Substance-Related & Addictive Disorders, Part 1

Alcohol Use Disorder (AUD) is a highly prevalent, highly disabling, highly comorbid, and relapsing brain disease that often goes untreated in the United States. It is characterized by compulsive alcohol use, uncontrolled dependence on products that contain alcohol, impaired ability to control alcohol intake, and a negative emotional state when not using (sometimes referred to as a “dry drunk”). It is a chronic condition that develops gradually and may last for several years or for a lifetime. It develops when a person ingests alcohol that results in chemical changes in the brain, initially providing a short alcoholic euphoria that makes the person want to drink again, despite the harm that alcohol causes. Some suggest that the euphoria results when the brain recognizes alcohol as a brain toxin and releases dopamine—the feel better chemical—in an attempt to combat it. 

Alcohol Use Disorder is among the most prevalent mental disorders worldwide are associated with many physical and psychiatric comorbidities. It contributes substantially to global morbidity and mortality and impairs productivity and interpersonal functioning. It places psychological and financial burdens on the individual’s family, friends, and coworkers; and imposes huge financial burdens on society as a whole through motor vehicle crashes, violence, erratic work history, and property crimes. Only about 19.8 percent of adults with Alcohol Use Disorder are ever treated.

Tobacco Use Disorder or Nicotine Use Disorder is a diagnosis assigned to individuals who are dependent on the psychoactive drug nicotine. A central nervous system (CNS) stimulant, nicotine is found in all tobacco products. It activates the nucleus accumbens, involved with the Brain Reward System. Nicotine has a half-life of about two hours. Nicotine can produce dependence fairly quickly, the onset of craving occurring about one hour after the last dose. 

A mild disorder is diagnosed when 2 or 3 symptoms are present. A moderate disorder demonstrates 4-5 symptoms. A severe disorder involves 6 or more symptoms.

Nicotine may be administered through multiple routes. It is important to realize that substituting a different route of administration still continues providing nicotine to the nucleus accumbens, which feeds the addictive behavior. Routes include:

• Inhalation – cigarettes (most common), cigars, pipes
• Buccal – chewing tobacco 
• Insufflation – snuff that is usually sniffed or snorted into the nasal cavity
• Vaporizing – electronic mechanisms that vaporize the nicotine
• Gum chewing – use of nicotine gum
• Transdermal – nicotine patches placed on the skin
• Lozenges – place in the mouth
• Spray – nicotine nasal spray 
• Inhaler – nicotine inhalers

Cannabis or marijuana is a commonly used drug in the United States. The effects of cannabis are caused by chemical compounds in the cannabis plant, including 400 different cannabinoids such as tetrahydrocannabinol (THC) which allows this drug to have a wide range of health, psychological. and physiological effects on the human body. 

Anandamide is an endogenous (internal) cannabinoid neurotransmitter that activates the brain’s cannabinoid receptors CB1 and CB2. When THC enters the bloodstream and reaches the brain, it binds to these cannabinoid receptors. The psychoactive effects of cannabis, known as a “ high “, are subjective and vary among persons and the method of use. Different plants of the genus Cannabis contain different and often unpredictable concentrations of THC and other cannabinoids and hundreds of other molecules that have a pharmacological effect, so that the final net effect cannot reliably be foreseen.

Studies by the National Academies of Sciences have shown that cannabis can be helpful in treating neuropathic pain caused by damaged nerves. More research is needed, however, to determine if marijuana is any better or any worse than other options for managing chronic pain. The downside is that cannabis use can impair cognition and is linked with:

• Memory problems 
• IQ level, especially in younger persons 
• Impaired depth perception, attention span, and concentration
• Slowed reaction time, decreased muscle strength and hand steadiness 
• Symptoms resembling  schizophrenia 
• Disorientation, unpleasant thoughts, anxiety, and paranoia 
• Psychosis, specifically among individuals who carry a particular gene variant
• Decreased energy and motivation
• Increased risk of heart attack, lung cancer, anxiety and depressive disorders 
• Suicidal ideation – users have a 50 percent chance of suicidal ideation and are 4 times more likely to attempt suicide compared to nonusers 

Gambling Disorder has been identified as an addictive disorder. A specific cause has not been identified. However, it is believed that gambling disorder has a neurobiological basis in common with other addictive disorders. It is characterized by risking money, or valued items, or sometimes behaviors, in the hope of gaining something of greater value. As with other addictive disorders, the individual needs progressively larger amounts of the activity to acquire the same effect that used to be experienced. 

A fMRI (functional Magnetic Resonance Imaging) study identified that the Brain Reward System is involved with the reward properties of gambling. Gamblers have cognitive distortions around cause and effect and reward and punishment, which can impel them to continue taking high risk gambling actions even when faced with substantial losses. In addition, problem gambling may be accompanied by cognitive distortions or rigidly held beliefs in superstition, elaborate systems to minimize losses and maximize gains, denial of reality, magical-fantasy thinking that disregards reality, and failure to grasp a very basic concept in gambling—chance events, by definition, cannot be controlled.