Now we move into substance abuse.
Abusing substances. Let's do some drugs.
So,
moving past a few things here to get to what's on your test.
I had to go to jury duty is morning they did not select me so,
I only missed my first class today, but
my goal is to get you all through all this and hopefully I won't miss one of
these classes.
Expectancy Effect. When one uses drugs one
tends to get the affect that one expect to get
from a drug unless they have no expectation.
In which case, anything goes. It's kinda of situation based.
Expectancy Effect is a real thing. It's akin to placebo
in the sense that if you believe that you have a good time
doing a drug you're more likely to have a good time.
If you believe that the drug might kill you or your really scared you're only
doing it to go along with other people
you might have a horrible experience with a drug.
A placebo works in a similar sense, I think I've given you this example.
They've done studies where they take people and put them into
contrive laboratory situations, total strangers to one another,
and they start giving them mixed drinks. Then they
have them rate their social interactions and how comfortable they feel
and predictably the more drinks they have
the more comfortable they report feeling and then observationally you
can see them loosing up and they start having conversations and they get more
comfortable with one another.
And then you say what accounts for that? They like, "Oh well I had a couple of drinks."
But in those cases they actually didn't have any drinks. They had
Virgin Daiguiri or non-alchoholic mixed drinks.
So it was their belief that they were drinking alcohol
and the belief that drinking alcohol makes you more socially facile
and comfortable
that led to them becoming more socially facile and comfortable
and they attributed to a drug they had not taken. So it's a fascinating what can
happen
with a lot of different drugs. Now there are certain drugs and certain doses of
drugs
Expectancy Effect really doesn't matter. You hit certain levels of certain drugs
you're going to become unconscious or you're going to risk death or you're going to have
potentially horrible experiences because most drug effects are dose-dependent.
And most users of drugs are not extremely sophisticated users of drugs
and I should hasten to mention that most people who manufacture illegal drugs
are not chemists. It ain't Breaking Bad. It ain't the high school
chemistry teacher that's manufacturing your meth.
It's some dude with zero training in chemistry
messing around with highly toxic stuff hoping that his buddy's recipe works out
and doesn't kill him.
And if it doesn't, you might get to buy some and hopefully it wouldn't kill you.
That's the kind of system that you're working with
in the current structure. The way we have it is a really interesting way to have
it. We've already talked
long ago about the opponent process theory.
When you're high, you are going to come down,
but you're not going to come down the baseline. You're gonna go
past baseline in the opposite direction. If you took an upper,
you're gonna get down. So
somebody's had too much alcohol will have a hangover.
Right? They had too much alcohol, they get so down you can even wake them up. They pass out
pass out. Right?
And then it takes a while to get over the effects of the drug
and recover and come back to normal consciousness. For people who are
taking downers. Well, alcohol is a downer,
uh, for the most part, but if they take downers, then they get
kind of, really jittery and a very fidgety
and uncomfortable, possibly nauseous in other words
you have this pleasant experience followed by an unpleasant experience,
which becomes a model for classical conditioning.
Your body like homeostasis. It doesn't want to be pulled dramatically
from its
normal set of mood and perception. When you pull it
from its normal state way in one direction,
it will counteract that and go in the opposite direction and then make
connections
with what were previously neutral stimuli.
(Music alarm on phone begins indicating end of class) That was a previously neutral stimulus, but it means it's time to go.
Ya'll have a great day and I'll see you on the next time.
So where we left off last time was at point of process theory. We're looking at
substance abuse as a class of disorders in the diagnostic and statistical manual
of mental disorders. The DSM 5th edition, so DSM 5.
We talk about Expectancy Effect and we just started getting into Opponent Process
Theory.
So the idea with Opponent Process Theory you could remember all the way back when we
talked in the learning chapter
about how addictions are so difficult to treat because there's so many
complex features of them that are not known to the general public. People
like to,
to label people in negative ways and then just the assume that there's something
fundamentally wrong with them. Rather than realizing all humans
are susceptible to mental disorders any type including substance abuse and
there's some pretty interesting processes that underlie this
and that we can put to our advantage in trying to correct things. So
an increase in positive feelings is then followed by the increase in negative
feelings. You go up
and then you come down. Go back to that that particular video if you if you get
a chance
it need a refresher. So, you know, you can get high but then you're gonna crash.
So eventually the body learns that. Right?
When you're in a certain environment drug administration is likely to happen
and it will signal cravings. It will then put your body in a negative state
anticipating the administration of the drug
so that you don't get out of balance, but come back to balance. In other words,
your body is trying to predict the use of the drug to prevent you from going
out of
It is now conditioning itself to respond to environmental stimuli that were
previously neutral,
but have been associated consistently with the administration of a drug
which would be unconditioned stimulus
that causes a withdrawal fact and now
the environment causes the withdrawal effects. In other words it causes the
feelings of cravings. So those cravings then
make people want to use. And I've explained before,
you put somebody in rehab for thirty days then the internal
triggers to those cravings will be extinguished when they get out.
But then they go back to where they came from or their work or their job or their
vehicle or whatever where they do drugs before
and that environment and the stimuli environment will trigger cravings
as though they always had them. That's a spontaneous recovery, that conditioned
reaction. And if they use the drug at that point
it's bad, bad situation. They don't usually know this very few people teach
this
and you should if you get the opportunity to people who are dealing with addictions.
Uh, if they can get past that craving
and not use then the craving will go away slowly
and stay away longer. In other words, you have to extinguish all these other environmental
stimuli that's causing the craving.
But if you administer the unconditioned stimulus drug again, most people think, "Oh
gosh," I just need to get a
over this all rough patch. They don't see themselves about to engage in full blown
addiction again,
but they're at risk for full blown addiction again because administering that condition
stimulus now makes
all the great things come back as I they never been extinguished, as they had
never been to rehab,
and that is a huge challenge when you try to treat substance abuse. So
we look at this situation where people
have this increased need for a higher dose
to get the same effect and eventually doesn't matter what the does is you don't
get much of an effect
out it, but you need the drug to feel normal.
Your body is so adapted to the use of the drug by environmental stimuli predicting
its use
that you don't get much of a high out of it, you don't get much of a buzz off of it, but you need
the drug
to stave off the cravings which are the withdrawal symptoms which
are often experienced has terrible, depending on the drug.
And believe me that works with any drug. Cigarette smoking is a prime example.
We'll be talking about a lot of drugs other than tobacco.
But I just talk to a person yesterday who told me that here it is
I think seven years later after a stop smoking class that she'd taken with me
way back
in family medicine that she's finally 15 days off those cigarettes.
And had she tried time and again, but the cravings were so powerful, the irritation
was so massive,
the discomfort was so unbearable that every time she quit before she was
unable to maintain it.
She had nightmares. She had sweats. She had all kinds of stuff. Those withdrawal
symptoms kept her going back to the cigarettes. And being off the cigarettes, all
these other things in the environment would trigger the cravings
even though she was no longer physically dependent on the nicotine.
So it's a powerful thing to understand. Substance use
is different then maybe some other ways of conceiving it. Now,
the DSM no longer looks at a distinction between abuse and
dependence. And that's fine. I like to distinguish these because I think it's
important understand
how we conceptualize drug use in our society.
And when I say drugs I'm talking about caffeine and nicotine and alcohol and
marijuana and every other illicit drug that you can imagine including prescription
pills and heroin and meth. You name it.
We're talking about all these together here. So
substance use is simply ingesting a psychoactive substance.
Moderate amounts it doesn't really interfere with functioning.
So for people who smoke cigarettes it has a long-term negative health effect,
but it doesn't make him crazy, it doesn't make them crash a vehicle, it doesn't make them
have fights with people typically speaking.
It doesn't have much effect at all because they're at the point where they're
just
using the drug not to feel the cravings. It doesn't really have an effect on them.
Right? People do this all the time they use alcohol
responsibly. They use it in a manner that society accepts. They take a couple of drinks
at maybe dinner and that's it. They don't get crazy drunk. They don't
get in a place where their risky, driving a vehicle intoxicated,
they don't have fights, they don't get in you know into arguments and things
like that.
So they use the drug responsibly. Well that can be for any drug.
People don't want to admit that, but that's true I know people who
have used cocaine who are upstanding members of society. I've never used cocaine.
I used alcohol and marijuana extensively. I have not been, uh,
I haven't used alcohol in almost twenty years and I haven't used marijuana in a
little over 10 years.
Actually, short term memory loss,
just over 13 years. So
I'm talking about these straight up. Not with a moral bent
where I think I'm better than anybody else not with a moral judgment in mind
with a practical understanding.
Because emotions get in the way of our clear thinking sometimes.
So when you look at people using drugs, can you use cocaine
in any kind of way that would be normal. Well,
cocaine wasn't even illegal until the early 1900's, In
other words
all society had access to this drug. If the world's was going to go to hell in a
handbasket because of drug use, it
would've done so before 1920's and 30's. All those drugs were
legal. Every drug was legal.
They tried to prohibit alcohol and you see what it did.
Probation did not bring about the end of alcohol use, it brought about
organized crime and terrible societal consequences as a result.
So bad that they were repealed this constitutional amendment
and now it's a commonplace drug to use.
Right? We got Nascar and organized crime
as a result of the trying to prohibit the use of alcohol.
Because it was a drug that many people want access to.
And it is a drug. Sometimes they say alcohol and other drugs.
Alcohol is a drug. It's a drug that has been defined by society as one that
under certain circumstances
can be used in an appropriate fashion. So "use"
means that you're just simply not causing problems
for yourself or other people. You're using it, you modify your consciousness briefly,
however long the effect of the drug is in a mild way and it doesn't cause problems
for you or other people.
Abuse causes problems or has the potential to cause problems.
Abuse could be long term or could be short term.
So it's a pattern, could be a very short pattern, of leading to distress or impairment.
Fights, fist fights, arguments,
crashing vehicles, falling down stairs, uh,
which would be hazardous situations. Maybe over sleeping because you had a
hangover.
Losing a job losing, losing a raise, losing the respect of other people.
Those things can happen with abuse. Abuse could be a pattern that happens on
weekends.
So for the, for the binge drinker, maybe they don't drink at all during the week.
And then once a month perhaps, they just tie one on so to speak
and have real problems result as a consequence.
If someone once had a lot of tequila,
first time they ever had a lot of tequila and they fell down the stairs and busted their face
open.
That was a hazardous situation. That was an abuse in one situation
vs. an abuse over time. But the people
don't have a need to use and there's a difference there
that you lead into dependence. Depends is a need to use
the drug whatever the drug is. If it's alcohol, if it's
tobacco with the nicotine in it, if it's caffeine, because you don't want the
headaches from quitting your caffeine and drinking your coffee.
If it's heroin, if it's meth, if it's Oxycontin,
you need it. You need it to function.
So it's a maladaptive pattern of use characterized by
an increased need to take in higher and higher amounts to achieve the desired effect,
that's tolerance. It causes negative effects
when it's withdrawn, so you have the withdrawal symptoms, you have the
cravings, but cravings aren't just
I really want something. Cravings are very powerful experiences of
suffering. People might get nauseous, they might get
feverish, they might get a jittery, they might get
uh, whatever. They certainly get agitated and
the drug removes that. And so there is this power need to get hold of the drug
to avoid this negative withdrawal symptom.
So, you also usually have unsuccessful efforts to control use.
Where a lot of effort is expended seeking the drug or recovering
from it's effects. So, you see the distinction I hope between use, which could be socially
appropriate no matter what drug is no matter what you think about drugs.
Substance abuse,
which is where you have to stress an impairment or hazardous situations is a
possible
outcome. And dependence we have this chronic use
where you need high levels to get the desired effect and usually desired effect
becomes eventually
stating of these withdrawal symptoms. And you have people like,
"I could quit, I could quit", but then they really can't quit. They try
but they fail and they feel bad they think they're a failure.
But this is a point at which they really become addicted
to the drug and they will spend a lot of time seeking
it out and recovering from its effect. And multiple dependencies are common.
So often times people will have dependency on more than one drug.
And that might be tobacco and alcohol. It might be tobacco or marijuana.
It might be alcohol and Ocycontin. It might be anything.
But comorbidity between substance dependencies are common.
But substance abuse
is interesting when we start to look at it societal level because we try to
legislate and regulated
it. In certain cases you can even have dependence without
abuse. Such is in the case of cancer patients using morphine for pain control.
So my grandmother
never touched alcohol as far as I know. She didn't touch
tobacco, she didn't touch any drugs. He lived a life
clean and sober. Never had an issue.
And then and the last stage of her life she had cancer and it
created such great pain that eventually when she was in the hospital they used
morphine to control it.
And the last days of her life the pain was so great that the morphine couldn't
control it. Now she wanted heroic effects taken to try to stay alive. She was scared to die like
most people. And I loved her and she had great faith
in God and, and she taught me some of that. But at the same time there's this woman
who's afraid to die and she said please do whatever you can for me.
And what they could do at that point was try to alleviate the pain,
but the very end the pain was so bad that she would just writhe in agony
when she had the full morphine drip. They couldn't go any higher legally
or ethically, but at that point it wasn't doing any good so they
didn't quit it either because to do so would have killed her. She couldn't have
handled withdrawal symptoms. They could have
tapered it down, but she didn't have many days left. They just left her on it. she was
dependent on morphine
at that point because as part of a prescribed medical regiment.
For a lot of people who wind up abusing prescription drugs that oftentimes how
it starts, they
take them for a legitimate need. Medical community prescribes it to them
and then it has other effects that they become dependent upon.