Ethanol

Alcohol is the most widely abused substance in the United States and in the world. In 1997, about 32 million Americans engaged in binge drinking, and approximately 11 million Americans (over 5 of the population) were heavy drinkers (2). Ethanol is rather unique among substances of abuse in that it is legal to consume in most countries, and also because there is evidence that it can have a positive or a negative effect on cardiovascular health, depending on the dose and the physiology of the...

Cognitive Impairments

Neurological defects secondary to HIV infection may be due to the direct effects of the retroviruses on the nervous system or to secondary infections after significant immune-system compromise. The dementias are often classified in two ways according to the underlying pathophysiology and according to the neurological location of injury. HIV-1 passes the blood-brain barrier easily, resulting in a greater concentration of the virus in the brain than in other organs of the body (67). It is...

Opiates And Depression

Opiate use has also been associated with depressive symptoms and, paradoxically, with depression treatment (152,153). Acute and chronic opiate use produces an initial mood elevation, but this mood is ultimately replaced by dysphoria (154). A protracted withdrawal syndrome has also been described, wherein depressive symptoms persisted for up to 24 weeks after withdrawal (155,156). A lifetime prevalence for depression of about 50 was found by Rounsaville et al. (157) in 533 opiate-addicted...

Mechanism of Cardioprotection by Ethanol

As shown in Table 1, the proposed mechanisms for the cardioprotective effect of moderate alcohol consumption include decreased plasma fibrinogen, increased serum high-density lipoprotein (HDL), decreased oxidation of low-density lipoprotein (LDL), decreased platelet activity, and stress reduction (12-22). The cardioprotective effects of alcohol may be mediated through increased antioxidant levels (15). It has been established that phenolic flavinoids, which are found in the skin of the grape...

Why The Common Association Between Comorbid Substance Use Disorders And Bipolar Disorder

Several possible explanations for the frequent co-occurrence of bipolar disorder and SUD are described below. One possibility that has been suggested is that this high association is due to a common causal pathway (e.g., common disturbance in neurotransmitter systems and or postreceptor signaling pathways, or genetic predisposition) (17,18). Another possibility might be related to the nature of the symptoms of mania. Manic patients may exhibit behavioral disinhibition and engage in high-risk...

Cocaine

Cocaine, or benzoylmethylecgonine C17H21NO4 , is an alkaloid extract from the leaves of the coca plant (Erythroxylon coca). Cocaine has been associated with myocardial infarction, cardiac dysrhythmia, and cerebrovascular disease, including intracranial hemorrhage. The drug has two forms cocaine HC1, which is water-soluble and used intranasally and intravenously, and the freebase form, also known as crack. In 1997, an estimated 1.5 million Americans were current cocaine users (2). The most...

Psychotherapies

Until recently, psychotherapeutic approaches to patients with bipolar disorder received scant research attention. Jamison et al. (52) found that patients with bipolar disorder were far more likely to value psychotherapy than were physicians who treated bipolar patients, despite the fact that most of the physicians surveyed were practicing psychotherapists. Many different types of psychotherapy for both bipolar disorder and SUD have been utilized (53-59). However, few studies have examined which...

Nicotine And Depression

Nicotine exposure is very common throughout the world. Because it readily crosses the blood-brain barrier, it is able to interact with neurochemical systems, for example, binding to acetylcholine (ACh) receptors in the brain and elsewhere (123). Both nicotine use and withdrawal have been associated with depression. Studies suggest an association between chronic nicotine use and depression (124-126). Smokers reported mood-elevating effects of smoking, hypothesized to be either relief of the...

Causal Models

The hypothesis that anxiety disorders lead to alcohol dependence through a self-medication mechanism has been repeatedly proposed, particularly for agoraphobia and social phobia (e.g., Refs. 169-171). The data in support of this viewpoint are problematic, as the effects of alcohol on anxiety have depended on dose, individual differences, anxiety type, and use circumstances (22). Childhood anxiety disorders may influence substance use and related problems that vary by developmental stage as well...

Future Directions

Considerable work needs to be done to determine the extent to which anxiety disorders other than PTSD are relevant for adolescent SUD etiology and treatment. Clinical and community studies have indicated that anxiety syndromes lead to SUD and are caused by substance consumption. Progress in this area may be inhibited by the tendency to hypothesize that only one or the other causal direction is true. In fact, a more complex model may be more valid in which SUD and psychopathology contribute to a...

Treatment

Although clinical observation suggests that adolescents who have comorbid SUD and antisocial behavior disorders have a worse prognosis and are more difficult to treat than adolescents with SUD without antisocial characteristics, only a limited number of studies are available to support this hypothesis. Kaminer and colleagues (54) showed that adolescents who had CD and SUD, in contrast to those with major depression and SUD, had a significantly higher early dropout rate from a dual diagnosis...

Relationships with Substance Use Disorders

In individuals with a life history including major depression and SUD, most report an onset of one of the involved disorders prior to age 20 (106). In adolescents with SUD, high rates of major depression have been reported (29,107-109), particularly in females (e.g., Refs. 110, 111). Using the PAARC sample, Clark, Pollock, and colleagues (34) reported that adolescents with alcohol dependence were three times more likely than controls to have a major depression history. For major depression...

Treatment Implications

There is a paucity of data on treatment effects in comorbid ADHD in SUD adolescents. SUD adolescents with comorbid ADHD may have increased difficulty with maintaining SUD recovery because of increased cravings and restlessness as well as decreased concentration and compliance with treatment (84). ADHD treatment may improve outcomes in these cases. Stimulant treatment has been shown to be effective in reducing ADHD symptoms in children and adults (98-100). There has been a concern that, among...

Mood Disorders Definitions

The DSM-IV definition of major depression is familiar to most clinicians, and includes either depressed mood or loss of interest or pleasure and five or more symptoms from a list of nine present during the same 2-week period. For children and adolescents, depressed mood or loss of interest are not required if irritable mood is present, and failure to make expected weight gains is an alternative symptom to weight loss. Dysthymia, indicated by at least 2 years of depressed mood in adults, may be...

Conclusions And Future Directions

The existing literature provides a wealth of information about the nature of the relationship between Cluster B personality disorders, particularly ASPD or BPD, and substance abuse. There is a high rate of comorbidity of these personality disorders with substance abuse both in the general population and among patients being treated for substance abuse. Individuals with ASPD or BPD have an increased likelihood of having a substance abuse disorder, which then exacerbates their maladaptive...

Deleterious Cardiovascular Effects of Alcohol

Acute ingestion of alcohol can have many deleterious effects on the cardiovascular system and can cause noncompliance with medications. Tachycardia and elevated blood pressure are common effects of alcohol, perhaps due to vagal withdrawal. For example, Rossinen et al. (23) had 20 patients with stable exertional angina Holter-monitored while given either juice alone or juice mixed with 1.25 g of ethanol. The mean heart rate increased from 57 to 64 beats per minute, while the mean systolic blood...

Research Problems And Future Directions

Although numerous studies have investigated the relationship between chronic pain and substance abuse, considerably more research is needed in this area. The issue of chronic opiate use in patients with a history of substance abuse is an area of heated debate, and large prospective studies are needed comparing the outcomes of nonmalignant chronic pain patients treated with opiates with those of patients treated without opiates. For now, decisions must be made on a case-by-case basis, preferably...

Preface

The important interrelationship between substance abuse and psychiatric or general medical illness has become increasingly clear from both clinical and scientific sources. Growing attention to this issue is evidenced by the establishment of subspecialties in addiction psychiatry and addiction medicine. This book provides current clinical, scientific and epidemiological information on the etiology, detection, pathology, and treatment of substance abuse patients who have a comorbid psychiatric or...

Presenting for Treatment

Studies have reported different rates of SUD depending on whether the estimates are based on the patient's presenting for treatment for his or her first manic episode or one of many. Tohen and colleagues (9) reported fairly low rates of lifetime SUD in first-episode manic patients. The authors reported that the lifetime prevalence of drug abuse or dependence in patients admitted for a first episode of mania was 17.1 (24 among women and 6 among men). In contrast, Keck et al. (10) reported much...

Introduction

Coronary artery disease is the leading cause of death in Western societies, and its prevalence in rural agrarian cultures is increasing rapidly as sedentary lifestyles and other Western influences grow. In the United States, about one-third of individuals who have a heart attack do not make complete recovery, and coronary heart disease is the number 1 cause of disability in the U.S. labor force. Stroke is the third leading cause of death in America, behind heart disease and cancer (1). Because...

Factors Mediating Substance Abuse In Schizophrenia

As previously mentioned, patients with schizophrenia abuse alcohol and drugs at a higher frequency than the general population as well as those with other psychiatric disorders, except for antisocial personality disorder and bipolar I disorder (1). Four hypotheses have been suggested to explain the high rate in schizophrenia 1. Positive re-enforcing effect (e.g., feeling high) of substances (2,52-58). 2. Self-medication to reduce depression, positive and negative symptoms, or side effects of...

History

In 1981, the first reported case studies of what was later identified as AIDS described five male homosexuals with pneumocystis pneumonia, acute cyto-megalovirus infections, and mucosal candidiasis (1). All five men had a history of inhalant-drug use, and one had concurrent intravenous drug use. By 1983 it was clear that certain behaviors put people at a significant risk of infection, and people with identified risk factors (injection drug use, homosexual activity) were asked to refrain from...

Opiates And Opioids

Opiates (extracts of the opium poppy, or Papaver somniferum, plant such as codeine or morphine) and opioids (artificially synthesized compounds such as meperidine) are popular substances of abuse that can be found in a number of different forms. Many opiates opioids are important pain medications, that can be used for appropriate purposes, but can also be abused. Others, such as heroin, are currently used in the United States for recreational use only. Opiates and opioids vary considerably in...

Laboratory Tests

Several laboratory tests are particularly useful for substance abuse assessment. Common markers for heavy drinking include gamma-glutamyl-transpeptidase (GGT), the liver function tests aspartate amino transferase and alanine aminotransferase, and carbohydrate-deficient transferrin (CDT) (10-12). GGT is a glycoprotein located in the membrane fraction of numerous tissues such as the liver, brain, kidney, and heart. Increases in serum GGT may be due to heptobiliary and pancreatic disease but can...

Other Anxiety Disorders Definitions

The DSM-IV diagnostic system includes the following anxiety disorders separation anxiety disorder, panic disorder, agoraphobia, specific phobias, social phobia, obsessive-compulsive disorder, and generalized anxiety disorders, as well as the previously considered posttraumatic stress disorder and acute stress disorder (see Ref. 164 for review). Separation anxiety disorder is defined by excessive and developmentally inappropriate anxiety about separation from parents or other primary attachment...

Overview Of Substance Abuse And Psychiatricmedical Disorders

The term dual diagnosis is often used to describe patients who meet diagnostic criteria for a substance use disorder and another axis I psychiatric disorder. It is in the diagnosis and treatment of the dually diagnosed patients that psychiatrists can make a special contribution by virtue of their knowledge and ability to treat relevant psychiatric disorders, substance abuse issues, and associated medical problems. Substance-related disorders are the most common form of psychiatric illness, with...

The Primary VersusSecondary Distinction

Historically, comorbid anxiety and substance use disorders were categorized as being primary or secondary disorders, based on the age of onset of one disorder in relation to the other. Thus, if an individual's substance dependence began at age 16 and his anxiety disorder at age 21, he could be considered as having a primary substance dependence disorder and a secondary panic disorder. In DSM-IV nomenclature, such a patient is considered as having substance dependence and a substance-induced...

Overview of Treatment

The most effective way to reduce the medical, social, and psychological impact of mental disorders, including addictive disorders, is through effective treatment. Clinical treatment outcome studies with anxiety disorders and addictive disorders have demonstrated that treatment can be effective. The optimal goal of treatment should be remission of anxiety symptoms and abstinence from psychoactive substances with addictive potential. Patients benefit from effective treatment by having the quality...

Marijuana And Depression

Marijuana, the most frequently used illicit drug in the United States, has been legalized in some states for medical use (88). Because of its frequent use, common comorbidity with depression, and multiple neuropsychiatry actions, the relationship between marijuana exposure and depression is of significant interest. Depression has been associated with chronic marijuana use, as part of the marijuana withdrawal syndrome and as a possible explanation for the reported amotivational syndrome. Using...

Demographic And Clinical Correlates Of Substance Abuse In Schizophrenia

Factors that have been associated with higher rates of substance abuse in schizophrenia include male gender (3,5,6,20,26), younger age (3,5,6,20), earlier age at onset (5,24), increased number of hospitalizations (20,23, 25,27,28), noncompliance with treatment (20,26), depressive symptoms (6,8,17,22,23,29,30), paranoid subtype (23,24,26), more functional impairment (5,21), increased risk of suicide (25,30,32), and increased violent behavior (33,34) (Table 1). Although most of the studies report...

Does Chronic Substance Abuse Cause Personality Disorders

One etiological pathway that has been proposed asserts that the pharmacological effects of chronic substance use results in a drug-induced personality state, a syndrome that is considered diagnostically compatible with the personality disorders (2). This model suggests that the effects of alcohol and drugs on the brain, combined with the immediate gratification of needs that occurs with drug use, results in a variety of traits that are common features of many personality disorders. Stimulants,...

References

American Heart Association. 1999 Heart and Stroke Statistical Update. 2. Department of Health and Human Services. Preliminary Results from the 1997 National Household Survey on Drug Abuse. 3. Marmot MG, Rose G, Shipley MJ, Thomas BJ. Alcohol and mortality a U-shaped curve. Lancet i(8220 Pt 1) 580-583, 1981. 4. Klatsky AL, Friedman GD, Siegelaub AB. Alcohol consumption before myo- cardial infarction results from the Kaiser-Permanente epidemiologic study of myocardial infarction. Ann Intern Med...

Assessment Instruments For Substance Abuse Screening

Patient questionnaires and laboratory tests are commonly used to screen for possible substance abuse problems. Several common questionnaire screening instruments include 2. Michigan Alcoholism Screening Test (MAST) or the Brief MAST 3. Drug Abuse Screening Test (DAST) 4. Alcohol Use Disorders Identification Test (AUDIT) 5. Alcohol Urge Questionnaire (AUQ) Other questionnaires have also been developed to screen for substance abuse. In addition, many screening psychiatric and general medical...

Opiate Treatment of Chronic Pain

The term opiate originates from the opium poppy, Papaver Somniferum. Numerous natural and synthetic opiates (opioids) are currently available for clinical use. Opiates can be properly and effectively used for most sufferers of chronic pain (2,25). However, it is also important to recognize that these medications can lead to serious problems such as substance abuse in some patients. It is because of their potential for abuse that opiate medications are highly regulated. Some animal studies...