Base Course

Drug Use and

Drug Use
Disorders
Bihildis C. Mabunga, MD, DPBP, FPPA
1. What is drug addiction?

2. Why do people take

drugs?
3. Why do some people become
addicted to drugs, while others
do not?

4. What factors determine if

a
person will become
2
5. Which biological factors increase
risk of addiction?

6. Can addiction be treated

successfully?

7. Can addiction be cured?

8. Does relapse to drug abuse mean

treatment has failed?

9. What are the basics of

effective
addiction treatment?
10. How can medication help treat
drug addiction?

11. How do behavioral

therapies
treat drug addictions?
Most Commonly Used
Substances
Caffeine
Most Commonly Used
Substances
Alcohol Cigarette
 Dominant Drugs in
Philippine Market
The primary drug of choice among abusers:
methamphetamine HCL or shabu

In 2013, 83.97% of the arrests involved

shabu

It is followed by marijuana or cannabis sativa

and methylenedioxymethamphetamine
(MDMA) or ecstasy .

PDEA Annual Report 2013

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WHY DO PEOPLE TAKE
DRUGS
Peer pressure
Unable to assert
Curiosity
To rebel
Boredom
To block out worries and
problems
 WHY DO PEOPLE TAKE
DRUGS
To feel more confident
To enhance a night out
To cope with stress and anxiety
Because they are available and
accessible
Because parents or older brothers and
sisters use
To self-medicate anxiety, depression,
Why do Mental Illnesses and
Substance Abuse Co-
occur?
Self-medication
substance abuse begins as a
means to alleviate symptoms
of mental illness
Causal effects
Substance abuse may increase
vulnerability to mental illness
Common or correlated
causes
the risk factors that give rise
to mental illness and
substance abuse may be
related or overlap
COMORBIDITY

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 Drug use management is
important
Drug use happens in almost all communities
and all walks of life
Drug use is associated with substantial health
and social problems
Drug use can lead to harm and dependence
Injecting drug users have high rates of HIV
and Hepatitis C
Intensive cannabis use may result in
psychotic disorders

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 Drug use management is
important
Non-specialist clinicians can
assess, manage or refer people
with drug use problems
You can make a difference

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 Remember
Addiction is:
a chronic brain disease
expressed as compulsive
behavior
expressed within a social
context
prone to relapse
treatable
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 Confidentiality is an important
aspect of trust in a therapeutic
relationship

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 Establish communication and
build trust
What is different about communication
and trust with a person with possible
drug use compared to alcohol use
The issues are mostly the same

However, the added stigma and

serious legal issues can make
communication more challenging

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 Establish communication and
build trust
Identify the person's immediate expectations
For what reason has the person come to
see you?
Consider that the person may be trying
to manipulate you
Consider family members to be enablers
or co-dependents
Manage the person's expectations
Be honest about what you can and
cannot do

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 Establish communication and
build trust
Assess the impact of drug use on the person's
life
How have their home and work life been
affected
Look for common ground
Explain that you both want to improve the
person's health
Do not judge
Avoid the righting reflex
Challenge misconceptions but avoid
confrontation

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 Establish communication and
build trust
Use good communication skills
Ask open questions
Remain neutral
Explain your understanding of the
situation to the person
Always be honest
Expect that it will take multiple
meetings to build trust
Honesty builds trust both ways. It can
be useful to confirm aspects of the
persons history with family members.
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 Elicit substance use
history
History of use should include which
substances have been used, including
alcohol, drugs, medications (prescribed or
not prescribed to the patient), and routes of
use (oral, snorting, or intravenous).
The frequency and amount of use should be
determined, keeping in mind the tendency
for patients to minimize or deny use that
may be perceived as socially unacceptable.

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 DSM 5:
Substance-Related
Disorders and Addictions

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 Substance-Related & Addictive
Disorders
The DSM 5 SRAD encompasses 10 separate classes of
drugs:
Alcohol
Caffeine
Cannabis
Hallucinogens (w/ separate categories for PCP)
Inhalants
Opioids
Stimulants (ATS, Cocaine, & other stimulants)
Sedatives, Hypnotics, & Anxiolytics
Tobacco
Other (or Unknown) Substances
 Substance-Related
Disorders
Substance Use Disorders
Substance-Induced Disorders:
Intoxication
Withdrawal
Other Substance/Medication-induced
mental disorders (psychotic d/o, bipolar &
related d/o, depressive d/o, anxiety d/o,
obsessive-compulsive & related d/o, sleep
d/o, sexual dysfunctions, delirium, and
neurocognitive d/o).
Substance Use Disorders
Essential Feature:
A cluster of cognitive,
behavioral, & physiological
symptoms indicating that the
individual continues using the
substance despite significant
substance-related problems
(except caffeine).
 Substance Use Disorders
To assist with organization, Criterion
A can be considered to fit with
overall groupings of:
Impaired Control (Criteria 1-4)
Social Impairment (Criteria 5-7)
Risky Use (Criteria 8-9)
Pharmacological Criteria (Criteria

10-11)
 Substance Use Disorders
Impaired Control (Criteria 1-4)
Criterion 1: The Individual may take the
substance in larger amounts or over a
longer period than was originally
intended
Criterion 2: The individual may express a
persistent desire to cut down or regulate
substance use & may report multiple
unsuccessful efforts to decrease or
discontinue use
 Substance Use Disorders
Impaired Control (Criteria 1-4)
Criterion 3: The individual may spend a
great deal of time obtaining the
substance, using the substance, or
recovering from its effects.
Criterion 4: Craving is manifested by
an intense desire or urge for the drug
that may occur at any time but is more
likely when in an environment where the
drug previously was obtained or used.
 Substance Use Disorders
Social Impairment: Criteria 5-7
Criterion 5: Recurrent substance use may result
in a failure to fulfill major role obligations at
work, school, or home
Criterion 6: The individual may continue
substance use despite having persistent or
recurrent social or interpersonal problems
caused or exacerbated by the effects of the
substance
Criterion 7: Important social, occupational, or
recreational activities may be given up or
reduced because of substance use.

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Substance Use Disorders
Risky Use of the Substance: Criteria 8-9
Criterion 8: Recurrent substance use in
situations in w/c it is physically hazardous
Criterion 9: The individual may continue
substance use despite knowledge of having a
persistent or recurrent physically or
psychological problem that is likely to have
been caused or exacerbated by the substance.
*The key issue in evaluating this criterion is not
the existence of the problem, but rather the
individuals failure to abstain from using the
substance despite the difficulty it is causing.
Substance Use Disorders
Pharmacological Criteria (Criteria 10-11)
Criterion 10: Tolerance is signaled by
requiring a markedly increased dose of
the substance to achieve the desired
effect of a markedly reduced effect when
the usual dose is consumed.
Criterion 11: Withdrawal a syndrome
that occurs when blood or tissue
concentration of a substance decline in
an individual who had maintained
prolonged heavy use of the substance.
 Severity and Specifiers
SEVERITY:
Mild SUD: presence of 2 to 3 symptoms
Moderate SUD: by 4 to 5 symptoms
Severe SUD: 6 or more symptoms
SPECIFIERS:
In early remission
In sustained remission
In a controlled environment

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 Remember
Always try to get a sense whether the
person with drug use problems is
sober, intoxicated or in a state of
withdrawal at time of the interview
If the person is intoxicated to the
point that their behaviour is
inappropriate, you may want to ask
them to come back later.

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 Brief Interventions for people with
harmful/hazardous drug use
Components of a brief intervention
Engage the person in a
conversation about
benefits/harms
Challenge misconceptions
Avoid arguing
Assess the impact of the drug use
on the person's life
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 Brief Interventions for people with
harmful/hazardous drug use
Components of a brief intervention
State clearly the recommendation to
cut down or stop harmful use and
your willingness to help
Encourage people to decide
themselves if they need to change
If people are not ready to stop or
reduce use, encourage them to come
back to discuss further, perhaps with
a family member or friend
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 Advice for breastfeeding
mothers
Strongly encourage breastfeeding mothers to avoid
psychoactive drugs
cannabis has very high concentrations in breast
milk
stimulants are neurotoxic

Refer to specialist care

In all cases, advise and support mothers with drug

use disorders to breastfeed exclusively for at least
the first 6 months, unless there is specialist advice
not to breastfeed.

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 Link with other services and
supports
People with a drug use problem may benefit from
Self-help groups
Support from family, friends and community members
Other available community supports
Housing and employment services
Religious leaders

People with drug dependence may benefit from

Planned withdrawal services and dependence
treatment
Rehabilitation services (i.e. drug free environments)

What is available in or near your community?

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 Schedule follow-up
Treating a person with drug use can be
a long process
It may take time for people to see their
drug use as a problem
You must be patient
It is important to schedule regular
follow up

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 Referring to a specialist
If the person continues to use despite brief
interventions or shows signs of dependence,
refer for further treatment
Effective treatment need not be voluntary
Sanctions/enticements (family, employer,
criminal justice system) can increase treatment
entry/retention
Treatment outcomes are similar for those who
enter treatment under legal pressure vs
voluntary

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 Referring to a specialist
If the person is not ready for further treatment, it
may be better to ask the person to come back to
discuss further, perhaps with a family member or
friend

Be aware of co-morbid diagnosis anxiety,

depression, post-traumatic stress, psychosis, mood
problems, impulsivity, etc that may be masked with
the drug problem

Effective treatment attends to multiple needs of the

individual, not just his/her drug use

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 Principles of Effective
Treatment
Remaining in treatment for an adequate
period of time is critical for treatment
effectiveness.
Counseling (individual and/or group) and
other behavioral therapies are critical
components of effective treatment for
addiction
Medications are an important element of
treatment for many patients, especially
when combined with counseling and
other behavioral therapies
 Principles of Effective
Treatment
Medical detoxification is only the
first stage of addiction treatment
and by itself does little to change
long-term drug use
Treatment does not need to be
voluntary to be effective
Possible drug use during treatment
must be monitored continuously
 Goals of
Treatment
Abstinence or
reduction in the
use & effects of
substances
Reduction in
the frequency
and severity of
relapse
Improvement in
psychological &
social/adaptive
functioning
 Key messages
Health care providers can make a difference
Treat associated health conditions
Provide brief interventions to reduce
hazardous/harmful substance use and to stop
drug use in those with drug dependence.
Offer harm reduction strategies for people who
inject drugs
Refer for further treatment if there is no
improvement

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 Doctor,
Doctor,
I m
addicted
!

Treatme
nt of
44
drug
Recovery from the
disease of addiction is
often a long-term
process, involving
multiple relapses before
a patient achieves
prolonged abstinence.
National Institute on Drug Abuse
 QUIZ
Question:

What is more
addictive,
SEX or DRUGS?
 ANSWER

It depends on
the pusher.