Konsep Penagihan Dadah

Dr. Sangeeth Kaur

Agensi Antidadah Kebangsaan
Ciri-ciri ketagihan
Kronik
Berulang
Progressive

ADDICTION IS A COMPLEX ILLNESS
INTRODUCTION
Addiction treatment in Malaysia :
changing concept from 1957 and
now

Earlier ideas of addiction as a moral
disorders and self inflicted
conditions

The recent understanding of
addiction as medical disorders

Addiction as biopsychosocial
phenomena

INTRODUCTION
Drug dependence is a complex condition
involving social, psychological and biological
components.
It is a serious condition associated with severe
morbidity and a high risk of death.
This risk arises from both drug overdose and
morbidity that result from chronic licit and
illicit drug use.
Experimenting


Abuse




Dependence
(lost of control over substance use)
Personality

Family
Genetic

Underlying
depression
anxiety
attention
deficits

Social/environment
Permanent
Biological
changes
in the brain
Voluntarily
act
compulsion
Important terminology
1. Harmful use
2. Physical dependence vs. addiction
3. Psychological craving
4. Tolerance
5. Withdrawal symptoms
6. Neurotransmitters and receptors
What is harmful use? (ICD-10)
A pattern of psychoactive substance use that is
damaging to physical and / or mental health.
What is drug addiction?
Drug addiction is a complex illness
characterised by compulsive, and at times,
uncontrollable drug craving, seeking, and
use that persist even in the face of
extremely negative consequences.
(NIDA, 1999)
Characteristics of addiction
Compulsive behaviour
Behaviour is reinforcing (rewarding or pleasurable)
Loss of control in limiting intake
(NIDA; www.projectcork.org)
Psychological craving
Psychological craving is a strong desire or urge to
use drugs. Cravings are most apparent during
drug withdrawal.
Tolerance
A state in which a person no longer responds
to a drug as they did before, and a higher
dose is required to achieve the same effect.
A period during which somebody addicted to
a drug or other addictive substance reduces
their use or stops taking it, causing the
person to experience painful or
uncomfortable symptoms
OR
A person takes a similar substance in order to
avoid experiencing the effects described
above.
Withdrawal (1)
Withdrawal (2)
When a drug is removed, physical and / or mental
disturbances may occur, including:
Physical symptoms
Emotional problems
Cognitive and attention deficits
Aggressive behavior
Hallucinations
Convulsions
Death

DSM IV criteria for substance dependence
Three or more of the following occurring at any
time during the same 12 month period:
Tolerance
Withdrawal
Substance taken in larger amounts over time
Persistent desire and unsuccessful efforts to cut down or stop
A lot of time and activities spent trying to get the drug
Disturbance in social, occupational, or recreational functioning
Continued use in spite of knowledge of the damage it is doing to
the user or others
(DSM-IV-TR, American Psychiatric Association, 2000.)
ICD-10 criteria for dependence
Dependence: 3 or more of the following:
(a) strong desire or sense of compulsion to take the substance;
(b) difficulties in controlling substance-taking behaviour in
terms of its onset, termination, or levels of use;
(c) a physiological withdrawal state;
(d) evidence of tolerance;
(e) progressive neglect of alternative pleasures or interests
(f) persisting with substance use despite clear evidence of
overtly harmful consequences
In this training, addiction will be the term used to
refer to the pattern of continued use of drugs despite
pathological behaviours and other negative
outcomes

Dependence will only be used to refer to physical
dependence on the substance as indicated by
tolerance and withdrawal as described above
To avoid confusion
Addiction = Brain Disease
Addiction is a brain disease that is chronic and
relapsing in nature.
(NIDA; www.projectcork.org)
A major reason people
take a drug is they like
what it does to their brains
How the reward system works
0
50
100
150
200
0 60 120 180
Time (min)
%

o
f

B
a
s
a
l

D
A

O
u
t
p
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t

NAc shell

Empty
Box Feeding
Source: Di Chiara et al.
FOOD
100
150
200
D
A

C
o
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c
e
n
t
r
a
t
i
o
n

(
%

B
a
s
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l
i
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e
)

Mounts
Intromissions
Ejaculations
15
0
5
10
C
o
p
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l
a
t
i
o
n

F
r
e
q
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n
c
y

Sample
Number
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Scr Scr
Bas
Female 1 Present
Scr
Female 2 Present
Scr
Source: Fiorino and Phillips
SEX
Natural rewards elevate dopamine levels
Activating the system with drugs
(NIDA; www.projectcork.org)
0
100
200
300
400
Time After Cocaine
%

o
f

B
a
s
a
l

R
e
l
e
a
s
e

DA
DOPAC
HVA
Accumbens
COCAINE
0
100
150
200
250
0 1 2 3 hr
Time After Nicotine
%

o
f

B
a
s
a
l

R
e
l
e
a
s
e

Accumbens
Caudate
NICOTINE
Source: Shoblock and Sullivan; Di Chiara and Imperato
Effects of Drugs on Dopamine Release
100
150
200
250
0 1 2 3 4hr
Time After Ethanol
%

o
f

B
a
s
a
l

R
e
l
e
a
s
e

0.25
0.5
1
2.5
Accumbens
0
Dose (g/kg ip)
ETHANOL
Time After Methamphetamine
%

B
a
s
a
l

R
e
l
e
a
s
e

METHAMPHETAMINE
0 1 2 3hr


1500


1000


500


0
Accumbens
Why cant people just stop drug use?
When people first try drugs, it is usually a
voluntary decision, but after using the drug for
a while, it is no longer voluntary.

Why cant people stop?

Partial Recovery of Brain Dopamine Transporters in
Methamphetamine (METH)
Abuser After Protracted Abstinence
Normal Control
METH Abuser
(1 month detox)
METH Abuser
(24 months detox)
0
3
ml/gm
(Volkow, N.D., et al. 2001. Journal of Neuroscience 21, 9414-9418.)


Their Brains


have been
Re-Wired
by Drug Use
Because
Prolonged drug use changes the
brain in fundamental and long-
lasting ways!
Why cant people just stop drug use?
Compulsive
Drug Use
(Addiction)
Voluntary
Drug Use

Its Not J ust

Addiction is, Fundamentally,
A Brain Disease

A Brain Disease

...BUT
DRUGS
BRAIN
MECHANISMS
BEHAVIOR
ENVIRONMENT
HISTORICAL
ENVIRONMENTAL
- previous history
- expectation
- learning
- social interactions
- stress
- conditioned stimuli
- genetics
- circadian rhythms
- disease states
- gender
PHYSIOLOGICAL
Some treatments were designed to
induce fear. Spinning the patient
until loss of consciousness occurred
was thought to help rearrange the
contents of the brain.
Other techniques included insulin
shock and frontal lobotomies.
How we used to perceive and treat mental illness
During the Middle Ages and
Renaissance Period, witchcraft and
demonic possession were considered to
be the root of psychosis and
schizophrenia.
Physical interventions included
trepanation - the boring of holes in the
skull to release the evil spirits.
Weve changed how we perceive and treat
mental illness (thank God!)
This illustration shows a colonial
surgeon attempting a trepanation
procedure, which required up to 60
minutes of constant drilling.
Was this an evidence-based
practice during that time?
How we used to perceive and treat drug and
alcohol addiction
In the past, society viewed drug
addiction as a moral flaw. Popular
"treatments" involved imprisonment,
sentencing to asylums, and church-
guided prayer.
The evidence is that drug addiction is a biologically-based
chronic disease expressed as compulsive drug seeking and
using behavior and characterized by fundamental and
long-lasting changes in the brain.
Addiction is a Chronic Illness Because:

It has both a genetic and environmental basis influencing its
development and manifestation

Recovery from it is often a long-term process requiring repeated
treatments

Relapses can occur during or after successful treatment episodes

Participation in self-help support programs during and following
treatment can be helpful in sustaining long-term recovery
Addiction is a moral weakness
You have to hit rock bottom to recover
You have to want treatment for it to be
successful
Drug abuse is more common among
minorities
Alcohol is not really a drug
And yet, despite the large body of science,
several myths about addiction still persist,
including:
used to be
Neuro-
biological

Physiological
Traditional


Psychosocial
A Paradigm Shift in Addiction
Treatment
Your Brain on Drugs Today
1-2 Min 3-4 5-6
6-7 7-8 8-9
9-10 10-20 20-30
YELLOW shows
places in brain
where cocaine
goes (striatum)
Front of Brain
Back of Brain
Fowler et al., Synapse, 1989.
Advances in science have revolutionized our
fundamental views of drug abuse and
addiction, showing us that:
abuse is a preventable behavior
addiction is a treatable disease
There are about
15,000,000 substances in the world.

However, of these
only about 55,000 are available for
human consumption.
Why do some drugs have abuse potential?

Interestingly, of these 55,000 substances . .
. .
only about 25 have abuse
potential !!
Uppers: CNS Stimulants. Amphetamine,
methamphetamine, cocaine
Drugs With Abuse Potential
Downers: CNS Depressants. Alcohol,
benzodiazepines (like valium, etc), barbiturates (like seconal,
etc.), Inhalants, etc.
All-arounders: Hallucinogens. LSD, mescaline,
MDMA (XTC), psilocybin (magic mushrooms), PCP, etc.
Pain Killers: Opioids. Heroin, codeine, morphine,
vicodin, fentanyl, Oxycontin, etc.
Whats Being Done
About All of This?
Scientifically-Based Approaches
to Addiction Treatment
Cognitivebehavioral interventions
Community reinforcement
Motivational enhancement therapy
12-step facilitation
Contingency management
Pharmacological therapies
Systems treatment

L. Onken (2002). Personal Communication. National Institute on Drug Abuse.
Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse