1. Substance UseSubstance Use
DisordersDisorders

2. Why Do We Do The Things That We Do?Why Do We Do The Things That We Do?
To satisfy basic drives, e.g. hunger.To satisfy basic drives, e.g. hunger.
Because they bring pleasure.Because they bring pleasure.
Because they will make some future thing thatBecause they will make some future thing that
is pleasurable.is pleasurable.
Because we feel “compelled” to.Because we feel “compelled” to.
To avoid unpleasant consequences.To avoid unpleasant consequences.
Most things are done because of a combinationMost things are done because of a combination
of several of these things.of several of these things.
There are neurotransmitter systems in the brainThere are neurotransmitter systems in the brain
involved with pleasure, happiness & motivation.involved with pleasure, happiness & motivation.

3. Substance Use DisordersSubstance Use Disorders
Often chemical.Often chemical.
Characterized by inability to stop.Characterized by inability to stop.
Life is organized around the addictiveLife is organized around the addictive
behavior.behavior.

4. Substance Related DisordersSubstance Related Disorders
The substance related disordersThe substance related disorders
encompass 10 separate classes of drugs:encompass 10 separate classes of drugs:
Alcohol; Caffeine; Cannabis;Alcohol; Caffeine; Cannabis;
Hallucinogens; Inhalants; Opioids;Hallucinogens; Inhalants; Opioids;
Sedatives; Hypnotics & Anxiolytics;Sedatives; Hypnotics & Anxiolytics;
Stimulants; Tobacco and Others.Stimulants; Tobacco and Others.
These 10 classes are not fully distinct.These 10 classes are not fully distinct.
All drugs that are taken in excess have inAll drugs that are taken in excess have in
common direct activation of the braincommon direct activation of the brain
reward system.reward system.

5. Substance Related DisordersSubstance Related Disorders
The pharmacological mechanisms byThe pharmacological mechanisms by
which each class of drugs produceswhich each class of drugs produces
reward are different but all producereward are different but all produce
feelings of pleasure.feelings of pleasure.
Individuals with lower levels of selfIndividuals with lower levels of self
control, which reflect impairments ofcontrol, which reflect impairments of
brain inhibitory mechanisms, arebrain inhibitory mechanisms, are
predisposed to develop substance usepredisposed to develop substance use
disorders.disorders.

6. DSM-V CriteriaDSM-V Criteria
A maladaptive pattern ofA maladaptive pattern of
substance use, leading tosubstance use, leading to
clinically significantclinically significant
impairment or distress, asimpairment or distress, as
manifested by the following,manifested by the following,
occurring at any time in theoccurring at any time in the
same 12-month period.same 12-month period.

7. DSM-V CriteriaDSM-V Criteria
The substance is often taken in larger amountsThe substance is often taken in larger amounts
or over a longer period than was intended.or over a longer period than was intended.
A persistent desire or unsuccessful efforts to cutA persistent desire or unsuccessful efforts to cut
down or control substance use.down or control substance use.
A great deal of time is spent in activitiesA great deal of time is spent in activities
necessary to obtain the substance (e.g., visitingnecessary to obtain the substance (e.g., visiting
multiple doctors or driving long distances), usemultiple doctors or driving long distances), use
the substance (e.g., chain-smoking), or recoverthe substance (e.g., chain-smoking), or recover
from its effects.from its effects.

8. DSM-V CriteriaDSM-V Criteria
Important social, occupational or recreationalImportant social, occupational or recreational
activities are given up or reduced because ofactivities are given up or reduced because of
substance use.substance use.
The substance use is continued despiteThe substance use is continued despite
knowledge of having a persistent or recurrentknowledge of having a persistent or recurrent
physical or psychological problem that is likelyphysical or psychological problem that is likely
to have been caused or exacerbated by theto have been caused or exacerbated by the
substance (e.g., current cocaine use despitesubstance (e.g., current cocaine use despite
recognition of cocaine-induced depression, orrecognition of cocaine-induced depression, or
continued drinking despite recognition that ancontinued drinking despite recognition that an
ulcer was made worse by alcohol consumption).ulcer was made worse by alcohol consumption).

9. ToleranceTolerance
A need for markedly increased amounts ofA need for markedly increased amounts of
the substance to achieve intoxication orthe substance to achieve intoxication or
desired effect.desired effect.
Markedly diminished effect with continuedMarkedly diminished effect with continued
use of the same amount of the substance.use of the same amount of the substance.

10. WithdrawalWithdrawal
Manifested by either of the following:Manifested by either of the following:
- The characteristic withdrawal- The characteristic withdrawal
syndrome for the substance.syndrome for the substance.
- The same (or a closely related)- The same (or a closely related)
substance is taken to relieve or avoidsubstance is taken to relieve or avoid
withdrawal symptoms.withdrawal symptoms.

11. DependenceDependence
Altered physiological state thatAltered physiological state that
develop to compensate fordevelop to compensate for
persistent drug exposure andpersistent drug exposure and
that gives rise to a withdrawalthat gives rise to a withdrawal
syndrome after cessation of drugsyndrome after cessation of drug
exposure.exposure.

12. Alcohol Use DisordersAlcohol Use Disorders
Alcohol Dependence & Abuse.Alcohol Dependence & Abuse.
Alcohol Intoxication:Alcohol Intoxication: Clinically significant problematicClinically significant problematic
behavioral or psychological changes, slurred speech,behavioral or psychological changes, slurred speech,
incoordination, unsteady gait, nystagmus, impairment attentionincoordination, unsteady gait, nystagmus, impairment attention
or memory, stupor or coma.or memory, stupor or coma.
Alcohol Withdrawal:Alcohol Withdrawal:
Autonomic hyperactivity, increased hand tremor, insomnia,Autonomic hyperactivity, increased hand tremor, insomnia,
nausea or vomiting, transient hallucinations or illusions,nausea or vomiting, transient hallucinations or illusions,
psychomotor agitation, anxiety & tonic clonic seizures.psychomotor agitation, anxiety & tonic clonic seizures.
Diagnostic Markers:Diagnostic Markers:
GGT; Gamma Glutamyl Transferase (› 35 units),GGT; Gamma Glutamyl Transferase (› 35 units),
CDT; Carbohydrate Deficient Transferase (≥ 20 units),CDT; Carbohydrate Deficient Transferase (≥ 20 units),
MCV; The Mean Corpuscular Volume.MCV; The Mean Corpuscular Volume.

13. Alcohol Induced DisordersAlcohol Induced Disorders
Alcohol Intoxication.Alcohol Intoxication.
Alcohol Withdrawal.Alcohol Withdrawal.
Alcohol Intoxication Delirium.Alcohol Intoxication Delirium.
Alcohol Withdrawal Delirium.Alcohol Withdrawal Delirium.
Alcohol Induced Persisting Dementia.Alcohol Induced Persisting Dementia.
Alcohol Induced Persisting AmnesticAlcohol Induced Persisting Amnestic
Disorder.Disorder.

14. Alcohol Induced DisordersAlcohol Induced Disorders
Alcohol induced Psychotic Disorder,Alcohol induced Psychotic Disorder,
with Delusions.with Delusions.
Alcohol induced psychotic Disorder,Alcohol induced psychotic Disorder,
with hallucinations.with hallucinations.
Alcohol induced mood disorder.Alcohol induced mood disorder.
Alcohol Induced Anxiety Disorder.Alcohol Induced Anxiety Disorder.
Alcohol Induced Sexual Dysfunction.Alcohol Induced Sexual Dysfunction.
Alcohol Induced Sleep Disorder.Alcohol Induced Sleep Disorder.

15. Alcohol InducedAlcohol Induced
Medical ComplicationMedical Complication
Wernicke’s Encephalopathy.Wernicke’s Encephalopathy.
Korsakoff’s Psychosis.Korsakoff’s Psychosis.
Alcohol-Induced Dementia.Alcohol-Induced Dementia.
Fetal Alcohol Syndrome.Fetal Alcohol Syndrome.

16. Caffeine Related DisordersCaffeine Related Disorders
Caffeine Intoxication (≥ 250 mg):Caffeine Intoxication (≥ 250 mg):
- Restlessness, Nervousness, Excitement,- Restlessness, Nervousness, Excitement,
Insomnia, Flushed face, Diuresis, GITInsomnia, Flushed face, Diuresis, GIT
disturbance, Muscle twitching, Tachycardiadisturbance, Muscle twitching, Tachycardia
oror
arrhythmia & psychomotor agitation.arrhythmia & psychomotor agitation.
Caffeine Withdrawal:Caffeine Withdrawal:
- Headache, Fatigue or Drowsiness, MoodHeadache, Fatigue or Drowsiness, Mood
(Dysphoric – Depressed – Irritable), Difficult(Dysphoric – Depressed – Irritable), Difficult
Concentration & Flu Like Symptoms.Concentration & Flu Like Symptoms.

17. Cannabis Related DisordersCannabis Related Disorders
Cannabis Use Disorder.Cannabis Use Disorder.
Cannabis Intoxication:Cannabis Intoxication:
-- Clinically significant problematic behavioral orClinically significant problematic behavioral or
psychological changes, Conjunctival injection,psychological changes, Conjunctival injection,
Increased appetite, Dry mouth, Tachycardia.Increased appetite, Dry mouth, Tachycardia.
Cannabis Withdrawal:Cannabis Withdrawal:
-- Irritability, anger or aggression, Nervousness orIrritability, anger or aggression, Nervousness or
anxiety, sleep difficulty, decreased appetite,anxiety, sleep difficulty, decreased appetite,
Restlessness, Depressed mood & Physical symptomsRestlessness, Depressed mood & Physical symptoms..

18. Hallucinogen Related DisordersHallucinogen Related Disorders
Phencyclidine & Other Hallucinogens UsePhencyclidine & Other Hallucinogens Use
Disorder.Disorder.
Phencyclidine Intoxication:Phencyclidine Intoxication:
- Clinically significant problematic behavioral or- Clinically significant problematic behavioral or
psychological changes, Nystagmus, Hypertension,psychological changes, Nystagmus, Hypertension,
Tachycardia, Numbness, Ataxia, Dysarthria, MuscleTachycardia, Numbness, Ataxia, Dysarthria, Muscle
rigidity, Seizures or Coma & Hyperacusis.rigidity, Seizures or Coma & Hyperacusis.
Hallucinogen Persisting Perception Disorder:Hallucinogen Persisting Perception Disorder:
- Following cessation of use.Following cessation of use.
- Re-experience of the perceptual symptoms.Re-experience of the perceptual symptoms.

19. Inhalant Related DisordersInhalant Related Disorders
Inhalant Use Disorder.Inhalant Use Disorder.
Inhalant Intoxication:Inhalant Intoxication:
- Clinically significant problematic behavioral or- Clinically significant problematic behavioral or
psychological changes, Dizziness, Nystagmus,psychological changes, Dizziness, Nystagmus,
Incoordination, Slurred speech, Lethargy, DepressedIncoordination, Slurred speech, Lethargy, Depressed
reflexes, Psychomotor retardation, Tremor, Musclereflexes, Psychomotor retardation, Tremor, Muscle
weakness, Blurred vision or diplopia, Stupor orweakness, Blurred vision or diplopia, Stupor or
Coma & Euphoria.Coma & Euphoria.
Inhalant Induced Psychotic Disorder.Inhalant Induced Psychotic Disorder.
Inhalant Induced Depressive Disorder.Inhalant Induced Depressive Disorder.
Inhalant Induced Anxiety Disorder.Inhalant Induced Anxiety Disorder.

20. Opioid Related DisordersOpioid Related Disorders
Opioid Use Disorder.Opioid Use Disorder.
Opioid Intoxication:Opioid Intoxication:
- Pupillary constriction or dilatation,- Pupillary constriction or dilatation,
Drowsiness or Coma, Slurred speech,Drowsiness or Coma, Slurred speech,
Impairment in attention or memory.Impairment in attention or memory.
Opioid Withdrawal:Opioid Withdrawal:
- Dysphoric Mood, Nausea or Vomiting, Muscle- Dysphoric Mood, Nausea or Vomiting, Muscle
Aches, Lacrimation or Rhinorrhea, PupillaryAches, Lacrimation or Rhinorrhea, Pupillary
Dilation, Piloerection or Sweating, Diarrhea,Dilation, Piloerection or Sweating, Diarrhea,
Yawning, Fever and Insomnia.Yawning, Fever and Insomnia.

21. Heroin & MorphineHeroin & Morphine
These act via an endogenous opioid system whoseThese act via an endogenous opioid system whose
normal function is probably to suppress pain untilnormal function is probably to suppress pain until
danger has passed.danger has passed.
Injection of opiates causes a rise inInjection of opiates causes a rise in
(NA dopamine)(NA dopamine)..
However, lesions to the NA do notHowever, lesions to the NA do not
impair opiate self-administration.impair opiate self-administration.
Therefore, there must beTherefore, there must be
a separate pathway.a separate pathway.

22. Sedative, Hypnotic or AnxiolyticSedative, Hypnotic or Anxiolytic
Related DisordersRelated Disorders
Sedative, Hypnotic or Anxiolytic Use Disorder.Sedative, Hypnotic or Anxiolytic Use Disorder.
Sedative, Hypnotic or Anxiolytic Intoxication:Sedative, Hypnotic or Anxiolytic Intoxication:
- Clinically significant problematic behavioral or- Clinically significant problematic behavioral or
psychological changes, Slurred speech, Incoordination,psychological changes, Slurred speech, Incoordination,
Nystagmus, Impairment in Cognition & Stupor orNystagmus, Impairment in Cognition & Stupor or
Coma.Coma.
Sedative, Hypnotic or Anxiolytic Withdrawal:Sedative, Hypnotic or Anxiolytic Withdrawal:
- Autonomic Hyperactivity, Hand Tremor, Insomnia,- Autonomic Hyperactivity, Hand Tremor, Insomnia,
Nausea or Vomiting, Transient Hallucinations orNausea or Vomiting, Transient Hallucinations or
Illusions, Psychomotor agitation, Anxiety & GrandIllusions, Psychomotor agitation, Anxiety & Grand
Mal Seizures.Mal Seizures.

23. Stimulant Related DisordersStimulant Related Disorders
Stimulant Use Disorder.Stimulant Use Disorder.
Stimulant Intoxication:Stimulant Intoxication:
- Clinically significant problematic behavioral or- Clinically significant problematic behavioral or
psychological changes, Tachycardia or Bradycardia,psychological changes, Tachycardia or Bradycardia,
Pupillary dilation, Elevated or Lowered BP, Chills,Pupillary dilation, Elevated or Lowered BP, Chills,
Nausea or Vomiting, Weight loss, PsychomotorNausea or Vomiting, Weight loss, Psychomotor
disturbance, Muscle weakness, respiratorydisturbance, Muscle weakness, respiratory
depression, chest pain, Arrhythmias, Confusion,depression, chest pain, Arrhythmias, Confusion,
Seizures or Coma.Seizures or Coma.
Stimulant Withdrawal:Stimulant Withdrawal:
- Dysphoric Mood, Vivid unpleasant dreams, Sleep- Dysphoric Mood, Vivid unpleasant dreams, Sleep
disturbance, Increased appetite, Psychomotordisturbance, Increased appetite, Psychomotor

24. Cocaine & AmphetaminesCocaine & Amphetamines
Most effective reinforcer, especially freebase (crack).Most effective reinforcer, especially freebase (crack).
Animals will self-administer until they die.Animals will self-administer until they die.
Cocaine psychosis indistinguishable fromCocaine psychosis indistinguishable from
schizophrenia.schizophrenia.
No physical withdrawal but psychological effects includeNo physical withdrawal but psychological effects include
depression and anhydonia.depression and anhydonia.
They are highly addictive but do not produce a physicalThey are highly addictive but do not produce a physical
dependence - only a behavioral dependence.dependence - only a behavioral dependence.
Both are dopamine agonists.Both are dopamine agonists.
Both inhibit dopamine reuptake but amphetamine mainlyBoth inhibit dopamine reuptake but amphetamine mainly
stimulates release from terminal buttons.stimulates release from terminal buttons.

25. Cocaine Action

26. Tobacco Related DisordersTobacco Related Disorders
Tobacco Use Disorder.Tobacco Use Disorder.
Tobacco Withdrawal:Tobacco Withdrawal:
- Irritability, Frustration, Anger,- Irritability, Frustration, Anger,
Anxiety, Difficulty Concentrating,Anxiety, Difficulty Concentrating,
Restlessness, Depressed Mood,Restlessness, Depressed Mood,
Insomnia.Insomnia.
Other Tobacco Induced Disorders:Other Tobacco Induced Disorders:
- Tobacco Induced Sleep Disorder.Tobacco Induced Sleep Disorder.

27. Etiology of SubstanceEtiology of Substance
Use DisordersUse Disorders
Biological Models.Biological Models.
Psychological Models.Psychological Models.
Socio-Cultural Models.Socio-Cultural Models.

28. The Ventral Striatum
(Nucleus Accumbens)
Human Monkey Rat

36. The Reward PathwayThe Reward Pathway
& Addiction& Addiction
Natural Rewards:Natural Rewards:
FOODFOOD
WATERWATER
SEXSEX
NURTURINGNURTURING

38. AddictionAddiction
A State in which an organismA State in which an organism
engages in a compulsive behavior.engages in a compulsive behavior.
The Behavior is reinforcingThe Behavior is reinforcing
(Rewarding or Pleasurable).(Rewarding or Pleasurable).
Loss of control in limiting intake.Loss of control in limiting intake.

39. ToleranceTolerance
A State in which an organismA State in which an organism
no longer responds to a drug.no longer responds to a drug.
A Higher dose is required toA Higher dose is required to
achieve the same effect.achieve the same effect.

40. DependenceDependence
A State in which an organismA State in which an organism
functions normally in the presencefunctions normally in the presence
of a drug.of a drug.
Manifested as physicalManifested as physical
disturbance when the drug isdisturbance when the drug is
removed (removed (WithdrawalWithdrawal).).

42. Psychological ModelPsychological Model
Psychological Models:Psychological Models:
- Addictive Personality.- Addictive Personality.
- Psychological Vulnerability.- Psychological Vulnerability.
- Self Medicating.- Self Medicating.
- Personality Issues (Anti-Social, C.D., etc..).- Personality Issues (Anti-Social, C.D., etc..).
- Self Esteem.- Self Esteem.
Psychoanalytic Models:Psychoanalytic Models:
- Oral.- Oral.
- Maternal Depravation.- Maternal Depravation.
- Sexual Adequacy.- Sexual Adequacy.
- Sexual Identity.- Sexual Identity.

43. Drug Self-Administration Protocol In Rats
This is a way of testing to see
whether a rat finds a drug rewarding

44. Pleasure & The “ Pleasure Centre ”
The Experiment by Olds & Milner

45. Tension & Stress Reduction ModelTension & Stress Reduction Model
Low tolerance for tension.Low tolerance for tension.
Stimulus augmenting.Stimulus augmenting.
Drugs (CNS) reduce tension =Drugs (CNS) reduce tension =
people use it and get thispeople use it and get this
response = Reinforcementresponse = Reinforcement..

46. Socio-Cultural ModelsSocio-Cultural Models
Cultural Circumstances -Tension.Cultural Circumstances -Tension.
Attitude toward drug taking.Attitude toward drug taking.
Cultural; substitutes as means ofCultural; substitutes as means of
satisfaction.satisfaction.
Alienation – Anomie.Alienation – Anomie.

47. Risk FactorsRisk Factors
Adolescence.Adolescence.
Academic Failure.Academic Failure.
Family History of Drug Use.Family History of Drug Use.
Risk Taking Behavior.Risk Taking Behavior.

48. Cost of Drug AbuseCost of Drug Abuse
Absenteeism.Absenteeism.
Low Productivity.Low Productivity.
Accidents.Accidents.
High Medical Costs.High Medical Costs.

49. Pathways To AddictionPathways To Addiction
4 Stages in a Relationship with Drugs4 Stages in a Relationship with Drugs
1. Experimentation
2. Active Seeking
3. Preoccupation
4. Addiction

50. Crime & DrugsCrime & Drugs
Illegal.Illegal.
Affect Behavior.Affect Behavior.
Drug users more likely to commitDrug users more likely to commit
crimes.crimes.
Frequency of use increasesFrequency of use increases
criminal activity.criminal activity.

51. Addiction
Biology/Genes Environment
DRUG

52. Genome
Protein Expression
Neuronal Circuits
DRUGS OF ABUSE
Social
Behavior
ADDICTION Requires
A Systems Approach
ADDICTION Requires
A Systems Approach

53. Remember...Remember...
• Addiction is an illness noAddiction is an illness no
one chooses to have.one chooses to have.
• Addiction is involuntaryAddiction is involuntary
& marked by a resistance& marked by a resistance
to give up drugs.to give up drugs.

54. Prof: Ashraf Tantawy