Substance Use Disorders

Substance use disorders (SUDs) represent a debilitating and damaging physical and mental health struggle for many.

Sadly, high rates of morbidity are also attributable to substance use disorders as they are responsible for the vast majority (~99%) of mental illness-related deaths globally (GBD 2016 Causes of Death Collaborators, 2017).

At present, contamination of the illicit drug supply in North America has resulted in the most severe drug-related crisis in history, involving a major increase in opioid poisonings and related death and morbidity (Kerr, 2019; Wilson et al., 2020; Wood, 2018).

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In Canada, below are the estimated lifetime prevalence of the following conditions.

18.1%

Alcohol use disorder

21.9%

Tobacco use disorder

6.8%

Cannibis use disorder

4%

Other substance use disorder (Pearson et al., 2015; Statistics Canada, 2015)

In the United States, below are the estimated lifetime prevalence of the following conditions.

29.1%

Alcohol use disorder

27.9%

Tobacco use disorder

9.9%

Other substance use disorder (Grant et al., 2016; Chou et al., 2016; Grant et al., 2015)

Etiology of Substance Use Disorders

As with all mental health disorders, the etiology of substance use disorders is complex and a detailed discussion of this is beyond the scope of this course. What is important to note however is that research has highlighted complex intersections of individual, social, and environmental factors that contribute to the development and maintenance of substance use disorders (Griffin and Botvin, 2004).

For example, Schepis et al. reviewed a range of underpinnings for the development of substance use disorders in adolescents, finding that a variety of neurobiological liabilities may converge with cognitive and behavioural traits linked to impairment in decision-making, affiliation with deviant peers, externalizing behaviour, and others to increase the risk of developing substance use disorders (2008). Furthermore, exposure to traumatic experiences, especially those occurring in childhood, has been linked to substance use disorders (Khoury et al., 2010).

Question

What is the role of dopamine in substance use disorders?

Substance use disorders have been linked to the dysregulation of dopamine in the mesolimbic system of the brain and issues related to impulse control (Grall-Bronnec et al., 2018; Yohn et al., 2019). As a result, we see a critical shift in neural circuits related to self-control, reward saliency, executive function, and motivation (Yohn et al., 2019).

Dopamine has especially been implicated in the maintenance of substance use disorders because the habitual use of substances decreases dopamine expression in the brain and thus decreases experiences of pleasure (Wise & Robble, 2020). The result of this is that substance use is neurochemically reinforced. This is because people who habitually use substances are motivated to continue to pursue pleasurable stimulus which releases dopamine, such as substance use, in order to relieve symptoms of decreased dopamine expression in the brain.

Outpatient Treatment Approaches for Managing Substance Use Disorders

Treatment approaches for substance use disorders have generally relied on a diverse set of interventions.

Non-Clinical Interventions

  • Peer support (e.g. mutual self-help groups like Alcoholics Anonymous)

  • Unstructured lifestyle interventions (e.g., mindfulness, yoga)

  • Alternative treatments (e.g., acupuncture, neurofeedback)

  • Activity-based therapies (e.g., art therapy, gardening therapy, equine therapy)

Clinical Interventions

  • Approved pharmacotherapies (e.g. medications known to reduce craving and rates of use such as varenicline in smoking, naltrexone for alcohol use, and opioid agonist therapy in opioid use)

  • Approved psychological treatments (e.g. cognitive behavioural therapy and motivational enhancement therapy)

  • Psychological counselling approaches to augment the above medical interventions (Miller et al., 2018)

  • Contingency Management (Pan et al., 2018)

References

Benzerouk, F., Gierski, F., Ducluzeau, P. H., Bourbao-Tournois, C., Gaubil-Kaladjian, I., Bertin, É., . . . Brunault, P. (2018). Food addiction, in obese patients seeking bariatric surgery, is associated with higher prevalence of current mood and anxiety disorders and past mood disorders. Psychiatry Res, 267, 473-479.

Berczik, K., Szabó, A., Griffiths, M. D., Kurimay, T., Kun, B., Urbán, R., & Demetrovics, Z. (2012). Exercise addiction: symptoms, diagnosis, epidemiology, and etiology. Subst Use Misuse, 47(4), 403-417.

Cheng, C., Lau, Y. C., Chan, L., & Luk, J. W. (2021). Prevalence of social media addiction across 32 nations: Meta-analysis with subgroup analysis of classification schemes and cultural values. Addict Behav, 117, 106845.

Chóliz, M., Marcos, M., & Lázaro-Mateo, J. (2021). The Risk of Online Gambling: a Study of Gambling Disorder Prevalence Rates in Spain. Int J Ment Health Addiction, 19, 404-417.

Chou, S. P., Goldstein, R. B., Smith, S. M., Huang, B., Ruan, W. J., Zhang, H., Jung, J., Saha, T. D., Pickering, R. P., & Grant, B. F. (2016). The Epidemiology of DSM-5 Nicotine Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III. The Journal of clinical psychiatry, 77(10), 1404–1412.

GBD 2016 Causes of Death Collaborators. (2017). Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet, 390(10100), 1151-1210.

Grant, B. F., Goldstein, R. B., Saha, T. D., Chou, S. P., Jung, J., Zhang, H., Pickering, R. P., Ruan, W. J., Smith, S. M., Huang, B., & Hasin, D. S. (2015). Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA psychiatry, 72(8), 757–766.

Grant, B. F., Saha, T. D., Ruan, W. J., Goldstein, R. B., Chou, S. P., Jung, J., Zhang, H., Smith, S. M., Pickering, R. P., Huang, B., & Hasin, D. S. (2016). Epidemiology of DSM-5 Drug Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III. JAMA psychiatry, 73(1), 39–47.

Grall-Bronnec, M., Victorri-Vigneau, C., Donnio, Y., Leboucher, J., Rousselet, M., Thiabaud, E., . . . Challet-Bouju, G. (2018). Dopamine Agonists and Impulse Control Disorders: A Complex Association. Drug Saf, 41(1), 19-75.

Griffin, K. W., & Botvin, G. J. (2004). Preventing addictive disorders. In R. H. Coombs (Ed.), Handbook of Addictive Disorders: A Practical Guide to Diagnosis and Treatment (pp. 535- 570). Wiley Publishers.

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Kerr T. (2019). Public health responses to the opioid crisis in North America. Journal of epidemiology and community health, 73(5), 377–378.

Khan, S. (2017). Concurrent mental and substance use disorders in Canada.

Khoury, L., Tang, Y. L., Bradley, B., Cubells, J. F., & Ressler, K. J. (2010). Substance use, childhood traumatic experience, and Posttraumatic Stress Disorder in an urban civilian population. Depression and anxiety, 27(12), 1077–1086.

Kwako, L. E., Momenan, R., Litten, R. Z., Koob, G. F., & Goldman, D. (2016). Addictions Neuroclinical Assessment: A Neuroscience-Based Framework for Addictive Disorders. Biol Psychiatry, 80(3), 179-189.

Miller, C. S., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2018). The ASAM Principles of Addiction Medicine: Sixth edition. Lippincott Williams & Wilkins.

Mills, J. G., Thomas, S. J., Larkin, T. A., & Deng, C. (2020). Overeating and food addiction in Major Depressive Disorder: Links to peripheral dopamine. Appetite, 148, 104586.

Pan, S., Gowing, L., Li, C., & Zhao, M. (2018). Contingency management for substance use disorders. The Cochrane Database of Systematic Reviews, 2018(9), CD010029.

Pearson, C., Janz, T., & Ali, J. (2015). Health at a Glance: Mental and substance use disorders in Canada. Statistics Canada.

Schepis, T. S., Adinoff, B., & Rao, U. (2008). Neurobiological processes in adolescent addictive disorders. Am J Addict, 17(1), 6-23.

So, R., Makino, K., Fujiwara, M., Hirota, T., Ohcho, K., Ikeda, S., . . . Inagaki, M. (2017). The Prevalence of Internet Addiction Among a Japanese Adolescent Psychiatric Clinic Sample With Autism Spectrum Disorder and/or Attention-Deficit Hyperactivity Disorder: A Cross-Sectional Study. J Autism Dev Disord, 47(7), 2217-2224.

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Yohn, S. E., Galbraith, J., Calipari, E. S., & Conn, P. J. (2019). Shared Behavioral and Neurocircuitry Disruptions in Drug Addiction, Obesity, and Binge Eating Disorder: Focus on Group I mGluRs in the Mesolimbic Dopamine Pathway. ACS Chem Neurosci, 10(5), 2125-2143.

Young, K. S., Yue, X. D., & Ying, L. (2011). Prevalence Estimates and Etiologic Models of Internet Addiction. In K. S. Young & C. N. de Abreu (Eds.), Internet Addiction: A Handbook and Guide to Evaluation and Treatment (pp. 1-17). John Wiley & Sons, Inc.