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4 Substance-Related and Addictive Disorders

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Learning Objectives

After reading this chapter, you should be able to:

• Explain what psychoactive substances are.

• Explain why psychoactive substances are so popular.

• Analyze the potential dangers of using psychoactive substances.

• Explain how substance-related disorders are treated.

• Discuss ways that substance-related disorders can be prevented.

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Section 4.1 Psychoactive Substances: Some Basic Information

4.1 Psychoactive Substances: Some Basic Information Chemicals that alter moods or behavior have been used for thousands of years by people from just about every culture and society. This chapter is concerned with why so many people use these psychoactive substances, the problems such substances can cause, how to help people who want to stop using substances, and how to prevent people from taking them up in the first place. Psychoactive substances—chemicals that alter our moods or behavior—touch every aspect of modern life; they affect the way we live, work, relax, and die. In the United States, the total cost of substance abuse in 2016 (the most recent year for which estimates are available) was more than $400 billion in lost workplace productivity (in part due to prema- ture mortality), health care expenses, law enforcement and other criminal justice costs (for example, drug-related crimes), and losses from motor vehicle crashes (U.S. Department of Health and Human Services [USDHHS], 2016). Furthermore, about three quarters of the costs associated with alcohol use were due to binge drinking, and about 40% of those costs were paid by the government, emphasizing the huge cost of alcohol misuse to taxpayers (USDHSS, 2016). This value represents both the use of resources to address health and crime conse- quences as well as the loss of potential productivity from disability, death, and withdrawal from the workforce.

There is no precise boundary between social drinking and alcohol abuse. Like many psy- chological problems, substance-related disorders are often just extreme cases of common behaviors. How common? Recent data reported by the Center for Behavioral Health Statistics and Quality (CBHSQ, 2015) reveal that slightly more than half of Americans aged 12 or older (139.7 million, or 52.7%) reported some amount of alcohol use. This refers to general use of alcohol—a beer with pizza or a glass of wine at dinner, for example. A bit more than two out of every five people aged 12 or older (60.9 million, or 40%) participated in binge drinking at least once in the past 30 days (CBHSQ, 2015). For males, binge drinking is defined as the consumption of five or more alcoholic drinks in a row on at least one occasion during the pre- ceding two-week period; for females, it refers to the consumption of four or more drinks dur- ing that time period (Bartel et al., 2017). The rates in 2009 and 2010 were similar (23.7%). Finally, heavy drinking was reported by 6.2% of the population aged 12 or older, or 16.3 mil- lion people (CBHSQ, 2015).

More disturbingly, data provided by the National Survey on Drug Use and Health (NSDUH) showed that in 2014, “17 million persons aged 12 or older were classified with an alcohol use disorder. This represented 6.4 percent of the population” (CBHSQ, 2015).

Psychoactive substances form a spectrum. At one end are everyday substances, such as the caffeine found in coffee, soft drinks, and tea. At the other end of the spectrum are illicit and potentially dangerous substances, such as opiates (for example, heroin). A variety of other substances lie between these two extremes.

Robert Jones presents an interesting example of an individual who may—or may not—have a drinking problem. Let’s meet him before we continue.

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Section 4.1 Psychoactive Substances: Some Basic Information

The Case of Robert Jones: Part 1

Robert (or Bob as he prefers to be called) is a 48-year-old African American male who has been married for 30 years to Paula. He has two children, aged 16 and 5. When Bob came to us, he was well dressed, presented pleasantly and appropriately, and had a friendly demeanor. He was not entirely sure why he was sent to the clinic, but he was sure that it was a mistake.

“I’ve got no idea what’s going on here. The cops stopped me one night after work. Both were African Americans, and they knew me. They’ve seen me in town, at church. They told me I was weaving all over the road, and they wanted to make sure I was okay. Of course I was okay! I’ve been driving for over 30 years and never had an accident, never had a ticket! They asked me twice if I’d been drinking. I don’t drink, well, not that much anyway. They thought I was drunk! Would I drive drunk? I’ve got two kids, one a teenager who’ll be driving soon herself. I told them no, and then they asked me to step out of the car as they wanted me to do some things for them . . . .”

Bob continued his story for us during his initial intake interview. “This was so insane! I’ve got a graduate degree. I’m an upstanding citizen. The cops asked me to walk a straight line, to touch the tip of my nose with the index finger of each of my hands. That wasn’t good enough! Then they asked me if I’d been drinking—again—and then they asked me to blow into a tube in this little machine. I wasn’t sure I needed to do this, but I’d heard if you refuse to do this you’re immediately arrested. Where’s the ‘innocent until guilty’ here?” Bob decided that he’d better go along with the officers’ request and he did, but he complained the whole time. The end result was shocking to him, to say the least: “They said I was drunk! My . . . BAR . . . or something like that [we corrected him and explained that this was his blood alcohol concentration (BAC)] was .20.”

BAC refers to the percentage of alcohol that is in the body as compared to the total blood supply. A BAC of 0.08 is equivalent to about four drinks consumed per hour for an average- sized individual.

“That meant zip to me, so they told me it seemed like I’d had about 10 drinks. 10 drinks! That’d make me a rummy, a lush! I only drink beer anyway. 10 beers in one hour! That’d kill me much less anyone else!”

We confirmed the BAC results on Bob’s paperwork, sent to us by his probation officer. She sent him to us as part of his plea bargain in order to avoid jail time. Bob believed that he had no reason to be in our office. “Why don’t you concentrate on the real problems out there— the murderers, lying politicians, and the drunks that kill people while driving—huh? I’m a hardworking family man; I don’t belong in here with the winos and the loony tunes.” We pointed out the conditions of his probation and gave him the option to leave. Bob thought about this for a while and then finally stood up to leave.

See appendix for full case study.

Because the DSM–5 includes many substance-related disorders, it is not possible to review each one here. Instead, this chapter emphasizes the common features of psychoactive sub- stance use by focusing on the four substances most frequently used by American college stu- dents: caffeine, nicotine, alcohol, and cannabis (marijuana). Let’s start by surveying the physi- cal and psychological effects of each of these substances.

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Section 4.1 Psychoactive Substances: Some Basic Information

Caffeine If you need proof that practically everyone uses psychoactive substances at one time or another, just consider caffeine. It is practically everywhere. The only way you can avoid it is to shun coffee, tea, Red Bull, many popular soft drinks, cocoa, and chocolate. Even then, you may not succeed because caffeine is also found in headache, diet, and cold medications. Today, coffee remains the world’s most popular source of caffeine (see Figure 4.1 for other common sources).

Figure 4.1: Common sources of caffeine

Source: Data from Consumer Reports, “What Caffeine Can Do for You and to You,” Consumer Reports on Health, 9(1997), pp. 97, 99–101, as appearing in S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 6.1, p. 238.

Caffeine (mg)

0 25 50 75 100 125 150 175 200

Espresso, 2 oz Regular coffee, brewed, 6 oz Instant coffee, 6 oz

Coffee

Jolt Cola, 12 oz Mountain Dew, 12 oz Surge, 12 oz Coca-Cola Classic, 12 oz Pepsi, 12 oz Java Water, 12 oz Water Joe, 12 oz Java Juice, 12 oz XTC Juice, 12 oz

Soft drinks

Black tea, 6 oz Green tea, 6 oz

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Aspirin-free Excedrin Anacin NoDoz maximum strength NoDoz

Medications

S o

u rc

e o

f c a ff

e in

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Section 4.1 Psychoactive Substances: Some Basic Information

Action Caffeine belongs to a class of chemicals called stimulants, whose main psychoactive effect is to make us more alert. Within 45 to 60 minutes after you drink a cup of coffee or munch on a chocolate bar, caffeine is absorbed from the stomach and the intestines. Once in the blood- stream, it causes blood pressure, pulse rate, and stomach acid production to increase. In the nervous system, caffeine acts as an antagonist to the neuroinhibitor adenosine (Kaster et al., 2015). Antagonists are chemicals that reduce the potency of other chemicals. In contrast, agonists are chemicals that increase the potency of other chemicals (for example, fluoxetine [Prozac] is a serotonin agonist). Caffeine is also a powerful diuretic because it increases the excretion of liquid from the body.

Health Effects Although it is widely used and generally regarded as safe, caffeine may still have adverse effects on health (de Mejia & Ramirez-Mares, 2014). For example, it increases the production of stomach acid, which may worsen digestive disorders and can cause acid reflux (“heartburn”). Insomnia, poor sleep, and anxiety are other potential results of overuse of caffeine. Excessive continual coffee consumption can also lead to bone loss, increased blood pressure, and lower bone density, meaning that fractures are more likely (Chaudhary, Grandner, Jackson, & Chakra- vorty, 2016; de Mejia & Ramirez-Mares, 2014). Some researchers, however, found that coffee consumption does not lead to ulcers or acid reflux (Papakonstantinou et al., 2016).

Psychological Effects Because caffeine is a stimulant, many people consume drinks containing it to combat drowsi- ness, increase alertness, and boost energy. Paradoxically, many people also consume caffeine to relax. It is possible that the relaxing effect of caffeine is not the result of its chemical action but of expectancies (what people expect when they use a drug or substance) and social rein- forcements. If we expect caffeine to be relaxing, it probably will be.

Nicotine Nicotine is the primary psychoactive ingredient in tobacco, a plant that has grown in the Americas for centuries. Let’s look at a few statistics to put tobacco use into perspective. Although tobacco usage has decreased over the past few years, in 2015 nearly 25.3% of high school students used some type of tobacco product, including 13% who reported cur- rently using at least two or more tobacco products (Singh, 2016). Among current high school users, smokeless tobacco was the product used most often during the past month (42%), followed by cigarettes

kolosigor/iStock/Thinkstock As with substances administered through a needle, our bodies react physiologically to nicotine within a matter of seconds.

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Section 4.1 Psychoactive Substances: Some Basic Information

(31.6%). Not surprisingly, e-cigarettes were used by about 15.5% of those surveyed (Neff et al., 2016). Cigar smoking was also common among high school students, at about 13.1% (Neff, Spiker, & Truant, 2015; Singh, 2016).

Action Nicotine is a powerful stimulant, so toxic that it has been used as a natural insecticide. A small amount instantly kills a variety of insects. In humans, nicotine is one of the fastest acting psy- choactive substances. Within seconds of a smoker’s puffing on a cigarette, nicotine reaches the smoker’s brain (Benowitz, 1996). It activates specific receptors in the midbrain that pro- duce increased arousal. The end result is similar to the one produced by caffeine—smoking makes people more alert and less drowsy.

Health Effects Carbon monoxide, the poisonous gas found in automobile exhaust emissions, is also present in cigarette smoke. It reduces the smoker’s oxygen supply, thereby affecting the heart and other circulatory organs. The organic chemicals suspended in smoke droplets, known as tar, contain several known carcinogens, or substances that can cause cancer. Many other danger- ous substances, such as formaldehyde (a well-known carcinogen) and nitric oxide (a poison- ous gas), are also found in tobacco smoke.

The effects of smoking on health have been known for decades. In 1948, researchers began a prospective study of more than 5,000 people living in Framingham, Massachusetts. Their aim was to identify the factors that contribute to heart disease. The now-famous Framingham Heart Study revealed a number of risk factors (characteristics, genetic or otherwise, that seem to be associated with an increased risk of disease onset or recurrence). Somewhat unex- pectedly, at least at the time, high among those risk factors was smoking (Dawber, 1980). The Framingham study was the first evidence that tobacco smoking was related to heart disease. It was followed by a study of 8,000 men of Japanese descent, which found that smoking is also a risk factor for stroke (Abbott, Yin, Reed, & Yano, 1986). Smokers have three times as many strokes as people who have never smoked. A 34-year follow-up of the Framingham study shows a continuing association between smoking and a range of diseases years after smoking ceases (Freund, Belanger, D’Agostino, & Kannel, 1993).

In addition to heart disease and stroke, smoking is a risk factor in respiratory diseases such as bronchitis and emphysema (Rigotti, 2013), in stomach ulcers, and in diseases of the mouth (Sood et al., 2014). Exposure to the smoke of other people’s cigarettes, pipes, and cigars (known as passive smoking) is also a health risk, especially for young children (Czogala et al., 2014). These researchers estimated that passive smoking kills more than 600,000 people worldwide every year, an astonishingly high figure (Czogala et al., 2014).

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Section 4.1 Psychoactive Substances: Some Basic Information

According to the World Health Organization (WHO), tobacco is the second leading cause of death around the globe. WHO estimates that 12% of all deaths among adults aged 30 or older are smoking related, which comes out to about 5 million people each year. This number is expected to grow to 8 million by 2030. Half of all smokers will die from their tobacco use (WHO, 2012). In 2015, WHO estimated that over 1.1 billion people smoked tobacco (WHO, 2012).

Although smoking is directly related to stroke, heart disease, diabetes, chronic obstructive pulmonary disease (COPD), and 12 types of cancer (Carter et al., 2015; Farsalinos et al., 2016), the best known link is the relationship between smoking and lung cancer (Carter et al., 2015).

Psychological Effects Despite nicotine’s arousing effects, most smokers, like most coffee drinkers, claim that they smoke to relax. Some research suggests that smoking may actually increase stress levels (Par- rott, 2000). Other studies reveal that smoking is relaxing and that smoking increases under stressful circumstances (Hughes, 2005). As with coffee drinking, the relaxing effects of ciga- rette smoking may be, at least in part, the result of expectancies and social reinforcement.

Personality may play a role in nicotine use. Despite the well-known health risks, millions of people continue to smoke. Hans Eysenck (1991) suggested that this phenomenon may be partly explained as a behavioral expression of the personality trait of extroversion. Accord- ing to Eysenck, extroverts are born with low levels of arousal. The experience of low arousal is perceived as unpleasant, so extroverts continuously seek stimulation—and smoking is a source of stimulation. Not all extroverts smoke, of course. There are other ways to raise arousal; some may drink lots of coffee. However, once extroverts start smoking (because of peer pressure, rebelliousness, or for some other reason), they are likely to continue because smoking provides the stimulation they crave (Hakulinen et al., 2015). In 2015, e-cigarettes were the most commonly used tobacco product among middle (5.3%) and high (16.0%) school students (Singh, 2016). During 2011–2015, significant increases in current use of e-cigarettes and hookahs occurred among middle and high school students. This finding is bothersome, but what is interesting is that the current use of conventional tobacco products such as cigarettes and cigars decreased during that timeframe. Many people falsely believe that e-cigarettes are healthier for you, and although ads may imply that this is the case, it is not true (Callahan-Lyon, 2014).

Nicotine, as a stimulant, belongs to the same class of substances as amphetamines, cocaine, and MDMA, which is also known as ecstasy or Molly (see Table 4.1).

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Section 4.1 Psychoactive Substances: Some Basic Information

Alcohol Alcohol (known more accurately as ethanol) is the second most commonly used psychoac- tive substance in the United States and perhaps in the world. It is estimated that 2 billion peo- ple worldwide use alcohol (WHO, 2011). Globally, 45% of the world’s population has never consumed alcohol (35% of men and 55% of women).

Alcohol is found in wine, liquor, spirits, beer, cider, and many cold medications. Unlike smok- ing, alcohol use is positively correlated with educational attainment. College graduates drink more than those who ended their education after high school (although college students with low marks drink more than high-performing students; Ansari, Stock, & Mills, 2013; Quinn & Fromme, 2011). International comparisons suggest considerable cross-cultural variability in

Table 4.1: Examples of stimulants (other than caffeine and nicotine)

Name Description

Amphetamine A synthetic (manufactured) compound that comes in legal prescription versions and ille- gal street versions, such as “speed.” Amphetamine powder can be inhaled (“snorted”) or injected. Amphetamines enhance neurotransmitter concentration, especially norepineph- rine and dopamine. This increased concentration produces alertness and arousal. Origi- nally intended as an asthma medication, amphetamines still have several medical uses. For example, drugs such as dextroamphetamine (Adderall) and methylphenidate (Ritalin) may be prescribed for people with attention-deficit/hyperactivity disorder (discussed in Chapter 11); and because they suppress appetite, they are sometimes used as diet aids. Large doses of amphetamines can also be fatal.

Cocaine Derived from the South American coca plant, cocaine, or coke, comes in several forms and was once an ingredient in Coca-Cola (Musto, 1992). Cocaine produces stimulatory effects similar to those produced by amphetamines. Also like amphetamines, cocaine can be injected, snorted, or smoked in forms known as free-base and crack. Cocaine acts to enhance the action of dopamine and other neurotransmitters, thereby increasing arousal while producing a variety of psychological effects including (after prolonged use) paranoia, anxiety, panic attacks, and even a psychotic disorder (Yudofsky, Silver, & Hales, 1993). Withdrawal does not seem to produce symptoms unless cocaine use extends over a consid- erable period, usually defined as six months or longer (Gawin & Kleber, 1992). Similar to amphetamines, cocaine can be fatal in large doses (Harlow & Swint, 1989). In 2010, about 1 million people had cocaine dependence in the United States (NSDUH, 2011).

MDMA MDMA (3, 4-methylenedioxymethamphetamine), also known as ecstasy, is technically a stimulant but is often considered to be a hallucinogen as it produces hallucinogenic effects. This drug is often used in clubs and at raves as it provides users with a boost in energy that allows them to go on dancing for extended time periods. MDMA has no medicinal effects and can lead to many physical problems, including increased blood pressure and heart rate, which can lead to cardiac arrest (Ksir, Hart, & Oakley, 2008). The popular nickname Molly (slang for “molecular”) often refers to the supposedly “pure” crystalline powder form of MDMA, usually sold in capsules. Sometimes the capsule is “cut” with another substance (meaning that another substance in addition to MDMA is added in, often without the user’s or buyer’s knowledge). Other stimulants include cocaine, ketamine, methamphetamine, over-the-counter cough medicine, and synthetic cathinones (“bath salts”).

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Section 4.1 Psychoactive Substances: Some Basic Information

alcohol consumption depending on availability and cultural prohibitions (Erol & Karpyak, 2015; WHO, 2014).

In all ethnic groups, males are much more likely than females to be binge drinkers, although women appear to be closing the gap (Erol & Karpyak, 2015). This also puts women at risk for other drug use, where they also seem to be catching up to men (Clinkinbeard & Barnum, 2015). Even so, the gap between men and women still exists. Why might that be? First, blood levels of alcohol build up more quickly in women than in men of the same size because women have less of the enzyme—known as alcohol dehydrogenase (ADH)—that helps break down alcohol in the stomach before it enters the bloodstream (Erol & Karpyak, 2015). Note, how- ever, that Erol and Karpyak (2015) also found some reports that suggested this is not the case. Second, many women do not drink when they are pregnant because of the now well-known fact that alcohol can cause birth defects (Landgraf, Nothacker, Kopp, & Heinen, 2013).

Action Chemically, alcohol is a depressant. It lowers arousal and makes people drowsy (Yi, 1991). Some of the other depressants included in the DSM–5 are described in Table 4.2.

Alcohol exerts a variety of effects on the central nervous system, but one of its most impor- tant is to reduce inhibition, which is controlled by the GABA neurotransmitter system (GABA stands for gamma-amino butyric acid; the “gamma” is typically abbreviated with the Greek letter for gamma). The result is that drinkers lose some degree of self-control. Alcohol dilates blood vessels, decreases blood pressure, lowers heart rate, and slows respiration. Although small amounts of alcohol are exhaled as vapor by the lungs, which can be measured by road- side Breathalyzers, most of the ingested alcohol goes to the liver, where it is gradually broken down (metabolized) and excreted. The average person can metabolize about one “standard drink”—the equivalent of one 12-ounce glass of beer, one 5-ounce glass of wine, or 1 ounce of 90-proof liquor—per hour. (We will discuss the BAC a bit later in this chapter.) Neither drinking black coffee nor splashing cold water on one’s face makes any difference in the rate at which alcohol is metabolized; there is no quick way to sober up.

Health Effects Drinking moderate amounts of alcohol, especially red wine, may reduce the likelihood of cor- onary heart disease (Chiva-Blanch, Arranz, Lamuela-Raventos, & Estruch, 2013). However, chronic use of alcohol can damage the heart and just about every other organ in the body (Shield, Parry, & Rehm, 2014; WHO, 2014). Alcohol irritates the digestive system, causing

ZzzVuk/iStock/Thinkstock Males are more likely to be binge drinkers than females, partly because women have less of the enzyme ADH (alcohol dehydrogenase) that helps break down alcohol in the stomach.

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Section 4.1 Psychoactive Substances: Some Basic Information

inflammation and bleeding. Prolonged and intensive use of alcohol can turn the liver into nonfunctioning, fibrous tissue. This syndrome is known as cirrhosis. A very high blood alco- hol level can be fatal, although most people become unconscious before drinking enough to cause death.

Heavy drinking during pregnancy can put a fetus at risk of developing fetal alcohol syn- drome (FAS), which is marked by intellectual disabilities, hyperactivity, facial deformities, and growth deficiencies of internal organs and the body’s systems (Caputo, Wood, & Jabbour, 2016; Landgraf et al., 2013). A classification known as fetal alcohol spectrum disorders (FASD) includes FAS, partial FAS, alcohol-related neurodevelopmental disorder, and alcohol-related birth defects (Landgraf et al., 2013). Even when they consume the same amount of alcohol, African American women and female members of certain Native American tribes are more likely to have children with FAS than are members of other groups (Caetano, Vaeth, Chartier, & Mills, 2014). Their increased vulnerability appears to be the result of genetic differences in alcohol metabolism (Caetano et al., 2014; Gordis, 1991).

Psychological Effects Moderate amounts of alcohol make most people feel talkative and relaxed. Even though drinkers may relax, even modest amounts of alcohol can affect cognition (Starkey & Charlton, 2014). After a few drinks, we concentrate on only the immediate and the most obvious cues in our environment, ignoring complexities and long-term consequences. For example, you may feel like talking back to a professor or to your supervisor at work, but a sober consideration of the consequences will probably inhibit you from actually saying anything. Under the influ- ence of alcohol, however, you may not consider the long-term consequences and just lash out. This narrowing of focus to the immediate is called alcoholic myopia (Fairbairn & Sayette, 2013). This can lead to having unprotected sex and inappropriate, even dangerous, acts of aggression (Giancola, 2015; Kiene, Simbayi, Abrams, & Cloete, 2016), for example.

As the amount of alcohol in the bloodstream builds, vision becomes blurred, hearing grows less acute, and motor control begins to break down. It is these effects that make drinking and driving so dangerous. Indeed, alcohol was associated with around 29% of all automobile accident fatalities in 2015 (National Highway Traffic Safety Administration [NHTSA], 2016).

The level of cognitive and motor impairment produced by alcohol depends on its concentra- tion in the blood. Concentrations below 0.05% of blood by volume usually produce feelings of relaxation, with minimal cognitive or motor effects. Higher concentrations affect judgment and motor coordination. Figure 4.2 shows the relationship between blood alcohol concentra- tion (BAC) and body weight.

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Section 4.1 Psychoactive Substances: Some Basic Information

Figure 4.2: Approximate blood alcohol concentration (BAC) and body weight

Source: P. M. Insel & W. T. Roth, Core Concepts in Health, 10th ed. Mountain View, CA: Mayfield Publishing Company, 2000, p. 254. Reprinted by permission.

1 hour

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190–209 lb

BAC zones:

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Not only is judgment affected by alcohol, but so are the attributional processes required to interpret and control emotions (Giancola, 2013). For example, alcohol makes some people feel sexually aroused. Because their judgment is impaired, they may interpret innocent signs as indicating that another person feels the same way. Couple this with disinhibition, and it is not surprising that people influenced by alcohol may do things they would never do while sober. It is primarily alcohol’s disinhibiting effect that makes people believe that it is “stimu- lating,” even though it is a depressant. Excessive disinhibition can sometimes lead to aggres- sion (Giancola, 2013). Aggression, combined with impaired judgment, makes alcohol a factor in child abuse (Freisthler & Gruenewald, 2013), as well as in many suicides (Borges et al., 2017). See Table 4.2 for a summation of depressants other than alcohol.

Table 4.2: Depressants other than alcohol

Name Description

Sedatives, hypnotics (sleep- inducing drugs), and anxiolytics (antianxiety drugs)

Barbiturates (Seconal, Nembutal, and others) were first used in 19th-century Germany as sleeping aids. Benzodiazepines (e.g., Valium) are considered safer than barbiturates. The main effect of all sedative and anxiolytic drugs is to depress bodily functions. At low doses, these drugs are calming and promote sleep, but they can affect memory and interfere with psychosocial functioning (Warneke, 1991). The abrupt cessation of any of these drugs after prolonged use can cause neuro- logical symptoms, including seizures. Because alcohol, sedatives, and anxiolytics all affect the GABA system (McKim, 1991), mixing alcohol and these drugs produces a strong and potentially deadly effect (Fils-Aime, 1993).

Opioids Opioid is the general term for substances derived from the opium poppy plant. Known as opiates or narcotics, these include opium, morphine, and heroin; syn- thetic variants, such as methadone; and naturally occurring brain substances, such as beta-endorphins (Jaffe, 1991). All opioids are habit-forming. Although they may produce a brief feeling of elation, opioids are depressants (Barinaga, 1992). There is also evidence that opioids reduce the functioning of the immune system, thereby lowering resistance to disease.

Cannabis Cannabis is actually a short name for Cannabis sativa, a type of hemp plant that produces sev- eral psychoactive substances. Marijuana (also known as pot, weed, and many other names) is a mixture of the dried shredded flowers and leaves of the plant. Hashish is a sticky resin obtained from cannabis flowers. Cannabis users usually roll the substance into a cigarette known as a joint or smoke it in a pipe.

The psychoactive ingredient in marijuana is delta-9-tetrahydrocannabinol, usually called THC. Ordinary marijuana contains about 3% THC, but some types can contain 20 times as much. At such high doses, THC can produce distorted sensations and perceptions (hallucina- tions). Technically, this makes cannabis a hallucinogen, but, as previously noted, the DSM–5 classifies it in a separate category because perceptual distortions do not always accompany cannabis intoxication. Several hallucinogens are described in Table 4.3.

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Cannabis is one of the oldest crops cultivated by human beings (see Grinspoon & Bakalar, 1993, for one example of a detailed history of marijuana). Ten-thousand-year-old clay pots unearthed in Taiwan were found to have strands of hemp fiber in their decorations. For centu- ries, and until fairly recently, hemp fiber was a major source of rope, canvas, paper, and cloth (the first Levi’s jeans were made of hemp).

Action Within a few minutes of inhaling cannabis smoke, users experience dry mouth, rapid heart- beat, some loss of coordination, and slower reaction times. Blood vessels in the eyes expand, and blood pressure rises. Once in place, THC stimulates chemical reactions that produce the euphoria that users experience when they smoke cannabis.

Health Effects Many people use cannabis regularly with little obvious effect on their health. In fact, the most common physiological effects reported by cannabis users are feelings of thirst and hunger (“the munchies”). However, cannabis smoke contains many of the same ingredients as tobacco, so cannabis smoking can result in the same respiratory problems that cigarette

Table 4.3: Common hallucinogenic substances

Name Description

MDMA Widely known as ecstasy, MDMA has both hallucinogenic and amphetamine-like stimu- lating qualities. MDMA destroys neurons, especially those containing dopamine. It not only produces hallucinations but also a loss of motor control (Fischer, Lankford, & Galea, 1995).

Natural (plant-derived) substances

Psilocybin (found in certain mushrooms), DMT (from the bark of the South American virola tree), mescaline (a cactus derivative), and other naturally occurring hallucinogens produce varying degrees of cognitive distortions depending on their concentration and on users’ expectations. (People who expect to see changing colors or bright lights are more likely to experience these sensations than those without such expectations.)

LSD Lysergic acid diethylamide is one of the most powerful hallucinogens. The physical effects of LSD are similar to those of stimulants: increased heart rate and blood pressure, loss of appetite, sleeplessness, and dry mouth. LSD’s psychological effects depend on the amount ingested, individual differences, expectations, and the social context. Typical reactions include rapid mood swings, distortions in time, and hallucinations. Sensations become confused, and some people claim to “hear” colors and “see” sounds (a phenom- enon known as synesthesia). People who find such sensory experiences frightening label their experience a “bad trip” (American Psychiatric Association [APA], 2000).

PCP Because its profile of psychological effects differs from those of LSD and MDMA, the DSM–5 puts phencyclidine (PCP) in a different category. Yet PCP is also a powerful hal- lucinogen. Widely known as angel dust, PCP was developed in the 1950s as a surgical anesthetic. However, many people given PCP had hallucinations.

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smoking causes: cough, increased susceptibility to colds, and lung disease. In fact, because cannabis smokers try to keep the smoke in their lungs as long as possible, smoking a mari- juana joint may actually have a greater effect on respiratory health than smoking a cigarette. Cannabis also increases blood pressure and heart rate, so it may have particularly negative effects on people with heart or circulatory diseases (Hall & Degenhardt, 2013; Owen, Sutter, & Albertson, 2014; Volkow, Baler, Compton, & Weiss, 2014).

Over the past few years, many regular users of marijuana have either demonstrated mari- juana abuse or become physiologically dependent, meaning they develop a tolerance for it and demonstrate irritability and restlessness when they stop using (Hasin et al., 2015). The long-term effects of cannabis smoking on the pulmonary-respiratory system are not as clear (Hall & Degenhardt, 2013). The 2014 National Survey on Drug Use and Health provides the following statistics: “Marijuana was the illicit drug with the highest rate of past-year depen- dence or abuse in 2014, followed by pain relievers and cocaine. Of the 7.1 million persons aged 12 or older classified with illicit drug dependence or abuse in 2014, 4.2 million had mar- ijuana or hashish dependence or abuse (representing 1.6 percent of the total population aged 12 or older, and 63.0 percent of all those classified with illicit drug dependence or abuse), 1.9 million persons had pain reliever dependence or abuse, and about 913,000 persons had cocaine dependence or abuse” (CBHSQ, 2015).

Medical Marijuana Usage According to the National Institute on Drug Abuse (NIDA, 2017), medical marijuana refers to using the whole, unprocessed marijuana plant or its basic extracts to treat symptoms of ill- ness and other conditions. The U.S. Food and Drug Administration (2017) has not recognized or approved the marijuana plant as medicine. THC can increase appetite and reduce nau- sea, which are extremely important for chemotherapy patients. THC may also decrease pain, inflammation (swelling and redness), and muscle control problems. These problems may also be treated with opioids, which can become physiologically addicting. Although the marijuana plant is still not FDA approved as of this writing, its potential medicinal usages require further research so that we can ascertain if (and how) this plant can have medicinal value.

Psychological Effects The psychological effects of cannabis are highly variable. They depend on the amount of THC ingested, the expectations of the individual, and the social context. Some people feel noth- ing at all when they smoke marijuana. Most report feeling lazy, relaxed, and mildly elated (a state usually summarized as feeling “stoned”). Distorted perceptions (sights, sounds, time, and touch) have also been reported (Hadland, Knight, & Harris, 2016). Occasionally, can- nabis users experience sudden feelings of anxiety and have paranoid thoughts (Hadland et al., 2016). A 2016 meta-analysis estimated that cannabis use is statistically associated, in a dose-dependent manner, with an increased risk of the development of psychotic disorders, which might include schizophrenia (Marconi, Di Forti, Lewis, Murray, & Vassos, 2016). Dose- dependent refers to a relationship in which a change in the amount, intensity, or duration of exposure to marijuana is associated with a change in risk of a specified outcome, in this case an increased risk of developing psychotic disorders.

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4.2 Why Are Psychoactive Substances So Popular? Why do we use psychoactive substances? According to ethologists, scientists who observe natural behavior in humans and animals, substance use is a “displacement” activity, some- thing done in place of another behavior. For example, psychoanalysts view smoking as a way of obtaining oral gratification, a displacement for the breast. Such simple explanations, how- ever, hardly do justice to the complex web of factors controlling substance use.

Perhaps the most obvious reason for using a substance is to change our state of conscious- ness. If we need to get started in the morning or if we are having trouble concentrating on our work, a cup of coffee or a cigarette may help. Similarly, when we are tense, alcohol or canna- bis may help us to relax. In other words, we use psychoactive substances to produce specific psychological effects.

Although they are important, the psychological effects of substances are only part of the story. Substance use is the complex result of several interacting factors: exposure and availability, reinforcement, expectancies, social and cultural context, and biological variables.

Modeling, Exposure, and Availability Before we can use a substance, we must first know that the substance exists and, second, have access to it. In the case of caffeine, modeling is almost universal. Parents, friends, practically everyone uses caffeine in one form or another. Alcohol use is also widely modeled. Children can readily identify the smell of alcohol (beer, wine, or whiskey), and many associate alcohol with adults or with unpleasant results (Jayne & Valentine, 2017).

Because we see so many people using caffeine, alcohol, and nicotine, often in happy surround- ings, and because these substances are heavily promoted in the media and by peers, it is not surprising that most of us decide to give at least one of them a try. Contrast the familiarity and availability of caffeine, nicotine, and alcohol with our knowledge of and access to amphet- amines. Amphetamines are also stimulants, but they are not as widely used. Few of us see our parents or friends using them, and they can be obtained legally only with a doctor’s prescrip- tion. In addition, marijuana is legal in some countries but not in others. Therefore, people who have been exposed to marijuana will be more familiar with it and its usage than will those who live in countries where marijuana is illegal. Medical marijuana usage remains part of the national debate in the United States.

Reinforcement Modeling and availability might determine which substances we are most likely to try, but other factors determine whether we will keep using those we do try. One of the most impor- tant factors is the positive reinforcement we get from changing our mental state through the use of a substance (Posner, Amira, Algaze, Canino, & Duarte, 2016). These changes in mental state are perceived as pleasurable because they stimulate the brain’s “pleasure center,” the part of the brain that gives rise to subjectively pleasant feelings (Olds, 1956; Wise, 2013).

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Although the exact location of the pleasure center is a matter of debate, it seems to be closely related to the dopamine system (Wise, 2013). One of the reasons that people continue to use substances is to experience the reinforcing feelings produced when substances stimulate the brain’s pleasure center (see Figure 4.3).

Figure 4.3: The chemical process of dependence on nicotine

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 6.4, p. 86.

Receptor sites

Dopamine

Transmitting nerve cell

Nerve signal

Nerve ending

Receiver cell

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The reasons for using a substance may change over time. Consider cigarette smoking, for instance. Most of the time, people find their first experience unpleasant. The first few ciga- rettes may cause coughing, dizziness, nausea, even vomiting. It is amazing that anyone would wish to repeat the experience, especially since most adolescents know the health risks before they light up their first cigarette, though they typically underestimate the risk involved (Ambrose et al., 2014). Yet many go on to become smokers. One reason is peer group accep- tance. Teenagers whose siblings or friends smoke are more likely to begin smoking than are those with no peers to emulate or impress (Huang et al., 2014). Because smoking is followed by peer approval, as well as by desired changes in mental state, it is reinforced. Exactly the same group dynamics reinforce the use of alcohol, cannabis, and other substances. Social reinforcement is an important determinant of substance use because substances are an inte- gral part of social activity.

In addition to positive reinforcement, negative reinforcement (escape from an aversive state) also plays an important role in substance use. Feeling tired or unable to concentrate is an unpleasant feeling. If a cigarette or a cup of coffee dissipates our fatigue and makes us more alert, we will be reinforced to try the same “cure” again the next time we feel tired or dis- tracted. Similar negative reinforcement comes from substances that reduce feelings of anxi- ety and depression (SAMHSA, 2016).

Expectancies Expectancies also influence usage (Harrell et al., 2015). How can a substance like nicotine, which increases blood pressure, pulse rate, and arousal, help people relax and fall asleep? We have discussed part of the answer; increases in arousal are reinforcing for low-arousal people, and stimulants affect the brain’s pleasure center, releasing pleasurable endorphins, chemicals in the body that inhibit pain and produce pleasure. But there is another factor operating as well—cognitive expectancies. If we believe that a cup of tea will help us to sleep or that a cigarette will help us relax, then they probably will have these effects even though both tea and cigarettes contain stimulants. These expectancies about the effects of substances are the result of direct experience with a substance as well as exposure to parents, peers, and the media (Chisolm, Manganello, Kelleher, & Marshal, 2014).

Social and Cultural Context As stated, the reinforcement produced by peer group acceptance is an important determi- nant of substance use, but economic factors are also related to substance use (Karriker-Jaffe, 2013). For instance, people in lower socioeconomic classes have higher substance abuse rates (Andrabi, Khoddam, & Leventhal, 2017; Karriker-Jaffe, 2013). Substance use is a particularly serious problem for some ethnic groups. Therefore, understanding substance use, and help- ing people with substance-related problems, requires sensitivity to the ways in which cultural norms affect substance-related behavior (Otiniano-Verissimo, Grella, Amaro, & Gee, 2014).

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Biological Variables and Individual Differences Some people may be genetically vulnerable to suffer from drug abuse (Palmer et al., 2015). If they are exposed to certain substances, people with such predispositions are more likely than others to use again. For example, genetics certainly play a role in alcohol use (Verhulst, Neale, & Kendler, 2015). A possible mechanism for a predisposition to alcoholism is the dopamine 2 (D2) gene found on chromosome 11 (Bühler et al., 2015; Mbarek et al., 2015). About 66% of excessive alcohol users (people whose alcohol use has caused them problems) carry this gene, whereas it is present in only 20% of the rest of the population. The existence of the D2 gene does not mean that some people are born “alcoholics.” Other genes may be connected to substance-related disorders (see Bühler et al., 2015). Chromosomes 4 and 12 have also been implicated (Bühler et al., 2015; Mbarek et al., 2015). In addition, an individual with a D2 gene might never drink because of religious reasons, choice, a preexisting medical condition, or for some other reason. The same gene is also associated with other substances, including nico- tine and opioids, and with compulsive binge eating and gambling (Bühler et al., 2015; Clarke et al., 2014; Gyllai et al., 2014; Kessler, Hutson, Herman, & Potenza, 2016; Lobo et al., 2015; Schulte, Grilo, & Gearhardt, 2016).

Some people with the D2 gene may never develop substance-related problems because they have also inherited competing dispositions that counteract the effects of D2. For example, as many as half of all people of Asian descent lack one of the enzymes that helps break down alcohol in the liver. When they drink alcohol, they experience an “alcohol-flush syndrome” that includes a blushing red skin, dizziness, and nausea (Newman et al., 2013). The alcohol- flush syndrome may be unpleasant enough to prevent affected people from drinking, even if they have inherited the D2 gene.

It is important to note that one third of problem drinkers do not have the D2 gene. This sug- gests that there may be two different types of people who develop problems with alcohol: (a) those with the D2 gene and a family history of excessive drinking, who develop alcohol-related problems early in life, and (b) those without the gene, whose drinking problems develop late in life and whose social and occupational functioning is only mildly affected (Schuckit & Smith, 1996; Yoshino & Kato, 1996). Drinking in the second group seems mainly affected by environmental factors (exposure, social reinforcement), whereas drinking in the first group may be influenced more by genetics.

The United States’ Opioid Epidemic In 2015 (the latest year for which data are available), 12.5 million people misused prescrip- tion opioids (USDHHS, 2017). Of those, 2.1 million people misused prescription opioids for the first time, and 2 million people had prescription opioid use disorder. In addition, 33,091 people died from overdosing on opioids, including 15,281 whose deaths were attributed to overdosing on commonly prescribed opioids, an inordinately high number. In 2013, the opioid epidemic cost the United States $78.5 billion (USDHHS, 2017). These numbers are increasing yearly, indicating the existence of a significant opioid epidemic, and one that is not going away soon. The USDHHS notes that the misuse and abuse of prescription medications in the United States remains high, but few people are aware of the extent of the problem. As we will discuss later, the best methods to address the problems of misuse and abuse are increased education and prevention. We need to determine why the abuse rate continues to increase, and how we

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can educate preteens and teenagers about the dangers of these substances. Perhaps then we will see the opioid abuse rate and the resulting death toll decrease.

4.3 Potential Problems of Sustained Substance Use The average American consumes 200 mg of caffeine per day, the equivalent of two strong cups of brewed coffee. Of course, many people consume much more. High caffeine consumption can induce caffeine intoxication, which is marked by restlessness, excitement, an inability to sleep, flushed face, muscle twitching, and in especially severe cases, rambling speech, heart rate abnormalities, and agitation (APA, 2013). Very large doses can even be fatal. Alcohol and cannabis also produce well-documented intoxication syndromes (APA, 2013).

You may know people who show no signs of intoxication even after consuming significant amounts of alcohol and wonder why these people seem immune to its intoxicating effects. The answer is tolerance (the lessening of the body’s response to a drug after continued use). As a result of tolerance, individuals using a drug will find that they begin to need greater and greater amounts in order to achieve the same effects as before, or even to achieve a lesser effect. Three beers may be enough to produce intoxication in a nonuser, whereas a much larger amount may have little or no effect on a habitual beer drinker. People can develop tol- erance to most (but not all) substances.

How much substance users consume, and how often, is determined partly by the amount of a substance in the user’s body. For example, smokers adjust their habit to maintain a certain level of nicotine in their bodies. If the amount of nicotine falls below the desired level, smok- ers may become irritable, restless, distractible, and hungry (Soyster, Anzai, Fromont, & Pro- chaska, 2016). These symptoms are known as nicotine withdrawal (APA, 2013). The DSM–5 also contains diagnostic criteria for alcohol withdrawal, which is marked by tremor, sweating, nausea, and anxiety. In severe cases, people withdrawing from alcohol may experience dis- turbances in consciousness, including hallucinations (known as delirium tremens, or the DTs). Withdrawal symptoms may be so severe that people continue using a substance just to avoid the symptoms. In such cases, substance use is being maintained by a form of negative reinforcement.

Substance Use Versus Substance Abuse Substance use, by itself, is not a psychological disorder. Substances present a psychological problem only when they produce adverse consequences. Consuming a glass of wine with din- ner does not lead to adverse consequences for most people; thus, it is not a sign of a psycho- logical disorder. In contrast, drinking to the point of intoxication and missing classes several times a week for a number of weeks could be a sign of what the DSM–5 refers to as a sub- stance use disorder.

The DSM–IV–TR had separate categories for substance abuse and substance dependence. Sub- stance dependence criteria included tolerance and withdrawal as well as loss of control (the feeling that once an individual began using a substance, he or she was unable to stop, even if intending to do so). The DSM–5 combined both categories into a new category: substance

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use disorder (APA, 2013). This new category codes the substance use disorder on a spec- trum using the following specifiers: mild, moderate, and severe. In addition, the criterion that the individual had to have recurrent legal problems in order to qualify for the old substance abuse diagnosis has been eliminated from the DSM–5 (APA, 2013). It is now also somewhat more difficult to “qualify” for substance use disorder. To qualify for the DSM–IV–TR substance abuse diagnosis, an individual had to satisfy minimally one criterion. In the DSM–5, the indi- vidual must satisfy minimally two or more criteria. For the moderate subcategory, an indi- vidual must satisfy minimally four or more criteria, as opposed to satisfying three or more for the old substance dependence disorder.

Perhaps more important, a new criterion was added to the DSM–5 regarding substance use disorder: craving, or a strong desire or urge to use a substance (APA, 2013). Craving implies physiological dependence which can lead to loss of control as well as intoxication.

Substance Dependence Chronic substance abuse or misuse may lead to a substance use disorder. The DSM–5 uses the term dependence rather than addiction because the latter has pejorative connotations and, according to APA, has an uncertain definition (APA, 2013). According to the DSM–5, all catego- ries of substances except caffeine can produce a substance use disorder.

Once a substance use disorder forms (meaning that the individual may have developed a dependence on that substance), people begin to organize their lives around satisfying their craving. The chronic use of substances may also change body chemistry because many sub- stances replace the body’s natural chemicals. When substances are discontinued, the body takes a while to restart its natural production. In the interim, the person experiences with- drawal symptoms.

Not all substances produce physical signs of tolerance and withdrawal. The opposite is also true: Tolerance and withdrawal can exist without the craving for a substance that marks dependence.

Scientists once thought that people who abuse alcohol enter an inevitable downward spiral in which they become increasingly dependent (Jellinek, 1946), but we now know that alcohol abuse does not necessarily lead to dependence, or a substance use disorder (Wise & Koob, 2014). What is still not entirely clear is why some alcohol abusers become dependent, whereas others do not (Sobell & Sobell, 1993; Vaillant & Hiller-Sturmhofel, 1997). It is important to emphasize that dependence is much the same disorder whatever the substance involved. Dependence on multiple substances is known as polysubstance dependence, a common pat- tern among many substance-dependent individuals (Connor, Gullo, White, & Kelly, 2014).

4.4 Overcoming Substance Use Disorders Substance use is often a difficult pattern to break. Even people who are highly motivated to quit may not necessarily succeed. This section illustrates the problems people face in overcoming a substance use disorder and maintaining recovery and offers some proposed

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solutions. Because the use of nicotine and alcohol is so common, the main focus of this section is on these two substances, but the discussion also shows how lessons learned from helping people give up common substances may be applied to less frequently used substances.

Practically all treatment programs for substance dependence combine several different meth- ods, a strategy known as multimodal treatment. The general idea is to wean people away from a substance; help them manage their craving; and give them the skills necessary to cope with social stress, anxiety, and other potential causes of substance abuse.

Stages in Overcoming Substance Use Disorders As summarized in Figure 4.4, people with a substance use disorder are thought to go through a series of stages in the process of recovery from substance dependence. This model was orig- inally put forward by Prochaska and DiClemente (1983), to describe the process of quitting smoking, but it is applicable to practically any substance (see also Kougiali, Fasulo, Needs, & Van Laar, 2017). From not even thinking about ceasing substance use and not thinking that they have a substance dependence (the precontemplation stage), people move through the contemplation stage, in which they are thinking about ceasing usage and are beginning to think that they have a substance dependence, to the action stage, in which they actually quit. In the final stage, maintenance, they consolidate their treatment gains and attempt to avoid relapse. Most psychological treatment programs are aimed at the action stage, and the major- ity also address maintenance issues. (See Part 2 of Robert Jones’s case in the appendix.)

Figure 4.4: Lichtenstein and Glasgow’s stages of giving up a substance

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 6.6, p. 261.

Precontemplation

Contemplation

Action

Maintenance

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Detoxification Once the action stage is reached, the first step in many treatment programs is detoxification, removal of the substance from the body. Smokers must stop smoking; alcohol-dependent peo- ple must stop drinking; heroin users must stop injecting or snorting.

To minimize withdrawal symptoms and maximize the probability that an individual will con- tinue treatment, detoxification is usually a gradual process (Sachdeva, Choudhary, & Chandra, 2015). Sometimes, people undergoing detoxification may be prescribed anxiolytics and anti- depressants to help with the stress of the withdrawal process (Sachdeva et al., 2015). Care must be taken, however, to limit the use of these drugs to ensure that people do not give up one substance only to start using another. Residential facilities (hospitals, drug treatment centers) often provide the safest environment for people undergoing withdrawal. However, inpatient treatment is more expensive than outpatient treatment, and there is little evidence that the extra expense necessarily produces better outcomes (Sachdeva et al., 2015). Most detoxifications today occur on an outpatient basis (Sachdeva et al., 2015). Inpatient treat- ment will offer better continuity for the patients, especially if they begin their treatment in a hospital. It also keeps the patient in an alcohol-free environment, lessening the relapse pos- sibility. In addition, one study demonstrated that relapse rates are high for those patients who do not receive a treatment follow-up to detoxification (Polydorou & Kleber, 2008).

Detoxification does not, by itself, constitute a treatment. Many substance-dependent people go through cycles of detoxification followed by abuse and dependence followed by detoxifica- tion again (McKay & Hiller-Sturmhoefel, 2011). To break this cycle, clinicians may prescribe a medication to block the action of the substance.

People who are dependent on alcohol (an alcohol use disorder) may be prescribed a drug called Antabuse. If they take Antabuse and then consume alcohol, they will become quite ill—their hearts will race, they will vomit violently, and they may break out in soaking sweats. In theory at least, people who take Antabuse will stop drinking alcohol to avoid becoming ill (Soyka et al., 2017). Unfortunately, these aversive treatments rely on the person actually tak- ing the Antabuse. A person who wants to drink without becoming sick needs only to stop tak- ing the Antabuse—and that is just what many people do (Winslow, Onysko, & Hebert, 2016).

Substance Replacement and Maintenance Some forms of substance use disorder may be so addictive that users settle for replacing a dan- gerous substance with a less dangerous one that they can stay on indefinitely. This is known as maintenance treatment. The most common drug maintenance program involves substitut- ing the synthetic opioid methadone for the more dangerous opioid heroin (D’Aunno, Pollack, Frimpong, & Wuchiett, 2014). Methadone needs to be taken once a day, requiring either a daily trip to a clinic or take-home dosages. Although maintenance treatment may help some people wean themselves off heroin, it is almost certain that participants in such programs will become dependent on methadone (McCance-Katz & Kosten, 2005). Methadone maintenance is still the primary treatment approach for opioid disorders, even as buprenorphine (Subutex) and nal- trexone (Vivitrol) have become more widely used (D’Aunno et al., 2014).

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Highlight: Celebrities and Substance Use Disorder

The list of famous people and celebrities who have died as a result of a substance use disorder is lengthy and continues to expand. In May 2017, Chris Cornell, Soundgarden’s frontman, killed himself by hanging. A recovering drug addict, he was taking the anxiolytic lorazepam (Ativan) and may have overdosed. Prince died of a drug overdose in 2016. Prince had espoused clean living and to many people’s knowledge did not smoke, drink, or use illicit substances. Michael Jackson overdosed on propofol (Diprivan) as well as various anxiolytics. Amy Winehouse, a British singer and songwriter, was just 27 when she died of alcohol poisoning. What is it about being famous (or in Jackson’s, Prince’s, and, to a lesser extent, Cornell’s cases, music superstars) that could lead these individuals to develop a substance use disorder? Perhaps the pressures of fame, touring, and always being in the public eye led them to develop significant anxiety, and they saw alcohol and substance misuse as a way to cope with the anxiety.

How about you? When you have a bad day, perhaps failing an exam for which you knew the material cold, how do you handle it? Do you say, “I need a drink,” and then have one. . .or three? Is this a normal way to alleviate stress? After all, alcohol has been around since the beginning of recorded history, and besides, what is so terrible about having a beer after a long and difficult day?

For Cornell, Jackson, and the others, perhaps the media’s never-ending stream of photos, information, and gossip led to their deaths, since famous people are in the public eye every waking moment. Maybe it was the pressure of performing, or of coming up with new songs and albums, that created their problems. Or perhaps the music world attracts individuals

who are prone to addiction: the addiction of fame, performing live, making millions of dollars at a young age, and being admired for their music and voices. Maybe these pressures, and the fear of losing everything quickly, led them to illicit substances.

We can only presume that these very talented individuals were suffering silently, perhaps burdened by their fame, and sought a way to disconnect, even for a short while. Sadly, if this is the case, the brief respite from reality and stress that substances provided became an addiction, leading eventually to their deaths.

Album/Album/SuperStock Michael Jackson overdosed on propofol in 2009.

Francesc Fàbregas/Album/SuperStock Prince passed away from an overdose in 2016.

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Self-Help Groups Self-help groups have a long history in the treatment of substance dependence. Alcoholics Anonymous (AA), for example, has been offering a self-help program around the world since 1935 (Nathan, 1993). Al-Anon is a related organization that provides support for the families of people dependent on alcohol (Timko, Young, & Moos, 2012). There are similar programs, such as Narcotics Anonymous, for people dependent on opioids and other substances (Miller, Gold, & Pottash, 1989). The AA program usually progresses through a series of 12 steps (see the accompanying Highlight). Alcohol-dependent people must first acknowledge their depen- dency, must then put their trust in a spiritual being (“a power greater than ourselves”), and must make amends to people whom they have harmed (Pagano et al., 2013). Because people are not randomly assigned to AA or a control group, it is not possible to conduct controlled clinical trials on the effectiveness of AA.

Relapse Prevention Most substance abuse treatment programs have high relapse rates. For example, practically all quit-smoking programs are successful at first, but after a time, 70% to 80% of participants begin smoking again. Some treatment programs attempt to improve on this by training peo- ple to deal with the potential causes of relapse before they occur. The main factor influencing relapse prevention and treatment efficacy seems to be treatment length. Longer, repeated, and more intense treatments produce better results than brief treatments (McKay & Hiller- Sturmhoefel, 2011). (See Part 3 of Robert Jones’s case in the appendix.)

Treatment of Substance Use Disorder (Substance Dependence): State of the Art Despite the best efforts of generations of psychologists, substance dependence remains difficult to treat. An 11-year follow-up study showed that 10.2% of men treated for heroin dependence were dead, 24.8% continued to use heroin, 46.6% were currently in treatment, and about 22% were involved with criminal activity (Teesson et al., 2015). More recent data reveal that, in the United States, the number of persons aged 12 or older needing treatment for an alcohol use problem was 18.0 million (6.9% of the population aged 12 or older; NSDUH, 2013). Even though the NSDUH report does not discuss the difficulty of preventing alcohol abuse or dependence relapse, practitioners and individuals with an alcohol abuse or depen- dence problem know the difficulty of maintaining recovery. In short, no single program seems to work for everyone.

Substance dependence is often associated with other psychological disorders (Lai, Clearly, Sitharthan, & Hunt, 2015). It is often difficult to determine whether substance abuse is the cause of another psychological disorder or its result, or both (Lai et al., 2015). In most cases, however, it is necessary to treat any serious psychological disorders before people can mod- erate their use of substances. The problems of mentally ill chemical abusers (MICAs) are especially severe, according to one study (Kutcher, Kachur, Marton, Szalai, & Jaunkalns, 1992). MICAs, who are most often young males, are generally poor, homeless, sickly, and likely to get into legal difficulties.

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Highlight: Some Thoughts on Alcoholics Anonymous (AA)

Chances are excellent that you have heard of Alcoholics Anonymous, or AA, sometimes called Friends of Bill W. on cruise ships and elsewhere (Bill Wilson, along with Dr. Bob Smith, founded AA). You may have some preconceived notions: that AA is for a bunch of drunks, that it’s an excuse to drink anonymously, that it’s only for men or ex-Navymen, that it’s only for alcoholics, that it espouses religion and if you’re not religious you cannot attend, or that it’s only for older people. All of these statements are unequivocally false. AA welcomes everyone: all genders and people of any ethnic, racial, or religious background, usually without an age floor (the lowest age allowed, within reason, of course). One does not need to have a

substance use disorder to attend. Open meetings are for people who want to learn about AA and for those who think they may have a substance use disorder or misuse a substance—in both cases, alcohol. Typically these meetings include a speaker who relates his or her story to the audience. The attendees may take turns discussing their connection to the night’s story or theme. Closed meetings are for those who have, or think they have, a substance use disorder. Typically these meetings have a leader who discusses a theme, speaks to how the theme relates

to himself or herself, and then goes around a table or the room to ask others what the theme means to them. There is never pressure to participate, nor to pay (meetings are free). A contribution “hat” may be passed, but it’s not mandatory to give. Most important, last names and even last initials are never used; the entire meeting is anonymous. Finally, although the 12 steps process has a religious overtone, AA itself is not a religious entity. According to the organization’s website, “A.A.’s Twelve Steps are a group of principles, spiritual in their nature, which, if practiced as a way of life, can expel the obsession to drink and enable the sufferer to become happily and usefully whole.”

As noted previously, AA and its relatives Al-Anon and Narcotics Anonymous have seemed to be effective in helping people to stay sober and clean. Many clinicians use these groups as a treatment adjunct (an addition to psychotherapy), and patients seem to appreciate feeling as though they are not alone.

AA is a worldwide organization and is still going strong after more than 80 years. What are your views on AA? Did you believe some of the myths shared at the beginning of this feature? Would you ever consider going to an open meeting to observe and learn?

Quoted text from www.aa.org.

KatarzynaBialasiewicz/iStock/Thinkstock

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Section 4.5 Prevention of Substance-Related Disorders

4.5 Prevention of Substance-Related Disorders Although they vary in their specifics, all clinical-based programs for substance dependence focus on the individual. The social forces maintaining substance abuse—peer pressure, lack of knowledge, advertising (in the cases of nicotine and alcohol), and legal restrictions—are rarely addressed. Clinical programs are also expensive; they involve multiple sessions, and only limited numbers of people can be treated at one time. In contrast, prevention programs have the potential to save money because keeping disorders from developing is usually cheaper than treating disorders after they develop. Prevention programs may benefit the most people who are unable to access or afford clinical treatment.

Legal Restrictions Perhaps the most straightforward approach to the primary prevention of substance abuse and dependence is to use the legal system. However, because legal restrictions on exposure to drugs have had limited success, public health authorities have argued that restricting access might be a more effective means of preventing substance abuse (Stockings et al., 2016).

One approach to restricting access is to ban substance use in certain settings. Smoking, which was once common in offices, restaurants, planes, and theaters, is now prohibited in most public areas. As the number of places where smoking is permitted decreases, smokers have fewer opportunities to pursue their habit. Thus, making smoking inconvenient may reduce its prevalence (Stockings et al., 2016).

Health Education Programs Although people who use substances are usually aware of the health risks, they tend to believe that these risks apply more to other people than to themselves (Gibbons, McGovern, & Lando, 1991). This feeling of invulnerability, which applies to adults as well as adolescents (Quadrel, Fischhoff, & Davis, 1993), may explain why people continue to use dangerous sub- stances even when they know they are harmful (Gibbons, Kingsbury, & Gerrard, 2012). The main value of health warnings (such as the surgeon general’s warning on cigarette packages or television commercials that talk about the perils of drug use) is in moving those who use substances from the precontemplation to the contemplation stage of the quitting process, at which point other, more powerful interventions take over.

Specific Educational Programs Global educational programs provide information about substances, but they do not address the factors that maintain substance use: peer pressure, mood changes, advertising, avoidance of withdrawal, and stress reduction. Specific educational interventions designed to teach those at risk how to resist these influences and temptations, and how to deal with stress and withdrawal, may have a greater chance of succeeding (Ksir et al., 2008).

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Chapter Summary

Worksite Programs As their name suggests, worksite programs are delivered to workers, and sometimes their families, at their places of employment. With the cooperation of employers, workers are given time off to attend these programs and may even be rewarded for success. In an attempt at secondary prevention, some employers also use chemical tests to screen employees for sub- stance use. However, such programs raise certain ethical problems involving consent and dis- closure of purpose (Forrest, 1997).

Highlight: Substance Use on the Big Screen

Do these titles sound familiar: Arthur, Fast Times at Ridgemont High, Harold and Kumar Go to White Castle? They are all Hollywood comedies that have as a central theme excessive alcohol or drug usage. In each film (and in far too many others to mention), the excessive usage is portrayed in a comedic fashion. To be sure, these films are quite funny, as comedies should be. But what kinds of messages do they send to the general public who watches them? In Fast Times, Sean Penn’s character, Spicoli, is perpetually stoned; the same is true for Kumar in that film series. Arthur is virtually always intoxicated.

Should the general public be laughing at individuals who, if they came into a psychologist’s office, would most likely be diagnosed with a substance use disorder? Is being perpetually stoned or drunk something that is funny, or is it dangerous? More important, let’s presume that the majority of the population does not understand what a substance use disorder is, and that these films (and similar television shows) are their primary exposure to the disorder. How could we make audiences understand that these comedic portrayals are fictitious, and that a real substance use disorder is not funny at all, but instead presents a risk to the person’s life, as well as to loved ones, family members, and innocent people, especially if the person chooses to drive while intoxicated?

An important component of a helping professional’s job is being an educator. We need to continue to educate the public about what a substance use disorder is, about how it truly presents itself, and, most important, that the situations and characters seen in movies, while amusing, are designed to make us laugh and are not accurate portrayals of the facts.

Chapter Summary

Psychoactive Substances: Some Basic Information • Practically everyone has used a psychoactive substance at some time in their lives.

These substances form a spectrum, from those that are commonly used, such as caf- feine, to highly dangerous drugs such as heroin and other opioids.

• Caffeine, nicotine, alcohol, and cannabis are the four psychoactive substances most commonly used by American college students.

• Caffeine is found in many drinks, as well as in headache, diet, and cold medications. Nicotine is the psychoactive ingredient in tobacco. Alcohol is found in wine, beer, spirits, and many medications. And cannabis is a type of hemp plant whose leaves may be ingested in a variety of ways.

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Chapter Summary

• Caffeine and nicotine are stimulants; they combat drowsiness, increase alertness, and help produce energy.

• Alcohol is a depressant, which slows body processes and induces sleep. • Cannabis has a variety of stimulant and depressant effects. It also has the potential

to produce sensory and cognitive distortions. • Although caffeine and nicotine may be dangerous to one’s health in large doses, they

have not been linked to any specific illness. • At higher doses, alcohol can cause serious health problems, and cannabis smoke

may be as dangerous as cigarette smoke. • Although both caffeine and nicotine are stimulants, many people claim to find them

relaxing. This may be a reflection of their ability to enhance the body’s natural opioids.

• Relaxation may also be the result of cognitive expectancies and social reinforcement. • A third possibility is that some personality types (extroverts) are chronically under-

aroused, a state they find unpleasant. Because stimulants increase their arousal to “normal” levels, they find these substances produce pleasant feelings.

Why Are Psychoactive Substances So Popular? • People begin to use substances such as nicotine, alcohol, and opioids partially

because of social conformity. • Certain personality traits—extroversion, for example—may also encourage people

to use substances.

Potential Problems of Sustained Substance Use • Using substantial amounts of many substances can result in intoxication. • Chronic use of substances may also produce tolerance, forcing users to continually

increase the amount they consume to achieve the same effect. • When one has a substance dependence, abruptly ceasing a habitually used substance

can produce the unpleasant symptoms characteristic of withdrawal.

Overcoming Substance Use Disorder • First, the person must decide to change. Next comes an active attempt to change.

Finally, the new behavior must be maintained. • Most psychological interventions are aimed at the action stage; many also target the

maintenance stage. • Practically all treatment programs aimed at substance abuse and dependence are

multimodal (they combine several treatment methods). • Sometimes, replacing one substance with another, less dangerous one (replacing

cigarettes with nicotine patches, for example) can assist the treatment process. • In addition to positive treatments, aversive conditioning has also been widely used

to help people who are dependent on substances.

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Chapter Summary

Prevention of Substance-Related Disorders • Public health interventions have the potential to reach many more people at much

less cost than psychological interventions. • Although they may be valuable in getting people to think about quitting, outright

prohibition and global educational programs have not proved successful in reducing substance dependence.

• Worksite programs and self-help strategies have the potential to help many people give up substances.

Critical Thinking Questions 1. Let’s assume that you are a regular coffee, tea, or cola drinker. How difficult would

it be for you to quit drinking “cold turkey,” that is, to stop drinking these beverages completely, with no treatment interventions?

2. Some people believe that a substance use disorder (substance dependence) is a moral flaw and is the fault of the dependent individual—that is, the individual can stop whenever he or she likes. What are your views on this perspective?

3. The chapter notes that some psychoactive substances cannot lead to physiological dependence. Discuss your views on this.

4. Alcoholics Anonymous (AA) has been around for more than 80 years, and, in spite of no solid research support, the organization seems to be successful. How can a self- help group where no therapy is provided help people stay sober and straighten out their lives?

5. Discuss your views on using psychoactive substances like methadone to treat opioid dependence.

6. We have mentioned elsewhere that psychotropic medications such as anxiolytics can be used to treat psychiatric disorders. It is possible to become dependent on some of these medications. What is your perspective on this? Is helping to treat a condition worth the risk of dependence?

Key Terms agonist A chemical that increases the potency of other chemicals.

alcohol (ethanol) The second most com- monly used psychoactive substance in the United States.

alcohol dehydrogenase (ADH) An enzyme that breaks down alcohol in the stomach and the liver.

alcoholic myopia Narrowing of focus to the immediate.

antagonist A chemical that reduces the potency of other chemicals.

binge drinking Consumption, for a male, of five or more alcoholic drinks in a row on at least one occasion during a two-week period; for a female, it is four or more drinks.

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Chapter Summary

caffeine A stimulant; the most commonly used psychoactive substance in the United States.

cannabis Marijuana or pot; a type of hemp plant that produces several psychoactive substances such as marijuana and hashish.

craving A strong desire or urge to use a substance.

delirium tremens (the DTs) A symptom of alcohol withdrawal, which can include hallu- cinations, disorientation, insomnia, physical discomfort, shaking, and nausea.

depressant A psychoactive substance that lowers arousal and makes people drowsy.

detoxification Removal of a substance from the body, usually done in an inpatient setting.

endorphins Chemicals in the body that inhibit pain and produce pleasure.

ethologists Scientists who observe natural behavior in humans and animals.

expectancies What people expect when they use a drug or substance.

extroversion A personality trait commonly found in people born with low levels of arousal. The experience of low arousal is perceived as unpleasant, so extroverts con- tinuously seek stimulation.

fetal alcohol syndrome (FAS) A disorder marked by intellectual disabilities, hyper- activity, facial deformities, heart defects, and organ malfunctions due to the mother’s excessive alcohol consumption during pregnancy.

hallucinogen A psychoactive substance that produces distorted sensations and per- ceptions (hallucinations).

lysergic acid diethylamide (LSD) A very powerful hallucinogen.

mentally ill chemical abusers (MICAs) Individuals, often young males, generally poor, homeless, sickly, and likely to get into legal difficulties, who misuse chemi- cal substances.

multimodal treatment Programs that combine several different methods to cure substance dependence.

nicotine A psychoactive substance found in cigarettes; it acts quickly and is addictive.

polysubstance dependence Dependence on multiple substances.

psychoactive substances Chemicals that alter a person’s moods or behavior.

risk factors Characteristics, genetic or otherwise, that seem to be associated with an increased risk of disease onset or recurrence.

stimulants Substances whose main psycho- active effects are to increase alertness.

substance use disorder (substance dependence) A condition in which the individual has a recurring pattern of substance-related difficulties. The more criteria the individual satisfies, the more likely the individual is physiologically dependent on that substance.

THC (delta-9-tetrahydrocannabinol) The psychoactive ingredient in marijuana.

tolerance The body’s response to a drug wherein it takes more (sometimes less) of a psychoactive substance to achieve the same effect.

withdrawal The physiological effects suf- fered by an individual once a psychoactive substance has been removed from the body.

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