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SUBSTANCE-RELATED DISORDERS
Substance use disorders are a significant public health problem with a wide range of adverse effects on individuals’ mental, physical, and social well-being. Mental health problems that co- occur with substance use disorders include depressive, anxiety, and psychotic disorders, as well as organic brain syndromes (American Psychiatric Association [APA], 2013). Substance use disorders share many of the same features but differ in pharmacology and associated behaviors that account for the unique effects of each substance (Boland & Verduin, 2022).
Alcohol, opioids, central nervous stimulants, cannabinoids, and tobacco are associated with substance disorders. Substance use disorders include cognitive, behavioral, and physiological symptoms that lead to intoxication, withdrawal, and dependence (APA, 2013). People with SUD have impaired functioning, regardless of presentation. Diagnosis is based on pathological patterns, but all substances activate the same brain reward pathway via dopaminergic neurotransmission (Paxos & Teter, 2019).
NEUROBIOLOGY OF SUBSTANCE USE DISORDERS
Substance use disorders (SUDs) are complicated physiologic and psychologic disorders with multiple intersecting factors, such as drug use behaviors and poor judgment influenced by the pharmacodynamics and pharmacokinetic actions of the drug (Boland & Verduin, 2022). The central element of drug dependence is drug-using behavior. Drug use initiates a cascade of rewarding or aversive physical, psychological, and social consequences that determine the likelihood of subsequent use (Boland & Verduin, 2022). The development and persistence of SUDs are primarily based on key components within the basal ganglia, amygdala (extended), and prefrontal cortex (U.S. Department of Health and Human Services [HHS], 2019a). The basal ganglia plays a role in positive motivation and pleasure, with key involvement in habits and routines in the reward circuit . Euphoria of drug highs are thought to produce overactivity in this circuit, causing chemical surges and signaling of endorphins and other neurotransmitters in the basal ganglia (National Institute on Drug Abuse [NIDA], 2020b). After repeated exposure, the reward circuit adapts to the drug, decreasing the individual’s ability to feel pleasure from anything except the drug (NIDA, 2020b). The amygdala plays a role in anxiety, irritability, and apprehension as the euphoria fades and the individual seeks the drug next high. The prefrontal cortex provides the ability to plan, solve problems, and demonstrate self-control (NIDA, 2020b). The circuit involvements of the amygdala and basal ganglia cause the individual to compulsively pursue drug use with very little impulse control. Since this is the last part of the brain to mature, teens are vulnerable to substance use. However, substance use disorder prevalence is highest among individuals aged 18–24 years (APA, 2013; NIDA, 2022).
Impulsivity causes the individual to act without forethought, the lack of reflection on previous behavior. They focus on immediate reward and display a failure of motor inhibition, choosing risky behavior while lacking the willpower to resist temptation (Stahl, 2020). Compulsivity is characterized by inappropriate actions which persist regardless of the situation (Stahl, 2020). Over time, impulsive substance use becomes compulsive addiction as this dysregulation becomes a dependent conditioned response. The impulses in the ventral loop of reward and motivation migrate dorsally because of neuroplasticity and engage in a habit system, creating the conditioned response of addiction (Stahl, 2020). Impulsive drug use produces a high, which, if experienced too often, causes the migration to compulsive use (addiction) to reduce the unpleasant effects of withdrawal. The mesolimbic pathway is hypothesized to be the final common pathway of reward and reinforcement in the brain, where all addictive drugs increase dopamine, especially with habitual use (Stahl, 2020; Wise & Jordan, 2021). Dopamine, the main neurotransmitter in substance use, is thought to reinforce pleasure rather than generating a direct effect. Pleasurable activities cause changes in neural activity leading to the formation of habit (NIDA, 2020b). Substance use causes powerful surges in dopamine, which lead the individual to repeat the activity without thought, leading to the drug habit. Daily activities in an individual’s life can trigger cravings, which can occur even when the drug has not been taken in a long time (NIDA, 2020b). The mesolimbic pathway is hypothesized to be the final common pathway of reward and reinforcement in the brain, where all addictive drugs increase dopamine, especially with habitual use (Stahl, 2020; Wise & Jordan, 2021). Addiction is now understood as a chronic, treatable brain disorder from which recovery is possible according to NIDA (2018).
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Book Code: AUS3024
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