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Substance Use / Drug Use 
> >  > Modelling

Dr Xxxxx Dr Xxxxx : The newest model of drug use classifies opioid dependence as being driven By
Drug Liking,
Withdrawal and
Craving.

Craving Craving is a difficult problem for "Drug" Users.

 

Dr Xxxxx Dr Xxxxx : Drug Liking


Addictive drugs such as opioids, activate reward centres within the brain with sharp increases in brain chemical effects – activating opioid receptors and even dopamine receptors. With repeated exposure, the dopamine producing neurones fire in an anticipatory response to the conditioned triggers for using (presence of needle, presence of packet, seeing blood). Unlike “natural rewards” such as food or sex, addictive drugs bypass  satiation or saturation effects operating within the brain.

They continue to directly increase dopamine levels leading to “intoxication” or “binge” use. “Natural rewards” generally lead to more feelings of being full or satisfied, meaning you are more likely to feel you have had enough. Opioid drugs however continue to increase dopamine levels with repeated use, and accentuate heavy or “binge” use of opioids in the long-term.


The substance user/addict experiences  euphoria or feeling good – with using.


Their behaviour begins to focus on escaping the dysphoria which develops in the absence of the drug. This leads to more compulsive drug consumption, focusing on drug use and losing interest in previously rewarding relationships and activities.


Typical comments in this phase include “ I feel isolated” or “I feel sad”.

 

Dr Xxxxx Dr Xxxxx : Withdrawal


Repeated drug exposure reduces the dopamine reward response to both drug and nondrug Stimuli. The “anti-reward” or stress response system also becomes overactive. Absence of the drug gives symptoms of anxiety, dysphoria, anhedonia, depression as well as physical withdrawal symptoms. These emotional responses are deeply ingrained and take a long time (weeks perhaps months) to downgrade. Short term abstinence and detoxification do not up- regulate the dopamine reward response.
Substance users/addicts feel reduced energy, and reduced excitement and develop depression anxiety and restlessness.


Substance users/addicts feel compelled to use the drug to obtain temporary relief from physical symptoms of withdrawal and dysphoria. They continue using the drug even if they are losing much of the pleasure response.


Typical comments in this phase include “I can’t sleep”, or “I just can’t relax”.

Cravings Another person with "cravings".

Dr Xxxxx Dr Xxxxx : Craving

: a phase of preoccupation and anticipation


Changes in the brain’s reward and emotional circuits are accompanied by impaired signalling of dopamine and glutamate in the prefrontal brain cortex. This seriously impairs executive processes such as self-regulation and, decision making. This weakens the individual’s ability to resist strong drug craving.


Substance users/addicts look forward to using the drug, desire the drug and scheme and plan to get their drug.


Drug users/addicts are unable to stop or reduce drug use despite a strong intention and desire to do so.


Typical comments on this phase include “I’m wanting to use”, or “I just think about drugs all the time”.
Drug craving can be triggered by internal thoughts such as feelings as well as is physical or environmental factors. Examples of internal thoughts and feelings include: emotional stress caused by events such as the breakdown of a relationship, job loss or death of a family member or friend; even boredom. Physical triggers include seeing injecting equipment, seeing a friend using drugs or return to a location we used to take drugs.


The 3 drivers of drug liking/withdrawal/craving act as multiple forces for reinforcement of the cycle of dependence. Drug liking provides positive reinforcement of dependence while drug taking to avoid dysphoria during withdrawal provides negative reinforcement. Drug craving, in association with impaired higher brain functions (executive functions), provides a stimulus for reinforcement of dependence.


Typical behaviour changes are- using more drug than a substance user / addict initially intended, becoming focused on drug taking, becoming less decisive and less able to monitor and assess their own behaviour, having a reduced capacity to cope with stress, losing interest in previously rewarding relationships and activities including sex.

 

THC Marijuana The dreaded Marijuana.

 

Dr Xxxxx Dr Xxxxx : Drug use can start in many ways. We’re going to focus on the main common drugs of addiction: opioids (oxycodone – brands such as Endone, OxyContin, Targin; methadone;
amphetamines or speed;
sedatives – (benzos such as diazepam/Valium/Antenex//Serepax/Alepam/Murelax ;)
and marijuana/weed.


The first thing to realise is that drugs are enjoyable. People enjoy their drugs. Unfortunately this enjoyment has consequences. Very adverse consequences. There is a cost in using drugs in many different ways – not just financial costs.
No one is immune to drug use.


Erasmus Erasmus : Developing addiction is a very fine threshold.
Taking large doses of painkillers (typically opioids) because they are needed, for example as in cancer pain treatment or postsurgical treatment is not necessarily a problem.


Deciding that you “like” a painkiller such as an opioid, even if the doses are relatively low, means that you now have a problem.

In short, taking these medications to feel good is a problem.
Taking these medications to feel normal is not.


Dr Xxxxx Dr Xxxxx : I think there is likely to be a drug out there for everyone. Uppers or downers or feel gooders or sedatives or hallucinogenics / dreamers appeal to different people. You probably won’t like all of these different drugs. But it is very likely you may like at least one of them.


The main method of avoiding addiction and substance use – is not to try drugs in the first place. Substance use  / addiction has serious consequences in many aspects of your life. No matter how much better the drug may make you feel – nothing in your life changes. Your capacity to cope with problems in your life decreases as new problems emerge. Don’t be tempted to try them for any reason.


One of the new waves of substance use is of middle-aged and older couples becoming addicted to amphetamines.

Just don’t go there.

 

A common pathway to opioid use is deciding that you like how opioids/painkillers make you feel after an event such as surgery or injury. You take them because you need them and - then you “like” them.


Some people start on what are known as soft drugs such as marijuana. This becomes a gateway to the drug using community. You become exposed to drugs and to people who “push” drugs to help them solve their own drug problems, (earning money by dealing drugs , so they themselves can get more drugs).


Some people make the transition to illegal injectable drugs such as heroin. Heroin is an old drug, but still remains very very popular.
Some people remain using prescribed opioids – such as from the doctor. These can also be obtained on the street – for money.


Some people leverage using over-the-counter mixed analgesics (painkillers) and achieve a narcotic high by swallowing for example large doses of paracetamol/codeine or ibuprofen/codeine products. Cough medicines have also long been a path to this type of usage. Australia has recently enacted laws which make it difficult for addicted people to obtain cough medicines or compound analgesics over-the-counter. The usage of these medications has become monitored.

There are many other categories of drugs which are used or abused. I intend only to talk about the common ones.

Dr Xxxxx Dr Xxxxx : The first and most important issue to address, is that assistance to people with drug addictions must be based on their readiness to change.
If a person (A user) wishes to cease using drugs, there is a one specific group of strategies.
If a person (A user) does not wish to cease using drugs, there is another specific group of strategies.

Drug Craving Drug Use paraphernalia

You cannot successfully force someone to stop using drugs. In my practice, when family members bring drug addicted people to me for treatment, prognosis is dependent on the commitment of the drug addicted person. A substance user/ addict who has brought himself or herself to see me of their own volition and desires to stop using drugs, will have a 90% success rate in ceasing drug use on an ORT program. A substance user / addict who has been forced to see me by their family or significant others and told to stop using drugs (against their will), has a 90% failure rate in ceasing drug use.


Asking someone” You do want to stop using, don’t you?” begs a “Yes” answer. If the User is saying this to keep you on side, they will not be serious about stopping their drug usage.


BUT


Getting the substance user/ addict to say “I will stop using” can still be worthwhile doing, even if not said with commitment. There is a transition between saying it and committing to it. But in the long term, commitment is critical.



Erasmus Erasmus : So let’s look at the strategies for each of these cases.

Committed           Not Committed