Addiction Prevalence, Symptoms & Course | Addiction Counselor Academy

Everybody to this video on addiction prevalence, symptoms and course. I'm your host, Dr. Donnelly Snipes. Using the past 30 day statistics in 2012 from the National Survey on Drug Use and Mental Health. The survey reported that 6.5% of the population over the age of 12 reported heavy drinking. And I know you're like, in 2024 now, why are we talking about 2012? I'll get to that. And 9.2% of people reported illicit drug use. Now, they're still kind of loosey goosey on that whole illicit drug use thing. Since marijuana has been approved or legalized in a lot of states, even for recreational use, but they haven't changed it on the National Survey on Drug Use and Health. So they ask about marijuana usage and they include that under illicit drugs. Depending on your state, depending on your locale in that state, and obviously whether somebody's using it for medical reasons like medical marijuana, or they're using it for recreation, it may be a little bit different. But this gives us a general idea. So that was in 2012. According to the 2021 report, 14.3% of people reported illicit drug use. Now you may be like, wow, that's a five point increase. It is. But how many of those people that we see the increase with is due to them answering, yes, I smoked marijuana because it's legal in my state, so I don't know that our illicit use, our, our use of illegal drugs is actually going up that much. I don't know that it isn't, but I don't know that it is. And 5.8% of the population over 12 reported heavy drinking. All right, now, number one, over 12. That's kind of heartbreaking that we have a lot of people that are not legal that are drinking, but it went down from 6.5% to 5.8%. Could that be because more people who were in engaging in heavy drinking were switched over to using marijuana? Possibly. But I can tell you from personal experience with friends and family and colleagues, there's a lot of drinking that goes on. And what most people consider heavy drinking is way heavier than what is actually defined as heavy drinking. Heavy drinking for a female is more than two glasses of wine per day. And I know a lot of my friends who it's more like half a bottle of wine a day, but they don't really consider that heavy drinking. So I don't know how accurate these statistics are. But is it. It is interesting to note that when you look at the Overall numbers in 2021, it is roughly 20 people reporting some sort of heavy drinking or illicit drug use. Now, each of those people is not independent. Some of the people who may be in great engaging in heavy drinking may also be being counted for illicit drug use. So we want to take this, I hate to say with a grain of salt, but it does give us an understanding that there's probably at least 10% of the population out there that that is unduplicated in these stats, that is struggling with a substance use disorder. And that doesn't even begin to count all the behavioral addictions like gambling and Internet gaming and just being on the Internet, shopping, eating, sex, pornography, lots of things that aren't even being counted there. But I digress. Addiction, it's important to know, is not a diagnosis. You can't look in the DSM 5TR and find addiction and the criteria for it. It is a description, not a diagnosis. Addiction, whether it's behavioral or chemical, erodes a person's self control and ability to make sound decisions. The DSM 5 and 5TR has three categories, intoxication withdrawal and substance use disorder. So it's no longer substance dependence and. No, we have three categories. Is the person intoxicated? Yes or no. Are they in withdrawal? Yes or no. And if they're not intoxicated or necessarily in overt withdrawal, do they qualify as having substance use disorder? Addiction is a primary chronic disease of brain reward, motivation, memory and related circuitry. And we're going to talk about this more in, in future classes. But it's important to remember that when people use, whether it is sex, porn or cocaine, they are causing their brain to have to rewire. They're flooding their brain with toxic levels of certain chemicals and their brain reacts by rewiring it. So it does cause physiological changes. It causes physiological changes in the reward system. Dopamine and endogenous opioids. Endorphins are two of the chemicals that are integrally involved in addiction. However, both dopamine and your endogenous opioids are responsible for a whole bunch more than just reward and motivation. They are involved in energy, they're involved in pain perception, they're involved in mood. When you alter levels of dopamine, it naturally alters levels of norepinephrine and serotonin and GABA and glutamate. So you can't monkey, if you will, with any of the neurotransmitters without affecting all of his buddies. And it's important for us to remember that in recovery, people are going to go through a process where their brain has to re. Remodel, if you will. It remodeled when it was, when the person started using to protect itself. Once the person is not using anymore, then it has to take down those barriers, if you will, and reconstruct the neural circuits that were destroyed. Dysfunction in these brain circuits leads to characteristic biological, psychological, social and spiritual manifestations reflected in a pathological pursuit of a reward and or relief by a substance or process. And I think it's important that we remember the process part of it. Because in addiction treatment, especially residential treatment centers, a lot of times the focus is on staying clean, not using cocaine, not drinking alcohol, not smoking weed. All right, well, that's important, true. But when people start replacing that with process addictions, they're creating a situation where they're flooding that neurocircuitry again and they're going to maintain the dysfunctional brain circuits and part of recovery is backing off so the brain can realize, hey, I'm not going to be flooded anymore. I can rebuild without treatment and, or engagement. Addiction is a progressive condition and can result in disability or premature death. Most addictions are going to take a toll on the body, whether it is gambling, gaming, sex, alcohol, cocaine. When we start causing stress on the body from surges of these neurochemicals as well as deficits or the withdrawal features, we start to trigger the stress response. When that stress response is regularly triggered, it causes inflammation throughout the body. That inflammation throughout the body has a variety of problematic effects, from, you know, pancreatitis to liver problems to gastritis, lots of GI problems. But it can also worsen other conditions and make a person more susceptible to stress related illnesses. Now, this definition of addiction, remember I said it's not a diagnosis, it's a definition. And it is what is put forth by the American Society of addictions Medicine in 2011 and the National Institute of of Drug Abuse in 2007. Now, I'm hoping that NIDA will kind of come into the future and start acknowledging process addictions, but that's not where their funding lies. So okie dokie. It is important for your exam that you're going to take eventually to understand this definition of addiction. To know this definition of addiction, kind of like the back of your hand, just putting that out there. Characteristics of a chronic disease. Many people don't like that term disease. They're like, well, it gives people an excuse to use because they say they have a disease. No, it doesn't. We have to recognize, however, that this behavior that they engaged in using chemicals or engaging in, in other behaviors Caused biological changes. Just like when you get a virus, it causes changes in your body and it is technically a disease. It disrupts normal functioning. Well, yeah, if somebody qualifies as having a substance use disorder, they've got disrupted normal functioning. It has serious harmful consequences. Yeah, check that block. It is preventable. Yes, it is. If people don't start using, then they won't develop an addiction. However, we need to ask ourselves, we, we can't start there and say, well, just don't use. People used for a reason. People started using because it numbed the pain. People started using because it helped them feel more comfortable recreationally, because it helped them relax. And then life threw them a curveball and they started using a little heavier and their body started getting used to it. So then when they weren't using, they felt like crap. So in order to get rid of the pain, if you will, the withdrawal symptoms, they would use again. We do know this, but preventing people from being able to access a substance is foolhardy. If we look back over way back in alcohol prohibition, if people weren't able to get it legally, they were making moonshine, they were finding other things to use, they were using LSD and all kinds of other stuff. So just taking away a substance isn't going to prevent addiction. Making it harder to get it might help some. Ultimately, we need to address those underlying issues that cause people to start using in the first place. Educate them about tolerance so they don't develop it, and start making sure that we have resources that are available for early intervention. Chronic diseases can last a lifetime. Once you've learned that, hey, if I do this, wow, I feel a lot better for a few minutes, I may not feel a whole lot better the next day, but, but it takes the edge off or it makes me feel better for a few minutes. You don't forget that you can learn to delay gratification. You can learn to tolerate distress so you're not using and causing a cascade of issues in your life. However, it's back there in the back of your brain. You don't forget something that you've learned. So if the pain gets bad enough, people are going to be tempted to relapse. Addiction is a chronic lifetime disease or condition that people are going to have to cope with. And when they start using or when they start using again, if they think, hey, I can sober up and I can start using socially, in most cases, they have difficulty stopping because they start using and it feels really good. And then they start chasing that high. Can I say that? Absolutely. Nobody out there can use recreationally after they've had a substance use disorder? No. Can I say that I know of anybody who does? No, I can't say that either. It's important that we do understand, however, especially when we're dealing with some of the process addictions and even food addiction. People can't go without food. We can't say, well, you've got to abstain. So they're going to have to learn how to manage that. Most people are not going to choose to go without sex, so they're going to have to learn how to manage that. But it's going to be something that they have to manage for the rest of their life. When they start to get stressed, that may be their go to response because it's easy and it's there and it's accessible. And it can be fatal if left untreated. And now again, we have to look at what we're talking about. We know alcoholism can be fatal if left untreated. It starts causing problems in the gut, it starts causing liver problems. It can cause him hepatic encephalopathy. It can make people a lot more vulnerable to cancer. Yes. So it can be fatal if left untreated. It also prevents people, for example, from absorbing a lot of nutrients that they eat. As a result, they start becoming malnourished and a malnourished body is a lot more susceptible. All right, so let's talk about thresholds though. Let's talk about actual diagnosis to meet the criteria for a substance use disorder. And I keep saying substance use disorder because that's what's in the DSM 5tr. That is the diagnosis right now. There is a diagnostic code for pathological gambling. There is a potential diagnostic code for Internet addiction. But none of our other process addictions are actually in the addiction category. Does that mean that we ignore it? Heck to the no. But it does mean that if we're making a diagnosis for billing reasons, we may have to choose a different diagnostic code. I digress. So if we're talking about a substance use disorder, person must have two symptoms. Two symptoms in a 12 month period. And I do want to point out that tolerance and withdrawal are symptoms, but you can have two other symptoms. You don't have to have tolerance or withdrawal to qualify as having a substance use disorder. That is a huge misconception that a lot of people have. If you've watched my other videos, you know, I am a big fan of mnemonic devices, especially if you're going to have to do something On a test. So the criteria for substance use disorder. I have the mnemonic device TW crap out. It was all I could come up with. I don't know who. Who TW is or why he crapped out, but that's the diagnostic stuff. So T stands for tolerance. When somebody needs more of the same substance, person, or activity in order to get the same feeling, the same relief, that's tolerance. That's the body going, hey, no, you're overwhelming me. That's too much. We can't go there. And you go, oh, yes, we can. Your body goes, no, no, we can't. It builds up walls. You figure out ways to go over those walls. Withdrawal. Experiencing withdrawal symptoms, including cravings when not using, when. When people. And we're going to talk about psychological and physical withdrawal, but when people go through withdrawals, it's their body saying, I don't have enough of this. Our brains, our bodies are designed to have a very specific balance of hormones and neurotransmitters to function, to run the hypothalamic pituitary adrenal axis, hypothalamic pituitary gonadal axis, and hypothalamic pituitary thyroid axis. You don't need to know those axes for your test, but those are your three axes or three of the main axes that keep your body functioning. And they all work together. They're all interconnected. You, when you alter levels of estrogen or testosterone or progesterone or even oxytocin, it impacts the levels of dopamine, serotonin, norepinephrine, acetylcholine. It. It's all interconnected. So when someone has developed tolerance and then they're not using, they're not getting those floods anymore, and the brain is going, we're out of balance. We need something. What happens? Stress response is kicked off. The person becomes agitated, irritable, starts craving that particular substance. Which takes us down to cravings. Not exactly sure why they have withdrawal and cravings separated, but they do. So cravings. If a person is spending an inordinate amount of time thinking about desiring that particular substance, that's a craving. It's or any related substance. And it's important to recognize that if they can't. Again, when I worked in residential treatment, theoretically, they couldn't get substances. And why do I say theoretically? Because I've worked with people in jail, in prison, and in residential treatment. And where there's a will, there's a way. So does do residential treatment centers occasionally get contraband in them. Yes. And let's just be honest about what actually is going to happen. But I digress. Cravings. If you can't access your substance of choice or your addiction of choice, you're still dopamine and other stuff deficient and your body is going to go, we need something. We need something to take the edge off. So the person may move to sugar, to caffeine, to sex. I learned when I was in teaching resident or working in residential that drop ceilings, if you navigate them correctly, can actually hold a person while they crawl across from the men's side to the women's side. Cravings, adrenaline is another thing that some people will use in order to quell their cravings because it gets that dopamine rush going. Repeated attempts to quit or control use that feel fail. If you tried to cut down or you tried to quit and it didn't work, that's what we call a clue. The amount of time spent obtaining, using or recovering from use is excessive. So we want to think about not only the amount of time the person was watching porn or using marijuana or cocaine or something. We also want to include in that. How much time were you obsessing about it when you were at work, when you were at home, when you were supposed to be doing something else else, and how much time did it take you to recover from use? And recovering from use may be not so bad for some things. But for other things like in relationship, especially toxic and and abusive relationships, the time spent recovering from that is that use that engagement can be pretty significant if there are physical injuries involved. So we do need to recognize that. We need to recognize that there are a lot of things that can become addictive. Addictive behaviors are used to numb or quell pain or discomfort, whether it's physical or emotional. That's pretty broad right there. P stands for precluded or reduced activities because of substance use. Did you choose not to go over and play tennis with your buddy or go play golf or go to your kids recital because you would rather use, you'd rather go to the bar, you'd rather stay home and watch porn, you'd rather do something else? Well, that's another one of those clues. If you're giving up things that are important and you're making the addiction more important in your life, it's a problem. Ongoing use despite harm. And this is another one that's pretty broad. Is it causing harm to you physically, financially, legally, at your job? Is it causing you harm, your self esteem? Is it causing you depression? Is it increasing Your pain, you know any of any areas, any of the pieces of your life, if it is causing harm and you continue to use knowing that, that it's causing harm, it meets that criteria. Use in risky situations. When it comes to substances, using while you're driving, using while you're at work, when it comes to porn, using while you're at work, for example, that's one of those risky situations. If somebody finds out, you probably going to get fired. And finally, trouble with social relationships caused or made worse by the effects of use. If your relationships, your, your healthy relationships start distancing themselves and the relationships that you are engaging in tend to be people who are using and as we say in recovery, co signing on your, then that's a problem. You only need two of these criteria to appear at some point over the course of 12 months to diagnose somebody with a substance use disorder. So it is a pretty loosey goosey kind of diagnosis which makes it good if you need to diagnose them for some reason so they can get treatment. So they can, you can bill for treatment. But it also in my opinion can be overused a little bit. When we talk about severity, somebody with mild substance use disorder has two or three of the symptoms in a 12 month period. Moderate four or five of the symptoms and severe six or more of the symptoms. Remember it can be any of the symptoms. There's none, no symptom that has to be there. And that's also important to remember. Early remission. None of the criteria except craving have been met for at least 3 to 12 months. Why is craving exempted? We're going to talk about this a lot when we get to the video on post acute withdrawal. But when people are in early remission that first 12 months, their brain is still remodeling, which means they're going to have cravings. Hopefully those cravings are getting less intense, less frequent and frequency, intensity and duration and lasting a shorter period of time. One question that comes up is what about what does that mean for people on medication, assisted therapy? If they are taking buprenorphine or Suboxone or methadone, Those are some of your main ones. Not Vivitrol for alcohol. What does that mean in terms of use? Now Vivitrol is probably not going to be an issue, but the other ones are at least partial opioid agonists. So it's kind of interesting to think about are they in early remission? And there's a lot of debate about that. I doubt a question that's that Specific would be on your test. Sustained remission. None of the criteria except craving have been met for 12 or more months. What does this tell us about relapse potential? Well, if none of the criteria except for addiction or except for craving have been met for 12 or more months, that means the person very well may still have cravings. Post acute withdrawal often takes a while. It's not just a 6 month thing or a 12 month thing. Depending on how heavy, how long the person used and their genetics and other things. It can take a couple years for them to get back to feeling what is normal for them. And it's important to recognize this. When people are having cravings, they are at high risk for relapse. When those cravings come, they can be very strong. It doesn't mean they have to act on them. They can have that craving and choose something else to do with it. According to Nadak, recreational use means the person doesn't have a substance use disorder. Mild substance use disorder is characterized by using to obtain obtain a specific effect in a specific context. Binge using is kind of interesting because a lot of people who binge use don't develop tolerance. They often don't have withdrawal symptoms. I mean, they may have one wicked hangover, but they don't have withdrawal symptoms but they are using super heavily. Pregaming is another example of a mild substance use disorder. Somebody may drink or smoke before going to a football game in order to loosen up. Those are all things that you know. It's a low level of use. And again, this is according to nadac. If you are taking the NADAC test, this is probably important to know. Moderate substance use disorder is an addictive behavior that is engaged in almost daily in low to moderate doses to achieve relief from a persistent problem or maintain a desired level of performance. I had a person that I worked with at one point who used marijuana and they literally couldn't figure out how to do their job. When they were clean, they had been, they learned it while they were stoned and they went through were able to do their job while they were under the influence. But when they sobered up, they got stressed out, they couldn't remember what to do next. So they kept using at a low level in order to be able to function at their job. Unfortunately, they got injured. Workers comp, they got found out, blah blah, blah, you know how it goes from there. And severe substance use disorder is daily use and developing tolerance and withdrawal. Now remember, that differs from the DSM criteria and I think it's important that we understand that it does differ from the NAADAC criteria. However, you know, it's a good general rule to figure out is this person going to fall under mild, moderate or severe. So let's apply the criteria to mild, moderate, severe and binge. Somebody who has a mild substance use disorder, remember we'll go back here. They're using occasionally binge use pregame for a desired effect. Are they going to have tolerance? Probably not. Withdrawal? Probably not. Cravings? Probably not, but maybe some psychological ones. Are they going to have repeated attempts to quit or control use that have failed? Well, if they're using to self medicate social anxiety before a social situation, then yeah, they're probably going to have difficulty here. The amount of time spent obtaining, using or recovering from use that could apply. Have they precluded or reduced activities because of substance use? Probably not. With mild use, they're using in order to theoretically enhance their ability to do something. Do they continue to use despite knowing it's causing problems in their life? Possibly. If their spouse says, you know when you pre game you're a real jerk for the rest of the day and the person goes tough, diddly winks, yeah, that's a problem. So we do need to recognize that. Are they using in risky situations? Are they drinking at their house before they go over to a buddy's house to watch a game or something and they're driving while they're intoxicated, That's a risky situation and trouble with social relationships. So you can see there are several of these characteristics that may appear in mild. In moderate the person has a persistent issue that they are basically self medicating and this could be that they are self medicating their own tolerance and when they're not using they don't feel like they can function effectively or they may be self medicating, depression or pain or something else, I don't know. So we want to look at this. And it also can be social situations. Maybe they really hate their job, so so they are drinking at noon or something in order to get through the day dealing with their crazy boss. I don't know, just speculating. But when people are using on a daily basis, even low to moderate amounts, it's possible for some people who are sensitive to develop tolerance and withdrawal symptoms. It's unlikely if they're using in low amounts, but it is theoretically possible. Are they going to have cravings? Well generally the physical cravings are not going to happen unless they are tolerant and in a withdrawal phase. But it's very possible they're going to have psychological cravings. And that's because they know that there's a way to make the pain stop. And, and they're feeling this pain and they just, they're trying not to reach out and use that solution. But you know what, it's there and they're thinking about it, they're like, oh, I can make this stop so easy. Repeated attempts to quit or control use. And this is one of the things I was referring to earlier, stopping use. Well that's great, but if you don't address the reasons that you were using, then it's going to be really hard to stay clean. It's going to be really hard to stay clean. The amount of time spent obtaining, using or recovering from use, well, this is getting probably bigger now. If you're using every day, then you've got to keep your stash up all the time. Precluded or reduced activities because of substance use. Very rarely is this actually seen if somebody is only using in a mild or or moderate way. But is it possible? Sure. Ongoing use despite harm use in risky situations and trouble with social relationships. Anytime somebody starts engaging in an addictive behavior, it is to numb a pain, to stop a some sort of distress. And when they can't access that self medication, then they tend to become more irritable even if they're not withdrawing from the substance. If they again that psychological dependence, if they can't access it, they may feel more anxious, more angry, more depressed. And the use itself is temporarily numbing the problem, but it's also keeping them from getting help for that underlying issue. And then severe. When somebody is using heavily, they are going to develop tolerance. That's just the way the brain works. Which means they're going to have withdrawal symptoms, they're going to have cravings, they're like they're going to have repeated attempts to quit or control use. Why does that not work? Well, because their brain has rewired itself to expect the drug. And when they don't have it, then there's a cascade of problems and whatever caused them to start using in the first place is still there. And they've probably made some choices along the way that's kind of worsened. And that issue kind of like getting a cut and instead of cleaning it out, you just slap a band aid on it and hope everything goes well. No, you got to clean out what's going on underneath the amount of time spent obtaining, using or recovering from use. A person who is tolerant needs the substance in their system to feel okay, which means that's going to be a pretty primitive drive for them. So, yeah, a lot of things are going to go to the. Go by the wayside and it's going to take a lot more time. They're going to keep using despite harm. The lesser of two evils, this pain over here, or my spouse being mad at me or getting fired from my job. Oftentimes the pain is so over overwhelming, so, so complex that the pain wins out. I just. I need to numb it. I can't even. That's overwhelming to even think about dealing it with it. So you can see how all of these can apply, and you can see how there may be different presentations. And I didn't do the math, but there can be a multitude of different presentations of addiction based on which symptoms a person has. The physiological course, the use of the substance, or the process causes surges of pleasure chemicals that are rewarding. Hey, this feels pretty good. The person repeatedly seeks the reward. We've all done it. If you like riding roller coasters, you know that you get this rush and you're like, wow, that was awesome. I'd love to do that again. So when you've got a vacation, you may go to the theme park and ride roller coasters. You're seeking that reward. We all seek things that produce pleasure. That's how we're wired. The brain is set to function with a certain amount of stimulation from neurotransmitters in a certain proportion. This is called homeostasis, and it's bolded because this very well may be a term on your exam. Homeostasis means balance. This is the way it. Everything is in a very particular balance. And when people occasionally drink or occasionally ride a roller coaster, the stuff gets thrown out of whack for a second. But then everything rebalances and it's all. All okay. If you've been to. Let's use that amusement park example again, and you ride the roller coaster 15 times, God help me, you're probably going to feel pretty dagum exhausted at the end of the day because you've burned through a whole bunch of dopamine and other neurochemicals as well as physical energy. What do you do? You go home, you go to sleep, you sleep like a baby. You wake up the next morning, all is well with the world. But people who regularly engage in this behavior, the brain doesn't have a chance to heal and rest and restore and rebalance. So it's out of homeostasis and it stays out of homeostasis. These repeated surges of those pleasure chemicals causes an overload. The brain adapts to the overload and becomes resistant or tolerant to, to the neurochemicals. It says, you're giving me all this dopamine, but it's just too much. It's too hot, too exciting, too whatever word you want to use, it's just too. I can't handle that much stimulation, so I'm not going to pay attention to it. I'm not even going to acknowledge it's there. Now when the person's not using, the brain doesn't have enough to function normally. The brain gets adapts to these surges because remember the brain says, I'm not going to pay attention. And the person with the addiction says, oh yes you are. If this doesn't, this amount doesn't help me feel better, then I'll double it. And that's the addicted brain. If one works, two is going to be better. And recognizing that the person with the addiction has intentionally overridden the brain self protected mechanisms to prevent overload, which is, which is what causes the eventual remodeling. The brain goes, okay, you know, let's figure out how we can defend ourselves. When the person doesn't have enough. We'll just say dopamine for simplicity. But these pleasure chemicals, when things are out of homeostasis, it triggers the stress response. The person will be irritable, they'll lack focus and they'll have obsessive thoughts generally about the addiction, what they need to do in order to feel better. And they'll have physical cravings. The brain's trying to get enough neurotransmitters to function. It's like the brain's saying, but, but you promised you were going to make the deliveries every day. You were going to bring me some stuff. And you're going, well, yeah, I know, but now we're not doing that anymore. So there's a, a, a disconnect. The person uses enough to override the brain's protective barriers and it gets rebalanced. So we're still in the addiction building process. The brain strengthens its resistance to the surges. The person uses more or harder addictions to override the increasingly strengthened protective barrier. In porn, this means looking at harder core stuff. In chemical addictions, it may mean moving from alcohol to cocaine or using them concurrently. It may mean going from beer to tequila. Ultimately the goal is to intensify the stimulation of the brain. So it wakes up, right now it's tolerant. It's basically sleeping through the lower levels. So we got to get it to wake up. Because the drive is for pain reduction. The addiction becomes the person's best friend on the outside and a lifeline on the inside. To everybody else that looks like, hey, Jim Bob is choosing alcohol over his family. And yeah, that's what it looks like. Inside is the person's lifeline. Jim Bob is saying, if I don't choose this, I feel like I'm going to die. Tolerance means the body needs more of the substance to get the same feeling. And I have substance with asterisks. Because what we're really saying is the body needs more of certain neurotransmitters, certain brain chemicals to get the same feeling. And it will do whatever it needs to do to get those brain chemicals. Like I said, the person's drug of choice is cocaine and they can't get it, they will do something else in order to try to get more of that dopamine, more of those endorphins. Going dependence is when the body's adjusted to the new levels of neurotransmitters and now requires regular administration to function. Acute tolerance is an immediate reaction to the substance as the body attempts to reduce the substances effect on neuronal activity. And, and people, when they immediately use, they start having certain feelings and it's the brain's way of going, hey, what the heck is that? Things are all out of whack trying to figure out how to adjust. Reverse tolerance develops when there's an increased sensitivity to the substance as a result of brain or liver changes. People with alcoholism very often exhibit reverse tolerance as their liver functioning starts to go down. Used to take a whole lot to get them drunk. Now it doesn't take very much at all because their liver can't process it. On your exams you may see these terms in actual practice. Acute tolerance is just one of those things, you know, happens to everybody, but it's not something that you're ever going to diagnose, if you will, in clinic. So just kind of trying to help you recognize what terms you need to remember and really hone in on. And which terms are you need to know for the test. Cross tolerance means the tolerance extends to similar substances. If someone is using opioids, for example, then similar substances include barbiturates, which are sedatives, benzodiazepines, which are anti anxiety medications or even paint and inhalants. All of those are depressant on the symptom on the system. Now opioids obviously engage the opioid receptors which the other ones don't do as much or don't do at all, but the ability to help the person feel calmer maybe helped out here. And one of the things we see, and we'll go into this during pharmacology more, but some people who take opioids actually feel more energetic when they're taking them. And I don't know about you, but I've had opioids in my life and they knock me on my butt. However, the patients that I've worked with who have had opioid addiction and has given them energy have been ones who have extreme anxiety. And the opioids actually blunt the anxiety. So they're not using so much energy being stressed out. They finally feel free for a minute. So it's kind of an interesting thing. People who use opioids and tend to feel more energetic feel like their uber selves are at really high risk of also becoming cross tolerant or using barbiturates or benzodiazepines. Paint is a, is a system depressant. It just melts your brain cells. But I've known people who last ditch effort it was available, they were going to use. Sorry y'. All. Cocaine and amphetamines are both stimulants. So people are going to be more likely to be cross tolerant to those two classes of drugs, if you will. Now, you'll notice marijuana and alcohol aren't on here. Alcohol actually has stimulant as well as depressant properties, which means it kind of goes with everything and, or can be cross tolerant with everything. And marijuana is kind of in its own little area. But a lot of people use marijuana to help them relax, which means you want to look at the underlying reason that they are using and you can identify the substances which they're more likely to also gravitate toward. Signs of dependence. When we talk about physical dependence or neurological dependence, we're talking about reduction and reduced sensitivity of the receptors, killing brain cells and literal neural remodeling. The way the body takes in information responds to neurotransmitters, it changes. Dopamine is responsible for a lot of things. As I mentioned earlier, Motivation, energy and mood are three of the big ones. When people's dopamine is low, they're going to be exhausted. When their dopamine is low, they're probably not going to be in the best mood and they're going to have a very low level of motivation. Dopamine is my, I've got some energy, I want to do it again. Neurochemical norepinephrine provides focus, energy and helps with Mood serotonin is involved in pain regulation, mood, sleep, as well as hunger and satiation. Endorphins, your in internal opioids are involved in pain and pleasure. And cortisol is not a neurotransmitter, it's actually a hormone, but it is helps you have energy. Cortisol is a chemical that's released when you're stressed out. When somebody is engaging in addictive behaviors again, when they flood the system, that's a threat. And then when the stuff goes out, often times it goes out faster than the body can adapt. So that's a stressor too. So you've got stress coming and going. So cortisol is constantly being secreted, which means the person is going to develop something that we call glucocorticoid resistance or cortis, resistance to the cortisol. So at a certain point, the cortisol is not going to function as well. To help the person get excited, to get motivated to do things, we need cortisol. Cortisol peaks in the morning to help us get the energy to get out of bed, and it declines throughout the day. All those other neurochemicals, if dopamine's out of whack, all of his buddies are going to be out of whack, which means all of those other issues, focus, energy, mood, sleep, pain management, all of those things are likewise going to be out of whack. And the person is going to be physiologically struggling. If you've got somebody in early recovery, and I use that term very loosely, it can be a week, it can be eight months, and they're showing low motivation, they're showing fatigue, lack of energy, irritability, mood swings, that's post acute withdrawal. They're still somewhat physiologically dependent on that substance and the body is still trying to adapt. Psychological dependence are the mood effects of the neurochemical imbalances. So when you're using and all those neurochemicals get out of whack, then you're probably going to feel pretty dagum cranky when you're not using. All right, so that's a sign of psychological dependence. You're going to be irritable because of the physiological dependence. You're going to be irritable because those neurotransmitters are out of whack. You're also probably going to be more irritable due to the stress response, since that stress response gets kicked off when you use as well as when it's leaving your body. Even if you're not dependent physiologically. Dependent, then you're probably going to have some irritability. And if you have consumed alcohol enough to have a really bad hangover in the morning, you probably have an idea of, you know, what your, how your mood might be impacted when you are as a result of the stress of trying to rebalance after that night. And you can also have psychological dependence because you're conditioned to, to use and you are irritable when you're unable to access that goal. Remember I said earlier, you know that there's this thing out there that can make the pain stop or that feels really good and you know it's out there and, but you can't have it. It's kind of like a little kid in the toy aisle seeing that there's a toy there that they really want or the candy aisle and their parents saying no, you can't have it and they get angry. Makes sense. Per Naidac, the recommended treatment depends on the severity, types of adverse effects, what their symptoms are and the available resources and motivation of the person. Yes, that is true. And, and we need to take into consideration their age and their cognitive functioning. Is it appropriate or the best placement for a 16 year old to be put in residential? Is a 16 year old going to be able to get to intensive outpatient? I don't know. We need to look at their age. We need to look at their cognitive functioning as well. They may be 30, 40, but they may have alcohol related dementia so they're not going to do as well in residential treatment. I've had somebody with alcohol related dementia and residential treatment and it was not productive. It was a very bad placement. We also need to consider other issues. I had another person who was in residential treatment who was, who had an intellectual disability and her IQ was probably somewhere between 65 and 70. She was doing good to get through her activities of daily living and putting her in residential treatment was not helpful. It was not healthy. She was surrounded by a bunch of neurotypical people of relatively average or above average intellectual who also had some addictive thinking behaviors that made her much more vulnerable to being taken advantage of. So we want to consider what is the best placement for this per particular person based on their age and cognitive functioning. In addition, we want to look at their concurrent physical and mental illnesses. Do they have intellectual disabilities? Fetal alcohol spectrum disorder. We'll do an entire course on that because it's that important. But one of the interesting characteristics of FASD is the person may not have phys facial features. So don't assume that they have to have the facial features. No, they don't. It's on a spectrum. And they also may be able to talk at the level if they're 23, they may be able to talk at the level of a 23, 24, 30 year old. But the, the information that they take in their receptive abilities, their, the information they understand coming from others is more like eight. Yeah, okay, big disparity there. So they can talk a good game, but they may not understand a dagum thing you're saying, which again means they're not going to do well in residential treatment, especially residential group treatment and non substance induced dementia if they have Alzheimer's, if they have some form of dementia. We need to pay attention to what their needs are and the best placement for them because there are a lot of settings that are not going to be able to meet their unique needs that come along with cognitive disabilities and physical issues. If somebody has chronic pain, if they have fibromyalgia, if they have pots, postural orthostatic tachycardia syndrome, they are going to have very specific needs throughout the day, every day. Can your facility or can the facility you're referring them to accommodate that? And if not, then another placement is going to be imperative. The next section next week we will discuss the models and theories of addiction. Addiction is a progressive brain disease that over time results in loss of neurons, brain cells as a result of the neurotoxic environment and, and rewiring of brain circuitry to adjust to surges of excess neurochemicals. Addiction occurs along a continuum from mild to severe. When making a diagnosis, it's important to look at all of the symptoms for that individual. It's also important to identify the underlying and concurrent issues that. Did they have depression prior to starting to use? Okay, well then that's a co occurring disorder. Did they develop depression when they were using or when they sobered up? Well, that's still a concurrent disorder because guess what, a depressed sober person ain't going to stay very sober very long unless they get the skills and tools to deal with it. So we need to make sure that, that we aren't overlooking issues like trauma, depression, anxiety, emotional intelligence that a person needs in order to achieve their highest level of recovery. Okay, so we have made it through. I told you this one was going to be kind of dry and I proved my point. What questions do you have about diagnosis? About addiction itself, Tolerance, if any? I know working in treatment centers I was exposed to a wide range of issues. My first job out of graduate School. I actually worked as the liaison to probation and parole. And all of my clients were on probation and they came to outpatient treatment. So that was something that was unique. And a lot of people who are involuntarily referred to treatment are going to deny any problems. They're going to deny any. Any of the symptoms that we listed. But we do know they've got at least one. And guess what? That is the continuing to use despite problems, despite that substance causing problems in your life. And some of my clients would say, hey, but I don't use. I'm a dealer. I. You're still addicted to dealing. If you continue to deal despite it causing you consequences, you know, at the very least, at the very worst, we may be looking at antisocial personality, but let's look at addiction and trauma first. I really want to de. Stigmatize a lot of that. And look, a lot of drug dealers, to be brutally honest, don't make that good a money. They are in it because it makes them feel powerful, it makes them feel important, it makes them feel needed, which all addresses issues that are related to abandonment anxiety. So could that theoretically be an addiction? Yeah, but from a novice counselor's point of view, I struggled the first few months in that position because people would come and they'd answer all my questions. So the screening said, hey, they don't have a problem. But then I look at their rap sheet and it was six pages long. Drug offense. Drug offense. Drug offense. Drug offense. Drug offense. Well, that's what we call a clue. And I did have an out with that because the judge, as part of their probation, had mandated treatment. But I struggled ethically at the beginning giving them any sort of substance use diagnosis because I was really looking for somebody to meet all these criteria, and that's just not the way it was. And I was looking for somebody who was. Had tolerance or withdrawal. Well, all these people were coming out of prison, so most of them had been clean for a while. Not all of them, but most of them. And those are the things that they don't really tell you about when you're going through diagnosis of substance use disorders. And we also miss a lot of people because people who binge drink, I remember in college being around the fraternities and sororities and ROTC and everything else, and there was a lot of binge drinking on the weekends. Did it cause them harm? Were they using in excessive amounts, more than they intended? A lot of times, probably. Was it causing them problems in their functioning well, without looking at their grades or talking to their significant others, I can't tell you. But I do know of a couple of people who flunked out their freshman year because of binge drinking and alcohol use. So there is a lot of. There are a lot of addictions that we miss. And gambling is another one that is hugely popular, especially now that you can do online gambling, which wasn't even a thing when I was in college because I'm that old, but the ability to play poker online and watch porn online and stuff now, and, oh, gaming. Gaming is crazy. Once the metaverse becomes a thing, because it seems like it's a reality now, not just a possibility, in the next few years, the metaverse will be a thing. I think we're going to see Internet addiction just skyrocket, where people, if they're not at work, they're going to have their VR headset on, and they are going to be in a virtual world. And you can argue that there are some benefits to it, but you can also argue that that may distance them from the people in real life. Think about how often you're talking to somebody and. Or you're eating dinner and they're sitting there playing on your phone, and you feel like you're getting fubbed, I guess is the new term for it, snubbed by the phone. Well, it's going to be worse than that because they're going to have a big old headset on. But I digress. All right, Charles, Sarcastic. Do compulsive behaviors and OCD count as a form of addiction, or is that in a different category? Really interesting question, Aubrey. Actually, it is a different category. Ocd, Obsessive Compulsive disorder is its own diagnosis and its own category. But for a long time, people argued that addiction was actually a obsessive compulsive behavior. And they've continued to argue that a little more vehemently now about process addictions like Internet addiction, like Facebook or social media addiction and other things. Is it an addiction or is it ocd? Doesn't matter. Ultimately, what we're looking at is the symptoms, and we're looking at. And. And the neurobiology is very similar between both of them. So we're looking at somebody who obsesses about this thing a lot, and they feel compelled to engage in that behavior or use that drug. So how do we help them address it? Well, first we got to understand what's causing these obsessions with somebody with OCD that typically starts out as an anxiety disorder, typically starts out as a fear of something. Then they feel relieved when they take certain actions. So then you start getting into a pattern there. With addictions, the compulsive thinking, the compulsive or the obsessions tend to start when the body becomes dependent or tolerant on the substance or the particular neurotransmitter levels. The surges of neurotransmitters. You could argue that for somebody with OCD who checks doors or washes hands, for example, that the surge of GABA and dopamine that they experience when they engage in that behavior actually is addictive on a lower level. Obviously it's not nearly as intense as cocaine or volume or something, but it does alter the neurotransmitter levels. Great question. And there's actually, if you go into PubMed, if you got that kind of time, there's all kinds of research on with pe, different scholars arguing about whether addiction is just a variant of ocd. So that. Excellent question. Any other questions? Let me actually hang on a second. Yeah, we don't care about 1887. Free full text. And here you go. Pubmed is a great place to go when you've got questions about these things. You won't necessarily get easy answers, but you can start understanding how, like deep brain stimulation for refractory depression, OCD and addiction. So they're finding that there are some similar treatments that we can use. OCD and bipolar comorbidity. Yeah, I could stay in there for way too long.