Substance Use Disorders DSM 5 TR Changes | Symptoms and Diagnosis

Hey there everybody, and welcome to today's presentation on substance abuse and addiction in the DSM 5TR. I'm your host, Dr. Donnellice Snipes. In today's presentation, we'll define addiction and substance abuse, identify the general categories in the DSM 5TR and explore the diagnostic criteria for substance use disorders and addictions in the DSM V. TR let's start out with talking about a few terms because there's a lot of confusion. We use the term substance abuse and substance dependence and addiction in the general community. However, in the DSM 5 it's very different. And we're going to talk about that in a minute. But let's start out by differentiating between dependence and abuse. Can you be dependent on something and not addicted to it? And the answer is yes. And I guess I should have put this flip flopped. Addiction is use of that substance or dependence on that substance such that it is causing you clinically significant distress or impairment. Dependence itself simply means that your body has gotten used to having that substance in it or having that rush of adrenaline or dopamine from behavioral addictions. So dependence in and of itself is not addiction. You can become dependent on a lot of things. I mean, you're dependent on food, you're dependent on water. If you start taking certain medications things, they may be lifelong medications. You may become dependent on them to the extent that your brain alters its chemistry in a way because it says, okay, I'm getting plenty from out there, I don't need to make my own. When you stop taking that particular substance, then your body may go through withdrawals because you're. It's expecting to have the input and it hasn't gotten the message yet that it's got to start making its own. In the case of, especially in the case of substances, substance abuse and dependence are now referred to substance use disorder. And why do I have substance in brackets? Because each substance or category of substances has its own list of, of the use disorder, intoxication, withdrawal and induced mental disorder as a result of that substance. So what we're talking about is alcohol abuse, stimulant abuse, anxiolytic abuse. We have a lot of different categories. We're going to talk about. The general categories that we look at in the DSM 5TR. They do have caffeine. Now, interestingly, caffeine use disorder is still back in the conditions for further study. However, caffeine intoxication, caffeine withdrawal and mental conditions caused by caffeine are in the DSM 5 TR. In the main Part cannabis use disorder is in there. Phencycline and hallucinogens is another category. Interestingly, now we're not going to go through each of the specific drugs going through the category for use intoxication withdrawal. I'm going to simplify it for you because there's a lot of overlap. And if you work with people who are in substance abuse recovery or you're doing assessments about substance abuse, you'll get to know those different drugs. If you're not, then you probably don't care about the granular information. So we're just not going to hit that here. But one thing that is interesting is for phencyclidine and hallucinogens category, hallucinogen persisting perception disorder is included under there. And that's obviously not included in any of the others. People who use hallucinogens, particularly LSD, but it can be with other hallucinogens, have a 4.2% risk of developing hallucinogen persistent perception disorder, which means that altered perceptions that they had during their substance use may persist after that use is over for days, weeks or even years. And it can be episodic. They may go, you know, a couple of years without having any symptoms and then all of a sudden they start having perceptual changes again. It can be episodic or it can be continuous. However, as opposed to with a psychotic disorder, with hallucinogen persistent perception disorder. Wow. I can't say that fast reality testing is intact. So the person recognizes that their perceptions are not accurate. The next category, and I lump these all under depressants. The DSM 5 TR does not inhalants, Opioids instead of sedative, hypnotic and anxiolytic are all three their own categories. But what do these three things have in common? They slow the heart rate, they slow the central nervous system. They're sedating or depressant in nature. And when we start looking at symptoms of intoxication and withdrawal, you will notice that all of these have a lot of overlap. And in their symptoms of intoxication and withdrawal in the DSM5TR, in the very beginning of this chapter, there is a really nice table that lists the substances of abuse down the left hand column and associated mental health issues along the top. So you can see, like anxiety, for example, tends to be a symptom of either intoxication or withdrawal for pretty much every substance out there. Then there are other things like GHB that don't have quite a or quite the same response. So anyway, that's A really handy table if you are doing a substance abuse assessment to identify things, other mental issues, mental disorders, mental health symptoms that you may be looking for. Stimulants. Now this is its own category. Cocaine, amphetamines, methamphetamines, even your prescription ADHD meds and bath salts, for example, all fall under the stimulant category. Tobacco, they have in there. And, and the other category means, is it means things that don't fit nicely into any of these other categories. Oh, and I forgot alcohol. Silly me. The DSM criteria for substance use disorder. Now this is going to be repeated. As I said in the DSM 5, each different substance category has diagnostic criteria for substance use disorder, but it's pretty much the same. They just replace the word alcohol for cannabis or something else. So anyway, to diagnose substance use disorder, the person has to be spending excessive time obtaining, using, or recovering from use of the substance activity. They need to use greater amounts over a longer period of time than was intended. So they may start using, let's take alcohol. They intend to have a drink or a couple of drinks, and next thing they know they've had 12. You know, that's much more than they anticipated. Or they intended to go out for a drink with somebody after work and four hours later they're still at the bar. That's giving you an idea. Again, occasionally that may happen for people. However, what we're looking at when we talk about substance use disorder is is it happening frequently or regularly? And do they have some of these other symptoms? Are they unable to cut down or control use? That's a big one. When they're not using, are they craving that substance? That could indicate that they've got tolerance. But there also can be a psychological craving. A lot of times people are using substances in order to numb pain of some sort. Whether it's anxiety or depression or physical pain or just stress. They are using in order to escape from that. So when they are not using, they're like, oh my gosh, I really need some relief. And they start craving that particular substance or activity. The person may have failure to fulfill major role obligations at work, at school, in their relationships. They may forget to pick their kids up from school, or they may start calling into sick to work a lot, or they may miss meetings. You get the point. They may give up activities that are important to them. Maybe they used to be an avid runner or rock climber or musician or painter. They may not do those as much anymore, especially as their addiction progresses. And they are more and more Focused on using, they become more and more dependent on the substance. More and more time is spending spent thinking about using, recovering from the substance, and other things just start to fall away. Problems in their life are caused or worsened by use, and they continue to use anyway. They may also have physical or psychological problems that are caused or made worse by the substance and they continue to use anyway. And, or they may use in risky or physically hazardous situations. One of the keys here is they continue to use anyway. If somebody is using and then they notice, hey, this is causing me problems in my relationship, maybe I ought to stop. And they stop, well, bada bing, then that obviously indicates that they are able to cut down or control their use. However, what we're seeing here is that the person has become so dependent on the substance or the activity to help them escape from pain or regulate their neurotransmitters or whatever it is it's doing for them that even things that are important to them like work and school and family and kids and hobbies, they're not able to give that time because they need to continue to stay medicated, if you will. Tolerance is defined by a substance or an activity having a diminished effect at the same level. So drinking X number of drinks or taking x milligrams of something or spending X amount of money gambling just doesn't do it for you anymore. It's like, yeah, done that, you know, old hat. They need more the brain. When people are using substances, when people are engaging in addictive behaviors, what happens? They get this tension and release, they get this feeling of euphoria. They get a rush of norepinephrine, of, of dopamine. HPA axis may get triggered. It depends on the substance. Your stimulants are going to trigger the HPA axis. Your depressants are actually going to trigger the relaxation response. But either way, it's helping the person, quote, feel better, which is going to trigger that release of dopamine and endorphins. And that is one of the things that they hypothesize people actually get addicted to is, is the altered levels of dopamine and endorphins in the brain. Sometimes the person doesn't use more of the substance or do more of the activity. They may instead combine it. So in substance use, they may combine two different drugs that are similar, so two different types of stimulants or two different types of depressants, which, which can be extremely dangerous if it's behavioral. They may combine gambling with alcohol or something else. What they're doing is they're trying to increase that dopamine rush again. They're trying to dial up how much dopamine and endorphins their brain sends out. Withdrawal or avoidance of withdrawal by taking a substance or, or a closely related substance to relieve symptoms is also another indication. Sometimes people, when they haven't used for a while, and depending on the substance or the activity, a while could be a couple of hours or a few days, they may engage in withdrawal behaviors or withdrawal avoidance behaviors because the withdrawal symptoms are so incredibly unpleasant. A general rule, your withdrawal symptoms will be the opposite of your intoxication symptoms. It makes sense. When you are intoxicated, you have supercharged the amount of the hormones and neurotransmitters that are involved with that substance. So if you're taking stimulants, for example, you're supercharging the amount of glutamate and adrenaline and norepinephrine and cortisol and the HPA axis activation. You are just ramping everything up way more than the body could on its own. So when you are withdrawing, then there's a deficit and you go the opposite direction with often with a similar intensity. So kind of going back to physics, for every action there's an equal and opposite reaction. So if you got really, really revved, you may feel really, really depressed. Likewise for people who use depressants in order to help them feel calmer, if they get really, really chill, then the rebound may be a high level of agitation and anxiety. What about gambling, Internet addiction and porn addiction? Well, Internet gaming addiction is still in the conditions for further study and porn and sex addiction is not even mentioned in the dsm. I'll get to that though. Let's start with gambling. Gambling disorder has made it into the main section of the DSM 5. It is characterized by gambling that causes clinically significant impairment with four or more symptoms over a 12 month period. As with all mental health issues, there is a spectrum. There is a range from non pathological. I'm trying to avoid using the other, the other word, non pathological use or non problematic use to use. My daddy used to love his poker games and he and my stepmother would go on their, to Vegas on their vacations pretty much every year. But that was, those were the only times he gambled. And he always had a certain amount that he had set aside and win, lose or draw, that was it. Either the vacation would end and he'd go home a winter or he would run out of money and he would have to just kind of hang out until it was time to go home. That was not pathological. It didn't cause him impairment in functioning. But for someone who does have gambling disorder, they have to use an increasing amount of money to achieve the desired excitement. So this is akin to tolerance. They often are restless or irritable when attempting to cut down or stop. This is evidence of withdrawal. Now you're saying, well, the person's not having any, ingesting any substances, so where's all this coming from? Well, part of it could be psychological. They are, when they are gambling, their attention is focused on what they're doing. So their attention is not focused on all their problems, or their attention is focused on how their problems could be solved if they win this jackpot. Not focusing on the problems as they are. It also could be biochemical. When the person is gambling, they are. They have this tension building phase when they're, you know, getting dealt the hand or whatever it is. And then they either win, which produces a flood of dopamine, or they lose, which doesn't produce a flood of dopamine, and they want that flood of dopamine. So then they play again. Playing gambling, just like Internet gaming and other behavioral addictions, also increases dopamine and endorphin levels. Maybe not to the same level as methamphetamine or another drug, but it does increase those levels. And we need to recognize that, because even if you're just doing it naturally or endogenously, as they say, regularly increasing those levels will cause your body to say, hey, you know, I'm getting too much dopamine coming through. I'm getting too much of the endorphins coming through. I don't need this much. Can't run this hot, whatever you want to say. So it adjusts down its sensitivity and it becomes less reactive to the dopamine and the endorphins when they're presented, which is what we call tolerance. So then in order for the person to get the same feeling, they have to up the ante, literally in gambling, in order to feel that tension and then get that amazing release. When they win, they may have difficulty controlling or stopping. Well, similar to substances, they may be preoccupied thinking about it, doing it, or recovering from it. Just like substances, they may gamble when they feel distressed. Now, this isn't something that's specifically articulated in substance use disorders. Sometimes people will drink when they are feeling happy, or they'll use when they're feeling happy. But a lot of times that was the beginning. And as their substance use disorder progresses or they get to the point of being having a substance use disorder they're using to relieve distress, physical distress, withdrawal symptoms, anxiety. So I think it's important to recognize that even though it's not specifically articulated under the substance use disorders, it's a pretty good bet that a lot of people are using whatever their addictive substance or behavior is as a result of distress in gambling. And this is a unique feature. They may return another day to chase their losses. If they had a losing night or they didn't feel like they won as much as they should have, they may come back to try to win it back. And there's a lot of mental gymnastics that goes along with that. I cover a lot of that in the videos on gambling disorder that I have on the YouTube channel. Way too much to go into right here. They may lie to hide the problem. This is common of all addictive behaviors. I have yet to meet someone with a substance use disorder or a behavioral addiction that doesn't deny, justify, blame, or flat out lie about their use, or at least the extent of their use. They may start having relationship, job, or school problems a result of using. Well, if they're preoccupied with the addiction all the time or most of the time, then they're not focusing on the other things that they need to focus on, which is going to start causing problems. They're going to start forgetting things, they're going to start making mistakes, they're going to start disappointing people. And another one that is somewhat unique to gambling, although not completely, is relying on others to provide money to support the habit. Many people who use substances may also get to a point where they have to beg, borrow, steal, you know, figure out some way in order to afford their substances. Now, this is not true of everybody. There are a lot of, and I hate the term, but I'm going to use it anyway. High functioning people with addictions that work corporate jobs and have plenty of money, thank you very much, and they're able to maintain just enough of a level that they're not getting fired and they're. They're able to constantly fund their habit. So we don't want to assume or only consider people for a diagnosis of substance use disorder or gambling disorder based on whether or not they are able to afford their habit and whether they're having problems in their life. There may be other things that are going on. Remember, you only have to have four of these symptoms within 12 months. And the gambling behavior is not better explained by a manic episode. If the person is in a manic episode, manic episodes Are characterized by impulsive behaviors. Therefore, if we know that they have bipolar disorder and their main presenting symptom, if you will, when we start talking about addictions is gambling, we need to recognize that that is part of can be part of the impulsive behaviors in bipolar disorder. So it may be better explained by the person being in a manic episode. All right, I told you we would get to Internet gaming and sex and pornography addiction. There is a lot of talk about these, and that's important because they are problematic for people. And again, before people start getting all upse, everything is on a continuum. There are people who engage in Internet gaming and it doesn't cause them problems. There are people who have sex and it doesn't cause them problems. There are people who view pornography and it doesn't cause them problems. I'm not pathologizing the behavior. What we're looking at is when that behavior becomes problem, when the pornography use or the gaming, Internet gaming, or any other behavior starts requiring an increasing amount of use to achieve the desired excitement. When people are restless or irritable, when they are attempting to cut down or stop, when their attempts to control or stop using or engaging in the behavior are ineffective, when they're preoccupied with it, when they start having relationship, job, school problems as a result of it, when we start seeing those things, that's when it's a problem. Especially if they continue to use Anyway, they're looking at this and they're like, yeah, I know it's causing a problem, but you know what? Screw it, I don't care. Interestingly, Internet gaming disorder was added to the ICD 11, which is the other diagnostic manual, and it is code 6C51. It has not made it out of conditions for further study in the DSM, but it is in the ICD11. If you are billing based on the ICD11, you may be able to bill for it. Now remember, when you're dealing with insurance, or for those of you who aren't familiar, when you're dealing with insurance, a lot of insurance companies will say, we will reimburse for treatment of these diagnoses, but not these diagnoses. So it's important to check even if something is in the DSM or if it is in the ICD 11. Now to make sure that the if you're going to be billing insurance, make sure that the insurance company actually covers that sex or pornography addiction. Compulsive sexual behavior disorder was added to the ICD11 as 1692. So again with the ICD11, we do have a diagnostic code in the DSM. It is neither made the conditions for further study nor the main part of the text. So the recommendation to date has been to use other specified sexual dysfunction, which is F552. 8. Making sure that the, the providers that you're billing cover. This is really important to providing treatment. You don't want to be providing treatment for somebody for six weeks and say, oh yeah, we'll bill your insurance. And then lo and behold, the insurance company doesn't cover it. That needs to be something in your informed consent. Just as a matter of ethics. Okay, so we've talked about substance use disorder and gambling disorder. Now let's talk about intoxication, withdrawal and associated features. Intoxication, whether it's depressant or stimulant, the use has to be recent and there has to be clinically significant changes in the person's behavior or symptoms during or shortly after use with stimulants. Now remember, stimulants trigger the fight or flight reaction. Stimulants will trigger the release of glutamate, cortisol, norepinephrine, adrenaline and dopamine. Norepinephrine is our focus chemical and dopamine is our motivation chemical. So sometimes people, and I'm going to jump to the bottom of the list first, sometimes people when they're using stimulants have hyper focus and they may be very excited and euphoric and so stimulants, that is a lot of their appeal. Other signs that a person may be using stimulants, One of the things that you can look for really easily in clinic or if you're worried about a loved one is pupil dilation. If their pupils are really big and not responsive to light. So if they walk into a bright place, their pupils still stay way bigger than they probably should be. That's an indication that they may be using stimulants. Now remember, ADHD medications are stimulants and some people are prescribed ADHD medications and take them as prescribed and may have some of these symptoms. So it's important again to recognize the difference between use as prescribed and illicit use or abuse. Tachycardia, that HPA axis is kicked off. So what's going to happen? That heart is going to start to race, blood pressure is going to go up, the person may start perspiring, they may get nauseous. Well, why is that? Remember, fight or flight says no time to rest and digest. So let's just clear everything out of the system and get going. When people get really Stressed, what happens? They generally get GI symptoms to not get too graphic for you. Well, that's what we're seeing. And when people are using stimulants, they are simulating a high stress situation in there. Neurochemically, weight loss is very common. Well, if you've got all these things coursing through your, through your system, your body's dumping blood sugar, your base metabolic rate probably goes up some, then yeah, you're probably going to lose weight. Another thing we see, because it's not time to rest and digest. Is people's appetite suppressed on stimulants? A lot of appetite suppressants are. Guess what? Stimulants. You may see psychomotor agitation. The person may be fidgety and restless. They can't sit still. Interestingly, they may have muscular weakness, confusion, seizures. It's not uncommon to see people have anxiety or aggressive behaviors when they are intoxicated with stimulants. Why is that? HPA axis is the fight or flight mechanism. It's activated, it is fully engaged. So the person is already primed to react more impulsively, if you will. The person is already primed to feel sensations that they label as anxiety and as I mentioned, hyper focus. A lot of these make sense. And if you've ever had an extra strong cup of coffee from, you know, a coffee shop, you may have on a very, very, very, very mild level, experienced some of what people experience when they are using your illicit stimulant medication or stimulant substances. So that gives you an idea. Just take that and multiply it by like ten or a hundred and you have an idea of what you might be looking for. Again, one of the easiest signs is to look for pupils. If their pupils are really dilated, that's stimulants. If their pupils are really pinpoint, that's opioids, depressant, opioid benzos and barbiturates. So depressants, typically just CNS depressants slow your system down, they slow your respiration, they reduce your blood pressure, they just slow everything down. Opioids are in that category of being a system depressant. They are also analgesic in nature. But what we're really talking about here is some of the CNS symptoms. Benzodiazepines are your anti anxiety medications like Xanax and Valium and barbiturates are your sedative hypnotics, your sleeping pills. With these medications, they're all designed to help you relax and feel calmer. Intoxication requires again, recent use and clinically significant distress during or shortly after use, as evidenced by pupil constriction. So pinpoint pupils, slurred speech, impairment in memory or attention, incoordination. You know, they kind of stumble around and stupor or drowsiness. And sometimes with depressants, you'll also see disinhibition. Now, where does alcohol fit in all this? Interestingly, both places I know, really, when people first ingest alcohol, it acts as a system depressant and a disinhibitor, but it leaves the system faster than your brain can adjust with relaxation chemicals to maintain the balance. So as the relaxation effects of the alcohol wear off, the body tries to compensate by sending in, you know, GABA and other relaxation chemicals. But it can't do it as fast as the alcohol is leaving the body. So then the person has rebound anxiety, hypertension, tachycardia, a lot of the symptoms that you would see in stimulants. Stimulant withdrawal requires cessation of prolonged use. Using stimulants once is not going to produce tolerance and is not going to produce withdrawal. Now it's not going to produce physiological tolerance and is not going to produce withdrawal. In order to be diagnosed with stimulant withdrawal, the person has to have dysphoric mood. So they need to be depressed and have two or more of the following fatigue, unpleasant, vivid dreams, nightmares, increased appetite, psychomotor retardation, hypersomnia, and concentration difficulties. So if somebody has been revved up, they have been, you know, going at it for days and then they stop. Their body has not had a chance to rest. So, yeah, of course they're going to have fatigue. When I worked on the detox unit, we would have people in stimulant detoxification who would just sleep and sleep and sleep because their body needed to in order to, you know, try to rebalance itself. The unpleasant dreams and the vivid nightmares they hypothesize are a result of the neurotransmitters trying to rebalance increased appetite. Remember I said withdrawal is the opposite of intoxication? Well, increased appetite makes sense because when people use stimulants, it suppresses their appetite. No time to rest and digest. We need to fight or flee. So eating is not something we're focused on. So when the stimulants are out of the system, the body is trying to replenish its stores. Psychomotor retardation or slowing, well, the person's exhausted. So this is another one that makes sense. Hypersomnia and concentration difficulties are not listed in the DSM 5tr as withdrawal symptoms, but they are listed in many other areas. And I can tell you from clinical experience, hypersomnia is very common, as well as concentration difficulties when people are using stimulants. Remember I said norepinephrine is your focus chemical and dopamine is your motivation chemical to be, you know, oversimplifying it, but those have been, you know, wide open while the person is using. Now that they're not using, there's a deficit. And so the person may have more difficulty concentrating because they're essentially deficient now in dopamine and norepinephrine depression. Depressant withdrawal is going to be the opposite of intoxication. When people are no longer using depressants, they're not going to be relaxed, they're not going to be as calm, they're not going to be as pain free. So we have cessation of prolonged use. And prolonged is kind of dicey when we're talking about depressants. But because people can start to develop a tolerance to opioids in as little as three to five days, and that tolerance is not going to be huge in three days, most likely depending on the intensity of the substance they're using. But it happens really, really quickly. Additionally, they have to have two or more symptoms developing hours to days after a reduction or cessation of use. It doesn't even have to be quitting completely. It can be when you are tapering, whether you're tapering off of methadone or Xanax or whatever it is, autonomic hyperactivity, that's that HPA axis, it's been sleeping, it's been dormant while the person has been abusing the depressants. Now that the depressants aren't there, keeping it tamped down, the HPA axis kind of wakes up and says, hey, where have I been for the past? However long, they may experience tremor, shaking, insomnia. Well, it's the opposite. Nausea, hallucinations, agitation, anxiety. Unfortunately, grand mal seizures, increased heart rate and increased blood pressure, increased heart rate and blood pressure were not in the DSM 5TR as diagnostic criteria for depressant withdrawal. But again, they are listed multiple other places. And clinically we know this to be true when people are stopping depressants after a long period of use. Long term effects of drug abuse, we have your acute effects during intoxication. When people are using, if they're using stimulants, they're triggering that HPA axis and likely they're also triggering a lot of oxidative stress and inflammation. If they're using depressants, well, they're calming everything down. But whenever the depressants leave their system, there's that rebound withdrawal, and that also causes inflammation and oxidative stress. So addiction and addictive behaviors, because of their intense whiplash of the balance of neurochemicals that often occurs, actually does create a. Condition, if you will, that is very similar to chronic stress or trauma on the body. It actually does start having neurochem causing neurochemical changes in the brain, shrinking of the hippocampus, and all kinds of other physiological changes, which is kind of interesting physically. People who are using substances often age faster, as I said, because of that increased oxidative stress. Now, S stands for stimulant, D stands for depressant, C stands for cannabis, and A stands for alcohol. I didn't want to have 17 million slides, so we're just going to go through these. Research has found that stimulants, depressants, cannabis, and alcohol all can contribute to impaired immunity, specifically with cannabis. Now, I know cannabis is used medicinally, so I do want to make the point that a lot of the research that has shown impairment of immunity by cannabis has been cannabis that has been smoked that is high in thc. THC alters or modulates the immune system in a different way than CBD or cannabidiol. And the chemicals that are produced by smoking cannabis are actually the things that are toxic, not the cannabis itself. So those are some interesting things. They're not really sure compared to other things about a lot of the use of cannabis, because there have been so many ways that it's been found to be useful medicinally, Especially when the THC CBD ratio is one to one or the CBD ratio is higher. They found that it is very helpful with certain conditions. So, yes, I recognize that. However, smoking the chemicals produced by smoking it, and if it has a high THC level, it has been found to negatively impact immunity. Diabetes, stimulants. Okay, well, let's think about this. Stimulants trigger that HPA axis. What happens when we trigger the HPA axis? Our body starts dumping blood glucose to prepare us to fight or flee. So, yeah, it can make sense that habitually using stimulants can keep blood sugar levels too high for too long and start causing the body to react in a negative way. And it may lead to that. It definitely does increase the risk of developing type 2 diabetes. Thought that was interesting. Cannabis increases the risk of diabetic ketoacidosis. Cannabis in and of itself is being studied as a treatment for diabetes to help regulate blood sugar. However, again, it depends on the level of thc and higher levels of THC increase the risk of diabetic ketoacidosis. Alcohol. Alcohol is a bugger for diabetes because it alters the way the body responds to insulin. It creates inflammation throughout the body, which triggers the HPA axis and may also contribute to increasing blood sugar levels. People who drink alcohol have a much harder time controlling their blood glucose, their A1C levels, than people who don't drink alcohol. Cardiovascular disease is associated with stimulants, cannabis and alcohol. Cannabis, again, from what I read, mainly when it's smoked because of the chemicals that are produced by burning the leaves can contribute to arterial narrowing and worsening of heart rhythm disorders and a variety of other things, as well as increasing sputum and cough and lung inflammation. Stimulants, well, stimulants increase blood pressure and they can contribute to a much greater risk of stroke and heart attack. And then alcohol has a whole list of ways that it negatively impacts the cardiovascular system, not the least of which is during the detox period. Remember I said the depressant effects of the alcohol exit the body faster than the body can supplement it with gaba. So when people are detoxing from alcohol, it is not unusual for for their blood pressure to skyrocket. It is not uncommon, unfortunately, to see people have a stroke. Alcohol detox is nothing to play with. It needs to be medically supervised, in my humble opinion, to be safe. All of these disorders, as I mentioned earlier, cause inflammation from oxidative stress. Alcohol and cannabis specifically were associated with increases in lung, pancreatic, kidney, bladder and a variety of throat and other cancers. Tobacco was too. I just wasn't looking at those things at tobacco going through this list. Cancer has been associated in many studies with increased inflammation. Substance use, substance abuse, addictive behaviors, stress tend to increase inflammation. That increased inflammation and increased inflammatory cytokines has been strongly associated with the development of cancer, dementia and cognitive decline has been associated with alcohol, cannabis, stimulants, depressants, but not, interestingly enough, opioids. And I double checked that on several different studies to make sure that I wasn't just getting a bad study. But opioids actually showed very little risk of causing cognitive decline or dementia as a long term outcome. Depressants, especially your benzodiazepines, have been shown to produce to increase the risk of dementia in people who take them frequently and over a long course. Now, if you're taking a Benzodiazepine for a week after a trauma or something that's not likely to have a significant negative impact. It's when people are taking it for years that they start to see the negative impact. Alcohol contributes through not only systemic inflammation, but also by causing inflammation of the, of the liver and potentially hepatic encephalopathy as a result of drinking. Hepatitis is associated with alcohol. Alcohol, we know, is associated with cirrhosis and hepatitis C because it causes inflammation of the liver. Cannabis is also associated with an increased risk of hepatitis. And opioids particularly are associated with hepatitis. Not because of what they do per se, but when people switch to injecting something. Injection methods are associated with a higher risk of hepatitis. And stimulants specifically. Interestingly enough, MDMA was associated with a much higher risk of developing hepatitis than other stimulants. Pancreatitis is associated with alcohol. Your pancreas produce produces enzymes to help break down food that you need in order to make the neurotransmitters and the hormones and the tissues and all that stuff. When the pancreas gets inflamed, it can't do that and it can potentially be life threatening. And then sexual side effects, especially erectile dysfunction. Orgasmic dysfunction is common in people who use depressants, stimulants and alcohol, especially for alcohol. When the person is under the influence of alcohol, suicidal thoughts and behavior may increase during stimulant withdrawal. Well, they were up on top of the world and now they're feeling super depressed. I can see how that would happen during alcohol intoxication. Alcohol is a disinhibitor. So during that depressant or relaxation phase, the initial phase of inebriation, if you will, people are much more likely to act on impulses than when they're not intoxicated. Alcohol intoxication was involved in 22% of suicides. When people are withdrawing from alcohol, they may start feeling very, very anxious and stressed. Opioids, interestingly, was associated with 20% of completed suicides. People get comfortably numb, so to speak, they hypothesize. And the depressant effects of the opioids also act as something of a disinhibitor. Benzodiazepine withdrawal is another high risk for suicidal thoughts and behavior. Behavior because the person is taking an anti anxiety medication and when they stop using it, when they start withdrawing from the benzodiazepines, their anxiety goes through the roof. And some people can find the withdrawal symptoms from benzos and the anxiety untenable, which is why Benzodiazepine withdrawal is also another one of those that often needs to be medically monitored to ensure somebody's safe. And people who are withdrawing from just any of the depressant class drugs, any of the CNS depressants, may experience rebound insomnia. They've been so relaxed and they've been sleeping so much, now they can't sleep. And when they're up at 2 in the morning, pacing the floor, their mind goes places that are very, very dark and that can contribute to triggering suicidal thoughts and behaviors. Risk and prognostic factors a person's physical health. People with chronic conditions are more likely to develop substance use disorders, maybe out of self medication, cognitive functioning. People with FASDs, for example, are at high risk of not being able to understand the consequences of what they're doing and becoming addicted. The availability of drugs. The easier it is to get them, the more likely someone is to start. And once they start, it's easier to get hooked. A history of trauma, a lack of social support, poor family functioning, use of highly addictive substances, something that is super potent, that starts altering those neurotransmitters the first time you take it is a lot more addictive and risky than other substances. And early use, use before the age of 24, when that prefrontal cortex is fully formed, the brain is a lot more malleable and a lot more susceptible to injury during that period, which can make a person more susceptible to developing addictive conditions associated issues. And I know I'm running short on time, so I'm going to kind of fly through these fatigue. Body's recovering, they're going to feel fatigued, their dopamine levels are low, that's going to contribute to feeling fatigued. As the body starts to rebalance and the neurotransmitters start to rebalance, that fatigue will start to lift. If they were using a substance or not engaged in much physical activity during their youth periods, they were sitting a lot, gambling, they were sleeping a lot on depressants or what have you. They may have deconditioned, so they may get fatigued easier. And a gradual rehabilitation program can help them develop their stamina again. Sleep changes and eating changes. Changes are also going to happen in response to whatever drug that they were using, and it'll take a while for that to balance back out again. Psychomotor agitation and retardation is another thing that we're going to see. People who are on depressants may be more agitated, people who are, who are on stimulants may find it even harder to kind of get through the day. People with fetal alcohol spectrum disorders, and I put this here because it is a condition that causes neurological damage to the fetus. But people with FASDs have difficulty anticipating consequences. And they found that people who were exposed in utero to alcohol are significantly more likely to develop substance use disorders and addictive behaviors. And as adolescents and people with eating disorders are at a much higher risk for developing substance use disorders and other addictive behaviors, Affectively or cognitively. People with addictions often have apathy or anhedonia. They're just plumb exhausted. They may have lack of motivation. You know, that's that dopamine not being there again. They may have anxiety with the alteration in their neurotransmitters not being what it needs to be. It takes a while for the brain to rebalance. There also may be anger, guilt and grief, not only in reaction to people in the present because they have very little patience, but also at themselves as a result of things they did or things they lost in their addiction. Emotional dysregulation is very common. Remember I said addiction impacts the body very similar to trauma. Therefore, the person may be at that state of flat and furious because their HPA axis is so dysregulated. So they are flat like Eeyore most of the time. And then when something finally does trigger them, they go to the other end of the spectrum. Bipolar disorder is very common, as is difficulty with attention or concentration, Even in people without adhd. As their norepinephrine levels and their dopamine levels recover, then that will return. Korsakoff syndrome is a syndrome that is caused by thiamine deficiency. This is something we see in alcoholism and anorexia. But in this presentation we're talking about alcoholism. If somebody has a thiamine deficiency, they're going to start evidencing signs of dementia when they are using or detoxing from alcohol. If you start to see a sudden onset of signs of dementia, it is a medical emergency and they need to get to the hospital to be evaluated for an IV infusion. Thiamine and ADHD and PTSD also significantly increase the risk environmentally. People with addictions and substance use disorders often have unstable housing, difficulty with employment. Maybe they got fired from their last job, or they have difficulty getting to their job because they're so depressed and fatigued right now. They may have legal problems or financial problems. This is not everybody. There are a lot of people, again, who are high functioning that may not have some of the core problems. It doesn't mean they don't have an addiction, it just means they didn't have that particular problem. And relationally low self esteem, a lack of healthy social supports, peer pressure, and a family history of addiction all contribute to putting somebody more at risk for developing an addiction as well as an associated issue that needs to be treated to prevent relapse during the recovery process. Substance use disorders and addictive behaviors represent harmful engagement in a particular behavior or substance use. Substance use disorders and addictive behaviors increase HPA axis activation, alter neurotransmitters, and have a self perpetuating negative impact on every area of life. So for example, if the substance is keeping the person from getting good sleep and then they may self medicate with a stimulant that helps them stay awake, but then they can't get good sleep and because they're not getting good sleep then they start getting forgetful and having problems at work and making mistakes which causes them more stress which makes them want to use more. So it feeds on itself. In addition to their acute effects, substance use disorders and addictive behaviors also have significant long term risks and effects that need to be addressed in the long term treatment plan.