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Alcohol And Substance Addiction Unit

1- What is addiction and what are the causes?

Addiction is to keep using a substance even it has negative effects on life and health Another characteristics of addiction is that the individual cannot stop using the substance after he/she started using it.

Addiction is a brain disorder and absolutely must be treated.

There are behavioral, social, biological and genetic causes of addiction but none of them, on its own, are sufficient to give a proper explantion. Although there are numerous factors contributing to the transformation of substance use into a addiction, it is a biological process in basic terms. The most important factors causing the individiual to start using a substance and become an addict are individual’s mental state, genetic predisposition, environmetnal factors, acces to substance, family structure, social environment and cultural feature

2- Who become substance addicts?

Firstly, it must be stated that all people using substance have the risk of becoming an addict. There is no substance we can safely use. In addition, people who are in search for new things, who easily take risks, people with a degenerate family structure, neglected adolescents, impulsive individuals and people with genetic predisposition are under higher risks

3- How the addiction develops?

Addiction is a vicious cycle. The individual firs take interest in the substance but, at the same time, he/she is afraid of the substance’s effects. If curiosity prevails over fear, the individual who starts using with the thought of “using for one won’t harm anyone” assumes that he/she will never use it again but the expectation never comes true. In the following phase, he/she denies that he/she has a problem regarding substance use and presumes that he/she has control and he/she can quit whenever he/she wants. To him/her, warnings of other people are nothing but exaggerated concerns.

4- The age of addiction?

There are numerous studies in many countries conducted with statistical methods regarding the starting age of addiction. In a study performed in Turkey, 2003, students in elementary and middle schools are included from 6 proovinces pcked from various geographical regions. This and similar studies indicate that the age of addiction has considerably dropped down.

How the addiction develops?

Individuals having substance abuse problems, start to take more of these substances than they intend. They are continuously engaged in futile efforts to quit or use the substances in a controlled fashion. They spend a lot of time on acquiring, using and getting rid of the effects of substances. Consequently, they neglect their daily tasks. Their attendance to school and academic performance decreases and they have arguments with their family. Their social circle changes and they start to come home at late hours, tell lies and spend most of their times in their rooms. Adults, on the other hand, have trouble in the workplace, don’t have enough neglect their families and constantly have arguments with them. In addition to all of this, they continue to use substance even though they are aware of the fact that they have physical and psychological problems. They make up your mind time over time to quit but never succeed. And because they didn’t succeed, they feel guilt and failure. To get over these feelings, they use more drugs.

5- What is the biological aspect of addiction?

It is known that a lot of areas in the brain such as Ventral tegmental area, known as the award center of brain; frontal cortex, which is responsible from numerous functions such as judgment, decision-making and urge control; amigdala which deals with the management of feelings and Nucleus Accumbens and Striatum which is related with learning etc. play an important role in the development of addiction. In each stage of addiction, changes appear in different areas of the brain. There for the development of addiction is a very complicated process. Normally, pleasure inducing stimuli such as art and eating cause the dopamin level to increase, which is located in the reward system of brain. Substance use, too, cause the reward system to release increased level of dopamin. And this dopamin enables the feeling of pleasure.

Under regular conditions, an individual has numerous purposes and he/she has decide on some of them. The occurrence of purposes, giving values to these purposes and choosing the action is related with frontal cortex. One of the important aspects of addiction is that the selection of these purposes, most of the times, stay limited to the ones related with substance use. In the course of time the release of dopamin, triggered by substance use, affects the frontal cortex, which results in making wrong decisions and the fact that preferred actions are limited to substance use. Additionally, dopamin also affects learning related areas such as Nucleus Accumbens and Striatum and causes the learning ability to degrade. Additionally substance abusers’ ability to learn, record and  remember new information are deteriorated as well. The repetitive and excessive release of dopamin, prevents the individual from having pleasure from eating, enjoying art and music, which are also called as natural rewards that normally give sufficient pleasure.

6- Is addiction genetically determined?

Research suggest that some people are predisposed to addiction. How is this possible? Individuals having abnormal genes for some reasons produce abnormal proteins which results in the production of abnormal enzymes and receptors. These abnormal enzymes and receptors causes irregularities in neurotransmitters located in the pleasure and reward path of the brain. Consequently, this forms the basis of control losses regarding substance use. Therefore, the genetically predisposed individual’s use of substance doesn’t just cause chemical irregularities but also initiates the process towards addiction. However, today’s technology is not advanced enough to conclusively determine who is genetically disposed and who is not. Therefore use of alcohol/substance poses numerous risks.

7- What are the substances causing addiction?

Anything that includes rewards may cause addiction. If we need to reduce this to substance, that is, we need to call it accessible substance rather than substance. Roughly, some of the substances identified up until today are tobacco, alcohol, ecstasy, cannabis, heroin, cocaine, inhalant substances (bally, uhu, gasoline, paint remover, ether, halothane etc.), LSD, GHB, several types of mushroom, ketamine, anabolic steroids, and methamphetamine. In recent years, people started to use substances which are chemical derivatives of cannabis and that cannot be detected in routine toxicology examinations.

However, the internet, as well, is a type of addiction.

It is becoming a widespread addiction especially among adolescent and young adults. While betting and gambling are types of addiction existed for some time, online betting appeared as a new concept which is also a type of addiction. Additionally, computer games, internet addiction, and online shopping addiction are some of the addiction types which must be treated.

8- Psychological aspects of addiction?

There are many psychological explanations trying to explain the cause and maintenance of addiction. Some of them are as follows:

a- Classical conditioning
The theory based on classical conditioning is used to explain the phenomena of urges and excessive desire which forms the basis of addiction and its development. Environmental stimuli related with substance use may become conditioned factors. For instance, while the smell of grilled fish at seaside would make an alcoholic to think of drinking alcohol, an insulin injection might trigger the urge of a heroin addict to use heroin.

b- Cognitive model of addiction
According to this model, the individual’s basic notion is activated by a critical event and this lead to addiction-related intermediate notions. And this, in turn, causes an excessive desire to use substance. Then, the excessive desire to use substance activates extremely tolerant intermediate notions leading to and allowing addictive behaviors. For instance, a child who acquired the basic notion of “a real man drinks alcohol” from his/her elders, develops the intermediate notion of “I must drink to prove that I am a man”. The individual who correspondingly develops a desire to drink alcohol starts to drink alcohol. From that point, any excuse becomes a reason to drink alcohol.

c-Stages of change Model
This model emphasizes change processes of people. The main concept is that behavioral patterns differ in different stages of change.

9- What are the behaviors causing addiction?

Of course, we cannot assert that just one type of behavior or lifestyle causes addiction, but especially in childhood, the attitude of families, the education received and religious beliefs play an important role in the emergence of addiction. In pre-school age, children having aggressive and ill-tempered dispositions are under risk because they are rejected by their peers and become isolated. After some time, they form social circles comprising from children with similar behavioral patterns and they start to neglect their education. In class hours, they hang out and go to cafes and their success in school deteriorates. Children of families who realize this problem and take necessary precautions may pull themselves together with a proper psychological, psychiatric and pedagogical support. Unfortunately, some families don’t present the required care or interest towards their children and, so to speak, they entrust their children to the streets. Parent attitudes have a significant role in the development of addiction. A mother who takes antianxiety drugs everytime she is upset, and a father that chain-smokes when he gets angry wouldn’t do much good for their children in dealing with stress. Children copycat the behaviours of the parents which they see as role models, thus when they face a problem they use the behavioral patterns which they are copying.

10- What are the psychiatric disorders accompanying substance use?

a- Substance use and psychosis
Nicotine, alcohol and psychostimulant substances are the most used substances which the psychotic patients use. Several studies showed that 70% of the schizophrenic patients smoke, more than 30% use alcohol and more than 20% smoke weed. When they are asked, most of them say that they use it for self-medication. They say that use alcohol for its relaxing effect and smoke weed to “shake off unpleasant moods”

On the hand it is known that in cannabis and its derivatives plays an important role in the development of psychotic disorders in predisposed individuals.

It is a known fact that stimulants such as LSD, Methamphetamine, Cocaine, Ecstasy cause hallucinations.

b- Substance Use and Depression
One fourth of the individuals diagnosed with major depression are also diagnosed with substance use disorder. It is also known that the individuals started using alcohol and other substances at early ages are more likely to suffer from depression in future periods when compared with individuals who don’t use. There may be some similarities in symptoms between the deprivation period of substance use and depression, so it is possible that this diagnosis may be overlooked. Additionally the depression of individuals who use substance frequently accompanied by anxiety and insomnia. The combination of substance use and depression poses a great risk regarding suicide. Therefore, these patients had better be treated as inpatients in the first couple of weeks.

c- Substance Use and Anxiety Disorders
While 30% of women and and 20% of men in society suffer from anxiety disorder, this rate is 50% among addicts. Substance use and other psychiatric disorders are interrelated. For instance, 4-5% of substance abusers also suffer from panic disorders and 16% of people having panic disorder also suffer from substance use disorder.

d- Substance Use and Adult Attention Deficit Hyperactivity Disorder
It is found out that 20% of the individuals having adult attention deficit hyperactivity disorder also diagnosed with substance use disorder and 50% of them have nicotine addiction. On the other hand, 50% of patients having alcohol, cocaine or heroin addictions also have attention deficit hyperactivity disorder. Due to the impulsivity and excessive curiosity caused by attention deficit hyperactivity, most of the adolescents tried many substances such as alcohol, cigarette, and weed. In this matter, preventive measures have a particular importance.

e- Substance Use and eating Disorders
Studies indicates that substance use disorder is related with binge eating disorder but not related with anorexia. Individuals with binge eating disorder, abuse substances such as diuretics and laxatives. Since they think it prevents weight gains, these individuals generally nicotine addiction. Early diagnosis and treatment of children with ADHD is of critical importance in preventing addictions. These young children experiencing attention and concentration disorders have difficulties in complying to the treatment because of the negative effects of the substances they use on their memory and other advanced brain functions. In comparison with individuals who don’t have ADHD, their motivation is lower and it is quite difficult for them to continue to their treatment.

f- Sleeping Disorders Caused By Substance Use
A common problem of people trying to overcome their addictions of alcohol and other substances is related with sleeping. Because, after a course of time, the sleeping problem manifest itself as a severe and explicit disorder which also might result in using alcohol/substance again. There are 4 types of sleeping disorders related with alcohol-substance use.

Insomnia: This sub-type is primarily characterized by having difficulties in falling asleep, maintaining the sleep or getting refreshing sleeps.
Hypersomnia: In this sub-type, the main complaint is constantly being in a state of somnolence.
Parasomnia: This sub-type is a sleeping disorder primarily characterized by abnormal behavioral situations related with sleeping or sleep transitions.
Complex: This sub-type is a sleeping disorder characterized by the symptoms of several sleeping disorders and which is related with a general medical situation.

11- What are the principles of Substance Use Therapy?

It is not appropriate that all substance abusers are treated with the same method. On order for individuals to be successful and productive in their family, social and professional lives, the treatment plan must focused on the proper needs and problems of individuals. The psychotherapy and the medication that are going to be used must be individual-oriented and planned exclusively.

The treatment must be accessible for 7/24. It is quite important that substance abusers who are having ambivalent thoughts about therapy must have access to therapy in the exact moment they decide to receive treatment.

For a treatment to be effective, the individual must be determined to solve his/her other biological, psychological and social problems in addition to his/her substance use problems. When planning the treatment, the patients legal, social, medical and psychiatric problems must be taken into consideration as well.

During the process, the treatment plan may have to be altered according to the patients needs and deficiencies. For instance, the patient might not have told the issues about his/her spouse at the beginning of the therapy; and when it is found out the recurrence of the illness is related with the patient’s issues with his/her spouse, couple therapy must be added to the treatment plan.

In order for the treatment to be effective, the patient continue to the treatment for a sufficient period of time. Studies show that the first 3 months after quitting the substance is extremely critical. Since most of the people applying to the treatment do not complete the therapy program, they have frequent recurrences.

In treating addiction, counselling services and behavioral approaches are very important. With regard to the improvement of problem solving skills, relationships with people, social and domestic functionality; there are significant benefits of counselling services and behavioral methods.

Medication has an important role in the therapeutical process. As previously explained in detail, drugs such as naltrexone (for opiate addiction) and accamprosate (for alcohol addiction) significantly contributes to the treatment of addictions.

Although detoxification of the body is the first and important stage of the treatment, it is not sufficient, on its own, in order for the addict to stay away from the substance. Detoxification therapy is performed as a preparatory practice for the outpatient care, which forms the basis of the therapy program, minimizing the physiological and psychological effects of deprivation. It is not sufficient on its own.

In order for the treatment to be effective, permissiveness is not a necessary condition. Today, almost none of the substance abusers voluntarily apply to therapy programs. On the contrary, a great number of patients apply because of compulsory reasons such as legal requirement, spousal pressure, or the risk being fired. Studies indicate that there is no significant difference between people that come mandatorily and those who participate voluntarily regarding the motivation, the period stayed in the program, and the period of “staying clean”.

It is known that some of the patients use substance, although it is sometimes for trying, during the treatment process. This must be inspected with tests conducted from time to time, because if such a situation exists it must be evaluated within the therapy process and the underlying causes should be investigated and confronted.

Therapy program also includes the examination of accompanying internal and neurological illnesses and related disciplines must be consulted when necessary. Hepatitis B, Hepatitis C, epilepsy, and cardiovascular diseases are some of the internal and neurological illnesses which is common among substance abusers. The scope of the therapy program requires these illnesses’ diagnosis its inclusion to the concerned expert’s treatment program.

Substance use therapy is a long term process where recurrences might occur and treatments must be repeated. Like in many other chronic diseases, substance us, too, may become severe and require intensive treatments. Both families and patients must realize that recurrences is not a sign of failure but a part of the process.

12- In what situations inpatient care is required?

  • Under the below-mentioned situations, the patient must be treated with inpatient care:
  • The patient’s response history regarding outpatient and follow-up care is not positive and the outpatient treatment have yielded no success for many times.
  • the patient has delirium tremens in his/her medical history or he/she has deprivational situations threatening other people’s lives.
  • he/she has a general medical condition in his/her history, which might threaten other people’s lives when he/she continues to use alcohol-substance during the treatment,
  • he/she has other accompanying mental disorders and there are active symptoms related to this disease,
  • The patient has the risk of hurting himself/herself or other people when he/she is left in a less restrictive environment,

The patient abuses more than one substances.

13- What is the content of the inpatient care? Biological Support Program

It includes both physical and psychiatric therapy. People having substance use disorder pose a higher risk of developing physical illnesses. For example, substances such as cocaine and ecstasy, which activate the sympathic system, increases the risk of cardiovascular and brain diseases and high blood pressure, and they also can cause cerebral hemorrhages and cardiac arrests. The fact that alcohol ruins liver functions and causes liver failure is a public knowledge. Therefore, patients using this kind of substances subjected to cardiogram, pulse-blood pressure monitoring, liver and renal function tests and the drug therapy is conducted if necessary. If the patient exhibits symptoms of deprivation, a vascular access is established and he/she is provided with serum and vitamin supplements. For instance, in the delirium tremens chart, there would be fluctuations in the patient’s conscious due to deprivation of alcohol and his/her vital functions would be in danger. In this phase, establishing a vascular access, providing a respiration support and giving B1 vitamin supplements will be a life-saving practice. If the B1 vitamin is given too late, permanent dementia chart might develop due to alcohol. After this emergency treatment, the patient’s psychiatric drug therapy is also rearranged. The purpose of using psychiatric medication is to relax the patient, reduce the disturbance, remove the urge to use substance and to alleviate conditions emerged after the substance use such as depression, anxiety disorder, panic, paranoia, insomnia, anorexia.

Preventing Recurrence In Substance Addiction

The most important matter in substance abuse is the fact that recurrences appear quite frequently. Recurrence is an important fact that addicts, relatives or people engaged in substance use therapy need to confront sooner or later. Therefore, preventing recurrence, that is, developing strategies to cope with the risk of recurrence is an integrated part of addiction therapy. A rough definition of recurrence would be the situation in which the individual having addiction issues starts to use substance again. However, this definition is incomplete, because trying for one time and starting to use again in a regular basis are two completely different things. As the scientific studies has shown, the first use of substance after a certain period of time doesn’t necessarily turn into extensive recurrences in which old substance using habits are regained.

Group Therapies

Group therapies help patients to confront their addictions, accept its harmful consequences and increase the motivations not to use substance. Patients learn several ways of dealing their emotional and interpersonal issues without consulting to stimulants.

14- What are the proper attitudes for families?

One of the most apparent problems noted in the monitoring and treatment of patients is the fact that there is no consensus within the family. Either because of this or that, there is always polarization between family members.

Therefore, there must be an agreement between family members and they need to form up a common language. Another important problem is that family members don’t abide what they decide. Even the slightest sign of pressure, make them step back from what they decided. And this leads to a situation where the addicts get what he/she wants. Adopting a determined standpoint, is one of the most efficient factors that prevents recurrence. The rules must be predetermined and everybody should do their best to comply with these rules. In cases where the rules are disregarded, no one should take a step back. Individuals addicted to alcohol and substance also are addicted to rewards. Therefore when the positive behaviors are rewarded and the negative behaviors are overlooked, he/she will continue to exhibit positive behaviors to get the reward. Regarding the reward, the emphasis must be on fulfilling emotional needs such as having shared quality times, or providing materials for the development of personal abilities and hobbies.



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