Etiology of Personality Disorders

11 substance-related disorders

learning objectives 11

·  11.1 What is alcohol abuse and dependence?

·  11.2 What is drug abuse and dependence?

·  11.3 Are there addictive disorders other than alcohol and drugs?

Remarkable Recoveries from Life-Threatening Substance Abuse Lyle Prouse was born in Wichita, Kansas, in 1938 of American Indian heritage. As a child he was very interested in aviation and won his first airplane ride by writing an essay for Beechcraft Aircraft Company. Prouse, who grew up in the Indian community in Wichita, had a serious, long-term substance abuse problem, as did his parents, both of whom died from alcohol abuse. Many of his friends and associates were heavy alcohol abusers. After he finished high school he joined the U.S. Marines, became a pilot, and served in the Vietnam War. He was awarded several medals for his service in Vietnam. He left the military and obtained a flying position at Northwest Airlines, where he attained the rank of captain and worked for 22 years, flying Boeing 727 passenger aircraft.

In 1990, Captain Prouse and his flight crew enjoyed a night of heavy drinking while on a layover in Fargo, North Dakota. Prouse consumed a number of rum-and-Diet-Cokes, and his crew drank several pitchers of beer and apparently were very loud and belligerent. Although his crew left the bar earlier, Prouse remained longer and continued drinking. During their drinking binge the flight crew angered a customer in the pub, who later called the FAA, warning them against the problem drinking of the crew. The next morning the Northwest crew continued their flight to Minneapolis and were arrested and given substance use tests. They showed high levels of alcohol in their bloodstreams and were charged with violating a federal law, which included prison time as a result of operating a public transportation carrier under the influence of drugs or alcohol. Captain Prouse and his crewmembers served 12 months of the 16-month sentence they received. All three pilots lost their jobs and their pilot’s licenses as a result of the substance use violations.

Captain Prouse felt a great deal of depression and shame at the problems that he created for himself and others following the loss of the aviation career that he loved. He also experienced a great deal of financial problems from his employment termination. On several occasions he contemplated committing suicide. Captain Prouse entered inpatient substance abuse treatment not long after the incident.

After completing his recovery in an inpatient substance abuse treatment center, Prouse began a long and difficult process of rehabilitation and effort to restore his life without using alcohol. He made many public speeches describing his substance abuse and later wrote a book detailing what he had gone through (Prouse,  2001 ). Throughout his recovery he was determined to regain his flying status. It was necessary for him to retrain and retake all of the FAA licensing examinations in order to have his qualifications restored because he was required to requalify for every one of his licenses and ratings.

Captain Prouse was assisted in his recovery by a number of people who were impressed by his public disclosure of wrong-doing and his high motivation to recover from his substance abuse. After he appealed to the court to allow him the opportunity to obtain recertification, the court waived the legal restrictions that had been placed upon him at the trial. A friend of his who owned a trainer aircraft allowed him to earn the necessary flying time needed to be relicensed as a pilot. The CEO of Northwest Airlines, John Dasburg, who himself had grown up in a family with alcoholic abuse problems, took personal interest in Prouse’s struggle and encouraged his return to duty. He returned to flying with Northwest Airlines. Captain Prouse’s efforts and success at rehabilitation were indeed impressive. In 2001 he was granted a presidential pardon by President Clinton.

Interestingly, another one of the pilots on the Northwest “drunk pilots” flight, flight engineer Joe Balzer, who also spent 12 months in federal prison, also rehabilitated himself. He became involved with Alcoholics Anonymous and, over time, requalified for the aviation certification, eventually returning to the cockpit as a pilot for American Airlines (see his autobiographical account in Balzer,  2009 ).

The extensive problem of substance abuse and substance dependence in our society has drawn both public and scientific attention. Although our present knowledge is far from complete, investigating these problems as maladaptive patterns of adjustment to life’s demands, with no social stigma involved, has led to clear progress in understanding and treatment. Such an approach, of course, does not mean that an individual bears no personal responsibility in the development of a problem. On the contrary, individual lifestyles and personality features are thought by many to play important roles in the development of substance-related disorders and are central themes in some types of treatment.

Substance-related disorders  can be seen all around us: in extremely high rates of alcohol abuse and dependence, and in tragic exposés of cocaine abuse among star athletes and entertainers.  Addictive behavior —behavior based on the pathological need for a substance—may involve the abuse of substances such as nicotine, alcohol, Ecstasy, or cocaine. Addictive behavior is one of the most prevalent and difficult-to-treat mental health problems facing our society today.

The most commonly used problem substances are those that affect mental functioning in the central nervous system (CNS)— psychoactive substances : alcohol, nicotine, barbiturates, tranquilizers, amphetamines, heroin, Ecstasy, and marijuana. Some of these substances, such as alcohol and nicotine, can be purchased legally by adults; others, such as barbiturates or pain medications like OxyContin (or marijuana in some states), can be used legally under medical supervision; still others, such as heroin, Ecstasy, and methamphetamine, are illegal.

The material described in this chapter was designed to provide both a historic and contemporary view of important research and theoretical strategies in understanding addictive disorders thus we will, in places, refer to the substance abuse versus substance dependence distinction. The following distinctions are important to understanding and diagnosing substance-related disorders:

·  •  Substance abuse  generally involves an excessive use of a substance resulting in (1) potentially hazardous behavior such as driving while intoxicated or (2) continued use despite a persistent social, psychological, occupational, or health problem.

·  •  Substance dependence  includes more severe forms of substance-use disorders and usually involves a marked physiological need for increasing amounts of a substance to achieve the desired effects. Dependence in these disorders means that an individual will show a tolerance for a drug and/or experience withdrawal symptoms when the drug is unavailable.

·  •  Tolerance —the need for increased amounts of a substance to achieve the desired effects—results from biochemical changes in the body that affect the rate of metabolism and elimination of the substance from the body.

·  •  Withdrawal  refers to physical symptoms such as sweating, tremors, and tension that accompany abstinence from the drug.

The picture shows an 1891 Stale Beer Dive on Mulberry Street Bend, New York, with several drunk people from the neighborhood and includes beers being served by a young girl (Campbell et al.,  1892 ).

Alcohol Related Disorders

The terms  alcoholic  and  alcoholism  have been subject to some controversy and have been used differently by various groups in the past. The World Health Organization no longer recommends the term alcoholism but prefers the term alcohol dependence syndrome—“a state, psychic and usually also physical, resulting from taking alcohol, characterized by behavioral and other responses that always include a compulsion to take alcohol on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence; tolerance may or may not be present” (1992, p. 4). However, because the terms alcoholic and alcoholism are still widely used in practice, in scientific journals, and in government agencies and publications, we will sometimes use them in this book.

People of many ancient cultures, including the Egyptians, Greeks, Romans, and Israelites, made extensive and often excessive use of alcohol. Beer was first made in Egypt around 3000 B.C. The oldest surviving wine-making formulas were recorded by Marcus Cato in Italy almost a century and a half before the birth of Christ. About A.D. 800, the process of distillation was developed by an Arabian alchemist, thus making possible an increase in both the range and the potency of alcoholic beverages. Problems with excessive use of alcohol were observed almost as early as its use began. Cambyses, King of Persia in the sixth century B.C., has the dubious distinction of being one of the early alcohol abusers on record.

The Prevalence, Comorbidity, and Demo Graphics of Alcohol Abuse and Dependence

Alcohol abuse and alcohol dependence are major problems in the United States and are among the most destructive of the psychiatric disorders because of the impact excessive alcohol use can have upon users’ lives and those of their families and friends. It is estimated that 50 percent of adults who are 18 or older are current regular drinkers and only 21 percent are lifetime abstainers (Pleis et al.,  2009 ). In 2008, 23.3 percent of Americans aged 12 or older reported binge drinking, and 6.7 percent were found to be heavy drinkers (Substance Abuse and Mental Health Services Administration,  2010 ). An estimated 12.4 percent of persons 12 or older drove under the influence of alcohol at least once over the past year. An estimated 22.2 million persons (8.9 percent of the population aged 12 or older) were classified with substance dependence or abuse in the past year based on DSM diagnostic criteria. In this sample, 3.1 million people were classified with dependence on or abuse of both alcohol and illicit drugs, 3.9 million were dependent on or abused illicit drugs but not alcohol, and 15.2 million were dependent on or abused alcohol but not illicit drugs (Substance Abuse and Mental Health Services Administration,  2009 ).

DSM-5 criteria for: Alcohol Use Disorder

·  A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

·  1. Alcohol is often taken in larger amounts or over a longer period than was intended.

·  2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

·  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

·  4. Craving, or a strong desire or urge to use alcohol.

·  5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

·  6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

·  7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

·  8. Recurrent alcohol use in situations in which it is physically hazardous.

·  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

·  10. Tolerance, as defined by either of the following:

·  a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

·  b. A markedly diminished effect with continued use of the same amount of alcohol.

·  11. Withdrawal, as manifested by either of the following:

·  a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499–500).

·  b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

The potentially detrimental effects of excessive alcohol use—for an individual, his or her loved ones, and society—are legion. Heavy drinking is associated with vulnerability to injury (Cherpitel  1997 ), marital discord (Hornish & Leonard,  2007 ), and becoming involved in intimate partner violence (Eckhardt,  2007 ). The life span of the average person with alcohol dependence is about 12 years shorter than that of the average person without this disorder. Alcohol significantly lowers performance on cognitive tasks such as problem solving—and the more complex the task, the more the impairment (Pickworth et al.,  1997 ). Organic impairment, including brain shrinkage, occurs in a high proportion of people with alcohol dependence (Gazdzinski et al.,  2005 ), especially among binge drinkers—people who abuse alcohol following periods of sobriety (Hunt,  1993 ).

One study reported that of the 1.3 million emergency room visits associated with drug misuse or abuse in 2007, 7 percent involved alcohol abuse in patients under age 21 (USDHHS, 2010). Cherpitel and colleagues ( 2006 ) explored the association of alcohol use and emergency room (ER) services among injured patients in several countries. Of 9,743 injured patients surveyed in 37 ERs in 14 countries, drinking within 6 hours before injury was associated with prior visits to the ER during the last 12 months. People who were heavy drinkers or were alcohol dependent were significantly more likely to report multiple prior emergency room visits.

Alcohol abuse is associated with over 40 percent of the deaths suffered in automobile accidents each year (Chou et al.,  2006 ) and with about 40 to 50 percent of all murders (Bennett & Lehman,  1996 ), 40 percent of all assaults, and over 50 percent of all rapes (Abbey et al.,  2001 ). About one of every three arrests in the United States is related to alcohol abuse, and over 43 percent of violent encounters with the police involve alcohol (McClelland & Teplin,  2001 ). In research on substance abuse and violent crime, Dawkins ( 1997 ) found that alcohol is more frequently associated with both violent and nonviolent crime than drugs such as marijuana and that people with violence- related injuries are more likely to have a positive Breathalyzer test (Cherpitel,  1997 ). Of the 1 million violent crimes that were suspected to be alcohol related in 2002, 30 percent of them were determined to involve alcohol use on the part of the offender. Two-thirds of cases in which victims suffered violence from an intimate (a current or former spouse) were alcohol related (U.S. Department of Justice,  2006 ).

Alcohol is associated with over 40 percent of deaths and serious injuries suffered in automobile accidents in the United States each year (see Chou et al.,  2006 ).

Alcohol abuse and alcohol dependence in the United States cut across all age, educational, occupational, and socioeconomic boundaries. Alcohol abuse is found in priests, politicians, surgeons, law enforcement officers, and teenagers; the image of the alcohol-abusing person as an unkempt resident of skid row is clearly inaccurate. Alcohol abuse is considered a serious problem in industry, in the professions, and in the military as well. Recent research has shown that alcohol abuse has a strong presence in the workplace, with 15 percent of employees showing problem behaviors; many (1.68 percent, or 2.1 million people) actually drinking on the job; and 1.83 percent, or 2.3 million workers, drinking before they go to work (Frone,  2006 ). Some myths about alcoholism are noted in  Table 11.1  on p. 372.

In the past, most problem drinkers—people experiencing life problems as a result of alcohol abuse—were men; for example, men become problem drinkers at about five times the frequency of women (Helzer et al.,  1990 ). Recent epidemiological research has suggested that the traditional gap between men and women has narrowed when it comes to the development of substance abuse disorders (Greenfield et al.,  2010 ). There do not seem to be important differences in rates of alcohol abuse between black and white Americans, although Native Americans tend to have higher rates of alcohol abuse, and Asian Americans tend to have lower usage. It appears that problem drinking may develop during any life period from early childhood through old age. About 10 percent of men over age 65 are found to be heavy drinkers (Breslow et al.,  2003 ). Surveys of alcoholism rates across different cultural groups around the world have found varying rates of the disorder across diverse cultural samples (Caetano et al.,  1998 ; Hibell et al.,  2000 ).

Over 37 percent of alcohol abusers suffer from at least one coexisting mental disorder (Lapham et al.,  2001 ). Not surprisingly, given that alcohol is a depressant, depression ranks high among the mental disorders often comorbid with alcoholism. There is a high comorbidity of substance abuse disorders and eating disorders (Harrop & Marlatt, 2009). It is also no surprise that many alcoholics commit suicide (McCloud et al.,  2004 ). In addition to the serious problems that excessive drinkers create for themselves, they also pose serious difficulties for others (Gortner et al.,  1997 ). Alcohol abuse also co-occurs with high frequency with personality disorder. Grant and colleagues ( 2004 ) report that among individuals with a current alcohol-use disorder, 28.6 percent have at least one personality disorder.

The diagnosis of substance use disorder in DSM-5 is based upon a pathological pattern of behaviors that are related to the use of a particular substance, for example, alcohol. The DSM Criteria for Alcohol Use Disorder are reproduced on page 370 as an illustration. Two additional diagnostic criteria for Alcohol Related Disorders can be found in the DSM-5 manual: Alcohol Intoxication (p. 497) and Alcohol Withdrawal (p. 499).

The Clinical Picture of Alcohol Related Disorders

A great deal of progress has been made in understanding the physiological effects of alcohol on the brain. The first is a tendency toward decreased sexual inhibition but, simultaneously, lowered sexual performance. An appreciable number of alcohol abusers also experience blackouts—lapses of memory. At first these occur at high blood alcohol levels, and a drinker may carry on a rational conversation or engage in other relatively complex activities but have no trace of recall the next day. For heavy drinkers, even moderate drinking can elicit memory lapses. Another phenomenon associated with alcoholic intoxication (intoxication is defined as a state of being affected by one or more psychoactive drugs) is the hangover, which many drinkers experience at one time or another. As yet, no one has come up with a satisfactory explanation of or remedy for the symptoms of headache, nausea, and fatigue that are characteristic of the hangover.

ALCOHOL’S EFFECTS ON THE BRAIN

Alcohol has complex and seemingly contradictory effects on the brain. At lower levels, alcohol stimulates certain brain cells and activates the brain’s “pleasure areas,” which release opium-like endogenous opioids that are stored in the body (Braun,  1996 ). At higher levels, alcohol depresses brain functioning, inhibiting one of the brain’s excitatory neurotransmitters, glutamate, which in turn slows down activity in parts of the brain (Koob et al.,  2002 ). Inhibition of glutamate in the brain impairs the organism’s ability to learn and affects the higher brain centers, impairing judgment and other rational processes and lowering self-control. As behavioral restraints decline, a drinker may indulge in the satisfaction of impulses ordinarily held in check. Some degree of motor uncoordination soon becomes apparent, and the drinker’s discrimination and perception of cold, pain, and other discomforts are dulled. Typically the drinker experiences a sense of warmth, expansiveness, and well-being. In such a mood, unpleasant realities are screened out and the drinker’s feelings of self-esteem and adequacy rise. Casual acquaintances become the best and most understanding of friends, and the drinker enters a generally pleasant world of unreality in which worries are temporarily left behind.

TABLE 11.1 Some Common Misconceptions About Alcohol and Alcohol Abuse

Fiction	Fact
Alcohol is a stimulant.	Alcohol is actually both a nervous system stimulant and a depressant.
You can always detect alcohol on the breath of a person who has been drinking.	It is not always possible to detect the presence of alcohol. Some individuals successfully cover up their alcohol use for years.
One ounce of 86-proof liquor contains more alcohol than two 12-ounce cans of beer.	Two 12-ounce cans of beer contain more than an ounce of alcohol.
Alcohol can help a person sleep more soundly.	Alcohol may interfere with sound sleep.
Impaired judgment does not occur before there are obvious signs of intoxication.	Impaired judgment can occur long before motor signs of intoxication are apparent.
An individual will get more intoxicated by mixing liquors than by taking comparable amounts of one kind—e.g., bourbon, Scotch, or vodka.	It is the actual amount of alcohol in the bloodstream rather than the mix that determines intoxication.
Drinking several cups of coffee can counteract the effects of alcohol and enable a drinker to “sober up.”	Drinking coffee does not affect the level of intoxication.
Exercise or a cold shower helps speed up the metabolism of alcohol.	Exercise and cold showers are futile attempts to increase alcohol metabolism.
People with “strong wills” need not be concerned about becoming substance abusers.	Alcohol is seductive and can lower the resistance of even the “strongest will.”
Alcohol cannot produce a true addiction in the same sense that heroin can.	Alcohol has strong addictive properties.
One cannot become a substance abuser by drinking just beer.	One can consume a considerable amount of alcohol by drinking beer. It is, of course, the amount of alcohol that determines whether one becomes a substance abuser.
Alcohol is far less dangerous than marijuana.	There are considerably more individuals in treatment programs for alcohol problems than for marijuana abuse.
In a heavy drinker, damage to the liver shows up long before brain damage appears.	Heavy alcohol use can be manifested in organic brain damage before liver damage is detected.
The physiological withdrawal reaction from heroin is considered more dangerous than is withdrawal from alcohol.	The physiological symptoms accompanying withdrawal from heroin are no more frightening or traumatic to an individual than alcohol withdrawal. Actually, alcohol withdrawal is potentially more lethal than opiate withdrawal.
Everybody drinks.	Actually, 28 percent of men and 50 percent of women in the United States are abstainers.

In most U.S. states, when the alcohol content of the bloodstream reaches 0.08 percent, the individual is considered intoxicated, at least with respect to driving a vehicle. Muscular coordination, speech, and vision are impaired and thought processes are confused. Even before this level of intoxication is reached, however, judgment becomes impaired to such an extent that the person misjudges his or her condition. For example, drinkers tend to express confidence in their ability to drive safely long after such actions are in fact quite unsafe. When the blood alcohol level reaches approximately 0.5 percent (the level differs somewhat among individuals), the entire neural balance is upset and the individual passes out. Unconsciousness apparently acts as a safety device because concentrations above 0.55 percent are usually lethal.

In general, it is the amount of alcohol actually concentrated in the bodily fluids, not the amount consumed, that determines intoxication. The effects of alcohol vary for different drinkers, depending on their physical condition, the amount of food in their stomach, and the duration of their drinking. In addition, alcohol users may gradually build up a tolerance for the drug so that ever-increasing amounts may be needed to produce the desired effects. Women metabolize alcohol less effectively than men and thus become intoxicated on lesser amounts (Gordis et al.,  1995 ).

DEVELOPMENT OF ALCOHOL DEPENDENCE

Excessive drinking can be viewed as progressing insidiously from early- to middle-to late-stage alcohol-related disorder, although some abusers do not follow this pattern. Many investigators have maintained that alcohol is a dangerous systemic poison even in small amounts, but others believe that in moderate amounts it is not harmful to most people. For pregnant women, however, even moderate amounts are believed to be dangerous; in fact, no safe level has been established, as is discussed in Developments in Research box below. The photos on page 374 show the differences between the brain of a normal teenager and those born with fetal alcohol syndrome (FAS), a condition that is caused by excessive alcohol consumption during pregnancy and results in birth defects such as mental retardation.

THE PHYSICAL EFFECTS OF CHRONIC ALCOHOL USE

For individuals who drink to excess, the clinical picture is highly unfavorable (Turner et al.,  2006 ). Alcohol that is taken in must be assimilated by the body, except for about the 5 to 10 percent that is eliminated through breath, urine, and perspiration. The work of alcohol metabolism is done by the liver, but when large amounts of alcohol are ingested, the liver may be seriously overworked and eventually suffer irreversible damage (Lucey et al.,  2009 ). In fact, from 15 to 30 percent of heavy drinkers develop cirrhosis of the liver, a disorder that involves extensive stiffening of the blood vessels. About 40 to 90 percent of the 26,000 annual cirrhosis deaths every year are alcohol related (Parrish et al.,  1991 ). Some countries, for example Britain and Scotland, have shown an increase in cirrhosis-related deaths in the last two decades because of the increased use of alcohol in their populations (Leon & McCambridge,  2006 ).

developments in RESEARCH: Fetal Alcohol Syndrome: How Much Drinking Is Too Much?

Research indicates that heavy drinking by expectant mothers can affect the health of unborn babies, particularly binge drinking and heavy drinking during the early days of pregnancy (Burd & Christensen,  2009 ; Calhoun & Warren,  2007 )—a condition known as fetal alcohol syndrome. Newborn infants whose mothers drank heavily during pregnancy have been found to have frequent physical and behavioral abnormalities (Alison,  1994 ), including aggressiveness and destructiveness (Gardner,  2000 ), and may experience symptoms of withdrawal (Thomas & Riley,  1998 ). For example, such infants have shown growth deficiencies, facial and limb irregularities, damage to the central nervous system, and impairment in cognitive functioning (Kodituwakku et al.,  2001 ). Neuroimaging research has shown that there is an overall reduction of brain size and prominent brain shape abnormalities, with narrowing in the parietal region along with reduced brain growth in portions of the frontal lobe (Spadoni et al.,  2007 ). Moreover, children with FAS often show significant working memory deficits and altered activations patterns in some brain regions (Astley et al.,  2009 ).

As noted in The Third Report on Alcohol and Health (HEW,  1978 ), alcohol abuse in pregnant women is the third-leading cause of birth defects—the first two being Down syndrome and spina bifida (the incomplete formation and fusion of the spinal canal). Although data on FAS are often difficult to obtain, the prevalence has been estimated at between 0.5 and 2 cases per 1,000 births (May & Gossage,  2001 ).

How much drinking endangers a newborn’s health? The HEW report warns against drinking more than 1 ounce of alcohol per day (one 12-ounce can of beer or one 5-ounce glass of wine, for example). The actual amount of alcohol that can safely be ingested during pregnancy is not known, but existing evidence for FAS is strongest when applied to binge drinkers or heavy alcohol users rather than to light or moderate users (Kolata,  1981 ). Nonetheless the surgeon general and many medical experts have concurred that pregnant women should abstain from using alcohol as the “safest course” until the safest amount of alcohol consumption can be determined (Raskin,  1993 ).

The effects of FAS can be both dramatic and long-lasting. This young child who had been diagnosed with FAS shows some of the permanent physical abnormalities characteristic of the syndrome.

MRIs of three teenagers: (left) normal control, 13-year-old female; (center) FAS, 13-year-old male with focal thinning of the corpus callosum; (right) FAS, 14-year-old male with complete agenesis (nondevelopment) of the corpus callosum.

Alcohol is also a high-calorie drug. A pint of whiskey—enough to make about eight to ten ordinary cocktails—provides about 1,200 calories, which is approximately half the ordinary caloric requirement for a day (Flier et al.,  1995 ). Thus consumption of alcohol reduces a drinker’s appetite for other food. Because alcohol has no nutritional value, the excessive drinker can suffer from malnutrition (Derr & Gutmann,  1994 ). Furthermore, heavy drinking impairs the body’s ability to utilize nutrients, so the nutritional deficiency cannot be made up by popping vitamins. Many alcohol abusers also experience increased gastrointestinal symptoms such as stomach pains (Fields et al.,  1994 ).

PSYCHOSOCIAL EFFECTS OF ALCOHOL ABUSE AND DEPENDENCE

In addition to various physical problems, a heavy drinker usually suffers from chronic fatigue, oversensitivity, and depression. Initially, alcohol may seem to provide a useful crutch for dealing with the stresses of life, especially during periods of acute stress, by helping screen out intolerable realities and enhance the drinker’s feelings of adequacy and worth. The excessive use of alcohol eventually becomes counterproductive, however, and can result in impaired reasoning, poor judgment, and gradual personality deterioration. Behavior typically becomes coarse and inappropriate, and the drinker assumes increasingly less responsibility, loses pride in personal appearance, neglects spouse and family, and becomes generally touchy, irritable, and unwilling to discuss the problem. Watch the Video Chris: Alcoholism on MyPsychLab

As judgment becomes impaired, an excessive drinker may be unable to hold a job and generally becomes unqualified to cope with new demands that arise (Frone,  2003 ). General personality disorganization and deterioration may be reflected in loss of employment and marital breakup. By this time, the drinker’s general health is likely to have deteriorated, and brain and liver damage may have occurred. For example, there is some evidence that an alcoholic’s brain is accumulating diffuse organic damage even when no extreme organic symptoms are present (Sullivan, Deshmukh, et al.,  2000 ), and even mild to moderate drinking can adversely affect memory and problem solving (Gordis,  2001 ). Other researchers have found extensive alcohol consumption to be associated with an increased amount of organic damage in later life (Lyvers,  2000 ); however, recent research using fMRI has shown that this damage is partially reversible if the person abstains from alcohol use (Wobrock et al.,  2009 ).

PSYCHOSES ASSOCIATED WITH SEVERE ALCOHOL ABUSE

Excessive use of alcohol can result in severe mental health problems. Several acute psychotic reactions fit the diagnostic classification of substance-induced disorders. These reactions may develop in people who have been drinking excessively over long periods of time or who have a reduced tolerance for alcohol for other reasons—for example, because of brain lesions from excessive long-term use. Such acute reactions usually last only a short time and generally consist of confusion, excitement, and delirium. There is some evidence that delirium may be associated with lower levels of thiamine in alcoholics (Holzbeck,  1996 ). These disorders are often called “alcoholic psychoses” because they are marked by a temporary loss of contact with reality.

Among those who drink excessively for a long time, a reaction called  alcohol withdrawal delirium (formerly known as  delirium tremens ) may occur (Palmstierno,  2001 ). This reaction usually happens following a prolonged drinking spree when the person enters a state of withdrawal. Slight noises or suddenly moving objects may cause considerable excitement and agitation. The full-blown symptoms include (1) disorientation for time and place, in which, for example, a person may mistake the hospital for a church or jail, no longer recognize friends, or identify hospital attendants as old acquaintances; (2) vivid hallucinations, particularly of small, fast-moving animals like snakes, rats, and roaches; (3) acute fear, in which these animals may change in form, size, or color in terrifying ways; (4) extreme suggestibility, in which a person can be made to see almost any animal if its presence is merely suggested; (5) marked tremors of the hands, tongue, and lips; and (6) other symptoms including perspiration, fever, a rapid and weak heartbeat, a coated tongue, and foul breath.

The delirium typically lasts from 3 to 6 days and is generally followed by a deep sleep. When a person awakens, few symptoms—except for possibly slight remorse—remain, but frequently the individual is badly scared and may not resume drinking for several weeks or months. Usually, however, drinking is eventually resumed, followed by a return to the hospital with a new attack. The death rate from withdrawal delirium as a result of convulsions, heart failure, and other complications once approximated 10 percent (Tavel,  1962 ). With drugs such as chlordiazepoxide, however, the current death rate during withdrawal delirium and acute alcoholic withdrawal has been markedly reduced.

A second alcohol-related psychosis is persisting alcohol disorder or alcohol amnestic disorder (formerly known as Korsakoff’s syndrome). This condition was first described by the Russian psychiatrist Korsakoff in 1887 and is one of the most severe alcohol-related disorders (d’Ydewalle & Van Damme,  2007 ). The outstanding symptom is a memory defect (particularly with regard to recent events), which is sometimes accompanied by falsification of events (confabulation). Persons with this disorder may not recognize pictures, faces, rooms, and other objects that they have just seen, although they may feel that these people or objects are familiar. Such people increasingly tend to fill in their memory gaps with reminiscences and fanciful tales that lead to unconnected and distorted associations. These individuals may appear to be delirious, delusional, and disoriented for time and place, but ordinarily their confusion and disordered actions are closely related to their attempts to fill in memory gaps. The memory disturbance itself seems related to an inability to form new associations in a manner that renders them readily retrievable. Such a reaction usually occurs in long-time alcohol abusers after many years of excessive drinking. These patients have also been observed to show other cognitive impairments such as planning deficits (Brokate et al.,  2003 ), intellectual decline, emotional deficits (Snitz et al.,  2002 ), judgment deficits (Brand et al.,  2003 ), and cortical lesions (Estruch et al.,  1998 ).

The symptoms of alcohol amnestic disorder are now thought to be due to vitamin B (thiamine) deficiency and other dietary inadequacies. Although it had been believed that a diet rich in vitamins and minerals generally restores such a patient to more normal physical and mental health, some research evidence suggests otherwise. Lishman ( 1990 ) reports that alcohol amnestic disorder did not respond well to thiamine replacement. Some memory functioning appears to be restored with prolonged abstinence. However, some personality deterioration usually remains in the form of memory impairment, blunted intellectual capacity, and lowered moral and ethical standards.

Alcohol Amnestic Disorder Averill B. was brought into the detoxification unit of a local county hospital by the police after an incident at a crowded city park. He was arrested because of his assaultive behavior toward others (he was walking through the crowded groups of sunbathers muttering to himself, kicking at people). At admission to the hospital, Averill was disoriented (did not know where he was), incoherent, and confused. When asked his name, he paused a moment, scratched his head, and said, “George Washington.” When asked about what he was doing at the park, he indicated that he was “marching in a parade in his honor.”

Biological Causal Factors in the Abuse of and Dependence On Alcohol

In trying to identify the causes of problem drinking, some researchers have stressed the role of genetic and biochemical factors (see Hartz, & Bierut,  2010 ); others have pointed to psychosocial factors, viewing problem drinking as a maladaptive pattern of adjustment to the stress of life; and still others have emphasized sociocultural factors such as the availability of alcohol and social approval of excessive drinking. As we will see, some combination of all of these factors seems to influence risk for developing alcohol abuse or alcohol dependency. As with most other forms of maladaptive behavior, there may be several types of alcohol abuse and dependency, each with somewhat different patterns of biological, psychosocial, and sociocultural causal factors.

How do substances such as alcohol, cocaine, and opium (discussed later in the chapter) come to have such powerful effects—an overpowering hold that occurs in some people after only a few uses of the drug? Although the exact mechanisms are not fully agreed on by experts in the field, two important factors are apparently involved. The first is the ability of most, if not all, addictive substances to activate areas of the brain that produce intrinsic pleasure and sometimes immediate, powerful reward. The second factor involves the person’s biological makeup, or constitution, including his or her genetic inheritance and the environmental influences (learning factors) that enter into the need to seek mind-altering substances to an increasing degree as use continues. The development of an alcohol addiction is a complex process involving many elements—constitutional vulnerability and environmental encouragement, as well as the unique biochemical properties of certain psychoactive substances. Let’s examine each of these elements in more detail.

THE NEUROBIOLOGY OF ADDICTION

Let’s first examine the role that substances like alcohol play in the process of addiction. Psychoactive drugs differ in their biochemical properties as well as in how rapidly they enter the brain. There are several routes of administration—oral, nasal, and intravenous. Alcohol is usually drunk, the slowest route, whereas cocaine is often self-administered by injection or taken nasally. Central to the neurochemical process underlying addiction is the role the drug plays in activating the “pleasure pathway.” The  mesocorticolimbic dopamine pathway (MCLP)  is the center of psychoactive drug activation in the brain. The MCLP is made up of neuronal cells in the middle portion of the brain known as the ventral tegmental area (see  Figure 11.1 ) and connects to other brain centers such as the nucleus accumbens and then to the prefrontal cortex. This neuronal system is involved in such functions as control of emotions, memory, and gratification. Alcohol produces euphoria by stimulating this area in the brain. Research has shown that direct electrical stimulation of the MCLP produces great pleasure and has strong reinforcing properties (Littrell,  2001 ). Other psychoactive drugs also operate to change the brain’s normal functioning and to activate the pleasure pathway. Drug ingestion or behaviors that lead to activation of the brain reward system are reinforced, so further use is promoted. The exposure of the brain to an addictive drug alters its neurochemical structure and results in a number of behavioral effects. With continued use of the drug, neuroadaptation to or tolerance and dependence on the substance develop.

FIGURE 11.1 The Mesocorticolimbic Pathway. The mesocorticolimbic pathway (MCLP), running from the ventral tegmental area to the nucleus accumbens to the prefrontal cortex, is central to the release of the neurotransmitter dopamine and in mediating the rewarding properties of drugs.

Source: Office of Technology Assessment,  1993 . Watch the Video In the Real World: Neurotransmitters on MyPsychLab

GENETIC VULNERABILITY

The possibility of a genetic predisposition to developing alcohol-abuse problems has been widely researched. Many experts today agree that heredity probably plays an important role in a person’s developing sensitivity to the addictive power of drugs like alcohol (Plomin & DeFries,  2003 ; Volk et al.,  2007 ). Several lines of research point to the importance of genetic factors in substance-related disorders.

A review of 39 studies of the families of 6,251 alcoholics and of 4,083 nonalcoholics who had been followed over 40 years reported that almost one-third of alcoholics had at least one parent with an alcohol problem (Cotton,  1979 ). Likewise, a study of children of alcoholics by Cloninger and colleagues ( 1986 ) reported strong evidence for the inheritance of alcoholism. They found that for males, having one alcoholic parent increased the rate of alcoholism from 12.4 percent to 29.5 percent and having two alcoholic parents increased the rate to 41.2 percent. For females with no alcoholic parents, the rate was 5.0 percent; for those with one alcoholic parent, the rate was 9.5 percent; and for those with two alcoholic parents, it was 25.0 percent.

Alcohol abuse problems clearly tend to run in families (Hartz & Beirut,  2010 ; Hasin & Katz,  2010 ). Research has shown that some people, such as the sons of alcoholics, have a high risk for developing problems with alcohol because of an inherent motivation to drink or sensitivity to the drug (Conrod et al.,  1998 ). Research on the children of alcoholics who were adopted by other (nonalcoholic) families has also provided useful information. Studies have been conducted of alcoholics’ children who were placed for adoption early in life and so did not come under the environmental influences of their biological parents. For example, Goodwin and colleagues ( 1973 ) found that children of alcoholic parents who had been adopted by nonalcoholic foster parents were nearly twice as likely to have alcohol problems by their late 20s as a control group of adopted children whose biological parents were not alcoholics. In another study, Goodwin and colleagues ( 1974 ) compared alcoholic parents’ sons who were adopted in infancy by nonalcoholic parents and sons raised by their alcoholic parents. Both adopted and nonadopted sons later evidenced high rates of alcoholism—25 percent and 17 percent, respectively. These investigators concluded that being born to an alcoholic parent, rather than being raised by one, increases the risk of a son’s becoming an alcoholic.

Another approach to understanding the precursors to alcohol-related disorders is to study prealcoholic personalities—individuals who are at high risk for substance abuse but who are not yet affected by alcohol. The heritability of personality characteristics has been widely explored (Bouchard & Loehlin,  2001 ). An alcohol-risk personality has been described as an individual (usually an alcoholic’s child) who has an inherited predisposition toward alcohol abuse and who is impulsive, prefers taking high risks, and is emotionally unstable.

Research has shown that prealcoholic men (those who are genetically predisposed to developing drug or alcohol problems but who have not yet acquired the problem) show different physiological patterns than nonalcoholic men in several respects. Prealcoholic men tend to experience a greater lessening of feelings of stress with alcohol ingestion than do nonalcoholic men (Finn et al.,  1997 ). Prealcoholic men also show different alpha wave patterns on EEGs (Stewart et al.,  1990 ) and have been found to have larger conditioned physiological responses to alcohol cues than individuals who were considered at a low risk for alcoholism, according to Earleywine and Finn ( 1990 ). These results suggest that prealcoholic men may be more prone to developing tolerance for alcohol than low-risk men.

Some research suggests that certain ethnic groups, particularly Asians and Native Americans, have abnormal physiological reactions to alcohol—a phenomenon referred to as “alcohol flush reaction.” Fenna and colleagues ( 1971 ) and Wolff ( 1972 ) found that Asian and Eskimo subjects showed a hypersensitive reaction including flushing of the skin, a drop in blood pressure, heart palpitations, and nausea following the ingestion of alcohol (see also Gill et al.,  1999 ). This physiological reaction is found in roughly half of all Asians (Chen & Yeh,  1997 ) and results from a mutant enzyme that fails to break down alcohol molecules in the liver during the metabolic process (Takeshita et al.,  1993 ). Although cultural factors may also play a role, the relatively lower rates of alcoholism among Asian groups might be related to the extreme discomfort associated with the alcohol flush reaction (Higuci et al.,  1994 ).

GENETICS—THE WHOLE STORY?

As with the other disorders described in this book, genetics alone is not the whole story, and the exact role it plays in the development of alcohol-related disorders remains unclear. This issue continues to be debated, and some experts are not convinced of the primary role of genetics in substance-abuse disorders. The genetic mechanism or model for the generally agreed-upon observation that alcoholism is familial is insufficient to explain the behavior fully. That is, genetic transmission in the case of alcohol-related disorders does not follow the hereditary pattern found in strictly genetic disorders. Some investigators have employed the evidence that genetics appears to play a stronger role in men than in women (Merikangas & Swendsen,  1997 ) to question the relative power of genetics as an explanatory factor in substance abuse. Searles ( 1991 ) points to the ambiguous evidence for the genetics of alcohol-related disorders and cautions against interpreting genetics as a causal factor in its development. Negative results have been found in both twin and adoptive studies and in studies designed to follow up the behavior of high-risk individuals. The great majority of children who have parents with alcohol-related problems do not themselves develop substance-abuse disorders—whether or not they are raised by their biological parents. The children of substance abusers who make successful life adjustments have not been sufficiently studied. In one study of high-risk children of substance abusers, a group of young men 19 to 20 years of age who were presumably at high risk for developing substance-abuse problems were carefully studied for symptoms of psycho-pathology. Schulsinger and colleagues ( 1986 ) found that they did not differ in psychopathology or in alcohol-abuse behavior from a control sample similar to the general population. In another study of high-risk individuals, Alterman, Searles, and Hall ( 1989 ) failed to find differences in drinking behavior or alcohol-related symptoms between a group of high-risk subjects (those who had alcoholic fathers) and a group of non-high-risk subjects.

Although much evidence implicates genetic factors in the etiology of alcoholism, we do not know what precise role they play. At present, it appears that the genetic interpretation of alcoholism remains an attractive hypothesis; however, additional research is needed for us to hold this view with confidence. It is not likely that genetics alone will account for the full range of alcohol and drug problems. Social circumstances are still considered powerful forces in providing both the availability and the motivation to use alcohol and other drugs. McGue ( 1998 ) notes that the mechanisms of genetic influence should be viewed as compatible, rather than competitive, with psychological and social determinants of this disorder.

GENETIC INFLUENCES AND LEARNING

When we talk about familial or constitutional differences, we are not strictly limiting our explanation to genetic inheritance. Rather, learning factors appear to play an important part in the development of constitutional or predetermined tendencies to behave in particular ways. Having a genetic predisposition or biological vulnerability to substance abuse, of course, is not a sufficient cause of the disorder. The person must be exposed to the substance to a sufficient degree for the addictive behavior to appear. In the case of alcohol, almost everyone in America is exposed to the drug to some extent—in most cases through peer pressure, parental example, and advertising (Andrews & Hops,  2010 ). The development of alcohol-related problems involves living in an environment that promotes initial as well as continuing use of the substance. People become conditioned to stimuli and tend to respond in particular ways as a result of learning. Learning appears to play an important part in the development of substance abuse and antisocial personality disorders. There clearly are numerous reinforcements for using alcohol in our social environments and everyday lives. However, research has also shown that psychoactive drugs such as alcohol contain intrinsic rewarding properties—apart from the social context or the drug’s operation to diminish worry or frustration. As we saw earlier, the drug stimulates pleasure centers in the brain and develops a reward system of its own.

Psychosocial Causal Factors in Alcohol Abuse and Dependence

Not only do alcohol abusers become physiologically dependent on alcohol, they develop a powerful psychological dependence as well—they become socially dependent on the drug to help them enjoy social situations.

FAILURES IN PARENTAL GUIDANCE

Stable family relationships and parental guidance are extremely important molding influences for children (Hasin & Katz,  2010 ), and this stability is often lacking in families of substance abusers. Children who have parents who are extensive alcohol or drug abusers are vulnerable to developing substance-abuse and related problems (Erblich et al.,  2001 ). The experiences and lessons we learn from important figures in our early years have a significant impact on us as adults. Children who are exposed to negative role models and family dysfunction early in their lives or experience other negative circumstances because the adults around them provide limited guidance often falter on the difficult steps they must take in life (Fischer et al.,  2005 ). These formative experiences can have a direct influence on whether a young person becomes involved in maladaptive behavior such as alcohol or drug abuse.

In one sophisticated program of research aimed at evaluating the possibility that negative socialization factors influence alcohol use, Chassin and colleagues ( 1993 ; Trim & Chassin,  2004 ) replicated findings that alcohol abuse in parents is associated with substance use in adolescents. They then evaluated several possible mediating factors that can affect whether adolescents start using alcohol. They found that parenting skills or parental behavior was associated with substance use in adolescents. Specifically, alcohol-abusing parents are less likely to keep track of what their children are doing, and this lack of monitoring often leads to the adolescents’ affiliation with drug-using peers. In addition, Chassin and colleagues ( 1993 ) found that stress and negative affect (more prevalent in families with an alcoholic parent) are associated with alcohol use in adolescents. They reported that “parental alcoholism was associated with increases in negative uncontrollable life events which, in turn, were linked to negative affect, to associations with drug-using peers, and to substance use” (p. 16). In a follow-up study, Chassin and colleagues ( 1996 ) reported that the direct effect of fathers’ alcohol abuse is strong, even after controlling for stress and negative affect. Extremely stressful childhood experiences such as physical abuse (Douglas et al.,  2010 ; Kaufman et al.,  2007 ) or child sexual abuse might also make a person vulnerable to later problems. Women who have a history of child sexual abuse are at risk for developing a wide range of psychological problems including substance abuse (Kendler et al.,  2000 ).

Parent substance use is associated with early adolescent substance use, and negative parental models can have longer-range negative consequences once children leave home.

PSYCHOLOGICAL VULNERABILITY

Is there an “alcoholic personality”—a type of character organization that predisposes a person to use alcohol rather than adopt some other defensive pattern of coping with stress? Research has suggested that personality factors related to having a family history of alcoholism are associated with the development of alcohol-use disorders (Larkins & Sher,  2006 ). Research has shown that children of alcoholics progressed more quickly from initial alcohol use to the onset of disorder than did matched adolescents in the control sample (Hussong et al.,  2008 ).

Do some individuals self-medicate or reduce their discomfort by excessive use of alcohol? In efforts to answer this question, investigators have found that many potential alcohol abusers tend to be emotionally immature, expect a great deal of the world, require an inordinate amount of praise and appreciation, react to failure with marked feelings of hurt and inferiority, have low frustration tolerance, and feel inadequate and unsure of their abilities to fulfill expected male or female roles. Persons at high risk for developing alcohol-related problems have been found to be significantly more impulsive and aggressive than those at low risk for abusing alcohol (Morey et al.,  1984 ).

In recent years, substantial research has focused on the link between alcohol-related disorders and such other disorders as antisocial personality, depression, and schizophrenia to determine whether some individuals are more vulnerable to substance-abuse disorders. About half of the persons with schizophrenia have either alcohol or drug abuse or dependence as well (Kosten,  1997 ). By far, most of the research on comorbidity has related antisocial personality and addictive disorders, where about 75 to 80 percent of the studies have shown a strong association (Alterman,  1988 ), and conduct disorder (Slutske et al.,  1998 ). Interestingly, antisocial personality disorder, alcohol, and aggression are strongly associated (Moeller & Dougherty,  2001 ), and in a survey of eight alcohol-treatment programs, Morganstern and colleagues ( 1997 ) found that 57.9 percent of those in treatment had a personality disorder, with 22.7 percent meeting criteria for antisocial personality disorder. One study reports that substance abusers with antisocial personality disorder had lower expectations of remaining abstinent from alcohol use (Di Sclafani et al.,  2007 ).

Considerable research has suggested that there is a relationship between depressive disorders and alcohol abuse, and there may be gender differences in the association between these disorders (Kranzler et al.,  1997 ). One group of researchers (Moscato et al.,  1997 ) found the degree of association between depression and alcohol-abuse problems stronger among women.

For whatever reason they co-occur, the presence of other mental disorders in alcohol- or drug-abusing patients is a very important consideration when it comes to treatment, as will be discussed later in this chapter.

STRESS, TENSION REDUCTION, AND REINFORCEMENT

Research studies on patients undergoing substance-abusing treatment have shown high levels of trauma in their prior histories—about 25 to 50 percent of PTSD patients also have substance-abuse disorders (Schafer & Najavits,  2007 ). In one study, Deters and colleagues ( 2006 ) found that 98 percent of the American Indian adolescents in their substance-abuse study reported having a history of trauma such as threat of personal injury, witnessing of injury, or sexual abuse. One recent controlled-treatment study of disaster workers who experienced PTSD following the World Trade Center trauma (Difede et al.,  2007 ) found that excessive alcohol use was associated with dropout from treatment. Wilk and colleagues ( 2010 ) found that high exposure to threatening situations and atrocities (i.e., among Iraq war veterans) was associated with a positive screen for alcohol abuse.

A number of investigators have pointed out that the typical alcohol abuser is discontented with his or her life and is unable or unwilling to tolerate tension and stress (for example, Rutledge & Sher,  2001 ). Hussong and colleagues ( 2001 ) reported a high degree of association between alcohol consumption and negative affectivity such as anxiety and somatic complaints. In other words, alcoholics drink to relax. In this view, anyone who finds alcohol tension-reducing is in danger of abusing alcohol, even without an especially stressful life situation. However, the tension-reduction causal model is difficult to accept as a sole explanatory hypothesis. If this process were a main cause, we would expect substance-abuse disorder to be far more common than it is because alcohol tends to reduce tension for most people who use it. In addition, this model does not explain why some excessive drinkers are able to maintain control over their drinking and continue to function in society whereas others are not.

EXPECTATIONS OF SOCIAL SUCCESS

Some research has explored the idea that cognitive expectation may play an important role both in the initiation of drinking and in the maintenance of drinking behavior once the person has begun to use alcohol (see, for example, Marlatt et al.,  1998 ). Many people, especially young adolescents, expect that alcohol use will lower tension and anxiety and increase sexual desire and pleasure in life (Seto & Barbaree,  1995 ). According to the reciprocal-influence model, adolescents begin drinking as a result of expectations that using alcohol will increase their popularity and acceptance by their peers.

This view gives professionals an important and potentially powerful means of deterring drinking among young people or at least delaying its onset. From this perspective, alcohol use in teenagers can be countered by providing young people with more effective social tools and with ways of altering these expectancies before drinking begins. Smith and colleagues ( 1995 ) have suggested that prevention efforts should be targeted at children before they begin to drink so that the positive feedback cycle of reciprocal reinforcement between expectancy and drinking will never be established (see the discussion on prevention of alcohol use in  Chapter 17 ).

Time and experience do have  moderating  influences on these alcohol expectancies, although heavy drinking in early college years can result in risky behavior and low academic motivation (Hoeppner, et al.,  2012 ). In a longitudinal study of college drinking, Sher and colleagues ( 1996 ) found that there was a significant decrease in outcome expectancy over time. That is, older students showed less expectation of the benefits of alcohol than beginning students (see The World Around Us).

research CLOSE-UP: Moderating

A moderating variable is a variable that influences the association between two other variables. For example, depression is common after bereavement. However, men who have lost a spouse tend to be more likely to be depressed than women who have lost a spouse. In this case, gender is a key moderating variable for the bereavement–depression relationship.

MARITAL AND OTHER INTIMATE RELATIONSHIPS

Adults with less intimate and supportive relationships tend to show greater drinking following sadness or hostility than those with close peers and with more positive relationships (Hussong et al.,  2001 ). Excessive drinking often begins during crisis periods in marital or other intimate personal relationships, particularly crises that lead to hurt and self-devaluation. The marital relationship may actually serve to maintain the pattern of excessive drinking. (See the case study below.) Marital partners may behave toward each other in ways that promote or enable a spouse’s excessive drinking. For example, a husband who lives with a wife who abuses alcohol is often unaware of the fact that, gradually and inevitably, many of the decisions he makes every day are based on the expectation that his wife will be drinking. These expectations, in turn, may make the drinking behavior more likely. Eventually an entire marriage may center on the drinking of a substance-abusing spouse. In some instances, the husband or wife may also begin to drink excessively. Thus one important concern in many treatment programs today involves identifying the personality or lifestyle factors in a relationship that tend to foster the drinking in the alcohol-abusing person. Of course, such relationships are not restricted to marital partners but may also occur in those involved in love affairs or close friendships.

The Drunken Wife and Mother Evelyn C., a 36-year-old homemaker and mother of two school-age children (from a previous marriage), began to drink to excess especially following intense disagreements with her husband, John, a manager of a retail business. For several months, she had been drinking during the day when her children were at school and on two occasions was inebriated when they came home. On one recent occasion, Evelyn failed to pick up her older daughter after an after-school event. Her daughter called John’s cell phone (he was out of town on a business trip), and he had an assistant pick her up. When they arrived home, Evelyn (apparently unaware of the problem she had caused) created a scene and was verbally abusive toward the assistant. Her out-of-control drinking increased when her husband of 3 years began staying out all night. These emotionally charged encounters resulted in John’s physically abusing her one morning when he came back home after a night away. John moved out of the house and filed for divorce.

Excessive use of alcohol is one of the most frequent causes of divorce in the United States (Perreira & Sloan,  2001 ) and is often a hidden factor in the two most common causes—financial and sexual problems. The deterioration in interpersonal relationships of the alcohol abuser or dependent, of course, further augments the stress and disorganization in her or his life. The breakdown of marital relationships can be a highly stressful situation for many people. The stress of divorce and the often erratic adjustment period that follows can lead to increased substance abuse.

the WORLD around us: Binge Drinking in College

Two alcohol-related student deaths shocked the Colorado college community in the fall of 2004. Lynn B., an entering freshman at the University of Colorado, drank so much whiskey and wine during a fraternity initiation that he became unconscious and died as a result of alcohol poisoning. This tragic incident occurred just 2 weeks after a 19-year-old sophomore at Colorado State University, Samantha S., died of alcohol poisoning after a party at which she had consumed an estimated 40 drinks (Sink,  2004 ).

How extensive is college binge drinking? In spite of the fact that alcohol use is illegal for most undergraduates, binge drinking on campus is widespread (Rabow & Duncan-Schill,  1995 ) and increased substantially between 1998 and 2005 (Mitka,  2009 ). Sher and Rutledge ( 2007 ) reported that college students who drank in high school are likely to continue drinking during their first year in college. According to a survey by Wechsler and colleagues ( 1994 ), 44 percent of college students in the United States are binge drinkers, and Goodwin ( 1992 ) reports that 98 percent of fraternity and sorority members drink some amount every week. Some research has suggested, however, that the pattern of drinking can vary widely, with binge drinking being more of an occasional rather than a regular event (Del Boca et al.,  2004 ). Wechsler and colleagues ( 1994 ) conducted a nationwide survey of 140 college campuses in 40 states and obtained survey information pertaining to the drinking behavior and health consequences of drinking on 17,592 students (with approximately a 69 percent response rate). Students completed a 20-page survey of their drinking practices, including such information as recency of last drink, how many times they had five drinks or more in a row, and how many times they had four drinks in a row. They were also asked to provide information as to whether they experienced any of the following consequences after drinking: had a hangover, missed a class, got behind in schoolwork, did something they later regretted, forgot where they were or what they did, argued with friends, engaged in unplanned sexual activities, failed to use protection when having sex, damaged property, got into trouble with the campus police, got hurt, or required medical treatment for an alcohol overdose.

The colleges surveyed in the study varied widely in the extent of binge drinking among the student body. As one might expect—some colleges earn reputations as being “party schools”—some institutions had a large number of students (70 percent) heavily involved in alcohol and binge drinking, but the problem occurred to some degree across most college campuses. Recent research has suggested that heavier drinking students may self-select into certain study abroad programs with specific intentions to use alcohol (Pedersen et al.  2010 ).

What are the reasons for the widespread problem of binge drinking in college? Many factors can be cited, such as students’ expressing independence from parental influence (Turrisi et al.,  2000 ); peer group and situational influences (Read et al.,  2003 ); developing and asserting gender roles, particularly for men adopting a “macho” role (Capraro,  2000 ); and holding beliefs that alcohol can help make positive transformations, such as “having a few drinks to celebrate special occasions” (Turrisi,  1999 ). One recent study suggested that a family history of alcohol abuse was associated with problematic drinking among college students (LaBrie, et al.  2010 ).

The consequences of college binge drinking can be far-reaching and often involve disinhibited behavior (Carlson et al.,  2010 ). In their survey, Wechsler and colleagues ( 1994 ) reported a strong association between the frequency of binge drinking and alcohol-related health and life problems. In fact, binge drinkers were nearly 10 times more likely than those who did not indulge in binge drinking to engage in unplanned sexual activity, not to use protection when having sex, to get into trouble with campus police, to damage property, and to get hurt after drinking. Men and women tended to report similar problems, except that men engaged in more property damage than women. Over 16 percent of the men and 9 percent of the women reported having gotten into trouble with the campus police. About 47 percent of the frequent binge drinkers, compared with 14 percent of the non–binge drinkers, indicated that they had experienced five or more of the problems surveyed. In a more recent follow-up survey of college drinking in 1997, Wechsler and colleagues ( 1998 ) reported strikingly similar results.

One recent study suggests that extensive drinking in college, even among the heaviest drinkers from sororities and fraternities, might be determined to a great extent by situational events, factors that change with graduation. In a follow-up study of drinking behavior a year after graduation, Sher, Bartholow, and Nanda ( 2001 ) reported that being a member of a fraternity or sorority did not predict postcollege drinking. Interestingly, a long-term follow-up of over 11 years has shown that the heavy drinking during college did not translate to heavy drinking during later years (Bartholow et al.,  2003 ). These investigators found that heavy drinking that is associated with Greek society involvement does not generally lead to sustained heavy drinking in later life.

Some institutions provide a psychological intervention in an effort to reduce the extent of drinking among college students. One recent study reported that a procedure referred to as Brief Motivational Intervention, or BMI, produced greater self-regulation among a sample of binging college students by providing skills for them to moderate their drinking behavior (Carey et al.,  2007 ). This procedure was more effective among students who also showed, in their pretreatment assessment, a readiness to change.

Family relationship problems have also been found to be central to the development of alcoholism (Dooley & Prause,  2007 ). In a classic longitudinal study of possible etiologic factors in alcohol abuse, Vaillant and colleagues ( 1982 ) described six family relationship factors that were significantly associated with the development of alcoholism in the individuals they studied. The most important family variables that were considered to pre-dispose an individual to substance-use problems were the presence of an alcoholic father, acute marital conflict, lax maternal supervision and inconsistent discipline, many moves during the family’s early years, lack of “attachment” to the father, and lack of family cohesiveness.

Sociocultural Causal Factors

Alcohol use is a pervasive component in the social life in Western civilization. Social events often revolve around alcohol use, and alcohol use before and during meals is commonplace. Alcohol is often seen as a “social lubricant” or tension reducer that enhances social events. Thus investigators have pointed to the role of sociocultural as well as biological and psychological factors in the high rate of alcohol abuse and dependence among Americans.

The effect of cultural attitudes toward drinking is well illustrated by Muslims and Mormons, whose religious values prohibit the use of alcohol, and by orthodox Jews, who have traditionally limited its use largely to religious rituals. The incidence of alcoholism among these groups is minimal. In comparison, the incidence of alcoholism is high among Europeans. For example, one survey showed the highest alcohol-use rates among young people to be in Denmark and Malta, where one in five students reported having drunk alcohol 10 times within the past 30 days (ESPAD,  2000 ). Interestingly, Europe and six countries that have been influenced by European culture—Argentina, Canada, Chile, Japan, the United States, and New Zealand—make up less than 20 percent of the world’s population and yet consume 80 percent of the alcohol (Barry,  1982 ). Alcohol abuse continues to be a problem in Europe by, for example, contributing to accidents (Lehto,  1995 ), crime (Rittson,  1995 ), liver disease (Medical Council on Alcoholism,  1997 ), and the extent to which young people are developing substance-use problems (Anderson & Lehto,  1995 ). The French appear to have the highest rate of alcoholism in the world, involving approximately 15 percent of the population. France has both the highest per capita alcohol consumption and one of the highest death rates from cirrhosis of the liver (Noble,  1979 ). In addition, France shows the highest prevalence rates: In a broad survey of hospital patients, 18 percent (25 percent for men and 7 percent for women) were reported to have alcohol-use disorders even though only 6 percent of admissions were for alcohol problems (Reynaud et al.,  1997 ). In Sweden, another country with high rates of alcoholism, 13.2 percent of men’s hospital admissions, and 1.1 percent of women’s, are attributed to alcohol (Andreasson & Brandt,  1997 ). Thus it appears that religious sanctions and social customs can influence whether alcohol is one of the coping methods commonly used in a given group or society.

The behavior that is manifested under the influence of alcohol also seems to be influenced by cultural factors. Lindman and Lang ( 1994 ), in a study of alcohol-related behavior in eight countries, found that most people expressed the view that aggressive behavior frequently follows their drinking “many” drinks. However, the expectation that alcohol leads to aggression is related to cultural traditions and early exposure to violent or aggressive behavior.

In sum, we can identify many reasons why people drink—as well as many conditions that can predispose them to do so and reinforce their drinking behavior—but the exact combination of factors that results in a person’s becoming an alcoholic is still unknown.

Treatment of Alcohol-Related Disorders

Alcohol abuse and dependence are difficult to treat because many alcohol abusers refuse to admit that they have a problem before they “hit bottom,” and many who do go into treatment leave before therapy is completed. DiClemente ( 1993 ) refers to the addictions as “diseases of denial.” However, in a review of several large alcohol-treatment studies, Miller, Walters, and Bennett ( 2001 ) reported that two-thirds of studies show large and significant decreases in drinking and related problems. In this section, we will examine both biological and psychosocial treatment strategies. Some treatment approaches appear to reduce drinking-related problems more effectively than others (Miller & Wilbourne,  2002 ; Zweben,  2001 ). In general, a multidisciplinary approach to the treatment of drinking problems appears to be most effective because the problems are often complex, requiring flexibility and individualization of treatment procedures (Margolis & Zweben,  1998 ). Also, a substance abuser’s needs change as treatment progresses. Treatment objectives usually include detoxification, physical rehabilitation, control over alcohol-abuse behavior, and the individual’s realizing that he or she can cope with the problems of living and lead a much more rewarding life without alcohol.

Traditional treatment programs usually have as their goal abstinence from alcohol (Ambrogne,  2002 ). However, some programs attempt to promote controlled drinking as a treatment goal for problem drinkers. For example, one procedure referred to as Brief Motivational Intervention attempts to modify clients’ behavior through providing information and advice about the consequences of the substance use in an effort to challenge the users about their use—but leaves the responsibility to the individual (Carey et al.,  2007 ; Miller & Rollnik,  2002 ; Peterson et al.,  2006 ). No matter what the treatment method, relapse is common, and many in the field see relapse as a factor that must be addressed in the treatment and recovery process.

USE OF MEDICATIONS IN TREATING ALCOHOL ABUSE AND DEPENDENCY

Biological approaches include a variety of treatment measures such as medications to reduce cravings, to ease the detoxification process, and to treat co-occurring health (National Institutes of Health,  2001 ) and mental health problems that may underlie the drinking behavior.

Medications to Block the Desire to Drink Disulfiram (Antabuse), a drug that causes violent vomiting when followed by ingestion of alcohol, may be administered to prevent an immediate return to drinking (Grossman & Ruiz,  2004 ). However, such deterrent therapy is seldom advocated as the sole approach because pharmacological methods alone have not proved effective in treating many severe alcohol-abuse problems (Gorlick,  1993 ). For example, because the drug is usually self-administered, an alcohol-dependent person may simply discontinue the use of Antabuse when he or she is released from a hospital or clinic and begins to drink again. In fact, the primary value of drugs of this type seems to be their ability to interrupt the alcohol-abuse cycle for a period of time during which therapy may be undertaken. Uncomfortable side effects may accompany the use of Antabuse; for example, alcohol-based aftershave lotion can be absorbed through the skin, resulting in illness. Moreover, the cost of Antabuse treatment, which requires careful medical maintenance, is higher than that for many other, more effective treatments.

Another type of medication that has been used in a promising line of research (Kranzler et al.,  2004 ) is naltrexone, an opiate antagonist that helps reduce the craving for alcohol by blocking the pleasure-producing effects of alcohol (Gueorguieva et al.,  2007 ; Lee et al.,  2010 ). O’Malley and colleagues ( 1996 ) have shown that naltrexone reduced the alcohol intake and lowered the incentive to drink for alcohol abusers compared with a control sample given a placebo. Some research has suggested that naltrexone is particularly effective with individuals who have a high level of craving (Monterosso et al.,  2001 ) and show effects of binge drinking (Johnson,  2010 ). Other research, however, has failed to find naltrexone effective at reducing craving (Krystal et al.,  2001 ), so confidence in its use for this purpose must await further research.

Medications to Reduce the Side Effects of Acute Withdrawal In cases of acute intoxication, the initial focus is on detoxification (the elimination of alcoholic substances from an individual’s body), on treatment of the withdrawal symptoms described earlier, and on a medical regimen for physical rehabilitation. One of the primary goals in treatment of withdrawal symptoms is to reduce the physical symptoms characteristic of withdrawal such as insomnia, headache, gastrointestinal distress, and tremulousness. Central to the medical treatment approaches are the prevention of heart arrhythmias, seizures, delirium, and death. These steps can usually best be handled in a hospital or clinic, where drugs such as Valium have largely revolutionized the treatment of withdrawal symptoms. Such drugs overcome motor excitement, nausea, and vomiting; prevent withdrawal delirium and convulsions; and help alleviate the tension and anxiety associated with withdrawal. Pharmacological treatments with long-lasting benzodiazepines, such as diazepam, to reduce the severity of withdrawal symptoms have been shown to be effective (Malcolm,  2003 ).

Concern is growing, however, that the use of tranquilizers—drugs that depress the CNS, resulting in calmness, relaxation, reduction of anxiety, and sleeping—does not promote long-term recovery and may simply transfer the addiction to another substance. Accordingly, some detoxification clinics are exploring alternative approaches including a gradual weaning from alcohol instead of a sudden cutoff. Maintenance doses of mild tranquilizers are sometimes given to patients withdrawing from alcohol to reduce anxiety and help them sleep. Such use of medications may be less effective than no treatment at all, however. Usually patients must learn to abstain from tranquilizers as well as from alcohol because they tend to misuse both. Further, under the influence of medications, patients may even return to alcohol use.

PSYCHOLOGICAL TREATMENT APPROACHES

Once the patient has her or his drinking under control, detoxification is optimally followed by psychological treatment, including family counseling and the use of community resources related to employment and other aspects of a person’s social readjustment. Although individual psychotherapy is sometimes effective, the focus of psychosocial measures in the treatment of alcohol-related problems often involves group therapy, environmental intervention, behavior therapy, and the approach used by Alcoholics Anonymous and family groups such as Al-Anon and Alateen.

Group Therapy  Group therapy has been shown to be effective for many clinical problems (Galanter et al.,  2005 ), especially substance-related disorders (Velasquez et al.,  2001 ). In the confrontational give-and-take of group therapy, alcohol abusers are often forced (perhaps for the first time) to face their problems and their tendencies to deny or minimize them. These group situations can be extremely difficult for those who have been engrossed in denial of their own responsibilities, but such treatment also helps them see new possibilities for coping with circumstances that have led to their difficulties. Often this paves the way for them to learn more effective ways of coping and other positive steps toward dealing with their drinking problem.

In some instances, the spouses of alcohol abusers and even their children may be invited to join in group therapy meetings. In other situations, family treatment is itself the central focus of therapeutic efforts. In that case, the alcohol abuser is seen as a member of a disturbed family in which all members have a responsibility for cooperating in treatment. Because family members are frequently the people most victimized by the alcohol abuser’s addiction, they often tend to be judgmental and punitive, and the person in treatment, who has already passed harsh judgment on himself or herself, may tolerate this further source of devaluation poorly. In other instances, family members may unwittingly encourage an alcohol abuser to remain addicted—for example, a man with a need to dominate his wife may find that a continually drunken and remorseful spouse best meets his needs.

Environmental Intervention As with other serious mal-adaptive behaviors, a total treatment program for alcohol abuse or dependency usually requires measures to alleviate a patient’s aversive life situation. Environmental support has been shown to be an important ingredient of an alcohol abuser’s recovery. People often become estranged from family and friends because of their drinking and either lose or jeopardize their jobs. As a result, they are often lonely and live in impoverished neighborhoods. Typically, the reaction of those around them is not as understanding or as supportive as it would be if the alcohol abuser had a physical illness of comparable magnitude. Simply helping people with alcohol-abuse problems learn more effective coping techniques may not be enough if their social environment remains hostile and threatening. For those who have been hospitalized, halfway houses—designed to assist them in their return to family and community—are often important adjuncts to their total treatment program.

Behavioral and Cognitive-Behavioral Therapy  An interesting and often effective form of treatment for alcohol-related disorders is behavioral therapy, of which several types exist. One is aversive conditioning therapy, which involves the presentation of a wide range of noxious stimuli with alcohol consumption in order to suppress drinking behavior. For example, the ingestion of alcohol might be paired with an electric shock or a drug that produces nausea. A variety of pharmacological and other deterrent measures can be used in behavioral therapy after detoxification. One approach involves an intramuscular injection of emetine hydrochloride, an emetic. Before experiencing the nausea that results from the injection, a patient is given alcohol, so that the sight, smell, and taste of the beverage become associated with severe retching and vomiting. That is, a conditioned aversion to the taste and smell of alcohol develops. With repetition, this classical conditioning procedure acts as a strong deterrent to further drinking—probably in part because it adds an immediate and unpleasant physiological consequence to the more general socially aversive consequences of excessive drinking.

One of the most effective contemporary procedures for treating alcohol abusers has been the cognitive-behavioral approach recommended by Alan Marlatt ( 1985 ) and Witkiewitz and Marlatt ( 2004 ). This approach combines cognitive-behavioral strategies of intervention with social-learning theory and modeling of behavior. The approach, often referred to as a “skills training procedure,” is usually aimed at younger problem drinkers who are considered to be at risk for developing more severe drinking problems because of an alcohol-abuse history in their family or their current heavy consumption. This approach relies on such techniques as imparting specific knowledge about alcohol, developing coping skills in situations associated with increased risk of alcohol use, modifying cognitions and expectancies, acquiring stress-management skills, and providing training in life skills (Connors & Walitzer,  2001 ). Cognitive-behavioral treatments have been shown to be effective; for example, O’Farrell and colleagues ( 2004 ) report that partner violence was significantly reduced following cognitive-behavioral treatment.

Self-control training techniques, such as the Brief Motivational Intervention noted earlier, in which the goal of therapy is to get alcoholics to reduce alcohol intake without necessarily abstaining altogether, have a great deal of appeal for some drinkers. For example, one recent approach to improve drinking outcomes by altering the drinker’s social networks was found to be successful (Litt et al.,  2007 ) and motivational interviewing with adolescents was found to be promising (Macgowan & Engle,  2010 ). There is now even a computer-based self-control training program available that has been shown to reduce problem drinking in a controlled study (Fals-Stewart & Lam,  2010 ; Neighbors et al.,  2004 ). It is difficult, of course, for individuals who are extremely dependent on the effects of alcohol to abstain totally from drinking. Thus many alcoholics fail to complete traditional treatment programs.

CONTROLLED DRINKING VERSUS ABSTINENCE

Other psychological techniques have also received attention in recent years, partly because they are based on the hypothesis that some problem drinkers need not give up drinking altogether but rather can learn to drink moderately (Miller, Walters, & Bennett,  2001 ; Sobell & Sobell,  1995 ). Several approaches to learning controlled drinking have been attempted (McMurran & Hollin,  1993 ), and research has suggested that some alcoholics can learn to control their alcohol intake (Senft et al.,  1997 ). Miller and colleagues ( 1986 ) evaluated the results of four long-term follow-up studies of controlled-drinking treatment programs. Although they found a clear trend of increased numbers of abstainers and relapsed cases at long-term follow-up, they also found that a consistent percentage (15 percent) of subjects across the four studies controlled their drinking. The researchers concluded that controlled drinking was more likely to be successful in persons with less severe alcohol problems. The finding that some individuals are able to maintain some control over their drinking after treatment (without remaining totally abstinent) was also reported in a classic study by Polich et al. ( 1981 ). These researchers found that 18 percent of the alcoholics they studied had reportedly been able to drink socially without problems during the 6-month follow-up of treatment.

Many people in the field have rejected the idea that alcohol abusers can learn to control their drinking, and some recent research has found that controlled drinking is not effective (Bottlender et al.,  2007 ). And some groups, such as Alcoholics Anonymous, are adamant in their opposition to programs aimed at controlled drinking for alcohol-dependent individuals.

ALCOHOLICS ANONYMOUS

A practical approach to alcoholism that has reportedly met with considerable success is that of Alcoholics Anonymous (AA). This organization was started in 1935 by two men, Dr. Bob and Bill W., in Akron, Ohio. Bill W. recovered from alcoholism through a “fundamental spiritual change” and immediately sought out Dr. Bob, who, with Bill’s assistance, also achieved recovery. They in turn began to help other alcoholics. Since that time, AA has grown to over 52,000 groups in the United States, with an annual growth rate of about 6 to 7 percent (Alcoholics Anonymous,  2007 ). In addition, there are nearly 5,000 AA groups in Canada and over 45,000 groups in many other countries.

Alcoholics Anonymous operates primarily as a self-help counseling program in which both person-to-person and group relationships are emphasized. AA accepts both teenagers and adults with drinking problems, has no dues or fees, does not keep records or case histories, does not participate in political causes, and is not affiliated with any religious sect, although spiritual development is a key aspect of its treatment approach. To ensure anonymity, only first names are used. Meetings are devoted partly to social activities, but they consist mainly of discussions of the participants’ problems with alcohol, often with testimonials from those who have stopped drinking. Such members usually contrast their lives before they broke their alcohol dependence with the lives they now live without alcohol. We should point out here that the term alcoholic is used by AA and its affiliates to refer either to persons who currently are drinking excessively or to people who have stopped drinking but must, according to AA philosophy, continue to abstain from alcohol consumption in the future. That is, in the AA view, one is an alcoholic for life, whether or not one is drinking; one is never “cured” of alcoholism but is instead “in recovery.”

An important aspect of AA’s rehabilitation program is that it appears to lift the burden of personal responsibility by helping alcoholics accept that alcoholism, like many other problems, is bigger than they are. Henceforth, they can see themselves not as weak willed or lacking in moral strength but rather simply as having an affliction—they cannot drink—just as other people may not be able to tolerate certain types of medication. Through mutual help and reassurance from group members who have had similar experiences, many alcoholics acquire insight into their problems, a new sense of purpose, greater ego strength, and more effective coping techniques. Continued participation in the group, of course, can help prevent the crisis of a relapse. Affiliated movements such as Al-Anon family groups and Ala-teen (which has over 35,000 groups in the United States and Canada) are designed to bring family members together to share experiences and problems, to gain understanding of the nature of alcoholism, and to learn techniques for dealing with their own problems living in a family with one or more affected individuals.

The reported success of Alcoholics Anonymous is based primarily on anecdotal information rather than on objective study of treatment outcomes because AA does not directly participate in external comparative research efforts. However, several studies have found AA conditions effective in helping people avoid drinking (Kelly, Stout et al.,  2010 ). In a classic study, Brandsma and colleagues ( 1980 ) included an AA program in their extensive comparative study of alcoholism treatments. The success of this treatment method with severe alcoholics was found to be quite limited. Another important finding was that the AA method had high dropout rates compared with other therapies. About half of the people who go to AA drop out of the program within 3 months. Chappel ( 1993 ) attributes the very high dropout rate to alcoholics’ denial that they have problems, resistance to external pressure, and resistance to AA itself. Apparently many alcoholics are unable to accept the quasireligious quality of the sessions and the group-testimonial format that is so much a part of the AA program. In the Brandsma study, the participants who were assigned to the AA group subsequently encountered more life difficulties and drank more than the people in the other treatment groups. On the positive side, however, a study by Morganstern and colleagues ( 1997 ) reports that affiliation with AA after alcohol treatment was associated with better outcomes than without such involvement, and a study by Tonigan and colleagues ( 1995 ) found that AA involvement was strongly associated with success in outpatient samples.

These people are participating in an Alcoholics Anonymous (AA) meeting. AA accepts both teenagers and adults, has no dues or fees, does not keep records or case histories, does not participate in political causes, and is not affiliated with any religious sect, although spiritual development is a key aspect of its treatment approach. To ensure anonymity, only first names are used at meetings. AA is one of the most popular alcohol-treatment programs, promoting total abstinence rather than controlled drinking.

OUTCOME STUDIES AND ISSUES IN TREATMENT

The outcome of treatment for alcohol-related disorders varies considerably, depending on the population studied and on the treatment facilities and procedures employed. Results range from low rates of success for hard-core substance abusers to recovery rates of 70 to 90 percent when modern treatment and aftercare procedures are used. Substance abusers who are also diagnosed as having a personality disorder or mood disorder tend to have poorer outcomes in alcohol treatment than those for whom the diagnosis is simply alcohol-abuse problems (Woelwer et al.,  2001 ). Treatment is most likely to be effective when an individual realizes that she or he needs help, when adequate treatment facilities are available, and when the individual attends treatment regularly. Having a positive relationship with the therapist is also associated with better treatment outcome (Connors et al.,  1997 ). One important treatment strategy is aimed at reinforcing treatment motivation and abstinence early in the treatment process by providing “check-up” follow-ups on drinking behavior. Miller and colleagues ( 1993 ) report that “Drinking Check-Up” sessions during the early stages of therapy resulted in a reduction of drinking in the first 6 weeks of therapy compared with clients who did not have check-up sessions.

Some researchers have maintained that treatment for alcohol-use and -abuse disorders would be more effective if important patient characteristics were taken into account (Mattson et al.,  1994 ). That is, patients with certain personality characteristics or with differing degrees of severity might do better with one specific therapeutic approach rather than with another. This view was evaluated in a study of patient–treatment matching (referred to as “Project MATCH”) that was sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA,  1997 ). This extensive study, initiated in 1989, involved 1,726 patients who were treated in 26 alcohol- treatment programs in the United States by 80 different therapists representing three treatment approaches. The research design included both inpatient and outpatient treatment components. The results of this study were unexpected: Matching the patients to particular treatments did not appear to be important to having an effective outcome because the treatments studied all had equal outcomes. Gordis ( 1997 ) concludes that patients from competently run alcoholism-treatment programs will do as well in any of the three treatments studied.

RELAPSE PREVENTION

One of the greatest problems in the treatment of addictive disorders is maintaining abstinence or self-control once the behavioral excesses have been checked (Tims et al.,  2001 ). Most alcohol-treatment programs show high success rates in “curing” the addictive problems, but many programs show lessening rates of abstinence or controlled drinking at various periods of follow-up. Many treatment programs do not pay enough attention to maintaining effective behavior and preventing relapse into previous maladaptive patterns (Miller & Rollnick,  2003 ).

Given that alcohol-dependent people are highly vulnerable to relapse, some researchers have focused on the need to help them remain abstinent. In one cognitive-behavioral approach, relapse behavior is a key factor in alcohol treatment (Witkiewitz & Marlatt,  2007 ). One recent study (Nattala et al.,  2010 ) found that relapse prevention treatment worked most effectively when family members were involved in the treatment.

The behaviors underlying relapse are seen as “indulgent behaviors” that are based on an individual’s learning history. When an individual is abstinent or has an addiction under control, she or he gains a sense of personal control over the indulgent behavior. The longer the person is able to maintain this control, the greater the sense of achievement—the self-efficacy or confidence—and the greater the chance that she or he will be able to cope with the addiction and maintain control. However, a person may violate this rule of abstinence through a gradual, perhaps unconscious, process rather than through the sudden “falling off the wagon” that constitutes the traditional view of craving and relapse. In the cognitive-behavioral view, a person may, even while maintaining abstinence, inadvertently make a series of mini-decisions that begin a chain of behaviors that render relapse inevitable. For example, an abstinent alcohol abuser who buys a quart of bourbon just in case his friends drop by is unconsciously preparing the way for relapse.

Another type of relapse behavior involves the “abstinence violation effect,” in which even minor transgressions are seen by the abstainer as having drastic significance. The effect works this way: An abstinent person may hold that she or he should not, under any circumstance, transgress or give in to the old habit. Abstinence-oriented treatment programs are particularly guided by this prohibitive rule. What happens, then, when an abstinent person becomes somewhat self-indulgent and takes a drink offered by an old friend or joins in a wedding toast? He or she may lose some of the sense of self-efficacy—confidence—needed to control his or her drinking. Feeling guilty about having technically violated the vow of abstinence, the person may rationalize that he or she “has blown it and become a drunk again, so why not go all the way?”

In relapse prevention treatment, clients are taught to recognize the apparently irrelevant decisions that serve as early warning signals of the possibility of relapse. High-risk situations such as parties or sports events are targeted, and the individuals learn to assess their own vulnerability to relapse. Clients are also trained not to become so discouraged that if they do relapse they lose their confidence. Some cognitive-behavioral therapists have even incorporated a “planned relapse” phase into the treatment. Research with relapse prevention strategies has shown them to be effective in providing continuing improvement over time (Rawson et al.,  2002 ). In other words, when patients are taught to expect a relapse, they are better able to handle it.

Appealing advertisements and displays that encourage drinking can make abstinence particularly difficult and can contribute, at the very least on a subconscious level, to a relapse.

in review

·  • What is the difference between alcohol abuse and alcohol dependence?

·  • What are the major physiological effects of alcohol?

·  • Identify the physical, interpersonal, and social/occupational problems that can result from chronic alcohol use.

·  • What neurobiological processes underlie addiction?

·  • What are the five major psychosocial causal factors that may contribute to alcohol abuse and dependence?

·  • Describe four psychosocial interventions used to treat alcohol dependence.

Drug Abuse and Dependence

Aside from alcohol, the psychoactive drugs most commonly associated with abuse and dependence in our society appear to be (1) narcotics such as opiates or opioids, including opium and heroin; (2) sedatives such as barbiturates; (3) stimulants such as cocaine and amphetamines; (4) antianxiety drugs such as benzodiazepines; (5) pain medications such as OxyContin (Whoriskey,  2013 ); (6) hallucinogens such as LSD (the effects of these and other drugs are summarized in  Table 11.2 ); and (7) caffeine and nicotine, which are also drugs of dependence (disorders associated with tobacco withdrawal and caffeine intoxication are included in the DSM-5 diagnostic classification system).

An estimated 20.1 million Americans who are 12 years of age or older reported using an illicit drug during the month before a recent survey. This represents 8.0 percent of the population (Substance Abuse and Mental Health Services Administration,  2009 ). According to the Monitoring the Future Study, in 2008 the annual prevalence rate of using any illicit drug was 37 percent for 12th graders, 35 percent for college students, 34 percent for 19- to 28-year-olds, 27 percent for 10th graders, and 14 percent for 8th graders (Johnston et al.,  2009 ). The extent of drug abuse in the population is likely to be underestimated because many abusers do not seek help (Compton et al.,  2007 ). Although they may occur at any age, drug abuse and dependence are most common during adolescence and young adulthood (Campbell,  2010 ) and vary according to metropolitan area, race and ethnicity, labor force status, and other demographic characteristics (Hughes,  1992 ). Substance-abuse problems are relatively more prominent in economically depressed minority communities (Akins et al.,  2003 ).

TABLE 11.2 Psychoactive Drugs Commonly Involved in Drug Abuse

Classification	Drug	Effect
Sedatives	Alcohol (ethanol)	Reduce tension
		Facilitate social interaction
		“Blot out” feelings or events
	Barbiturates	Reduce tension
	Nembutal (pentobarbital)
	Seconal (secobarbital)
	Veronal (barbital)
	Tuinal (secobarbital and amobarbital)
Stimulants	Amphetamines	Increase feelings of alertness and confidence
	Benzedrine (amphetamine)
	Dexedrine (dextroamphetamine)	Decrease feelings of fatigue
	Methedrine (methamphetamine)	Stay awake for long periods
	Cocaine (coca)	Increase endurance
		Stimulate sex drive
Opiates	Opium and its derivatives	Alleviate physical pain
	Opium	Induce relaxation and pleasant reverie
	Morphine	Alleviate anxiety and tension
	Codeine
	Heroin
	Methadone (synthetic narcotic)	Treatment of heroin dependence
Hallucinogens	Cannabis	Induce changes in mood, thought, and behavior
	Marijuana
	Hashish
	Mescaline (peyote)	“Expand” one’s mind
	Psilocybin (psychotogenic mushrooms)	Induce stupor
	LSD (lysergic acid diethylamide-25)
	PCP (phencyclidine)
Antianxiety drugs	Librium (chlordiazepoxide)	Alleviate tension and anxiety
(minor tranquilizers)	Miltown (meprobamate)	Induce relaxation and sleep
	Valium (diazepam)
	Xanax

Note: This list is by no means complete; for example, it does not include drugs such as Ritalin, which are designed to produce multiple effects; it does not include the less commonly used volatile hydrocarbons such as glue, paint thinner, gasoline, cleaning fluid, and nail polish remover, which are highly dangerous when sniffed for their psychoactive effects; and it does not include the antipsychotic and antidepressant drugs, which are abused, but relatively rarely. We shall deal with these and the antianxiety drugs in our discussion of drug therapy in  Chapter 16 .

The extent to which drug abuse has become a problem for society is reflected in a study of drug involvement among applicants for employment at a large teaching hospital in Maryland (Lange et al.,  1994 ). Beginning in 1989, and for a 2-year period, all applicants for employment were screened through a preemployment drug-screening program (individuals were not identified in the initial study). Of 593 applicants, 10.8 percent were found to have detectable amounts of illicit drugs in their systems. The most frequently detected drug was marijuana (55 percent of those who tested positively), followed by cocaine (36 percent) and opiates (28 percent).

The impact of drug use among employed people has also been reported to be significant. In an extensive survey of illegal drug use among 40,000 currently employed workers, researchers found the following rates of illicit drug use within the month prior to the survey: 19 percent for those age 18 or younger, 10.3 percent for those between 18 and 25, 7 percent for those between 26 and 34, 7 percent for those between 35 and 49, and 2.6 percent for those between 50 and 64 (Larson et al.,  2007 ). The overall frequency of illegal drug use rate in this work sample was 8.2 percent. The high rate of drug use in this population (many reported actually using drugs on the job) is problematic. For example, among those workers who reported current illicit drug use, 12.3 percent reported that they had worked for three or more employers in the past year, compared with 5.1 percent for nonabusing workers.

Among people who abuse drugs, behavior patterns vary markedly depending on the type, amount, and duration of drug use; on the physiological and psychological makeup of the individual; and, in some instances, on the social setting in which the drug experience occurs. Thus it appears most useful to deal separately with some of the drugs that are more commonly associated with abuse and dependence in contemporary society.

Opium and Its Derivatives (Narcotics)

OPIUM  People have used opium and its derivatives for centuries. Galen (a.d. 130–201) considered theriaca, whose principal ingredient was opium, to be a panacea:

·  It resists poison and venomous bites, cures inveterate headache, vertigo, deafness, epilepsy, apoplexy, dimness of sight, loss of voice, asthma, coughs of all kinds, spitting of blood, tightness of breath, colic, the iliac poisons, jaundice, hardness of the spleen, stone, urinary complaints, fevers, dropsies, leprosies, the trouble to which women are subject, melancholy and all pestilences. (See Brock,  1979 , for a discussion of Galen.)

Even today, opiates are still used for some of the conditions Galen mentioned.

Opium  is a mixture of about 18 chemical substances known as alkaloids. In 1805, the alkaloid present in the largest amount (10 to 15 percent) was found to be a bitter-tasting powder that could serve as a powerful sedative and pain reliever; it was named  morphine  after Morpheus, the god of sleep in Greek mythology. The hypodermic needle was introduced in America around 1856, allowing morphine to be widely administered to soldiers during the Civil War—not only to those wounded in battle but also to those suffering from dysentery. As a consequence, many Civil War veterans returned to civilian life addicted to the drug, a condition euphemistically referred to as “soldier’s illness.”

Scientists concerned with the addictive properties of morphine hypothesized that one part of the morphine molecule might be responsible for its analgesic properties (that is, its ability to eliminate pain without inducing unconsciousness) and another for its addictiveness. At about the turn of the century, it was discovered that if morphine was treated with an inexpensive and readily available chemical called acetic anhydride, it would be converted into another powerful analgesic called  heroin . Heroin was hailed enthusiastically by its discoverer, Heinrich Dreser (Boehm,  1968 ). Leading scientists of his time agreed on the merits of heroin, and the drug came to be widely prescribed in place of morphine for pain relief and related medicinal purposes. However, heroin was a cruel disappointment, for it proved to be an even more dangerous drug than morphine, acting more rapidly and more intensely and being equally, if not more addictive. Eventually, heroin was removed from use in medical practice.

As it became apparent that opium and its derivatives—including codeine, which is used in some cough syrups—were perilously addictive, the U.S. Congress enacted the Harrison Act in 1914. Under this and later legislation, the unauthorized sale and distribution of certain drugs became a federal offense; physicians and pharmacists were held accountable for each dose they dispensed. Thus, overnight, the role of a chronic narcotic user changed from that of addict—whose addiction was considered a vice, but was tolerated—to that of criminal. Unable to obtain drugs through legal sources, many turned to illegal channels, and eventually to other criminal acts, as a means of maintaining their suddenly expensive drug supply.

The adolescent shown here is injecting the drug heroin—a dangerous and highly addictive substance that is widely available to adolescents today.

In one survey, about 2.4 million Americans acknowledged having tried heroin, and almost a quarter of a million people admitted to using it within the previous 12 months (U.S. Department of Health and Human Services, 1997). In 2005, heroin overdose accounted for 10 percent of all drug-abuse-related emergency room admissions (DAWN Report,  2010 ).

BIOLOGICAL EFFECTS OF MORPHINE AND HEROIN

Morphine and heroin are commonly introduced into the body by smoking, snorting (inhaling the powder), eating, “skin popping,” or “mainlining,” the last two being methods of introducing the drug via hypodermic injection. Skin popping is injecting the liquefied drug just beneath the skin, while mainlining is injecting the drug directly into the bloodstream. In the United States, a young addict usually moves from snorting to mainlining.

Among the immediate effects of mainlined or snorted heroin is a euphoric spasm (the rush) lasting 60 seconds or so, which many addicts compare to a sexual orgasm. However, vomiting and nausea have also been known to be part of the immediate effects of heroin and morphine use. This rush is followed by a high, during which an addict typically is in a lethargic, withdrawn state in which bodily needs, including needs for food and sex, are markedly diminished; pleasant feelings of relaxation and euphoria tend to dominate. These effects last from 4 to 6 hours and are followed—in addicts—by a negative phase that produces a desire for more of the drug.

The use of opiates over a period of time generally results in a physiological craving for the drug. The time required to establish the drug habit varies, but it has been estimated that continual use over a period of 30 days is sufficient. Users then find that they have become physiologically dependent on the drug in the sense that they feel physically ill when they do not take it. In addition, users of opiates gradually build up a tolerance to the drug so increasingly larger amounts are needed to achieve the desired effects.

When people addicted to opiates do not get a dose of the drug within approximately 8 hours, they start to experience withdrawal symptoms. The character and severity of these reactions depend on many factors including the amount of the narcotic habitually used, the intervals between doses, the duration of the addiction, and especially the addict’s health and personality.

Withdrawal from heroin is not always dangerous or even very painful. Many addicted people withdraw without assistance. Withdrawal can, however, be an agonizing experience for some people, with symptoms including runny nose, tearing eyes, perspiration, restlessness, increased respiration rate, and an intensified desire for the drug. As time passes, the symptoms may become more severe. Typically, a feeling of chilliness alternates with flushing and excessive sweating, vomiting, diarrhea, abdominal cramps, pains in the back and extremities, severe headache, marked tremors, and varying degrees of insomnia. Beset by these discomforts, an individual refuses food and water, and this, coupled with the vomiting, sweating, and diarrhea, results in dehydration and weight loss. Occasionally, symptoms include delirium, hallucinations, and manic activity. Cardiovascular collapse may also occur and can result in death. If morphine is administered, the subjective distress experienced by an addict temporarily ends and physiological balance is quickly restored.

Withdrawal symptoms are usually on the decline by the third or fourth day and by the seventh or eighth day have disappeared. As the symptoms subside, the person resumes normal eating and drinking and rapidly regains lost weight. After withdrawal symptoms have ceased, the individual’s former tolerance for the drug is reduced; as a result, there is a risk that taking the former large dosage might result in overdose.

SOCIAL EFFECTS OF MORPHINE AND HEROIN

Typically, the life of a person addicted to opiates becomes increasingly centered on obtaining and using drugs, so the addiction usually leads to socially maladaptive behavior as the individual is eventually forced to lie, steal, and associate with undesirable contacts to maintain a supply of drugs. Many addicts resort to petty theft to support their habits, and some addicts turn to prostitution as a means of financing their addictions.

Along with the lowering of ethical and moral restraints, addiction has adverse physical effects on an individual’s well-being—for example, disruption of the immune system (Theodorou & Haber,  2005 ). Lifestyle factors can lead to further problems; an inadequate diet, for example, may lead to ill health and increased susceptibility to a variety of physical ailments. The use of unsterile equipment may also lead to various problems including liver damage from hepatitis (Lucey et al.  2009 ) and transmission of the AIDS virus. In addition, the use of such a potent drug without medical supervision and government controls to ensure its strength and purity can result in fatal overdose. Injection of too much heroin can cause coma and death. In fact, heroin-related deaths have shown an increase in cities where data are collected (DAWN Report,  2006 ) and among soldiers in Afganistan where eight deaths were recorded from opiates in 2011 (Martinez, 2011). The most common drug-related deaths in the United States involve combinations of heroin, cocaine, and alcohol. Women who use heroin during pregnancy subject their unborn children to the risk of dire consequences. One tragic outcome is premature babies who are themselves addicted to heroin and vulnerable to a number of diseases.

Addiction to opiates usually leads to a gradual deterioration of well-being (Brown & Lo,  2000 ). For example, some research has shown that opiates actively alter the immune system, rendering the person vulnerable to organ damage (McHugh & Kreek,  2004 ). The ill health and general personality degeneration often found in opiate addiction do not always result directly from the pharmacological effects of the drug, however; rather, they are often products of the sacrifices of money, proper diet, social position, and self-respect as an addict becomes more desperate to procure the required daily dosage.

CAUSAL FACTORS IN OPIATE ABUSE AND DEPENDENCE

No single causal pattern fits all addictions to opiate drugs. Kendler and Sundquist ( 2012 ) recently reported that drug abuse is etiologically complex involving both genetic and environmental influences. A study by Fulmer and Lapidus ( 1980 ) concludes that the three most frequently cited reasons for beginning to use heroin were pleasure, curiosity, and peer pressure. Pleasure was, by far, the single most widespread reason—given by 81 percent of addicts. Other reasons such as a desire to escape life stress, personal maladjustment, and sociocultural conditions also play a part. Zuckerman ( 2007 ) provided the view that substance abuse such as smoking, drinking, and the use of drugs are all related to a personality characteristic he refers to as “sensation seeking.” He considered this trait to be mediated through genetic and biological mechanisms as well as through peer influences.

NEURAL BASES FOR PHYSIOLOGICAL ADDICTION

Research teams have isolated and studied receptor sites for narcotic drugs in the brain (Goldstein et al.,  1974 ). Such receptor sites are specific nerve cells into which given psychoactive drugs fit like keys into the proper locks. This interaction of drug and brain cells apparently results in a drug’s action and, in the case of narcotic drugs, may lead to addiction. The repeated use of opiates results in changes in the neurotransmitter systems that regulate incentive and motivation and the ability to manage stress (DeVries & Ship-penberg,  2002 ). Research has demonstrated that heroin users show a number of CNS dysfunctions including slowed reaction time, impaired learning and attention, impaired cognitive processing, and impulse control problems (Angelucci et al.,  2007 ).

The human body produces its own opium-like substances, called  endorphins , in the brain and pituitary gland. These substances are produced in response to stimulation and are believed to play a role in an organism’s reaction to pain. Some investigators have suspected that endorphins play a role in drug addiction, speculating that chronic underproduction of endorphins leads to a craving for narcotic drugs. Research on the role of endorphins in drug addiction has generally been inconclusive, and no effective treatment has resulted from this line of research.

ADDICTION ASSOCIATED WITH PSYCHOPATHOLOGY

A high incidence of antisocial personality has been found among heroin addicts (Alterman, et al.,  1998 ; Feske et al.,  2006 ). In a comparison between a group of 45 young institutionalized male addicts and a control group of nonaddicts, Gilbert and Lombardi ( 1967 ) found that the distinguishing features were “the addict’s antisocial traits, his depression, tension, insecurity, and feelings of inadequacy, and his difficulty in forming warm and lasting interpersonal relationships” (p. 536). Meyer and Mirin ( 1979 ) found that opiate addicts are highly impulsive and unable to delay gratification. Kosten and Rounsaville ( 1986 ) reported that about 68 percent of heroin abusers are also diagnosed as having a personality disorder. As in the case of alcoholism, however, it is essential to exercise caution in distinguishing between personality traits present before and those present after addiction; the high incidence of psychopathology among narcotics addicts may in part result from, rather than precede, the long-term effects of addiction.

DRUG USE ASSOCIATED WITH SOCIOCULTURAL FACTORS

In our society, a so-called narcotics subculture exists in which addicts can obtain drugs and protect themselves against society’s sanctions (Johnson,  2007 ). The decision to join this culture has important future implications, for from that point on, addicts’ activities will revolve around their drug-user role. In short, addiction becomes a way of life. In a survey of three large cities in Texas, Maddux and colleagues ( 1994 ) found that the majority of illicit drug injectors were undereducated and unemployed individuals from minority groups.

Celebrities Lindsay Lohan and Paris Hilton have received jail terms for substance-related driving offenses.

With time, most young addicts who join the drug culture become increasingly withdrawn, indifferent to their friends (except those in the drug group), and apathetic about sexual activity (Tremble et al.,  1994 ). They are likely to abandon scholastic and athletic endeavors and to show a marked reduction in competitive and achievement strivings. Most of these addicts appear to lack clear sex-role identification and to experience feelings of inadequacy when confronted with the demands of adulthood. They feel progressively isolated from the broader culture, but their feelings of group belongingness are bolstered by continued association with the addict milieu. At the same time, they come to view drugs both as a means of revolt against authority and conventional values and as a device for alleviating personal anxieties and tensions.

TREATMENTS AND OUTCOMES

Treatment for opiate addiction is initially similar to that for alcoholism in that it involves building up an addict both physically and psychologically and providing help through the withdrawal period. Addicts often dread the discomfort of withdrawal, but in a hospital setting it is less abrupt and usually involves the administration of medication that eases the distress.

After physical withdrawal has been completed, treatment focuses on helping a former addict make an adequate adjustment to his or her community and abstain from the further use of opiates. Traditionally, however, the prognosis has been unfavorable, with many clients dropping out of treatment (Katz et al.,  2004 ). Withdrawal from heroin does not remove the craving for the drug. Thus a key target in treatment of heroin addiction must be the alleviation of this craving. One approach to dealing with the physiological craving for heroin was pioneered by a research team at Rockefeller University in New York. It involved the use of the drug  methadone  in conjunction with a rehabilitation program (counseling, group therapy, and other procedures) directed toward the “total resocialization” of addicts. Methadone hydro-chloride is a synthetic narcotic that is related to heroin and is equally addictive physiologically. Its usefulness in treatment lies in the fact that it satisfies an addict’s craving for heroin without producing serious psychological impairment, if only because it is administered as a “treatment” in a formal clinical context and can result in reduced drug use and improved cognitive performance (Gruber et al.,  2006 ; Kreek et al.,  2010 ). (See the Unresolved Issues section at the end of this chapter.)

Other medications, such as buprenorphine, have also been used to treat heroin addiction (Meier & Patkar,  2007 ). Buprenorphine promises to be as effective a substitute for heroin as methadone but with fewer side effects (Ling et al.,  2010 ). It operates as a partial antagonist to heroin and produces the feelings of contentment associated with heroin use (Mendelson & Mello,  1992 ). Yet the drug does not produce the physical dependence that is characteristic of heroin (Grant & Sonti,  1994 ) and can be discontinued without severe withdrawal symptoms. Like methadone, buprenorphine appears to work best at maintaining abstinence if it is provided along with behavior therapy (Bickel et al.,  1997 ).

Cocaine and Amphetamines (Stimulants)

In contrast to narcotics, which depress (slow down) the action of the CNS, cocaine and amphetamines stimulate it (speed it up).

COCAINE

Like opium,  cocaine  is a plant product discovered in ancient times and used ever since. It was widely used in the pre-Columbian world of Mexico and Peru (Guerra,  1971 ). Because for many years it was typically very costly in the United States, cocaine was considered as the “high” for the affluent. However, with more widespread availability and lowering of prices, the drug’s use increased significantly in the United States during the 1980s and 1990s—to the point where its use was considered epidemic, especially among middle- and upper-income groups. “Crack” is the street name that is applied to cocaine that has been processed from cocaine hydrochloride to a free base for smoking. The name refers to the crackling sound emitted when the mixture is heated.

In 2008, cocaine use was reported in 1.5 percent of young adults (Substance Abuse and Mental Health Services Administration,  2009 ). In 2005, there was a substantial increase in cocaine-related emergency room visits per 100,000 drug-related admissions (about 29 percent of drug-related emergencies). This amount is about three times greater than heroin-related admissions (DAWN Report,  2010 ).

Like the opiates, cocaine may be ingested by sniffing, swallowing, or injecting. Also like the opiates, it precipitates a euphoric state of 4 to 6 hours’ duration, during which a user experiences feelings of confidence and contentment. However, this blissful state may be preceded by headache, dizziness, and restlessness. When cocaine is chronically abused, acute toxic psychotic symptoms may occur, including frightening visual, auditory, and tactual hallucinations similar to those in acute schizophrenia.

Unlike the opiates, cocaine stimulates the cortex of the brain, inducing sleeplessness and excitement as well as stimulating and accentuating sexual feelings. Dependence on cocaine also differs somewhat from dependence on opiates. It was formerly believed that tolerance was not increased appreciably with cocaine use. However, acute tolerance has now been demonstrated, and some chronic tolerance may occur as well. Moreover, cognitive impairment associated with cocaine abuse is likely to be an important consideration in long-term effects of the drug (Abi-Saab et al.,  2005 ; Mann,  2004 ). The previous view that cocaine abusers did not develop physiological dependence on the drug also has changed. Gawin and Kleber ( 1986 ) demonstrated that chronic abusers who become abstinent develop uniform, depression-like symptoms, but the symptoms are transient. Our broadened knowledge about cocaine abuse, particularly with respect to the many health and social problems resulting from dependence on the drug, has resulted in considerable modification of professional views of cocaine over the past 20 years. For example, the modifications in the DSM-5 diagnostic classification reflect a significant increase in our knowledge of cocaine’s addictive properties. A new disorder is described—cocaine withdrawal—that involves symptoms of depression, fatigue, disturbed sleep, and increased dreaming (Foltin & Fischman,  1997 ). The psychological and life problems experienced by cocaine users are often great. Employment, family, psychological, and legal problems are all more likely to occur among cocaine and crack users than among nonusers. Many life problems experienced by cocaine abusers result in part from the considerable amounts of money that are required to support their habits. Increased sexual activity, often trading sex for drugs, has been associated with crack cocaine use (Weatherby et al.,  1992 ), as has engaging in sexual activity with anonymous partners (Balshem et al.,  1992 ). However, problems in sexual functioning have been reported to be associated with crack cocaine use. Kim and colleagues ( 1992 ) report that most users lose interest in sex and develop sexual dysfunction with prolonged usage.

Women who use cocaine when they are pregnant place their babies at risk for both health and psychological problems. Although research has suggested that there is no “fetal crack syndrome” similar to what has been shown with alcohol-abusing mothers (Azar,  1997 ), children of crack-using mothers are at risk of being maltreated as infants as well as of losing their mothers during infancy. Wasserman and Leventhal ( 1993 ) studied a group of cocaine-exposed children and a control sample of non-exposed children for a 24-month period following their birth. They found that children who were regularly exposed to cocaine in utero were more likely to be mistreated (23 percent compared with only 4 percent of controls).

TREATMENT AND OUTCOMES

Treatment for dependence on cocaine does not differ appreciably from that for other drugs that involve physiological dependence (see Kosten et al.,  1992 ; Schmitz et al.,  2004 ). In order to reduce cravings as part of psychological therapy and to ensure treatment compliance, drugs such as naltrexone have been used to reduce cocaine use (Carroll et al.,  2004 ). The feelings of tension and depression that accompany absence of the drug have to be dealt with during the immediate withdrawal period. One recent study reported that methadone was effective in promoting abstinence among individuals with less severe cocaine use (Weinstock et al.,  2010 )

Some success in the treatment of cocaine abusers has been reported. For example, Siqueland and colleagues ( 2002 ) found that patients who remained in drug treatment longer used drugs less often after treatment than those who dropped out; and Stewart, Gossop, and Marsden ( 2002 ) found that patients who completed therapy had lower rates of drug overdose than those who failed to complete treatment. Carroll and colleagues ( 1993 ) have shown that many cocaine abusers do well in maintaining treatment goals, and one-third are abstinent at a 12-month follow-up. They found several factors associated with poorer outcomes: severity of abuse, poorer psychiatric functioning, and presence of concurrent alcoholism. Higgins, Badger, and Budney ( 2000 ) found that people who were not able to sustain abstinence during the treatment had poorer outcomes following therapy.

One of the problems clinicians face in working with cocaine abusers is their “dropping out”: Only 42 percent of those in one study remained in treatment for six or more sessions (Kleinman et al.,  1992 ). Another problem encountered in drug treatment is that many of the cocaine-dependent patients have severe antisocial personality disorder—a situation resulting in treatment resistance (Poling et al.,  2007 )—or are “psychosis-prone” personalities (Kwapil,  1996 ). Arndt and colleagues ( 1994 ) found that cocaine-dependent patients with antisocial personality characteristics made few therapeutic gains, whereas those without antisocial features made significant progress. Gallop and colleagues ( 2007 ) report a study in which gender differences were found for being able to maintain abstinence from cocaine use; men tended to have more problems transitioning to abstinence after cocaine abuse.

Is treatment always necessary for cocaine abusers to recover? An interesting study suggests that some abusers can improve without therapy. Toneatto and colleagues ( 1999 ) describe a study of natural (nontreated) recovery among cocaine abusers. They report that abusers who resolved their dependence on cocaine were similar to those who did not resolve their cocaine problems in terms of demographic characteristics, substance abuse, and psychiatric history. The successful abstainers considered their “improved self-concept” crucial to their success.

AMPHETAMINES

The earliest  amphetamine  to be introduced—Benzedrine, or amphetamine sulfate—was first synthesized in 1927 and became available in drugstores in the early 1930s as an inhalant to relieve stuffy noses. However, the manufacturers soon learned that some customers were chewing the wicks in the inhalers for “kicks.” Thus the stimulating effects of amphetamine sulfate were discovered by the public before the drug was formally prescribed as a stimulant by physicians. In the late 1930s, two newer amphetamines were introduced—Dexedrine (dextroamphetamine) and Methedrine (methamphetamine hydrochloride, also known as “speed”). The latter preparation is a far more potent stimulant of the CNS than either Benzedrine or Dexedrine and hence is considered more dangerous. In fact, its abuse can be lethal.

Initially these preparations were considered to be “wonder pills” that helped people stay alert and awake and function temporarily at a level beyond normal. During World War II, military interest was aroused in the stimulating effects of these drugs, and they were used by both Allied and German soldiers to ward off fatigue (Jarvik,  1967 ). Similarly, among civilians, amphetamines came to be widely used by night workers, long-distance truck drivers, students cramming for exams, and athletes striving to improve their performances. It was also discovered that amphetamines tend to suppress appetite, and they became popular with people trying to lose weight. In addition, they were often used to counteract the effects of barbiturates or other sleeping pills that had been taken the night before. As a result of their many uses, amphetamines were widely prescribed by doctors.

Today amphetamines are occasionally used medically for curbing the appetite when weight reduction is desirable; for treating individuals suffering from narcolepsy, a disorder in which people cannot prevent themselves from continually falling asleep during the day; and for treating hyperactive children. Curiously enough, amphetamines have a calming rather than a stimulating effect on many of these young people. Amphetamines are also sometimes prescribed for alleviating mild feelings of depression, relieving fatigue, and maintaining alertness for sustained periods of time. By far, however, the most frequent use of amphetamines is for recreational purposes, the most typical user being a young person interested in the high that the drug induces (Klee,  1998 ).

Since the passage of the Controlled Substance Act of 1970 (Drug Enforcement Administration,  1979 ), amphetamines have been classified as Schedule II controlled substances—that is, drugs with high abuse potential that require a prescription for each purchase. As a result, medical use of amphetamines has declined in the United States in recent years, and they are more difficult to obtain legally. However, it is often easy to find illegal sources of amphetamines, which thus remain among the most widely abused drugs. Amphetamines are among the most widely used illicit drugs in other countries as well, for example, in Australia (Lintzeris, Holgate et al.,  1996 ). In 2007, about 5 percent of drug-related emergency room visits involved amphetamines or methamphetamines (DAWN Report,  2010 ).

EFFECTS OF AMPHETAMINE ABUSE

Despite their legitimate medical uses, amphetamines are not a magical source of extra mental or physical energy. Instead, they push users toward greater expenditures of their own resources—often to the point of hazardous fatigue. Amphetamines are psychologically and physically addictive, and the body rapidly builds up tolerance to them (Wise,  1996 ). Thus habituated abusers may use the drugs in amounts that would be lethal to nonusers. In some instances, users inject the drug to get faster and more intense results.

For a person who exceeds prescribed dosages, amphetamine consumption results in heightened blood pressure, enlarged pupils, unclear or rapid speech, profuse sweating, tremors, excitability, loss of appetite, confusion, and sleeplessness. Injected in large quantities, Methedrine can raise blood pressure enough to cause immediate death. In addition, chronic abuse of amphetamines can result in brain damage and a wide range of psychopathology, including a disorder known as “amphetamine psychosis,” which appears similar to paranoid schizophrenia. Suicide, homicide, assault, and various other acts of violence are also associated with amphetamine abuse.

TREATMENTS AND OUTCOMES

Research on the effectiveness of various treatments for withdrawing patients from amphetamines is scarce (Baker & Lee,  2003 ). Although withdrawal from amphetamines is usually safe, some evidence suggests that physiological dependence upon the drug is an important factor to consider in treatment (Wise & Munn,  1995 ). In some instances, abrupt withdrawal from the chronic, excessive use of amphetamines can result in cramping, nausea, diarrhea, and even convulsions. Moreover, abrupt abstinence commonly results in feelings of weariness and depression. The depression usually peaks in 48 to 72 hours, often remains intense for a day or two, and then tends to lessen gradually over a period of several days. Mild feelings of depression and lassitude may persist for weeks or even months. If brain damage has occurred, the residual effects may include impaired ability to concentrate, learn, and remember, with resulting social, economic, and personality deterioration.

Methamphetamine

Methamphetamine, referred to on the streets as “crystal” or “ice” because of its appearance, is a highly addictive stimulant drug that can provide a quick and long-lasting “high.” However, it is one of the most dangerous illegal drugs because of its treacherous properties and its unwelcome results (Covey,  2007 ). Methamphetamine is a form of amphetamine that can be “cooked” in large quantities in makeshift laboratories in out-of-the-way places that defy and frustrate detection. This drug is relatively cheap to manufacture and is often referred to as “poor people’s cocaine.” It can be manufactured, for example, in a portable cooler with ingredients that can be legally obtained from any drugstore. The drug can be ingested in a variety of ways, through smoking, snorting, swallowing, or injecting. The drug’s effects can be almost instantaneous if it is smoked or injected.

Methamphetamine operates by increasing the level of dopamine in the brain, and prolonged use of the drug produces structural changes in the brain (Chang, Alicata et al.,  2007 ). The severity of psychiatric symptoms associated with the drug is significantly related to the duration of use (Yoshimoto et al.,  2002 ). Moreover, discontinuing the drug after the person has become habituated can result in problems with learning, memory, and cognitive dysfunction (Cretzmeyer et al.,  2003 ; Rothman et al.,  2000 ) and severe mental health problems such as paranoid thinking and hallucinations (Brecht et al.,  2004 ; Srisurapanont et al.,  2003 ). This drug is metabolized more slowly than other drugs such as cocaine and produces a high for a longer period of time. When the drug wears off or when users “come down from the high,” they are likely to feel extremely weak, lethargic, sleepy, and depressed.

Methamphetamine, known as “crystal” or “ice,” can be “cooked” in large quantities in makeshift laboratories. The man shown in this photo was arrested in a police raid on one such laboratory.

DSM-5 THINKING CRITICALLY about DSM-5: Can changes to the diagnostic criteria result in increased drug use?

There are a number of modifications in the way some disorders are diagnosed in DSM-5 that will likely influence medical treatment with many more patients being treated with stimulant drugs. One of these modified disorders, Attention Deficit/Hyperactivity Disorder or ADHD (see  Chapter 15  for details), results in an expanded population of patients who can receive this diagnosis across the adult years. Although, the diagnostic criteria for ADHD in DSM-5 are similar to those in DSM-IV for young people, several changes have been introduced in DSM-5 that expands the application among adults. This change will likely result in many more adults being treated with prescription drugs for ADHD symptoms.

One of the most popular treatments for ADHD in children and adolescents is the drug Methylphenidate (Morton, Gwendolyn, & Stockton,  2000 ), classified as a CNS stimulant. Methylphenidate, when used intranasally, has receptor effects similar to those of cocaine. These frequently prescribed drugs (Ritalin, Adderall, and Quillivant) are also FDA approved for treatment of adults. The side effects of these medications can result in long-term problems such as sleep problems, headaches, decreased appetite and jitteriness. Moreover, Methylphenidate drugs are addicting and can result in long-term use.

The concern over expanded medication use and potential for abuse has been raised by Batstra & Frances ( 2012 ) in their review of the DSM-5 committees changes. They pointed out that DSM-5 will likely trigger a fad of diagnosing Adult Attention Deficit Disorder and lead to widespread misuse of stimulant drugs for performance enhancement and recreation use and will contribute substantially to the already extensive problem of simulant abuse.

Use of the drug increased substantially during the 1990s; 4.9 million people in the United States (2.3 percent of the population) had tried methamphetamine by 1998 (NIDA,  2003 ). In one survey of almost 630,000 high school students, Oetting and colleagues ( 2000 ) report that methamphetamine use more than doubled between 1989 and 1996. The number of people starting to use methamphetamine decreased in 2008 and was significantly lower than it was in 2007 (Substance Abuse and Mental Health Services Administration,  2009 ). Interestingly, the use of methamphetamine in the United States has been somewhat of a regional phenomenon; most use has occurred in the Southwest, on the West Coast, and in Hawaii, with very little use in the North, South, and Midwest (DAWN,  2007 ). This situation results from the fact that meth labs have been concentrated in Mexico, California, and Hawaii.

There is some evidence that people become more quickly addicted to methamphetamine and require treatment sooner than those using cocaine (Castro et al.,  2000 ). Addicted meth-amphetamine users are highly resistant to treatment, and post-treatment relapse is common. In one California study of 98 methamphetamine abusers, the investigators reported that over half of the participants had returned to methamphetamine use by the time they were interviewed 2 to 3 years following therapy; 36 percent reported that they had returned to methamphetamine use within 6 months of therapy (Brecht et al.,  2000 ).

Barbiturates (Sedatives)

For over a hundred years, powerful sedatives called  barbiturates  have been available as an aid to falling asleep (Lopez-Munoz et al.,  2005 ). Although barbiturates have legitimate medical uses, they are extremely dangerous drugs commonly associated with both physiological and psychological dependence and lethal overdoses.

EFFECTS OF BARBITURATES

Barbiturates were once widely used by physicians to calm patients and induce sleep. They act as depressants—somewhat like alcohol—to slow down the action of the CNS (Nemeroff,  2003 ) and significantly reduce performance on cognitive tasks (Pickworth et al.,  1997 ). Shortly after taking a barbiturate, or “downer,” an individual experiences a feeling of relaxation in which tensions seem to disappear, followed by a physical and intellectual lassitude and a tendency toward drowsiness and sleep—the intensity of such feelings depends on the type and amount of barbiturate taken. Strong doses produce sleep almost immediately; excessive doses are lethal because they result in paralysis of the brain’s respiratory centers. Impaired decision making and problem solving, sluggishness, slow speech, and sudden mood shifts are also common effects of barbiturates (Lemmer,  2007 ).

Excessive use of barbiturates leads to increased tolerance as well as to physiological and psychological dependence. It can also lead to brain damage and personality deterioration. Unlike tolerance for opiates, tolerance for barbiturates does not increase the amount needed to cause death. This means that users can easily ingest fatal overdoses, either intentionally or accidentally.

CAUSAL FACTORS IN BARBITURATE ABUSE AND DEPENDENCE

Although many young people experiment with barbiturates, most do not become dependent. In fact, the people who do become dependent on barbiturates tend to be middle-aged and older people who often rely on them as “sleeping pills” and who do not commonly use other classes of drugs (except possibly alcohol and minor tranquilizers). These people have been referred to as “silent abusers” because they take the drugs in the privacy of their homes and ordinarily do not become public nuisances. Barbiturates are often used with alcohol. Some users claim they can achieve an intense high by combining barbiturates, amphetamines, and alcohol. However, one possible effect of combining barbiturates and alcohol is death because each drug potentiates (increases the action of) the other.

TREATMENTS AND OUTCOMES

As with many other drugs, it is often essential in treatment to distinguish between barbiturate intoxication, which results from the toxic effects of overdose, and the symptoms associated with drug withdrawal, because different procedures are required. With barbiturates, withdrawal symptoms are more dangerous, severe, and long-lasting than in opiate withdrawal. A patient going through barbiturate withdrawal becomes anxious and apprehensive and manifests coarse tremors of the hands and face; additional symptoms commonly include insomnia, weakness, nausea, vomiting, abdominal cramps, rapid heart rate, elevated blood pressure, and loss of weight. An acute delirious psychosis may develop.

For persons accustomed to taking large dosages, withdrawal symptoms may last for as long as a month, but usually they tend to abate by the end of the first week. Fortunately, the withdrawal symptoms in barbiturate addiction can be minimized by administering increasingly smaller doses of the barbiturate itself or another drug that produces similar effects. The withdrawal program is still a dangerous one, however, especially if barbiturate addiction is complicated by alcoholism or dependence on other drugs.

Hallucinogens: LSD and Related Drugs

The  hallucinogens  are drugs that are thought to induce hallucinations. However, these preparations usually do not in fact “create” sensory images but distort them so that an individual sees or hears things in different and unusual ways. These drugs are often referred to as psychedelics. The major drugs in this category are LSD (lysergic acid diethylamide) or “acid,” mescaline, and psilocybin.

LSD

The most potent of the hallucinogens, the odorless, colorless, and tasteless drug  LSD  can produce intoxication with an amount smaller than a grain of salt. It is a chemically synthesized substance first discovered by the Swiss chemist Albert Hoffman in 1938. Hoffman was not aware of the potent hallucinatory qualities of LSD until he swallowed a small amount. This is his report of the experience:

·  Last Friday, April 16, 1943, I was forced to stop my work in the laboratory in the middle of the afternoon and to go home, as I was seized by a peculiar restlessness associated with a sensation of mild dizziness. On arriving home, I lay down and sank into a kind of drunkenness which was not unpleasant and which was characterized by extreme activity of imagination. As I lay in a dazed condition with my eyes closed (I experienced daylight as disagreeably bright) there surged upon me an uninterrupted stream of fantastic images of extraordinary plasticity and vividness and accompanied by an intense kaleidoscope-like play of colors. This condition gradually passed off after about 2 hours. (Hoffman,  1971 , p. 23)

Hoffman followed up this experience with a series of planned self-observations with LSD, some of which he described as “harrowing.” Researchers thought LSD might be useful for the induction and study of hallucinogenic states or “model psychoses,” which were thought to be related to schizophrenia. About 1950, LSD was introduced into the United States for purposes of such research and to ascertain whether it might have medical or therapeutic uses. Despite considerable research, however, LSD did not prove to be therapeutically useful.

After taking LSD, a person typically goes through about 8 hours of changes in sensory perception, mood swings, and feelings of depersonalization and detachment. The LSD experience is not always pleasant. It can be extremely traumatic, and the distorted objects and sounds, the illusory colors, and the new thoughts can be menacing and terrifying. For example, while under the influence of LSD, a British law student tried to continue time by using a dental drill to bore a hole in his head (Rorvik,  1970 ). In other instances, people undergoing bad trips have set themselves aflame, jumped from high places, and taken other drugs that proved lethal in combination with LSD.

An interesting and unusual phenomenon that may occur sometime following the use of LSD is the  flashback , an involuntary recurrence of perceptual distortions or hallucinations weeks or even months after the individual has taken the drug. Flashbacks appear to be relatively rare among people who have taken LSD only once—although they do sometimes occur. Even if no flashbacks occur, one study found that continued effects on visual function were apparent at least 2 years after LSD use. In this study, Abraham and Wolf ( 1988 ) report that individuals who had used LSD for a week had reduced visual sensitivity to light during dark adaptation and showed other visual problems compared with controls.

Although the widespread use of LSD during the 1960s and 1970s has waned in recent years with the availability of other drugs, it is still used among young people associated with the “rave culture” or club scene. One recent study reported that in a sample of 782 youths in treatment for substance abuse, 42 percent had used LSD (Hopfer et al.,  2006 ).

MESCALINE AND PSILOCYBIN

Two other hallucinogens are  mescaline , which is derived from the small, disc-like growths (mescal buttons) at the top of the peyote cactus, and  psilocybin , which is obtained from a variety of “sacred” Mexican mushrooms known as Psilocybe mexicana. These drugs have been used for centuries in the ceremonial rites of Native peoples living in Mexico, the American Southwest, and Central and South America. In fact, they were used by the Aztecs for such purposes long before the Spanish invasion. Both drugs have mind-altering and hallucinogenic properties, but their principal effect appears to be enabling an individual to see, hear, and otherwise experience events in unaccustomed ways—transporting him or her into a realm of “non-ordinary reality.” As with LSD, no definite evidence shows that mescaline and psilocybin actually “expand consciousness” or create new ideas; rather, they mainly alter or distort experience.

Ecstasy

The drug  Ecstasy , or MDMA (3,4-methylenedioxymethylamphetamine), is both a hallucinogen and a stimulant that is popular as a party drug among young adults. The drug was originally patented in 1914 by the pharmaceutical company Merck, supposedly to be sold as a diet pill, but the company decided against marketing the drug because of its side effects. The drug was further evaluated and tested during the 1970s and 1980s as a potential medication for use in psychological treatment for a wide range of conditions such as posttraumatic stress, phobias, psychosomatic disorders, depression, suicidality, drug addiction, and relationship difficulties (Grob,  2000 ). However, its value in this capacity was not supported. At present, this drug is considered a “dangerous” drug and is listed in the most restricted category by the Drug Enforcement Administration (Murray,  2001 ). It is currently available in the United States only through illicit means.

Ecstasy is chemically similar to methamphetamine and to the hallucinogen mescaline and produces effects similar to those of other stimulants, although some research has suggested that the drug’s hallucinogenic properties exceed those of mescaline (Kovar,  1998 ; Parrott & Stuart,  1997 ). Usually about 20 minutes after ingesting Ecstasy (typically in pill form), the person experiences a “rush” sensation followed by a feeling of calmness, energy, and well-being. The effects of Ecstasy can last for several hours. People who take the drug often report an intense experience of color and sound and mild hallucinations (Fox et al.,  2001 ; Lieb et al.,  2002 ; Soar et al.,  2001 ) in addition to the high levels of energy and excitement that are produced. The drug MDMA is an addictive substance, but it is not thought to be as addictive as cocaine (Degenhardt et al.,  2010 ). Use of the drug is accompanied by a number of adverse consequences such as nausea, sweating, clenching of teeth, muscle cramps, blurred vision, and hallucinations (Parrott,  2001 ).

The Ecstasy drug (MDMA—3,4-methylenedioxymethylamphetamine) is taken in pill form and is often used at “raves” or nightclubs to enhance mood. Ecstasy is an illegal substance, and manufacturers do not follow regulation and quality control.

Ecstasy has been used increasingly among college students and young adults as a party enhancement or “rave” drug at dances (Hopfer et al.,  2006 ). In a survey of 14,000 college students, Strote and colleagues ( 2002 ) found that between 1997 and 1999, Ecstasy use increased 69 percent, from 2.8 percent to 4.7 percent. Ecstasy reportedly grew in use among 8th, 10th, and 12th graders, as noted by the Monitoring the Future study, in which nearly 5 percent of 10th and 12th graders and about 2 percent of 8th graders reportedly had used MDMA in the past year. In a recent survey of Americans over the age of 12, .02 percent of the sample reported using Ecstasy (Substance Abuse and Mental Health Services Administration,  2009 ).

As with many other illicit drugs, the recreational use of Ecstasy has been associated with personality characteristics of impulsivity and poor judgment (Morgan,  1998 ). Ecstasy users have been found to be more likely to use marijuana, engage in binge drinking, smoke cigarettes, and have multiple sexual partners (Strote et al.,  2002 ). However, Ecstasy use is also found among naïve partygoers who are provided the drug as a means of staying awake while socializing (Boys et al.,  2001 ).

The negative psychological and health consequences (including death) of using Ecstasy have been widely reported in the literature. One study reported on the case of a 21-year-old man who developed panic disorder after taking Ecstasy (Windhaber et al.,  1998 ); in another case study, an 18-year-old woman reportedly developed a prolonged psychosis after a single recreational use of Ecstasy (Van Kampen & Katz,  2001 ). The use of Ecstasy has also been found to be associated with memory impairment (Parrott et al.,  1998 ) and obstructive sleep apnea (Chamberlin & Saper,  2009 ; McCann et al.  2009 ). Severe organic brain problems have also been reported. Granato and colleagues ( 1997 ) describe a case in which a 20-year-old male suffered from cerebrovascular injury after taking Ecstasy. The youth went into a coma about a minute or so after taking the drug. Upon awakening, he was found to have dissociation, delirium, visual hallucinations, and poor memory for past events. Subsequent examination showed damage to his frontal lobes and his right temporal lobe. Ecstasy users have consistently shown memory deficits (Roberts et al.,  2009 ). A recent study by Schilt and colleagues ( 2010 ) found long-term harmful neurological effects in middle-aged Ecstasy users. Moderate to heavy Ecstasy users showed moderate memory loss compared to controls.

Marijuana

Marijuana  comes from the leaves and flowering tops of the hemp plant, Cannabis sativa, which grows in mild climates throughout the world. In its prepared state, marijuana consists chiefly of dried green leaves—hence the colloquial name grass. It is ordinarily smoked in the form of cigarettes (variously referred to as “pot,” “reefers,” “joints,” “stash,” “weed,” etc.) or in pipes. In some cultures the leaves are steeped in hot water and the liquid is drunk, much as one might drink tea. Marijuana is related to a stronger drug,  hashish , which is derived from the resin exuded by the cannabis plant and made into a gummy powder. Hashish, like marijuana, is usually smoked. Although marijuana can be considered a mild hallucinogen, there are significant differences between the nature, intensity, and duration of its effects and those induced by drugs like LSD, mescaline, and other major hallucinogens.

Both marijuana use and hashish use can be traced far back into history. Cannabis was apparently known in ancient China (Blum,  1969 ) and was listed in the herbal compendiums of the Chinese Emperor Shen Nung, written about 2737 B.C. Until the late 1960s, marijuana use in the United States was confined largely to members of lower-socioeconomic-status and minority groups and to people in entertainment and related fields, but marijuana use is commonplace today. Now marijuana is the most frequently used illicit drug. In 2008, 6.7 percent of the U. S. population between 12 and 17 years of age used marijuana; 16.5 percent of young adults did as well (Substance Abuse and Mental Health Services Administration,  2009 ), although according to the most recent Monitoring the Future study, college students have begun to show some decline in marijuana use in recent years (Johnston et al.,  2009 ).

Minority group members and Caucasians have been shown to have comparable rates of use (Brown et al.,  2004 ), however, one recent survey found that Hispanic American adults had lower rates of current illicit drug use (Substance Abuse and Mental Health Services Administration,  2010 ). Cannabis is the most commonly used drug by people with schizophrenia (Coulston et al.,  2007 ). Marijuana use is likely to show an increase in the future, given that it has been legalized in some states even though it is illegal according to U.S. legal standards.

Marijuana can produce extreme euphoria, hilarity, and hypertalkativeness, but it can also produce intense anxiety and depression as well as delusions, hallucinations, and other psychotic-like behavior.

In a recent survey of drug-related visits to the emergency room (DAWN,  2010 ), 16 percent were for marijuana abuse. Many of these emergency room visits, as one might suspect, involved the use of other substances along with marijuana.

EFFECTS OF MARIJUANA

The specific effects of marijuana vary greatly, depending on the quality and dosage of the drug, the personality and mood of the user, the user’s past experiences with the drug, the social setting, and the user’s expectations. However, considerable consensus exists among regular users that when marijuana is smoked and inhaled, a state of slight intoxication results. This state is one of mild euphoria distinguished by increased feelings of well-being, heightened perceptual acuity, and pleasant relaxation, often accompanied by a sensation of drifting or floating away. Sensory inputs are intensified. Marijuana has the effect on the brain of altering one’s internal clock (O’Leary et al.,  2003 ). Often a person’s sense of time is stretched or distorted so that an event that lasts only a few seconds may seem to cover a much longer span. Short-term memory may also be affected, as when one notices that a bite has been taken out of a sandwich but does not remember having taken it. For most users, pleasurable experiences, including sexual intercourse, are reportedly enhanced. When smoked, marijuana is rapidly absorbed, and its effects appear within seconds to minutes but seldom last more than 2 to 3 hours. Marijuana has also been used to relieve pain or nausea; see The World Around Us box on page 397 for a discussion of the controversy over medical marijuana.

TREATMENT

Some research has reported that many marijuana users who abstain report having uncomfortable withdrawal-like symptoms such as nervousness, tension, sleep problems, and appetite change (Budney et al.,  2003 ; Zickler,  2002 ). One study of substance abusers showed that marijuana users were more ambivalent and less confident about stopping use than were cocaine abusers (Budney et al.,  1998 ).

Psychological treatment methods have been shown to be effective in reducing marijuana use in adults who are dependent on the drug (Marijuana Treatment Project Research Group,  2004 ). In a comparative review of psychological treatment studies of marijuana users, Nordstrom and Levin ( 2007 ) conclude that a number of therapies have been found to be effective in treating cannabis dependency, but no specific treatment approach has been found to be more effective than the others. Some investigators have also reported that many patients do not show a positive treatment response. No pharmacotherapy treatment for cannabis dependency has been shown to be very effective (Nordstrom and Levin,  2007 ); however, one recent study using busiprone for treatment of marijuana dependency showed slight improvement over a placebo group (McRae et al.,  2009 ).

As with other addictive drugs, there may be among the users many individuals with serious antisocial or “psychosis-prone” personalities (Kwapil,  1996 ). Treatment of marijuana use is hampered by the fact that there might be an underlying personality disorder. One study compared the effectiveness of two treatments, Relapse Prevention and Support Group, with marijuana-dependent adults (Stephens et al.,  1994 ). Both treatment conditions resulted in substantial reduction in marijuana use in the 12 months following treatment. Relapse Prevention and Support Group discussion sessions were equally effective in bringing about changes in marijuana use.

the WORLD around us: Should Marijuana Be Marketed and Sold Openly as a Medication?

Although marijuana is a Schedule 1 Drug according to the 1970 Controlled Substances Act, and U. S. Government drug control agencies have strongly opposed legalization of the drug (Walters,  2006 ), there have been substantial efforts to broaden its use and availability. In recent years marijuana has been distributed for pain or nausea relief from medical conditions such as cancer, AIDS, glaucoma, multiple sclerosis, migraines, and epilepsy. Proponents of medical marijuana cite its value in the treatment of these conditions, and some have pointed out that medical marijuana treatment is consistent with participation in other forms of drug treatment and may not adversely affect the outcome (Swartz,  2010 ). Marijuana does not cure any illness; it only reduces pain for which other medications exist (Watson, Benson et al.,  2000 ).

Proponents of medical marijuana have made considerable inroads in securing legalization of marijuana as a treatment in 14 states and the District of Columbia. Although many professional researchers and practitioners discourage the use of marijuana because of the ill effects, others, including mental health professionals, politicians, and lay persons, press society to change the rigid control over the drug and make it legal.

States vary in how medical marijuana is made available to the public. Some locations, such as the District of Columbia, have approved medical marijuana use by a limited and controlled number of dispensaries (Southall,  2010 ) while others have allowed a broad and less controlled environment to develop. A recent article by Vick ( 2009 ) pointed out that California’s medical marijuana law (Proposition 215) enabled the opening of more than 400 public dispensaries of medical marijuana in the Los Angeles area and resulted in marijuana becoming “mainstream.” The ready access to marijuana heightened concerns over the drug serving as an “entry level” drug for more addictive and dangerous illicit substances. This problem has been a focus of the U.S. government’s opposition to legalizing marijuana since it has become more widely available (Walters,  2006 ). In 2012, the Los Angeles City Council rescinded its early approval of the sale of medical marijuana and closed down the numerous “clinics” that provided open access to the drug (Zahniser,  2012 ). It is uncertain as to what the future access to medical marijuana will be as various states may change their positions on marijuana use and availability.

A number of problems with the use of medical marijuana have been reported, in part because of the unregulated availability of the drug; for example, one can get a “prescription” for the drug by walking into one of the many “treatment centers” and talking with a salesperson. A recent article by Moore ( 2009 ) describes the sentencing of an owner of a marijuana dispensary to a year in prison for distributing marijuana. Thus, providers of medical marijuana to the public can still face the possibility of jail time in some situations. Yardley ( 2010 ) recently pointed out a number of crimes that resulted from the medical marijuana users having had large amounts of marijuana in their homes. Mascia ( 2010 ) highlighted another problem in using medical marijuana in employment settings. A number of people have lost jobs or have not been offered a position as a result of drug screening—a requirement for employment in many positions such as security personnel, police applicants, pilots, and even some corporations such as Walmart.

Iversen ( 2008 ) makes a strong case for the research supporting the use of medical marijuana, but others continue to question the scientific basis of the medical use (Walters,  2006 ). Others have also pointed out that medical use of cannabis has been shown to be significantly associated with nonmedical use and could result in adverse consequences (Parakh,  2010 ).

Should “medical marijuana” be considered a legitimate pharmaceutical treatment? Is marijuana an effective drug based on the research, or is it without any medical value? Is marijuana being unfairly criminalized by the federal government, or does its potential as an entry drug and its medical side effects counter its value as a treatment? Should cannabis be approved for medical use by a vote of the people, as already has been done in many states, or should medical marijuana be scientifically evaluated and its use be guided by science? The controversy is likely to continue as more states vote to legalize medical marijuana and as other problems with the broadened availability of the drug emerge.

Marijuana may lead to unpleasant as well as pleasant experiences. For example, if a person uses the drug while in an unhappy, angry, suspicious and paranoid, or frightened mood, these feelings may be magnified. With higher dosages and with certain unstable or susceptible individuals, marijuana can produce extreme euphoria, hilarity, and overtalkativeness, but it can also produce intense anxiety (Zvolensky et al.,  2010 ) and depression as well as delusions, hallucinations, and other psychotic-like experiences. Evidence suggests a strong relationship between daily marijuana use and the occurrence of psychotic symptoms (Raphael et al.,  2005 ).

Marijuana’s short-range physiological effects include a moderate increase in heart rate, a slowing of reaction time, a slight contraction of pupil size, bloodshot and itchy eyes, a dry mouth, and increased appetite. Furthermore, marijuana induces memory dysfunction and a slowing of information processing (Pope et al.,  2001 ). Continued use of high dosages over time tends to produce lethargy and passivity along with reduced life success (Lane et al.,  2005 ). In such cases marijuana appears to have a depressant and a hallucinogenic effect. The effects of long-term and habitual marijuana use are still under investigation, although a number of possible adverse side effects have been found to be related to the prolonged, heavy use of marijuana (Earleywine,  2002 ). For example, marijuana use tends to diminish self-control. One study exploring past substance-use history in incarcerated murderers reported that among men who had committed murder, marijuana was the most commonly used drug. One-third indicated that they had used the drug before the homicide, and two-thirds were experiencing some effects of the drug at the time of the murder (Spunt et al.,  1994 ).

SYNTHETIC MARIJUANA

Not all discoveries or product developments today are innovations that contribute to the public good. An example of a recent chemical that is widely marketed and can result in harm for the consumers is a marijuana substitute that goes under the name of “Spice.” Spice is an herbal compound that is touted as an incense blend (as are several other chemical brands such as “K2,” “Blaze,” and “Red X Dawn”) and marketed on the Internet and in specialty shops. These products are advertised as a legal alternative to controlled substances such as marijuana. Spice is typically smoked along with tobacco; however, it tends to take longer to feel the effects than marijuana.

Many people who use Spice report that it has effects equal to or stronger than those obtained by smoking cannabis. Very little is known at this point about the make-up of Spice or its long-term effects. Reports suggest that it may contain up to 15 different herbs, of which wild dagga (Leonotis leonurus) and Indian warrior (Pedicularis densiflora) are considered to be the most likely candidates for producing a psychoactive effect. In addition, other synthetic chemicals may have been added to the drug (Griffiths et al.,  2010 ). Although there is a limited amount of research and clinical information about synthetic marijuana, there are reports that the  toxicity  lasts 3 to 4 hours and often has adverse effects such as anxiety, tachycardia, hypertension, abnormally fast breathing, chest pain, heart palpitations, hallucinations, racing thoughts, and seizures (Wells & Ott,  2011 ).

Bath salts are becoming a widely used and dangerous stimulant drug and are now considered an illegal substance even though they are often available in bath products or fertilizers. The drug’s effects are very similar to ecstasy or cocaine. Bath salts contain amphetamine or cocaine-like chemicals, such as methylenedioxypyrovalerone (MPDV). They tend to cause intense euphoria and make the user very talkative and sexually aroused and often produce bizarre results.

Spice has come under the attention of drug control agencies because of the extreme and damaging side effects. A number of efforts are being made to place legal restrictions on its use and availability (McLachlan,  2009 ). In November 2010, the United States Drug Enforcement Administration (DEA) used its emergency scheduling authority to temporarily control five chemicals that are used to make fake marijuana products. In March of 2011, the DEA declared these chemicals to be illegal substances (Kraft,  2011 ).

Stimulants: Caffeine and Nicotine

DSM-5 includes addictions to two legally available and widely used substances:  caffeine  and  nicotine . Although these substances do not involve the extensive and self-destructive problems found in alcohol- and drug-use disorders, they can create important physical and mental health problems in our society for several reasons:

·  • These drugs are easy to abuse. It is easy to become addicted to them because they are widely used and most people are exposed to them early in life.

·  • These drugs are readily available to anyone who wants to use them; in fact, because of peer pressure, it is usually difficult to avoid using them in our society.

·  • Both caffeine and nicotine have clearly addictive properties; use of them promotes further use, until one craves a regular “fix” in one’s daily life.

·  • It is difficult to quit using these drugs both because of their addictive properties and because they are so embedded in the social context. (Nicotine use, however, is falling out of favor in many settings.)

·  • The extreme difficulty most people have in dealing with the withdrawal symptoms when trying to “break the habit” often produces considerable frustration.

·  • The health problems and side effects of these drugs, particularly nicotine, have been widely noted (USDHHS, 1994). One in seven deaths in the United States is associated with cigarette consumption.

Because of their tenacity as habits and their contributions to many major health problems, we will examine each of these addictions in more detail.

CAFFEINE

The chemical compound caffeine is found in many commonly available drinks and foods. Although the consumption of caffeine is widely practiced and socially promoted in contemporary society, problems can result from excessive caffeine intake. The negative effects of caffeine involve intoxication rather than withdrawal. Unlike addiction to drugs such as alcohol or nicotine, withdrawal from caffeine does not produce severe symptoms, except for headache, which is usually mild.

Because they are socially acceptable and readily available, caffeine and nicotine can be insidiously addictive substances. Though they do not result in the same kind of extensive, self-destructive problems as alcohol and drug disorders, caffeine and nicotine addiction can cause a myriad of health problems and are now included in the DSM-5.

As described in DSM-5 caffeine-related disorder involves symptoms of restlessness, nervousness, excitement, insomnia, muscle twitching, and gastrointestinal complaints. It follows the ingestion of caffeine-containing substances such as coffee, tea, cola, and chocolate. The amount of caffeine that results in intoxication differs among individuals.

NICOTINE

The poisonous alkaloid nicotine is the chief active ingredient in tobacco; it is found in such items as cigarettes, chewing tobacco, and cigars, and it is even used as an insecticide. The use of tobacco is a significant problem in the general population. The number of Americans aged 12 and older who use some form of tobacco is estimated at 70.9 million people, or about 28.4 percent of the population (Substance Abuse and Mental Health Services Administration,  2009 ). However, an estimated 63 percent of women and 53 percent of men have never smoked (Pleis et al.,  2009 ). The DSM-5 contains a diagnostic category for nicotine abuse. The criteria for tobacco use disorder are the same for other addictive disorders.

Strong evidence exists for a nicotine-dependence syndrome (Malin,  2001 ; Watkins et al.,  2000 ), which nearly always begins during the adolescent years and may continue into adult life as a difficult-to-break and health-endangering habit. Supporting the finding that nicotine may have an antianxiety property, nicotine use has been observed as being highly prevalent among those with anxiety disorders (Morissette et al.,  2007 ). Recent evidence from stroke-related brain injury suggests that nicotine addiction might be controlled by a portion of the brain near the ear called the insula (Naqvi et al.,  2007 ). A stroke patient with damage to that area of the brain reported that his craving for cigarettes vanished. This result suggests that the insula might be an important center for addiction to smoking, but more research is needed to support this conclusion.

The “Tobacco Withdrawal disorder,” as it is called in DSM-5, results from ceasing or reducing the intake of nicotine-containing substances after an individual has developed physical dependence on them. The diagnostic criteria for nicotine withdrawal include (1) the daily use of nicotine for at least several weeks, and (2) the following symptoms after nicotine ingestion is stopped or reduced: craving for nicotine; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; and increased appetite or weight gain. Several other physical concomitants are associated with withdrawal from nicotine including decreased metabolic rate, headaches, insomnia, tremors, increased coughing, and impairment of performance on tasks requiring attention.

These withdrawal symptoms usually continue for several days to several weeks, depending on the extent of the nicotine habit. Some individuals report a desire for nicotine continuing for several months after they quit smoking. In general, nicotine withdrawal symptoms operate in a manner similar to those of withdrawal from other addictions—they are time limited and are reduced over time as the drug intake stops, (Hughes,  2007 ).

TREATMENT OF NICOTINE WITHDRAWAL

Over the past three decades, numerous treatment programs have been developed to help smokers quit (Hughes,  2007 ). Available programs use many different methods including social support groups; various pharmacologic agents that replace cigarette consumption with safer forms of nicotine such as candy, gum, or patches; self-directed change that involves giving individuals guidance in changing their own behaviors; and professional treatment using psychological procedures such as behavioral or cognitive-behavioral interventions. One recent study provided smokers with ultrasound photographs of their carotid and femoral arteries along with quit-smoking counseling. This group showed higher quit rates than controls (Bovet et al.,  2002 ).

In general, tobacco dependence can be successfully treated, and most of the quit-smoking programs enjoy some success. They average only about a 20- to 25-percent success rate, however, although rates have been reported to be higher with treatment (Hays et al.,  2001 ). This same level of success appears to result from the use of nicotine replacement therapy (NRT). Shiffman and colleagues ( 2006 ) point out that high-dose NRT reduces withdrawal symptoms. Treatment with active patches reduced withdrawal and craving during cessation and completely eliminated deprivation-related changes in affect or concentration. Recently, encouraging results have been reported on the use of the drug bupropion (Zyban) in preventing relapse for smokers trying to quit. The drug reduced relapse as long as the person was taking it, but relapse rates were similar to those of other treatments once the drug was discontinued (Barringer & Weaver,  2002 ). The highest self-reported quit rates for smokers were reportedly among patients who were hospitalized for cancer (63 percent), cardiovascular disease (57 percent), or pulmonary disease (46 percent; Smith, Reilly, et al.,  2002 ).

Not all addictive disorders involve the use of substances with chemical properties that induce dependence. As discussed in the next section, people can develop “addictions” to certain activities that can be just as life-threatening as severe alcoholism and just as damaging, psychologically and socially, as drug abuse. One such addiction,  pathological gambling , is in many ways similar to substance abuse. The maladaptive behaviors involved and the treatment approaches shown to be effective suggest that these addictive disorders are quite similar to the various drug-use and drug-induced disorders.

in review

·  • What are the major biological and psychological effects of using opiates such as morphine and heroin?

·  • What are the three major causal factors in the development of opiate abuse and dependence?

·  • What is methamphetamine? What are the major health factors related to methamphetamine use?

·  • What are the physical risks of taking Ecstasy?

·  • Describe the effects of cannabis.

·  • Describe the effects of nicotine and caffeine use, and explain why these commonly available substances are included in this chapter on substance abuse.

Gambling Disorder

Although pathological gambling does not involve a chemically addictive substance, it is considered by many to be an addictive disorder because of the personality factors that tend to characterize compulsive gamblers (Petry & Madden,  2010 ). Like the substance abuse disorders, pathological gambling involves behavior maintained by short-term gains despite long-term disruption of an individual’s life. There is a high comorbidity between pathological gambling and alcohol abuse disorders (Blanco, Cohen et al.,  2010 ) and with personality disorders (Sacco et al.,  2008 ). Pathological gambling, also known as “compulsive gambling” or disordered gambling, is a progressive disorder characterized by continuous or periodic loss of control over gambling, a preoccupation with gambling and with obtaining money for gambling, and continuation of the gambling behavior in spite of adverse consequences.

Estimates place the number of pathological gamblers worldwide at between 1 and 2 percent of the adult population (Petry,  2005 ). Both men and women appear to be vulnerable to pathological gambling (Hing & Breen,  2001 ). However, rates differ by subpopulation; for example, in some high-risk populations, such as alcoholics, the rates are higher. One study of elderly African Americans from two senior citizen centers documented the extent of gambling problems in this population; 17 percent were found to be people with gambling disorders (Bazargan et al.,  2001 ). Pietrzak and colleagues ( 2007 ) found that older, disordered gamblers were significantly more likely than nongambling older adults to have alcohol-abuse problems, nicotine addiction, and health problems.

DSM-5 criteria for: Gambling Disorder

·  A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period:

·  1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.

·  2. Is restless or irritable when attempting to cut down or stop gambling.

·  3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.

·  4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).

·  5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).

·  6. After losing money gambling, often returns another day to get even (“chasing” one’s losses).

·  7. Lies to conceal the extent of involvement with gambling.

·  8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

·  9. Relies on others to provide money to relieve desperate financial situations caused by gambling.

·  B. The gambling behavior is not better explained by a manic episode.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

Cultural factors also appear to be important in the development of gambling problems. Pathological gambling is a particular problem among Southeast Asian refugees, especially those from Laos. Surveys of mental health problems have reported almost epidemic compulsive gambling among such groups (Aronoff,  1987 ; Ganju & Quan,  1987 ).

Gambling in our society takes many forms including casino gambling, betting on horse races or sports (legally or otherwise), Internet gaming, numbers games, lotteries, dice, bingo, and cards. Whatever an individual gambler’s situation, compulsive gambling significantly affects the social, psychological, and economic well-being of the gambler’s family. In fact, studies have found that a high proportion of pathological gamblers commit crimes that are related to gambling (Blaszczynski et al.,  1989 ), family violence (Afifi et al.,  2010 ) and other crimes of aggression (Folino & Abait,  2009 ).

Pathological gambling seems to be a learned pattern that is highly resistant to extinction. Some research suggests that control over gambling is related to duration and frequency of playing (Scannell et al.,  2000 ). However, many people who become pathological gamblers won a substantial sum of money the first time they gambled; chance alone would dictate that a certain percentage of people would have such “beginner’s luck.” The reinforcement a person receives during this introductory phase may be a significant factor in later pathological gambling. Because everyone is likely to win from time to time, the principles of intermittent reinforcement—the most potent reinforcement schedule for operant conditioning—could explain an addict’s continued gambling despite excessive losses.

Despite their awareness that the odds are against them, and despite the fact that they rarely or never repeat their early success, compulsive gamblers continue to gamble avidly. To “stake” their gambling, they often dissipate their savings, neglect their families, default on bills, and borrow money from friends and loan companies. Some resort to embezzlement, writing bad checks, or other illegal means of obtaining money. In a pioneering study of former pathological gamblers, Rosten ( 1961 ) found that they tended to be rebellious, unconventional individuals who did not seem to understand fully the ethical norms of society. Half of the group described themselves as “hating regulations.” Often they had the unshakable feeling that “tonight is my night.” Typically, they had also followed the so-called “Monte Carlo fallacy”—that after so many losses, their turn was coming up and they would hit it big. Many of the men discussed the extent to which they had “fooled themselves” by elaborate rationalizations.

Later studies also describe pathological gamblers as typically immature, rebellious, thrill-seeking, superstitious, basically antisocial, and compulsive (Hollander et al,  2000 ). Research has shown that pathological gambling frequently co-occurs with other disorders, particularly substance abuse such as alcohol and cocaine dependence (Kausch,  2003 ; Welte et al.,  2004 ) and impulse disorders (Grant & Potenza,  2010 ). Those with co-occurring substance-abuse disorders typically have the most severe gambling problems (Ladd & Petry,  2003 ).

The causes of impulse-driven behavior in pathological gambling are complex. Some research has suggested that early trauma might contribute to the development of compulsive gambling (Scherrer et al.,  2007 ). Although learning undoubtedly plays an important part in the development of personality factors underlying the “compulsive” gambler, recent research in brain mechanisms that are involved in motivation, reward, and decision making indicates that these mechanisms could influence the underlying impulsivity in personality (Chambers & Potenza,  2003 ). These investigators have suggested that important neuro-developmental events during adolescence occur in brain regions associated with motivation and impulsive behavior. Recent research has also suggested that genetic factors might play a part in developing pathological gambling habits (Slutske et al.,  2010 ).

Treatment of pathological gamblers has tended to parallel that of other addictive disorders. The most extensive treatment approach used with pathological gamblers is cognitive-behavioral therapy (Okuda et al.,  2009 ). For example, Sylvain, Ladouceur, and Boisvert ( 1997 ) provided cognitive-behavioral therapy for 58 pathological gamblers recruited through the media. Although 18 participants dropped out at the start and 11 quit during therapy, those who remained in treatment showed significant improvement. Of those who completed therapy, 86 percent were considered “no longer” pathological gamblers at a 1-year follow-up. However, one study (Hodgins & el-Guebaly,  2004 ) reports very high relapse rates among pathological gamblers—only 8 percent were free of gambling 12 months after treatment. Even studies that show improvement during treatment also report participants’ difficulty remaining abstinent. In a study of 231 gamblers (Petry et al.,  2006 ), some improved when receiving cognitive-behavioral therapy and when attending at Gambler’s Anonymous (GA), an organization modeled after Alcoholics Anonymous, or when attending GA and receiving a workbook. The patients tended not to remain abstinent, although incidents were less than they usually reported. Most participants reported some gambling during the follow-up period. More positive outcomes in treating pathological gambling have been found when family relationship problems are addressed in the treatment (McComb et al.,  2009 ).

Pathological gambling is on the increase in the United States (Potenza,  2002 ), particularly with the widely available gambling opportunities on the Internet (Griffiths,  2003 ). Liberalized gambling legislation has permitted state-operated lotteries, horse racing, and gambling casinos in an effort to increase state tax revenues. In the context of this apparent environmental support and “official” sanction for gambling, it is likely that pathological gambling will increase substantially as more and more people “try their luck.” Given that pathological gamblers are resistant to treatment, future efforts to develop more effective preventive and treatment approaches will need to be increased as this problem continues to grow. Watch the Video Ed: Gambling Disorder on MyPsychLab

UNRESOLVED issues: Exchanging Addictions: Is This an Effective Treatment Approach?

Withdrawal from heroin can be extremely difficult because of the intense craving that develops for the drug. Wouldn’t it be great if we had a magic bullet—a medication—that would allow people who are addicted to heroin to withdraw from it painlessly? One approach that has been used for several decades involves the administration of metha-done (methadone hydrochloride, a synthetic narcotic that is as addictive as heroin), often in conjunction with a psychological or social rehabilitation program that is aimed at resocialization of the abuser. The value of this treatment comes from the fact that methadone satisfies an addict’s craving for heroin without producing serious psychological impairment.

Many researchers have concluded that in addition to facilitating psychological or social rehabilitation, this drug is effective at reducing the dependence on heroin (Kreek et al.,  2010 ). Thus, it enables many people to experience reduced craving, allowing them to alter somewhat the often desperate life circumstances they find themselves in through trying to support their expensive and all-consuming habit. In addition, opiate addicts who remain on methadone have a substantially lower death rate than those discharged from methadone maintenance programs (Fugelstad et al.,  2007 ).

The idea that addicts may need to be maintained for life on methadone, itself a powerful and addicting drug, has been questioned both on moral and practical grounds. Methadone advocates, however, point out that addicts on methadone can function normally and hold jobs, which is not possible for most heroin addicts. In addition, methadone is available legally, and its quality is controlled by government standards. Advocates for methadone programs point out that it is not necessary to increase the dosage over time as it is with heroin use. In fact, some patients can eventually stop taking methadone without danger of relapse to heroin addiction.

However, negative consequences are sometimes associated with the use of methadone (Miller & Lyon,  2003 ). Methadone patients are at increased risk for health problems such as hepatitis (McCarthy & Flynn,  2001 ) and cognitive impairment (Scheurich,  2005 ; Verdejo et al.,  2005 ). In addition, many social problems, such as trading sex for drugs, persist (El-Bassel et al.,  2001 ); some addicts get involved with other drugs such as cocaine (Avants et al.  1998 ; Silverman et al.,  1996 ); suicide attempts are common (Darke & Ross,  2001 ); and violent deaths and drug overdoses are common among methadone patients (Sunjic & Zabor,  1999 ).

A great deal of research has shown that administering psychotherapy along with methadone increases the effectiveness of treatment (Marsch et al.,  2005 ). However, a persistent problem of methadone maintenance programs has been the relatively high dropout rate. Several variations in methadone maintenance programs have been aimed at keeping addicts in therapy. These variations include the use of such additional drugs as clonidine (an antihypertensive drug used to treat essential hypertension and prevent headache), which aid in the detoxification process and reduce the discomfort of withdrawal symptoms. In one study, the joint use of tranquilizers such as diazepam was shown to decrease the amount of methadone consumed (Spiga et al.,  2001 ). Another approach involves the use of behavioral shaping through contingent reinforcers (monetary vouchers) to reward abstinent patients (Preston et al.,  2001 ).

A new approach to treating opiate dependence is one that promotes drug abstinence for addicts rather than permanent maintenance on methadone (Kosten,  2003 ). This program, referred to as methadone transition treatment (MTT), involves several elements over its 180-day duration. During the first 100 days, the addict is provided a stable dose of methadone to begin the withdrawal from heroin. During this period the addict also receives a psychosocial intervention that includes weekly psychoeducational classes, biweekly group therapy, and 6 months of individual therapy that continues after drug maintenance has terminated. The program ends with 80 days of phaseout in which the addict is “weaned” from methadone through systematically decreasing the doses (Piotrowski et al.,  1999 ).

11 summary

·  11.1 What is alcohol abuse and dependence?

·  • Substance-related disorders such as alcohol or drug abuse and dependency are among the most widespread and intransigent mental health problems facing us today.

·  • Many problems of alcohol or drug use involve difficulties that stem solely from the intoxicating effects of the substances.

·  • Dependence occurs when an individual develops a tolerance for the substance or exhibits withdrawal symptoms when the substance is not available.

·  • Several psychoses related to alcoholism have been identified: withdrawal delirium, chronic alcoholic hallucinosis, and dementia associated with alcoholism.

·  • Drug-related abuse disorders may involve physiological dependence on substances such as opiates—particularly heroin—or barbiturates; however, psychological dependence may also occur with any of the drugs that are commonly used today—for example, marijuana.

·  • A number of factors are considered important in the etiology of substance-abuse disorders. Some substances, such as alcohol and opiates, stimulate brain centers that produce euphoria—which then becomes a desired goal.

·  • It is widely believed that genetic factors play some role in causing susceptibility to alcohol-abuse problems through such biological avenues as metabolic rates and sensitivity to alcohol.

·  • Psychological factors—such as psychological vulnerability, stress, and the desire for tension reduction—and disturbed marital relationships or failure in parental guidance are also seen as important etiologic elements in substance-use disorders.

·  • Although the existence of an “alcoholic personality type” has been disavowed by most theorists, a variety of personality factors apparently play an important role in the development and expression of addictive disorders.

·  • Sociocultural factors such as attitudes toward alcohol may predis-pose individuals to alcohol-related disorders.

·  11.2 What is drug abuse and dependence?

·  • Possible causal factors in drug abuse include the influence of peer groups, the existence of a so-called “drug culture,” and the availability of drugs as tension reducers or pain relievers.

·  • Some recent research has explored a possible physiological basis for drug abuse. The discovery of endorphins, opium-like substances produced by the body, has led to speculation that a biochemical basis of drug addiction may exist.

·  • The so-called “pleasure pathway”—the mesocorticolimbic pathway (MCLP)—has come under a great deal of study in recent years as the possible potential anatomic site underlying the addictions.

·  • The treatment of individuals who abuse alcohol or drugs is generally difficult and often fails. The abuse may reflect a long history of psychological difficulties; interpersonal and marital distress may be involved; and financial and legal problems may be present.

·  • In addition, all such problems must be dealt with by an individual who may deny that the problems exist and who may not be motivated to work on them.

·  • Several approaches to the treatment of chronic substance-related disorders have been developed—for example, medication to deal with withdrawal symptoms and withdrawal delirium, and dietary evaluation and treatment for malnutrition.

·  • Psychological therapies such as group therapy and behavioral interventions may be effective with some alcohol- or drug-abusing individuals. Another source of help for alcohol abusers is Alcoholics Anonymous; however, the extent of successful outcomes w ith this program has not been sufficiently studied.

·  • Most treatment programs require abstinence; however, some research has suggested that some alcohol abusers can learn to control their drinking while continuing to drink socially. The controversy surrounding controlled drinking continues.

·  • Relapse prevention strategies have proved successful in helping substance-abusing patients to deal with the challenges encountered in abstinence-based treatment approaches.

·  11.3 Are there addictive disorders other than alcohol and drugs?

·  • This chapter also includes discussion of several addictive disorders that are different than alcohol or drug abuse, caffeine, tobacco and gambling.

key terms

·  addictive behavior  368

·  alcohol withdrawal delirium  374

·  alcoholic  369

·  alcoholism  369

·  amphetamine  391

·  barbiturates  393

·  caffeine  398

·  cocaine  390

·  delirium tremens  374

·  Ecstasy  395

·  endorphins  389

·  flashback  394

·  hallucinogens  394

·  hashish  396

·  heroin  387

·  lSD  394

·  marijuana  396

·  mescaline  395

·  mesocorticolimbic dopamine pathway (MClP)  375

·  methadone  390

·  morphine  387

·  nicotine  398

·  opium  387

·  pathological gambling  400

·  psilocybin  395

·  psychoactive substances  369

·  substance abuse  369

·  substance dependence  369

·  substance-related disorders  368

·  tolerance  369

·  toxicity  398

·  withdrawal  369