Employers paid them a lower wage
Ref. University of Nevada
(14%)
Words Matter!
Stigma (Cont..)

 Stigma Negatively affects recovery rates.

 The stress of hiding an SUD either out of
shame or to avoid stigmatizing responses from
others can cause other medical and social
problems.
Strategies to Counter
Stigma
Language: People First

 Person with a substance use disorder

 Person who injects drugs
 Person with addiction
Strategies to Counter Stigma
 Awareness Programs
 Evaluating our own attitudes and feelings
What is an Evidence-
based practice?
Evidence-based Practice (EBP)
 Practices for which the evidence is strongest
and most accepted—and that are most likely to
have significant impact on improving care.
(National Quality Forum, 2007)
• These are approaches that may include
element from more than one counselling
theory.
Evidence-based Practice (EBP) –
Improving Care
Substandard Treatment:

 Substandard treatment for SUDs was/are common

 Defined as treatment that is not,
 Safe
 Effective
 Patient-centered
 Timely
 Efficient
 Equitable (fair)
Why do we need to
know about and care
about EBP?
Recommended EBPs
 Pharmacotherapy (the use of medications to treat
SUDs)
 Cognitive-behavioral therapies
 Motivational enhancement therapy
 Contingency management
 Therapeutic Community
 Marital and family therapies
 12-Step facilitation therapy
 Matrix Model
Ineffective treatments for SUDs
 Acupuncture, relaxation therapy, education,
drug testing, and detoxification as stand alone
treatments.
 Individual psychodynamic therapy
 Unstructured group therapy
 Confrontation as the main approach to
treatment
 Discharge from treatment in response to relapse
Treatment Plan
Learning Objectives

 Describe Treatment Structure

 Describe different components of
Treatment
 Substance Use in DSM-V
Treatment Structure
 Screening
 Intake Form
 Assessment
 Narrative Summary Form
 Treatment Planning (Person-Centered)
 Progress Notes (SOAP Note)
 Continuing Care/Discharge Summary
 Waiver/ Informed Consent: Release Form/s
Addiction Severity Index (ASI) – Key
points
 ASI in an Interview not a Test.
 The interview consists of seven parts, i.e. Medical,
Employment/Support, Alcohol, Drugs, Legal,
Family/Social and Psychiatric.
 Severity -defined as the need for new or
additional treatment based on the amount,
duration and intensity of symptoms within each
area.
 All ratings are based on objective and subjective
data within each area.
 Can be used for in-patient and the follow-up
clients
 Patient input is important.
DSM-V

 Substance-Related and Addictive

Disorders
What’s New?

 Restructuring of substance use

disorders for consistency and clarity.
How to Diagnose?
 Criteria

Grouping;
 Im-paired control (1-4)
 Social impairment (5-7)
 Risky use (8-9)
 Pharmacological criteria (10-11)
Severity and Specifiers
Severity:

 Mild 2-3 Symptoms

 Moderate 4-5 Symptoms
 Severe 6 or More

Specifiers:

 In early remission min. 3 months to less than 12

months
 In sustained remission min. 12 months or more
 On maintenance therapy
 In a controlled environment
Example
Tentative Diagnosis:

According to DSM;
(F11.20) Severe Opioid Use Disorder
Current Severity: Severe
Specify with: In a controlled
Environment
Narrative Summary
Person-Centered Planning—Narrative Summary
Outline
Treatment
Planning Sample Treatment
Plan
Treatment Plan (Cont..)
SOAP progress
note SOAP PROGRESS NOTE
Form
Discharge Summary and Continuing
CareSample
Plan Discharge Summary and Continuing Care Plan
Form for Written Release of
Information
Inter-program Consent to Release Confidential
Information
Your strength, Understanding
Resilience
The ability to bounce back , adapt, and grow in
face of adversity.
Components are
 Self efficacy
 Coping skills
 Self awareness
 Problem solving abilities
 optimism
 Conclusion
 SUD is a complex disease, but recovery is absolutely
possible.
 Reiterate theme>
 Your strength is greater than any kind of drug.
 Its in your brain ability to heal.
 Its in your capacity for change.
 Its in your desire for a better life.
 Its in the connections you build.