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					Assessment and Treatment of
    Addictive Behaviors
         Carl W. Lejuez, PhD

           Lecture 2
       Alcohol & Smoking
• Alcohol is a Central Nervous System depressant.
   – Exact mechanism of alcohol’s action are unknown
   – May be a GABA antagonist
   – Also effects dopamine in the nucleus accumbens

• Why does it feel like a stimulant?
   – At low doses, alcohol relaxes the area of the cerebral cortex that inhibits
     the sub-cortical areas of the brain
   – Net effect: Lowered inhibitions, feelings of relaxation and increased
     social interactions
   – As BAC increases, sedative effects become more pronounced.
   – At lethal doses, the respiration centers in the medulla are shut down,
     and you stop breathing.
How Alcohol Works in the Body
  – Alcohol is rapidly absorbed into the bloodstream from
    stomach, small intestine, and colon.

  – The drinker's blood alcohol concentration depends
     • the amount consumed in a given time
     • the drinker's size, sex, body build, and metabolism
     • the type and amount of food in the stomach (Once the alcohol has
       passed into the blood, however, no food or beverage can retard or
       interfere with its effects.)
 Blood Alcohol Concentration
Blood Alcohol Concentration/Blood Alcohol Level
  – The number of grams of alcohol in the blood relative to 100
    milliliters of blood, expressed as a percentage
  – The higher the number, the more alcohol in your bloodstream.
  – To compute, you need to know your weight, the number of
    drinks, and the amount of time since your first drink

Elimination of Alcohol
  – 5% is eliminated through the lungs
  – 95% is eliminated through the urine
  – Body breaks down about ½ ounce per hour (about 1 standard
    drink) per hour
  Blood Alcohol Concentration
BAC         Effect Of Alcohol Intoxication
0.02-0.03   No loss of coordination, slight euphoria and loss of shyness;
            depressant effects are not apparent

0.04-0.06   Feeling of well-being, relaxation, lower inhibitions, sensation of
            warmth. feelings of euphoria are present; some minor impairment of
            reasoning and memory, lowering of caution

0.07-0.09   Slight impairment of balance, speech, vision, reaction time, and
            hearing. feelings of euphoria are present; judgment and self- control
            are reduced, and caution, reason and memory are impaired; it is
            illegal to operate a motor vehicle at this level of intoxication (.08) in
            most states
0.10-0.125 Significant impairment of motor coordination and loss of good
           judgment. Speech may be slurred; balance, vision, reaction time
           and hearing will be impaired; feelings of euphoria are present;
           legally intoxicated in all states
 Blood Alcohol Concentration
BAC         Effect Of Alcohol Intoxication (continued)
0.13-0.15   Gross motor impairment and lack of physical control; blurred vision
            and major loss of balance; euphoria is reduced and dysphoria is
            beginning to appear

0.16-0.20   Dysphoria (anxiety, restlessness) predominates, nausea may
            appear; the drinker has the appearance of a "sloppy drunk."

0.25        Needs assistance in walking; total mental confusion; dysphoria with
            nausea and some vomiting

0.30        Loss of consciousness

0.40        Onset of coma, possible death due to respiratory arrest
  Alcohol Abuse/Dependence
• Lifetime Prevalence of DSM-IV disorders

  Alcohol Abuse
     9.4% overall
     12.5% of men
     6.4% of women

  Alcohol Dependence
     14.1% overall
     20.1% of men
     8.2% of women
      College Prevalence Rates
2001 CORE Survey
    Average Number of Drinks per Week
    The following tables give the average number of drinks per week .
                 Male             Female           Total
    Freshman      9.38            4.15             6.24
    Sophomore     9.93            4.43             6.62
    Junior       10.48            4.66             7.02
    Senior       10.46            4.65             7.07
    Total         9.87            4.37             6.58

Binge Drinking
• Binge drinking is defined as five of more drinks in one sitting.
•   49.7% of students in the sample engaged in binge drinking at least
    once during the two weeks prior to completing the Core survey.
 Alcohol Use Screening Measures

• Alcohol Use Disorders Identification Test
• Michigan Alcohol Screening Test (MAST)
Alcohol Consequences:
         Alcohol Withdrawal
•   Abstinence syndrome is MEDICALLY
    MORE SEVERE and more likely to
    cause death than narcotic withdrawal

•   In untreated advanced cases, mortality
    may be as high as one in seven
     •   Recommended that initial period of detoxification
         (allowing the body to rid itself of alcohol) be
         carried out in an inpatient medical setting
    Alcohol Withdrawal Timeline

•    Acute Stage: 3-5 days

•    Sub-Acute Stage: approximately 3 weeks
      •   during this time, individual may still be
          experiencing measurable cognitive deficits

•    Chronic Stage: Up to one year
      •   Slow, steady improvement in cognitive
  Stages of Acute Withdrawal
1. Tremors, excessively rapid heartbeat,
    hypertension, heavy sweating, loss of
    appetite, insomnia
2. Hallucinations
     •   auditory, visual, tactile, or a combination

3. Delusions, disorientation, delirium,
    sometimes intermittent in nature and
    usually followed by amnesia
4. Seizure activity & DTs
         Long-term Effects 1
•   Malnutrition: Because alcohol provides
    “empty” calories, many heavy drinkers do
    not eat well. This results in malnutrition
     •   Malnutrition can result in tissue damage which is
         secondary to the alcohol consumption itself (not
         DIRECTLY caused by alcohol consumption).

     •   It is difficult to separate the effects of alcohol
         exposure from those of malnutrition.
         Long-term Effects 2
•   Brain Damage:
     •   Major damage is loss of brain tissue.
     •   Ventricles in the brain become enlarged.
     •   Fissures in the cortex are widened.
     •   Probably due to direct effects of alcohol toxicity
    Brain Damage (continued)

•   Alcohol dementia: global decline in
    intellect affecting Frontal area & memory
    Brain Damage (continued)
•   Korsakoff’s Syndrome
     •   Associated with a deficiency of thiamine
         (vitamine B1) and can sometimes be corrected
            » Symptoms include confusion, ataxia, (impaired
              coordination while walking) and abnormal eye
            » Also, most Korsakoff’s patients also experience
              Korsakoff’s Psychosis (memory dysfunction,
              inability to remember recent events or to learn new
            » Also, confabulation (tends to be fantastic)
            » Abulia – blandness in affect and personality. Not
              much drive or motivation.
         Long-term Effects 3
•   Liver Disorders:
     •   Fatty Liver. - Fatty acids (lipids) accumulate in
         the liver and are stored as small droplets in liver
         cells. This condition is known as alcohol-related
         FATTY LIVER. For most drinkers, not a serious
            » Sometimes droplets increase in size to the point
              where they rupture the cell membrane, causing
              death of the liver cells
            » Up to the point where liver cells die, a fatty liver is
              completely reversible and usually of minor medical
         Long-term Effects 4
•   Liver Disorders continued:
     •   Alcoholic Hepatitis
            » Serious disease that includes both inflammation
              and impairment of liver function.

            » MAYBE a connection to fatty liver?

            » Can get hepatitis even in the absence of fatty liver.

            » Probably due to toxic effects of alcohol on the liver.
         Long-term Effects 5
•   Liver Disorders continued:
     •   Cirrhosis – related to high and prolonged
         alcohol consumption
            » Usually takes up to 10 years of steady heavy
              drinking (equivalent of a pint or more of
         Long-term Effects 6
•   Cirrhosis (continued)
     •   Liver cells are replaced by fibrous tissues
         (collagen) which changes liver structure
            » changes decrease blood flow and, along with the
              loss of cells, result in a decreased liver functioning
     •   When liver doesn’t function, fluid accumulates in
         the body, jaundice develops, other infections or
         cancers proliferate
     •   Yellow skin (and in whites of eyes) is a sign that
         liver is not functioning properly and toxins are
         accumulating in the blood.
     •   Cirrhosis is not reversible. Cessation of drinking
         can retard its development.
Alcohol Consequences:
     Alcohol and Depression

•   Alcohol and depression are commonly

•   Among those with a history of Alcohol
    Dependence , lifetime rates of major
    depressive disorder [MDD] range from
    24.3% for men to 48.5% for women
    (Kessler et al., 1997).
    Alcohol and Depression 2
• Clinically significant levels of depressive
  symptoms in majority of patients entering
  treatment for an alcohol use disorder
• Two explanations often have been offered
  for AUD and MDD
     • Alcoholic drinking may occur as a means of self-
       medication for underlying depression
     • Depression may result from the pharmacological
       effects of excessive alcohol use.
    Alcohol and Depression 3
• Two Types of MDD associated with AUD
     • Schuckit (1983)
           » “independent” depression
           » "substance-induced" depression

• The diagnostic distinction has potentially
  important clinical implications
     • Most depressive symptoms remit once abstinence
       from alcohol has been achieved
     • If primary depressive disorder, less rapid
       reductions in depressive symptoms after alcohol
       treatment than w/ substance-induced depression
Cigarette Smoking
        Nicotine and Cigarettes
• Nicotine is 1 of 4000 compounds released by the burning
  of cigarette tobacco.
• Nicotine is the primary psychoactive ingredient in
• Nicotine accounts for the acute psychoactive effects of
  smoking and for the dependence on cigarettes.
• The adverse, long-term cardiovascular, pulmonary, and
  carcinogenic effects of cigarettes are related to other
  compounds contained in the product
• The delivery device (the tobacco cigarette) is responsible
  for much of its toxicity
  Nicotine Dosage from Cigarettes
• Most cigarettes contain between .5 and 2.0 mg
  of nicotine.
• Only about 20% (.1 and .4 mg) is actually
  absorbed into the blood stream
• One Pack Per Day: 2 to 8 mg of nicotine
• Two Packs Per Day: 4 to 16 mg of nicotine
• 60 mg of pure nicotine would be fatal
        Nicotine and the CNS
• Primarily an acetylcholine agonist

• Also stimulates the release of dopamine in the
  nucleus accumbens, the same area of the brain
  responsible for the reinforcing properties of
  opiates, cocaine, and alcohol.

• Nicotine “kick" caused in part by the stimulation
  of the adrenal glands and resulting discharge of
  epinephrine (adrenaline).
        Nicotine and the CNS
Nicotine is quickly absorbed and eliminated

     • Smoked nicotine reached the brain in 7 seconds,
       and “peak effects” are achieved before the
       smokers finishes the cigarette.

     • Nicotine half-life is about 2 hours
Physiological Effects of Nicotine
Primary Effects of Nicotine
     •   Increased HR, BP, and metabolism
     •   Feelings of exhilaration and energy
     •   Increased mental alertness and concentration
     •   Increased task performance
     •   Increased short-term memory
     •   Decreased appetite
     •   For some, increased relaxation (muscle relaxation,
         relief of withdrawal symptoms, increased
          Nicotine Addiction
Why is nicotine so addictive?
     • Rapid absorption and elimination
     • Indirect stimulation of dopamine system
     • Repetition (20 cigarettes, 200 puffs)
     • Environmental cues and easy access
     • Use can be used to Fight withdrawal
            Nicotine Withdrawal
Symptoms of Nicotine Withdrawal
     •   Dysphoric or Depressed Mood
     •   Insomnia
     •   Irritability, Frustration, or Anger
     •   Anxiety
     •   Difficulty Concentrating
     •   Restlessness
     •   Decreased Heart Rate
     •   Increased Appetite or Weight Gain
Typical Course
 Physiological (physical) symptoms:
     begin almost immediately following last cigarette
     more severe symptoms begin at 6 hrs & peak at about 48 hrs
     symptoms begin to improve after 72 hrs
     minor symptoms may last up to 2-3 weeks
 Psychological withdrawal can last indefinitely
Smoking Consequences:
              Lung cancer
• Symptoms include persistent cough, chest
  pain, hoarseness, pneumonia & bronchitis
• Malignant tumor in the lungs invades and
  destroys lung tissue and can spread
• Treatment may involve removal of affected
  area and sometimes the entire lung
• The disease has usually spread by the
  time it is discovered, and the five-year-
  survival rate is only 13 percent
              Bladder Cancer
• Smoking is the greatest risk factor and smokers
  have more than double the risk of bladder
  cancer compared to nonsmokers
• Symptoms are blood in the urine, pelvic pain
  and increased frequency of urination
• Treatment involves surgery, chemotherapy and
  radiation. If the bladder must be removed, it is
  necessary to create an opening in the body
  through which urine can pass into a pouch.
• If detected early, 5 yr survival rate is 91 percent .
                     Oral Cancer
• Smoking cigars, cigarettes or pipes increases the risk for
  these cancers up to 60 percent by some estimates
• Symptoms include a sore that bleeds easily and doesn't
  heal; a lump or thickening; a red or white patch that
  doesn't go away; difficulty in chewing, swallowing or
  moving the tongue and jaw
• Radiation therapy and surgery are the main treatments
  for this cancer. In some cases, your voice box, the
  larynx, must be removed
      • Patient must use artificial voice aid in order to speak
      • Speech is most often a low, hoarse wound forced through a
        mechanical device inserted into the mouth or throat
 Smoking Consequences
430,000 annual deaths are attributable to cigarette smoking

Source: CDC, MMWR 1997; 46; 448-51
     Smoking Consequences
• Leading preventable cause of
  death/disability in US
• 1/3 of cancer deaths are tobacco related
• Lung cancer is almost 2x as common as
  breast cancer in women