Pioneer Batch  Class of 2012

MODULE PSYCHIATRY DATE February 10, 2010 (Wednesday, AM)

LECTURE Addiction Psychiatry LECTURER Dr Tolentino

OUTLINE  There is a truth to the euphemism: Once an addict, always an

Definition of Terms addict!
I. Origin and Causes of Addiction
a. Genetic Determinant of Addiction
i. Twin Studies  Reinforcement – is a tendency of pleasure-producing drug to
ii. Adoption studies lead to repeated self-administration; It can go two ways: (1)
b. Trait Markers of Alcoholism POSITIVE reinforcement – you are rewarded, meaning you get
i. Biochemical Markers
ii. Potential Difference in Cognitive Performance
high! It’s pleasurable. You want to take it and take it because you
iii. Personality Profiles are reinforced positively. Kasi masya ka; (2) NEGATIVE
II. Neuroadaptation reinforcement – withdrawal. You cannot stop because the moment
III. Biology of Drug Addiction you stop, it’s difficult!
a. Mesolimbic Dopamine System
If it were not for any of the health effects of smoking, it
IV. Neuroimaging Studies in Addiction
V. The Psychosocial Perspective would have been a perfect drug! Why do writers have to
VI. The Treatment for Drug Addiction smoke while thinking? Because it makes people
a. Psychiatric Management concentrate. Why do people smoke after eating?
b. Pharmacology Treatment Because it hastens metabolism.
c. Rehabilitation: The Therapeutic Community
But when you stop, smokers know it is hard to
In behalf of Group 5, I’d like to apologize as we came late for
concentrate when they stop smoking. They feel too full
transcribing this lecture. Dr Tolentino said he’d give Dr Marinas his and they want a cig soon after eating or drinking.
lecture in PDF but he apparently forgot. Most of the earlier parts
are all in Audio format. Tolerance – concept develops after repeated administration –
Dr Marinas said exam questions would cover the objectives, would there has to be repeats – of a given dose of a drug. It produces a
test recall, and would include cases. decreased effect OR when increasing larger doses must be
administered to obtain the effects observed with original use. It
Lesh shows if substance is addictive or not: it has to produce tolerance

 Addiction is not purely psychological but mostly in the brain.
Learning Objectives
1. Define different concepts in addiction
2. Understand where it comes from – origins and causes of
addiction as we know it today
3. Neuroadaptation – new term in addiction
4. We have shifted into biology. Try to understand addiction in
biological terms
DEFINITION OF TERMS
Abuse – self-administration of any drug (e.g. nicotine, alcohol,
marijuana)
 It depends on your culture to say if you have abused it. Ex:
Quezon province – you drink alcohol every night. Amongst
provinces, Quezon is #1 use/abuse of alcohol in the country
 Background of culture dictates if you are abusing (ie.
Philippines – use valium = abuse; USA – use valium = normal)
 It is the culture approves/disapproves if it’s abuse or just use
Addiction – behavioral pattern of drug abuse characterized by
overwhelming involvement with the use of the drug – there is
compulsive use: “I need to use it!” – and the securing is high and
very high tendency to relapse after discontinuation
 Addiction is the whole gamut of wanting it, needing it, using it
on a regular basis – that’s when it becomes addiction
 Keyword: behavioral pattern of drug abuse
Dependence – focuses on the physiological state of non-
adaptation produced by repeated administration of a drug
necessitating continued administration to prevent the appearance of
withdrawals
 Can I still be an addict if I am not currently dependent? YES!
Dependence is physical. I am not dependent on it right now
but addiction is behavioral. Even if they are not dependent
right now, may ugaling adik. Behavior encompasses mentality,
etc. They still are irresponsible, they don’t work, they steal, etc.
= ugaling adik!  They remain addicts even though they may
not be dependent
Cross-Tolerance or Cross-Dependence – These
concepts are important because we need to understand
how certain drugs function when we are treating them;
Ability of one drug to suppress the manifestation of
physical dependence produced by one drug, and to
maintain the physically-dependent state.
 Patients withdrawal from alcohol – what is given instead:
valium (it is addictive but it is an agonist); Valium is also
addictive but it is an agonist. You can control it.
 (US, AUS) For heroin addiction – they give methadone (more
stable substance even if highly addictive). You could control its
use. It stays in the body for 24hours. Allows less criminality
and allows people to work.
Withdrawal – both psychologic and physiologic
reactions to abrupt cessation of a dependence-
producing drug
 (Substance Abuse Conference) Debate at that time: whether
shabu is truly addictive – it has mostly psychologic reactions
but not so much physiologic
 It has to be both or maybe, psychologic or physiologic
reactions
Relapse – recurrence upon discontinuation of an
effective medical treatment of the original condition
from which the patient suffered
 When it happens while you are still recuperating from the
illness. Important in psychiatry because most of our illness are
prolonged
 A new episode: recurrence, strictly speaking; “Went back to
being normal.” Years after, I get into another depression =
recurrence
 Relapse: in same condition. If I’m depressed, took
medications, then stop medications, then feels depressed,
again. In same patient becomes better, becomes functional,
then depression comes back = relapse

Page 1 of 10  ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex

 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY
LECTURE Addiction Psychiatry
Rebound – new episode; not due to medical condition;
the exaggerated condition or a medical education
sometimes felt by patient sometimes immediately after
stopping effective treatment
 For a few nights, you take sleeping aids, after you stop
sleeping aids, you can’t sleep, insomnia becomes worse =
REBOUND! It’s not about the illness it’s about the symptom
you are trying to work on.
I. ORIGIN AND CAUSES OF ADDICTION
GENETIC DETERMINANT OF ADDICTION
1940s, Jellinek et al focused on environmental,
developmental and social factors
It is a debilitating, heterogeneous group of disorders
with multi-factorial origins.  How do you study that?
o Family Studies – Plutarch asserted, “drunks
beget drunkards.” Was based on anecdotal
observations.
o Rates of alcoholism are substantially higher in
relatives of alcoholics than in relatives of non-
alcoholics with COA demonstrates –
o Increased rate for the disorder among relatives of
alcoholic probands while the same group does not
show higher rates of schizophrenia or MDI
If parents were drunks, the children will become drunks
also
Argument: non-sequitur! Does not follow!
A. TWIN STUDIES
Rationale:
Identical twin pairs who share all of their genes
show higher concordance rates for gene-
transmitted disorders.
Environmentally influenced disorders would show
no difference between monozygotic and dizygotic
twin pairs so long as both types of twins were
exposed to the same childhood environment.
Kaiji (Sweden): concordance rate for alcoholism
in monozygotic pairs was 58% vs. 28% in dizygotic
twins. – stronger than family studies but not quite
o Argument – gene differentiation! It doesn’t matter
A USVA twin register study revealed a similar
higher concordance rate for identical twin pairs.
2 Scandinavian studies have found that identical
twins are more concordant for quantity and freq. of
drinking but not for adverse consequences of
drinking.
Results are conflicting.
WHAT THIS MEANS
The disparity in results from twin studies probably
reflects the multiple factors that affect alcohol
absorption and metabolism (eg. The use of other
drugs, diet, etc.), and some investigators are
skeptical of these results.
Majority of twin studies support the notion that
alcoholism is genetically influenced and that
heritable factors might play a role in the quantity
and frequency of drinking.
Page 2 of 10
DATE February 10, 2010 (Wednesday, AM)
LECTURER Dr Tolentino
The lack of unanimity of these studies points to the
complexity of these issues and the interaction
between genetic and environmental factors.
B. ADOPTION STUDIES  Best design
 Mostly in Scandinavian countries – they can trace from birth
to death
- Most convincing way to separate genetic from
environmental factors.
- Schukit et al: individuals rose apart from biologic
parents but who had either a biologic or surrogate
parent with alcoholism would show. Subjects with a
biologic parent with severe alcohol problems were
significantly more likely to have alcoholism
themselves than if their surrogate parent were
alcoholic.
 Negate sa surrogate parents the effect of the environment
as long as you have the genetic predisposition
- Goodwin (Denmark): Sons of alcoholics (SOA)
were about 4x more likely to be alcoholic than sons
of non-alcoholics. Although SOA’s were found at
highest risk for alcoholism, they were no more
likely to have other psychiatric disorders.
 Separating it from other psy sickness
- Clonginer et al (Sweden): showed significantly
higher rates of alcohol abuse in adopted-out sons
of biologic fathers registered with alcohol
problems.
- Only 1 study by Roe, has found contrary results,
and most authors agree that the disparity reflects
methodologic problems in the design (small sample
size and lack of rigorous diagnostic criteria for
alcohol problems in the parents).
The combination of family, twin, and adoption studies
strongly suggests that genetic determinants play an
important part in the etiology of alcoholism.
 Why focus on alcohol? It’s legal! It is also a GENERATIONAL
drug. Lolo doesn’t take ecstasy. Great grandfather didn’t
take/have shabu. You can study alcoholism not addiction of
drugs.
 Always find most studies on alcohol because it is a
generational drug
C. TRAIT MARKERS OF ALCOHOLISM
i. BIOCHEMICAL MARKERS
Who gets flushed or red when you drink alcohol? You are
more ORIENTAL! You lack aldehydes. These are trait markers
of the male species.
- 30%-50% of Orientals lack 1 of the isoenzyme
forms of aldehyde dehydrogenease (ALDH), the
major enzyme that degrades the 1st metabolite of
ethanol, acetaldehyde, in the liver. After imbibing
alcohol, affected individuals develop higher blood
acetaldehyde levels with associated facial flushing,
tachycardia, and a burning sensation in the mouth.
 Biological marker that you lack ALDH
 ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex
 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY
LECTURE Addiction Psychiatry
- MAO: several studies comparing alcoholics with
controls have found dec. platelet MAO activity
levels among alcohol abusers. SOA’s show similar
trend for lower MAO activity.
ii. POTENTIAL DIFFERENCE IN
COGNITIVE PERFORMANCE
- There are potential cognitive difference in the performance of
alcoholics, particularly son of alcoholics (SOA)
- SOA’s demonstrated lower verbal IQs, decreased auditory
word span performance, impaired reading comprehension, a
greater number of errors on a neuropsychiatric battery, and
problems in constructional praxis, and abstract problem
solving.
- SOA’s are also “punished” because of poor cognitive
performance.
iii. PERSONALITY RPOFILES
 Alcoholics are likely to show abnormalities on personality
tests. Why? It is also possible that because alcohol may be
toxic to the brain, it causes [personality disorders]. If you
start drinking too early, generally, it will affect cognitive
functions. If you take it over time, by the time they age, they
were practically goners because of chronic alcohol or drug
use.
- Results on baseline assessments of personality
traits in high- and low-risk populations provide
conflicting results because:
o During the course of heavy drinking and the
periods of early recovery, alcoholics are likely
to show abnormalities on personality tests that
might reflect the sequelae of ethanol’s effects
on brain functioning of the life stresses and
mood swings inherent in an alcoholic lifestyle.
o Some personality traits that remain ff.
abstinence may reflect other primary
psychiatric diagnosis.
o The diversity of personality measures used,
questions about the cross-validity of the
various test devices used, the variety of
populations studied, and the multiple
approaches to data analyses employed make it
unlikely to expect unanimity of results.
II. NEUROADAPTATION
 Explains why addicts remain addicted!
Vignette: Derek goes to the mailbox. It’s Friday, and there is
little promise anything more that junk mail. He flips though
the envelopes with disinterest. Suddenly his eyes are riveted
by a familiar return address. “The check is here, and more
than a week early!” As he clutches the envelope and turns
from the mailbox, his heart begins to pound. It actually less
than five minutes to the corner and some very special
cocaine. A wave of intense feeling rushes from the tips of
his toes up to his head and back down again. VROOM!
VROOM! His thoughts race, jumping to the corner and what
awaits there. He begins to taste the coke at the back of his
throat. As he approached the familiar corner, he begins to
start sweating, heart pounding, ears ringing. “If I am feeling
this high already, why do I even bother to buy the stuff?”
Page 3 of 10
DATE February 10, 2010 (Wednesday, AM)
LECTURER Dr Tolentino
He questions himself. “Because,” he smiles at his intended
pun, “coke is the real thing.”
 Everything in the story is happening. It’s all true.
CLASSICALLY CONDITIONED FACTORS IN DRUG
DEPENDENCE
 For any classical condition especially in drug dependence, you have to
remember one word: relevance or SALIENCY. It’s used now both in
depression and schizophrenia.
- Relevance: cues “set off” a host of feelings and
reactions w/c could prompt drug-seeking and drug use.
 To addicts, seeing fellow addicts already sets off the motion of
increasing dopamine levels in their brain; like Pavlov, ringing the
bell would already cause the dog to salivate.
- Drug-related cue reactivity is relevant in its potential
link to relapse.
That is the reason why addiction specialist drug addicts are
told not to see friends; why patients stay 6 months in a drug
rehab center  where you come from, even in your room, that
is relevant/salient. Just by being there already sets off –
because of your dopamine increasing.
- Two basic kinds of learning:
o Instrumental learning, in which behaviors (drug
seeking) reliability followed by the drug are later
likely to increase in probability
 If I go to the corner store where I buy the drugs every time I
get the check, and I know I will get the drug, that’s
instrumental learning. I will be rewarded.
o Classical or Pavlovian, conditioning, in which stimuli
reliably signaling arrival of the drug can acquire the
ability to later elicit special drug-related responses.
 Ringing of the bell, food will happen; next time, ring the bell
then you salivate – classical Pavlovian conditioning
CLASSICALLY CONDITIONING IN THE CONTEXT OF
DRUG ADMINISTRATION
- Basic premise: events that reliably signal the
administration or effects of a drug can become
conditioned stimuli (CSi) that later elicit responses
(conditioned responses, or CRs) related to the signaled
drug (the unconditioned stimulus, or US).
o Derek: getting the check – nacocondition; whenever the check
comes, that goes to buying the drugs
- The stimulus events that signal the drug can be
multiple: external cues (sight of drug den or drug
using friend) or internal cues (depression, anger)
o Why addicts nagwawala, the more they want to take drugs
- The potential related events (USs): (a) direct
pharmacologic actions of the drug; (b) Homoeostatic
responses of the body as it attempts to compensate for
the intrusion of the drug; (c) in the case of drugs
causing physical dependence pharmacologic
withdrawal.
o Because the body is highly plastic, when you are not an
addict, you have a different reaction
o Tried marijuana – 1st time, you feel nothing (because hindi pa
sanay). The body will keep you where you are. IF you are
constantly using marijuana, the brain now adapts to the
marijuana – it will now be plastic towards pathology or to drug
use --- that is adaptation
 ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex
 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY DATE February 10, 2010 (Wednesday, AM)
LECTURE Addiction Psychiatry LECTURER Dr Tolentino

- Conditioned Withdrawal: Wikler observed that drug-
free ex-opiate users talking aout their prior drug use
often began to experience signs and symptoms of
opiate withdrawal (sniffing, yawning, tearing, etc.)
Wikler hypothesized that drug-related cues repeatedly
paired with actual opiate withdrawal in the course of
the patient’s addiction had acquired the ability to elicit a
“learned” or conditioned withdrawal, response through
the process of classical conditioning.
o There is adaptation to the drug. Once the brain is repeatedly
exposed to an addictive substance then it adapts
o Talking will just make you react
o What is this telling us? Once an addict, always an addict! They
have already stopped, for a long time. The mere fact that you
give them certain factors, it will make them start to withdraw
- Conditioned withdrawal is a possible trigger for
drug relapse: opiate px, even when long abstinent,
might experience conditioned withdrawal discomfort
when exposed to drug-related cues in their natural
environment and seek opiates to relieve discomfort.
- Rats will administer DA, amphetamines, & cocaine
(elevates DA by blockinh reuptake) suggesting that DA
receptors in the NAc mediate reinforcing stimuli.
- Ethanol, nicotine, and cannabinoids also cause increase
DA release in the NAc, by disinhibition of VTA DA
neurons.
 If you were not taking drugs but you were shown cues, then that
will start the reaction
- May also involve in mediating drug craving. Based on
the fact that stimuli that induce relapse in animal
models and drug craving in human studies are all
known to increase DA levels in the NAc. These stimuli
include small priming doses of drugs, stress, and drug-
associated cues.
Mesolimbic Dopamine Pathway and the
Psychopharmacology of reward

- Conditioned Compensatory Responses: the result

of the body’s repeated efforts to counter the onset
effects of the drug and to maintain homeostasis.
- Siegel’s experiments suggest that the conditioning of
drug-opposite responses may play an important role in
the tolerance.  The brain will adapt

- His studies show that animals repeatedly injected with

opiates in a distinction environment will develop
tolerance to the analgesic or lethal effects of the drugs.
If a subgroup of these animals is later injected in a
novel environment (w/o cues present during prior
injections), tolerance is substantially reduced compared
with the response of animals retested in the familiar
environment.
o If the same cage, then you inject opiates constantly, after a
while, there is no effect. But if you put them in a psychedelic IV. NEUROIMAGING STUDIES IN ADDICTION
stage, then with same dose, it will be as if its their first time –  Nora Vilkow – leader in neuroimaging of addicts have found out
novel environment what makes a drug high addictive is this
 Novel stimulus will make you avoid tolerance (in drugs)! Like in sex, - The reinforcing effects of DOA in humans are
when it becomes normal and same old routine... boring. But when you contingent upon large and fast increases in DA that
go somewhere else and do the nasty – exciting! ^u^ mimic but exceed in the intensity and duration those
induced by DA cell firing to environmental events.
 Food – increase dopamine by 100%
III. BIOLOGY OF DRUG ADDICTION  Sex 200% increase of dopamine
 If I give you cocaine – 1200% increase of dopamine
A. MESOLIMBIC DOPAMINE SYSTEM
It is everything about dopamine
Dopamine handles pleasure
Drugs are all about pleasure
The more dopamine, the more pleasure

- Major neural substrate for reinforcing effects of

psychostimulants, ethanol, nicotine and cannabinoids.
- Consists of DA neurons in the Ventral Tegmental
Area (VTA) and their target neurons in forebrain
regions such as the Nucleus Accumbens (NAc)

Page 4 of 10  ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex

 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY DATE February 10, 2010 (Wednesday, AM)
LECTURE Addiction Psychiatry LECTURER Dr Tolentino

Effects of Drugs and Natural Reinforces on Dopamine Raclopride Binding In Cocaine Abusers (n=18)
Levels in NAc Viewing a Neutral and a Cocaine-Cue Video

*** Viewing a video of cocaine scenes decreased

specific binding of [11C] raclopride presumably
from DA increase
o Raclopride – binds to dopamine
o Showed a former cocaine addict – neutral film and film of a
person sniffing cocaine
o Decrease specific binding of raclopride presumably from
dopamine increases

Effect of Cocaine Abuse on Dopamine D2

Receptors

 Haiti victim, They gave you food that looks like putik –
increase in dopamine would be 100%
 Food – slowly
 Supraphysiologic – too much, too fast! You have to
chase the increase in dopamine, so you take and take
and take
- NI studies have also documented a role in DA in
motivation which appears to be encoded by both fast as
well as smooth DA increases.
- Since DA cells fire in response to salient stimuli, the
supraphysiological activation by drugs is likely to
be experienced as highly salient (driving attention,
arousal of conditioned learning and motivation) and
may also reset the thresholds required for environment
events to activate DA cells.
o Salient features – relevance, friends, depression, stress
o You change! If it’s repeatedly 1000-fold, you’re usual activities
= under the sea. Para sumaya, you need dopamine increase
1000-level
 After 1 month, dimming
 After 4 months, whatever you’re taking, as a control, if you’re
not used to this, your brain still lights up and reacts. The d2
receptors are lower in addiction
 Kung repeated ang use mo of substance that increases your
dopamine to a 1000% - you get literally wasted
 Your dopamine is in a deficit
 Constant use, addiction, dopamine d2 receptors START OUT
LOW – your reward circuits are TOO LOW so you need MORE
 Non-drug abuser – you get stimulated
 Drug abuser – if too few, hindi ka matutuwa, you need more to
be rewarded
o Dependent on a lot of factors
o Genetic predisposition

Page 5 of 10  ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex

 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY
LECTURE Addiction Psychiatry
Dopamine D2 Receptors are Lower in Addiction
 In a non-addicted brain, not salient – no effect
 Such that, masmalakas control sa cingulated gyrus (CG);
More control  stronger inhibition; Orbital frontal cortex
(OFC) (decisions and executive thinking)  tells you to STOP
 Not much memory in the amygdala  “ok, whatever”  OFC
tells you to stop
 In addicted brain constantly exposed  highly salient
 Pakita mo lang, somebody sniffing  diminished control 
increased drive “go!”  goes to behavior to look for drug and
to TAKE drug
 Memory is increased in the amygdala that you know you will
feel pleasure if you take it again!
 You need drugs to increase dopamine receptors to make it
light up again
V. THE PSYCHOSOCIAL PERSPECTIVE
What causes addiction from a social and
psychodynamic point of view?
Social perspective on Etiology of Substance Abuse
- Peer pressure – shocking but substance use is normative
(normal) and purposive (with a purposive). Agree or disagree?
100% almost, there is NOBODY who hasn’t taken a drug here?
 Purpose? Rite of passage
- Poverty
- Personality characteristics
- Stress (representing coping)
 When people abuse substances to present coping
 Times of crisis = increase intake
- Financial
WHO Schematic model of drug use and dependence
Page 6 of 10
DATE February 10, 2010 (Wednesday, AM)
LECTURER Dr Tolentino
Psychodynamic Formulations
- Response to psychological suffering: an
attempt to feel “ok”, “better”, “not overwhelmed”,
“not panicked”, “not out of control”
- Self-regulatory Deficiencies: in self-care, self
development, and self-esteem, self-object
relationships, and affects. The ego must serve as a
signal and guide in protecting the self against
realistic, external dangers and against instability
and chaos in internal emotional life.
Go to another substance which “will regulate me”
Hyper people prefer downers
Some who are too shy prefer alcohol – becomes
boisterous and more bolder
- Impairment in Self-care: emphasis is on the
developmental and structural deficits in substance
abusers that make it difficult to regulate their
behavior. Thus drug dependents show a disregard
of possible dangers to heir “well-being” by using
abusive substances. Related to signal anxiety,
reality-testing, judgment, and synthesis.
Patients who turned out to be ADHD or bipolar and they
had to take shabu
ADHD – treated with amphetamine-substance; hyper-
active child; dopamine will make it salient
“Yellow prescription” – opium prescription
Pharmacologic properties of methylphenetate – increase
dopamine but very slow to decrease. Not addictive! They
are addictive but to the blackboard so they can focus.
Give hyperactive kid a drug but it gives that effect – all
about the saliency
- Vulnerabilities in Self-development and self-
esteem: the boundary between defects in the ego
and the self is somewhat arbitrarily drawn.
Need to take something to feel more confident
- Troubled Self-Object Relations: deficits in self-
esteem and self-development of the substance
abusers cause major problems in relationships.
They are experts in disguising their need for
nurturance, although these needs can be
excessive. They are at the mercy of their
“significant other” or external world to supply their
self- esteem, but they are paralyzed in asking for
validation.
Object relations, you will learn later on, how we develop
into our own object as we grow older. Separate from
mom and dad. Certain people are not successful there.
Ex: Borderline. You get diffused. Troubled self-object
relations.
- Deficit in Affect Tolerance: defined within 3
areas:
(1) state of the inner container of the SA which is
too porous, allowing contents (rage, anger) to pour
out uncontrollably;
 ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex
 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY
LECTURE Addiction Psychiatry
(2) The capacity to verbalize feelings (alexithymia);
(3) The capacity to fantasize (diasaffected, lifeless
emotional experience)
No definite boundaries
Capacity to verbalize feelings: Filipinos SHOW feelings;
we do not say it
So, for all of these, you need to take drugs
| QUIZ |
Question: What is more addictive, SEX or DRUGS?
Answer: It depends on the PUSHER. c:
Lesson 1| What did we learn so far?
- Addiction has a complex, multi-determined, multi-
faceted cause or origin. Even as biological factors
are at the forefront of current research and
understanding, the psychosocial aspects remain to
be important. No single entity can lay claim to be
the headline.
VI. TREATMENT TO DRUG ADDICTION
Doctor, Doctor, I’m Addicted!
“Recovery from the disease of drug addiction is often a
long-term process, involving multiple relapses before a
patient achieves prolonged abstinence.”
– National Institute of Drug Abuse
 You can abstain for 10-20 years and still go back
Question: What is the Favorite Junk Food of Addicted
Individuals?
Answer: Marijuana
Principles of Effective Treatment
- No single treatment is appropriate for all individuals  it
must be tailor-fitted to the patient in front of you
- Treatment needs to be readily available  Kulang ang
methods of treatment – we don’t have methadone here
- Effective treatment attends to multiple needs of the
individual, nit just his or her drug use
 Australia – there is a case manager that looks at different
dimension. Can be psychiatrist, psychologist, or nurse. Case
manager would tell you an integrated plan of treatment/action
- An individual’s treatment and services plan must be
assessed continually and modified as necessary to
ensure that the plan meets the person’s changing
needs
 Teenagers in high school – After, then what? Constantly assess if
they are taking drugs. Challenge them to a drug test – Undated
drug test. Immediately upon coming home, if they went out with a
drug-using friend, test them!
- Remaining in treatment for an adequate period of time
is critical for treatment effectiveness
 Success rate in addiction treatment is measure by RETENTION.
How long do you remain in your program? The LONGER they
remain in the program, the higher the success rates
Page 7 of 10
DATE February 10, 2010 (Wednesday, AM)
LECTURER Dr Tolentino
- Counseling (individual and/or group) and other
behavior therapies are critical components of effective
treatment for addiction
 Not just medication. Counseling has a role.
- Medications are an important element of treatment for
many patients, especially when combined with
counseling and other behavioral therapies.
 The more combined modalities involved, the better for the patient
- Addicted or drug-abusing individuals with co-existing
mental disorders should have other disorders treated in
an integrated way
 Dual diagnosis – substance abuse problem and psychiatric
problem = hardest to treat; need to treat both! If not, you FAIL!
- Medical detoxification is only the first stage of addiction
treatment and by itself does little to change long-term
drug use
 If one goes to detox, do NOT expect too much
- Treatment does not need to be voluntary to be
effective
 In the Philippines, there are lot of cases that are involuntary in
admissions. Along the way, they realize, it’s the best thing that
happened to them
- Possible drug use during treatment must ne monitored
continuously
 If I did a drug test today, and known addict is negative, does it
mean he’s not taking anymore? No!
 Drug tests only measure RECENT drug use.
 If I was taking marijuana, for the first time, I took it this Sunday
for a party. Today is Wednesday. If I took a drug test today,
will I still be positive? Yes.
 If I took shabu last Sunday, will I still be positive on
Wednesday? No. Why? What’s the difference?
 First time: 5-7 days (fat soluble)
 Chronic: if you stop on Sunday, you’ll be positive for at least a
month
- Treatment programs should provide assessment for
HIV/AIDS, hepatitis B & C, tuberculosis and other
infectious diseases, and counseling to help patients
modify or change behaviors that place themselves at
risk of infection
 It increasing in younger generation. Especially in CCP (call
center people)
 Gonorrhea is also increasing
- Recovery from drug addiction can be a long-term
process and frequently requires multiple episodes of
treatment.
Goals of Treatment
1. Abstinence or reduction in the use and effects of
substances
 To an alcoholic or chronic alcoholic, it should be TOTAL
abstinence and NOT reduction = neuroadaptation (even
with priming doses, to an alcoholic, one drink is one too
many)
2. Reduction in the frequency and severity of relapse
3. Improvements in psychological and social/adaptive
functioning
 Make sure they are abstinent, reduce in frequency, and
improve psychologic and social functioning
 ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex
 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY
LECTURE Addiction Psychiatry
Phases of Treatment
a. Assessment Phase
 How much they’re taking, what they’re taking, or attempts to
stop? Success or failure rates? Factors?
b. Treatment of intoxication/withdrawal
c. Development and implementation of an overall
treatment strategy
 Decide whether to do (1) detox then outpatient or (2) detox
then rehab
 Alcoholic Anonymous (we have this) – support groups
should be assessed
 Spiritual dimension included
Treatment
- Facilitating adherence to treatment plan and
preventing relapse
- Providing education about substance use disorders and
their treatments  a lot of addicts do not know about the
substance they are taking
- Diagnosing and treating associated psychiatric disorders
 Look into possibility that over 50% there is a psychiatric disorder.
Check possibility of dual diagnosis
A. Psychiatric Management
- Establishing and maintaining a therapeutic alliance
 Therapeutic alliance – even after he is treated, we are
monitoring constantly. We were able to preplan in an
outpatient setting; we are firm but they know we are
there to support them even through the relapses
 “You are not a failure even if you relapsed.” Doc says.
“Now let’s work on (number).”
- Monitoring the patient’s clinical status
 Baka bumalik yun psychosis
- Managing intoxication and withdrawal states
- Reducing the morbidity and sequelae of substance
use disorders
 Know about education, occupational or legal factors
 Follow up with a sequelae – what is it doing to your job?
Your relationships?
 In Philippine Airlines (PAL) – if they approach us, we pay
for their rehab. It increases their productivity 100-fold.
After treatment, they are usually there in the company.
They would avoid stressors (like the holidays) and work
productively.
B. Pharmacology Treatments
- To ameliorate the signs and symptoms of drug
intoxication or withdrawal
 For alcohol, so that they would not into seizure, we give
Valium (agonistic)
- To decrease the effect of an abused substance
(subjective reinforcing effects)
 Rather than feeling addiction, for heroin, you give
methadone (substituting)
- To make the use of an abused substance aversive
(e.g. Antabuse)
 If you took Antabus and took alcohol, you’d rather die. You’ll
feel headaches, nausea, vomiting, and dizziness. Seriously,
you’d rather die.
Page 8 of 10
DATE February 10, 2010 (Wednesday, AM)
LECTURER Dr Tolentino
- To use an agonist substitution strategy to promote
abstinences from a more dangerous elicit
substance (e.g. Methadone for Heroin addiction)
- To treat co-morbid psychiatric or general medical
condition
 Psychosis due to shabu intake – take atypical antipsychotic
Detoxification
- A “misnomer”
- Provides a setting in which a patient may enter
recovery from addiction
- Serves to eliminate only the physical dependence
upon the drug
- Does nothing to eliminate the disease (addiction)
Objective of Detoxification
- Enhance the removal of the substance (toxins) from
the body (to minimize its damaging effects)
- Treat or minimize the symptoms associated with
withdrawal  like seizures
- Identify and manage associated medical illnesses
which may or may not be related to substance use
 By the time addicts reach doctors, they’d have used
substances for at least 2 years. Manage also medical
problems
- Provide the initial setting for patient’s recovery
Detoxification Techniques
- Urine addiction therapy  enhance excretion
o Ascorbic acid 500 mgs – 1 gm every 6
hours until urine pH is 5.5
- Forced dieresis
o Mannitol 50-100 ml every 6 hours to
increase UO to 2 ml/kg/hr
- Multiple Dose Activated Charcoal (MDAC)
o Activated charcoal 50 mg in 100 ml water
as a slurry every 6 hours
Detoxification: Summary
- Detoxification programs are important initial
components in the treatment of substance abusing
patients
- These programs do not cure the illness (addiction)
- Pace the way for the recovery process from addiction
- Primarily done to help patients go through the
withdrawal phase with the minimum symptoms and
complications
- Address medical illnesses that are usually associated
with chronic substance use
**Rehabilitation: Therapeutic Community
 Philippines – popular in therapeutic community
 Therapeutic community – microcosm of bigger society
 Based on how you follow rules, you are given more privileges (to
call home, receive visitors, etc)
 Have rehab at least access to education – especially if it houses
adolescent population
 ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex
 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY
LECTURE Addiction Psychiatry
- Founded on a social learning model that fosters
behavioral and attitudinal change as a result of
membership in a community
- Through intensive peer-based approach, the client
learns pro-social values and address self-destructive,
and anti-social behavior patterns
- Offer individual and group counseling, family services,
medical and mental health services, and vocational and
educational services.
- A concept designed to provide clients with tools for
growth on an emotional, spiritual, and intellectual plane
- Clients attend:
o Morning meetings
o Encounter groups
o Seminars
o Static groups
o Request groups
o Skills development
- As they progress in treatment, they earn more
challenging and responsible assignments and a higher
level of status
Family Therapy
 Tied to a contract. Meaning, I’m married and my wife is an alcoholic.
Contract – if wife does not seek treatment, then we will separate. This
should always be tailored fit to your circumstance!
Stages of Treatment
 There should be an object, contract, management of crisis for therapy
1. Defining the problem and negotiating a contract
2. Establishing the context of chemical-free life
3. Ceasing substance abuse
4. Managing the crisis and stabilize the family
5. Family reorganization and recovery
6. Termination
Individual Therapies
Individual psychodynamic psychotherapy
Individual interpersonal psychotherapy
- Is psychotherapy effective with substance abusers?
It would have hard to follow when bangag ka.
 With substance abusers, the psychotherapeutic approach is
different. In normal psychotherapy, it is passive. The
psychotherapist of substance abusers, on the other hand, they
are more active, “I understand you did this, but why?”
o PT’c techniques have demonstrated robust positive
treatment effects with all major categories of
SUD’s.
o Traditional weekly, insight oriented PT sessions are
not appropriate tx for substance abusers who are
actively using or recently detoxified from
alcohol/drugs.
o Clinicians can modify psychotherapeutic
approaches or combine with other treatment
elements.
Page 9 of 10
DATE February 10, 2010 (Wednesday, AM)
LECTURER Dr Tolentino
Clinical Features Influencing Treatment
1. Psychiatric factors  consider hospitalization
a. Risk of suicide of homicide
b. Co-morbid psychiatric disorder
c. Use of multiple substances
2. Co-morbid general medical disorders  have HIV?
3. Pregnancy  conservative treatment! Think of baby!
4. Age: adolescents and the elderly  be more careful
Ex: “Lola Punk” – injecting Nubain, then substituted to
benzodiazepine and became addicted
Indications for Institutionalization
- Psychiatric or medical conditions that require close
observation and treatment, such as psychotic
states, severe depressive symptoms, suicidal or
homicidal ideation, and severe withdrawal
phenomena
- The inability to cease drug use despite appropriate
outpatient maneuvers
- The need to interrupt a living situation that
reinforces continued drug use
- The need to enhance or motivation or break
through denial
 Example: Patient lived-in with girlfriend (who is the pusher).
How can you stop? He had an epiphany to go to the
hospital for treatment and broke up with his girlfriend.
 For people involuntarily admitted – sometimes, we need to
create a crisis situation – a BREAK through their denial – so
they can be treated (they deny of being sick or needing
help)
Relapse Prevention
- Case management  case manager addresses different
dimensions of patient
- Educative programs that painstakingly help
patients find new ways to work, associate, and
recreate
- Empower patients  ask what they want
- Gently appraise them of their psychopathology
 common: personality disorders associated with substance
abuse
- Encourage them examine how drugs and
psychopathology have affected their lives
- Treatment issue like rule-breaking, lack of sharing,
etc., should be discussed
- Awareness of self-medicating behavior
- Repetition of concrete rules of behavior for
severely disturbed
 Treatment should be tailored-fit to the patient.
 At the end of the day, we won’t drop them into the basement. If
treatment does not work, teach them the Serenity Prayer.
Serenity Prayer
Lord, grant me the serenity to accept
the things I cannot change;
courage to change the things I can; and the Wisdom to
know the difference.
 ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex
 Pioneer Batch  Class of 2012
MODULE PSYCHIATRY DATE February 10, 2010 (Wednesday, AM)
LECTURE Addiction Psychiatry LECTURER Dr Tolentino

If all fails…
“Towards an ideal treatment program… Provide a
range of levels and intensities of treatment targeted
to individual patients’ needs.”

|Q&A|
Q: Champix? – To help individual to stop smoking.
A: Need to take Champix, 1-2 weeks before treatment. How does it work?
Positive reinforcement – When you smoke, you don’t feel pleasure.
Negative reinforcement – Set quit date as Valentine’s date to be more
meaningful. Just check on the dose
Q: Difference sensitivity in urine and blood drug testing?
A: First and foremost, you will end up with urine. At the end of the day,
gold standard would be urine. For now, it is not hair. Why? Hair is also
exposed to several things. Also, it may not reflect recent drug use.
They don’t have much hair. You need a couple of hair so you can
pound it and get substance out of it. It’s a patch of hair. Blood test is
hardly used. Gold standard is urine. If you are under suspicion, you
need to be watched.
If you get a license, you need to take a drug test. Where you pee,
there has to be a blue-ing agent. No other water source. (Rules of Happy Valentine’s Day
DOH) You cannot dilute. Once you give it to them, they put tape then and
hold it, it has to be body temperature. They also check color. They look 新年快乐
at specific gravity. Human urine only goes for a specific gravity. Then
Happy (Chinese) New Year!
babantayan ka, they will make you drink until you pee.
It’s a stupid test! It’s once a year test that you can use the drug test
valid for one year. If you’re using shabu, stop two days before the drug
test.

~ THE END ~

WHO Schematic model of drug use and dependence

Page 10 of 10  ChillPill: Jover, Lesh, Je, Hannah G, Jules, Judith, Alex