For Stanford Writer

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I am Duncan. I am an alcoholic.” The audience settled deeper into their chairs at these

familiar words. Another chronicle of death and rebirth would shortly begin [at] Alcoholics

Anonymous. . . .

. . . “I must have been just past my 15th birthday when I had that first drink that everybody

talks about. And like so many of them . . . it was like a miracle. With a little beer in my gut,

the world was transformed. I wasn’t a weakling anymore, I could lick almost anybody on the

block. And girls? Well, you can imagine how a couple of beers made me feel like I could have

any girl I wanted. . . .

“Though it’s obvious to me now that my drinking even then, in high school, and after I got to

college, was a problem, I didn’t think so at the time. After all, everybody was drinking and get-

ting drunk and acting stupid, and I didn’t really think I was different. . . . I guess the fact that I

hadn’t really had any blackouts and that I could go for days without having to drink reassured

me that things hadn’t gotten out of control. And that’s the way it went, until I found myself

drinking even more—and more often—and suffering more from my drinking, along about my

third year of college.

. . . “My roommate, a friend from high school, started bugging me about my drinking. It wasn’t

even that I’d have to sleep it off the whole next day and miss class, it was that he had begun

to hear other friends talking about me, about the fool I’d made of myself at parties. He saw

how shaky I was the morning after, and he saw how different I was when I’d been drinking

a lot—almost out of my head was the way he put it. And he could count the bottles that

I’d leave around the room, and he knew what the drinking and carousing was doing to my

grades. . . . [P]artly because I really cared about my roommate and didn’t want to lose him

as a friend, I did cut down on my drinking by half or more. I only drank on weekends—and

then only at night. . . . And that got me through the rest of college and, actually, through law

school as well. . . .

“Shortly after getting my law degree, I married my first wife, and . . . for the first time since

I started, my drinking was no problem at all. I would go for weeks at a time without touching

a drop. . . .

“My marriage started to go bad after our second son, our third child, was born. I was very

much career-and-success oriented, and I had little time to spend at home with my family. . . .

My traveling had increased a lot, there were stimulating people on those trips, and, let’s face

it, there were some pretty exciting women available, too. So home got to be little else but a

nagging, boring wife and children I wasn’t very interested in. My drinking had gotten bad again,

too, with being on the road so much, having to do a lot of entertaining at lunch when I wasn’t

away, and trying to soften the hassles at home. I guess I was putting down close to a gallon of

very good scotch a week, with one thing or another.

“And as that went on, the drinking began to affect both my marriage and my career. With

enough booze in me and under the pressures of guilt over my failure to carry out my responsibili-

ties to my wife and children, I sometimes got kind of rough physically with them. I would break

furniture, throw things around, then rush out and drive off in the car. I had a couple of wrecks,

lost my license for two years because of one of them. Worst of all was when I tried to stop. By

then I was totally hooked, so every time I tried to stop drinking, I’d experience withdrawal in

all its horrors . . . with the vomiting and the ‘shakes’ and being unable to sit still or to lie down.

And that would go on for days at a time. . . .

TOPIC OVERVIEW Depressants Alcohol Sedative-Hypnotic Drugs Opioids

Stimulants Cocaine Amphetamines

Hallucinogens

Cannabis

Combinations of Substances

What Causes Substance-Related Disorders? Sociocultural Views Psychodynamic Views Cognitive-Behavioral Views Biological Views

How Are Substance-Related Disorders Treated? Psychodynamic Therapies Behavioral Therapies Cognitive-Behavioral Therapies Biological Treatments Sociocultural Therapies

Putting It Together: New Wrinkles to a Familiar Story

SUBSTANCE-RELATED DISORDERS C H A P T E R :10 “

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286 ://CHAPTER 10

“Then, about four years ago, with my life in ruins, my wife given up on me and the kids with her, out

of a job, and way down on my luck, [Alcoholics Anonymous] and I found each other. . . . I’ve been dry

now for a little over two years, and with luck and support, I may stay sober. . . .”

Spitzer et al., 1983, pp. 87–89

Human beings enjoy a remarkable variety of foods and drinks. Every substance on earth probably has been tried by someone, somewhere, at some time. We also have discovered substances that have interesting effects—both medical and pleasurable—on our brains and the rest of our bodies. We may swallow an aspirin to quiet a headache, an antibiotic to fight an infection, or a tranquilizer to calm us down. We may drink coffee to get going in the morning or wine to relax with friends. We may smoke cigarettes to soothe our nerves. However, many of the substances we consume can harm us or disrupt our behavior or mood. The misuse of such substances has become one of society’s biggest problems; it has been estimated that the cost of drug misuse is more than $200 billion each year in the United States alone (ONDCP, 2008).

A drug is defined as any substance other than food that affects our bodies or minds. It need not be a medicine or be illegal. The term “substance” is now frequently used in place of “drug,” in part because many people fail to see that such substances as alcohol, tobacco, and caffeine are drugs, too. When a person ingests a substance—whether it be alcohol, cocaine, marijuana, or some form of medication—trillions of powerful mol- ecules surge through the bloodstream and into the brain. Once there, the molecules set off a series of biochemical events that disturb the normal operation of the brain and body. Not surprisingly, then, substance misuse may lead to various kinds of abnormal functioning.

Drugs may cause temporary changes in behavior, emotion, or thought. As Duncan found out, for example, an excessive amount of alcohol may lead to intoxication (literally, “poisoning”), a temporary state of poor judgment, mood changes, irritability, slurred speech, and poor coordination. Drugs such as LSD may produce a particular form of intoxication, sometimes called hallucinosis, which consists of perceptual distortions and hallucinations.

Some substances can also lead to long-term problems. People who regularly ingest them may develop maladaptive patterns of behavior and changes in their body’s physi- cal responses (APA, 2000). In one such pattern, called substance abuse, they rely on the drug excessively and chronically and in so doing damage their family and social relationships, function poorly at work, or put themselves and others in danger. A more advanced pattern, substance dependence, is also known as addiction. In this pattern, people not only abuse the drug but also center their lives on it and perhaps acquire a physical dependence on it, marked by a tolerance for it, withdrawal symptoms, or both (see Table 10-1). When people develop tolerance, they need increasing doses of a drug in order to keep getting the desired effect. Withdrawal consists of unpleasant and even dangerous symptoms—cramps, anxiety attacks, sweating, nausea—that occur when in- dividuals suddenly stop taking or cut back on the drug (Allen, 2009).

Duncan, who described his problems to fellow members at an Alcoholics Anony- mous meeting, was caught in a pattern of alcohol dependence. When he was a college student and later a lawyer, alcohol damaged his family, social, academic, and work life. He also built up a tolerance for the substance over time and experienced withdrawal symptoms such as vomiting and shaking when he tried to stop using it. In any given year, 9.2 percent of all teens and adults in the United States, around 23 million people, display a pattern of substance abuse or dependence (NSDUH, 2008). The highest rate of substance abuse or dependence in the United States is found among Native Ameri- cans (19 percent), while the lowest is among Asian Americans (4.3 percent). White Americans, Hispanic Americans, and African Americans display rates between 9 and 10 percent (NSDUH, 2008) (see Figure 10-1). Only 26 percent of all people with a pattern of substance abuse or dependence receive treatment from a mental health professional (Wang et al., 2005).

table:

SUBSTANCE ABUSE 1. A maladaptive pattern of sub-

stance use leading to significant impairment or distress

2. At least one of the following fea- tures occurring within one year:

(a) Recurrent substance use, resulting in failure to fulfill major role obligations at work, school, or home

(b) Recurrent substance use in situations in which it is physi- cally hazardous

(c) Recurrent substance-related legal problems

(d) Substance use that contin- ues despite its causing or increasing persistent social or interpersonal problems

SUBSTANCE DEPENDENCE 1. A maladaptive pattern of sub-

stance use leading to significant impairment or distress

2. At least three of the following: (a) Tolerance (b) Withdrawal (c) Substance often taken in larger

amounts over a longer period than was intended

(d) Persistent desire for substance or unsuccessful efforts to con- trol substance use

(e) Considerable time spent trying to obtain, use, or recover from the substance

(f) Substance use in place of important activities

(g) Substance use that continues despite its causing or increas- ing persistent physical or psychological problems

Based on APA, 2000.

10-1

DSM Checklist

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Substance-Related Disorders :// 287

Many drugs are available in our society, and new ones are introduced almost

every day. Some are harvested from nature, others derived from natural substances, and still others produced in the laboratory. Some, such as antianxiety drugs, require a physician’s prescription for legal use. Others, such as alcohol and nicotine, are legally available to adults. Still others, such as heroin, are illegal under all circum- stances. In 1962 only 4 million people in the United States had ever used mari- juana, cocaine, heroin, or another illegal substance; today the number has climbed to more than 94 million (NSDUH, 2008). In fact, 28 million people have used illegal substances within the past year, and more than 20 million are using one currently. Almost 22 percent of all high school seniors have used an illegal drug within the past month ( Johnston et al., 2007).

The substances people misuse fall into several categories: depressants, stimulants, hallucinogens, and cannabis. Many people take more than one of these substances at a time, a practice known as polydrug use. In this chapter you will read about some of the most problematic substances and the abnormal patterns they may produce.

jjDepressants Depressants are substances that slow the activity of the central nervous system. They reduce tension and inhibitions and may interfere with a person’s judgment, motor activity, and concentration. The three most widely used groups of depressants are alcohol, sedative-hypnotic drugs, and opioids.

Alcohol The World Health Organization estimates that 2 billion people worldwide consume alcohol. In the United States more than half of all individuals at least from time to time drink beverages that contain alcohol (NSDUH, 2008). Purchases of beer, wine, and liquor amount to tens of billions of dollars each year in the United States alone.

When people consume five or more drinks on a single occasion, it is called a binge- drinking episode. Twenty-three percent of people in the United States over the age of 11, most of them male, binge-drink each month (NSDUH, 2008). Nearly 7 percent of persons over 11 years of age are heavy drinkers, individuals who have at least five binge-drinking episodes each month (NSDUH, 2008). Among heavy drinkers, males outnumber females by more than 2 to 1, around 8 percent to 4 percent.

All alcoholic beverages contain ethyl alcohol, a chemical that is quickly absorbed into the blood through the lining of the stomach and the intestine. The ethyl alcohol im- mediately begins to take effect as it is carried in the bloodstream to the central nervous system (the brain and spinal cord), where it acts to depress, or slow, functioning by bind- ing to various neurons. One important group of neurons to which ethyl alcohol binds are those that normally receive the neurotransmitter GABA. As you saw in Chapter 4, GABA carries an inhibitory message—a message to stop firing—when it is received at certain neurons. When alcohol binds to receptors on those neurons, it apparently helps GABA to shut down the neurons, thus helping to relax the drinker (Ksir et al., 2008).

At first ethyl alcohol depresses the areas of the brain that control judgment and inhibition; people become looser, more talkative, and often more friendly. As their inner control breaks down, they may feel relaxed, confident, and happy. When more alcohol is absorbed, it slows down additional areas in the central nervous system, leav- ing the drinkers less able to make sound judgments, their speech less careful and less clear, and their memory weaker. Many people become highly emotional and perhaps loud and aggressive.

Motor difficulties increase as drinking continues, and reaction times slow. People may be unsteady when they stand or walk and clumsy in performing even simple ac- tivities. They may drop things, bump into doors and furniture, and misjudge distances. Their vision becomes blurred, particularly side vision, and they have trouble hearing.

19%

9%

10%

9%

4.3%

Percentage Who Exhibit Substance Abuse or Dependence

Native Americans

Hispanic Americans

White Americans

African Americans

Asian Americans

Figure 10-1 How do races differ in substance abuse and dependence? In the United States, Native Americans are more likely than members of other ethnic or cultural groups to abuse or be dependent on substances (NSDUH, 2008).

•substance abuse•A pattern in which people rely on a drug excessively and regularly, bringing damage to their rela- tionships, functioning poorly at work, or putting themselves or others in danger.

•substance dependence•A pattern in which people organize their lives around a drug, possibly building a tolerance to it, experiencing withdrawal symptoms when they stop taking it, or both. Also called addiction.

•tolerance•An adjustment by the brain and the body to the regular use of cer- tain drugs so that ever larger doses are needed to achieve earlier effects.

•withdrawal•Unpleasant, sometimes dangerous reactions that may occur when chronic users of a drug stop taking it or reduce their dosage.

•alcohol•Any drink containing ethyl alcohol, including beer, wine, and liquor.

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288 ://CHAPTER 10

As a result, people who have drunk too much alcohol may have great difficulty driving or solving simple problems.

The extent of the effect of ethyl alcohol is determined by its concentration, or propor- tion, in the blood. Thus a given amount of alcohol will have less effect on a large person than on a small one (see Table 10-2). Gender also affects the concentration of alcohol in the blood. Women have less of the stomach enzyme alcohol dehydrogenase, which breaks down alcohol in the stomach before it enters the blood. So women become more in- toxicated than men on equal doses of alcohol (Brady & Back, 2008).

Levels of impairment are closely related to the concentration of ethyl alcohol in the blood. When the alcohol concentration reaches 0.06 percent of the blood volume, a person usually feels relaxed and comfortable. By the time it reaches 0.09 percent, however, the drinker crosses the line into intoxication. If the level goes as high as 0.55 percent, death will probably result. Most people lose consciousness before they can drink enough to reach this level; nevertheless, more than 1,000 people in the United States die each year from too high a blood alcohol level (Ksir et al., 2008).

The effects of alcohol subside only when the alcohol concentration in the blood falls. Most of the alcohol is broken down, or metabolized, by the liver into carbon dioxide and water, which can be exhaled and excreted. The average rate of this breakdown is 25 percent of an ounce per hour, but different people’s livers work at different speeds; thus rates of “sobering up” vary. Despite popular belief, only time and metabolism can make a person sober. Drinking black coffee, splashing cold water on one’s face, or “pulling oneself together” cannot hurry the process.

Alcohol Abuse and Dependence Though legal, alcohol is actually one of the most dangerous of recreational drugs, and its reach extends across the life span. In fact, around 10 percent of elementary school students admit to some alcohol use, while nearly

Relationships between Sex, Weight, Oral Alcohol Consumption, and Blood Alcohol Level

Blood Alcohol Level (percent)

Absolute Beverage Female Male Female Male Female Male Alcohol (oz.) Intake* (100 lb.) (100 lb.) (150 lb.) (150 lb.) (200 lb.) (200 lb.) 1⁄2 1 oz. spirits† 0.045 0.037 0.03 0.025 0.022 0.019 1 glass wine 1 can beer

1 2 oz. spirits 0.090 0.075 0.06 0.050 0.045 0.037 2 glasses wine 2 cans beer

2 4 oz. spirits 0.180 0.150 0.12 0.100 0.090 0.070 4 glasses wine 4 cans beer

3 6 oz. spirits 0.270 0.220 0.18 0.150 0.130 0.110 6 glasses wine 6 cans beer

4 8 oz. spirits 0.360 0.300 0.24 0.200 0.180 0.150 8 glasses wine 8 cans beer

5 10 oz. spirits 0.450 0.370 0.30 0.250 0.220 0.180 10 glasses wine 10 cans beer

*In 1 hour. †100-proof spirits.

Source: Ksir et al., 2008, p. 209.

table: 10-2

BETWEEN THE LINES

Terms for “Hangover” Around the World Germany: “Wailing of cats” (Katzenjammer) <<

Italy: “Out of time” (stonato) <<

France: “Woody mouth” (gueule de bois) <<

Norway: “Workmen in my head” ( jeg har tommeermenn) <<

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Substance-Related Disorders :// 289

45 percent of high school seniors drink alcohol each month (most to the point of intoxication) and 3 percent report drinking every day ( Johnston et al., 2007). Similarly, alcohol misuse is a major problem on college campuses.

In any given year, 6.6 percent of the world’s population display a long-term pattern of alcohol abuse or dependence, either of which is known in popular terms as alcoholism, and over 13 percent experience one of the patterns sometime during their lifetime (Somers et al., 2004). Similarly, surveys indicate that over a one-year period, almost 8 percent of all adults in the United States display an alcohol use disorder, while over 13 percent experience it at some time in their lives (NSDUH, 2008; Kessler et al., 2005). Men with an alco- hol use disorder outnumber women by at least 2 to 1 (Kessler et al., 2005). In addition, many teenagers experience alcohol abuse or dependence ( Johnston et al., 2007).

The prevalence of alcoholism in a given year is around the same (7 to 9 percent) for white Americans, African Americans, and Hispanic Americans (SAMHSA, 2008). The men in these groups, how- ever, show strikingly different age patterns. For white American and Hispanic American men, the rate of alcoholism is highest—over 18 percent—during young adulthood, compared to 8 percent among African American men in that age group. For African American men, the rate is highest during late middle age, 15 percent compared to 8 percent among white American and Hispanic American men in that age group.

Native Americans, particularly men, tend to display a higher rate of alcohol abuse and dependence than any of these groups. Overall 15 percent of them abuse or depend on alcohol, although their specific prevalence rates differ across the various Native American reservation communities (SAMHSA, 2008; Beals et al., 2005). Generally, Asians in the United States and elsewhere have a lower rate of alcoholism (3 percent) than do people from other cultures. As many as one-half of these individuals have a de- ficiency of alcohol dehydrogenase, the chemical responsible for breaking down alcohol, so they react quite negatively to even a modest intake of alcohol. Such reactions in turn prevent extended use (Wall et al., 2001).

ALCOHOL ABUSE Generally speaking, people who abuse alcohol drink large amounts regularly and rely on it to enable them to do things that would otherwise make them anxious. Eventually the drinking interferes with their social behavior and ability to think and work. They may have frequent arguments with family members or friends, miss work repeatedly, and even lose their jobs. MRI scans of long-term heavy drinkers have revealed damage in various regions of their brains and, correspondingly, impairments in their short-term memory, speed of thinking, attention skills, and balance (Grilly, 2006; Meyerhoff et al., 2004).

Individually, people vary in their patterns of alcohol abuse. Some drink large amounts of alcohol every day and keep drinking until intoxicated. Others go on periodic binges of heavy drinking that can last weeks or months. They may remain intoxicated for days and later be unable to remember anything about the period. Still others may limit their excessive drinking to weekends, evenings, or both.

ALCOHOL DEPENDENCE For many people, the pattern of alcohol misuse includes depen- dence. Their bodies build up a tolerance for alcohol, and they need to drink ever greater amounts to feel its effects. They also experience withdrawal when they stop drinking. Within hours their hands, tongue, and eyelids begin to shake; they feel weak and nause- ated; they sweat and vomit; their heart beats rapidly; and their blood pressure rises. They may also become anxious, depressed, unable to sleep, or irritable (APA, 2000).

A small percentage of people who are dependent on alcohol experience a particu- larly dramatic withdrawal reaction called delirium tremens (“the DTs”). It consists of terrifying visual hallucinations that begin within three days after they stop or reduce

Experiencing alcohol’s effects A 16-year-old student weaves her way through an obstacle course while wearing a pair of alcohol-impaired goggles. The exer- cise is part of a program at her New Mexico high school, designed to give students hands-on experience regarding alcohol’s effects on vision and balance.

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•delirium tremens (DTs)•A dramatic withdrawal reaction experienced by some people who are alcohol- dependent. It consists of confusion, clouded conscious- ness, and terrifying visual hallucinations. Also called alcohol withdrawal delirium.

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290 ://CHAPTER 10

their drinking. Some people see small, frightening animals chasing or crawling on them or objects dancing about in front of their eyes. Like most other alcohol withdrawal symptoms, the DTs usually run their course in two to three days. However, people who experience the DTs or other severe withdrawal reactions may also have seizures, lose consciousness, suffer a stroke, or even die. Today certain medical procedures can help prevent or reduce such extreme reactions (Doweiko, 2006).

What Is the Personal and Social Impact of Alcoholism? Alcoholism destroys millions of families, social relationships, and careers. Medical treatment, lost productivity, and losses due to deaths from alcoholism cost society many billions of dol- lars annually. The disorder also plays a role in more than one-third of all suicides, homi- cides, assaults, rapes, and accidental deaths, including 30 percent of all fatal automobile

drinkers in high school are more likely to binge-drink in college.

Efforts to change such patterns have begun. For example, some universities now provide substance-free dorms: One study found that 36 percent of the residents in such dorms were binge drinkers, compared to 75 percent of those who lived in a fra- ternity or sorority house (Wechsler et al., 2002). This and other current research ef- forts are promising. However, most people in the clinical field agree that much more work is needed to help us fully understand, prevent, and treat what has become a major societal problem.

public health hazard” for full-time college students, and many researchers and clini- cians have turned their attention to it. Re- searchers at the Harvard School of Public Health, for example, have surveyed more than 50,000 students at 120 college cam- puses around the United States (Wechsler & Nelson, 2008; Wechsler et al., 2004, 1995, 1994). One of their surveys found that the students most likely to binge-drink were those who lived in a fraternity or so- rority house, pursued a party-centered life- style, and engaged in high-risk behaviors such as substance misuse or having multi- ple sex partners. Their surveys have also suggested that students who were binge

PSYCH WATCH

Drinking large amounts of alcohol in a short time, or binge drinking, is a seri- ous problem on college campuses, as well as in many other settings (NSDUH, 2008). Studies show that 40 percent of college stu- dents binge-drink at least once each year, some of them six times or more per month (NCASA, 2007; Sharma, 2005; Wechsler et al., 2004). Yet, in the minds of many people, alcohol use is an accepted part of college life. Is society taking the issue too lightly? Consider some of the following statistics:

◗ Around 83 percent of all campus arrests are alcohol-related (NCASA, 2007).

◗ Alcohol may be a factor in nearly 40 percent of academic problems and 28 percent of all college dropouts (Anderson, 1994).

◗ Approximately 600,000 students each year are physically assaulted or emotionally traumatized by a student drinker (NCASA, 2007; Hingson et al., 2002).

◗ Binge drinking by college students has been tied to 1,700 deaths, 500,000 injuries, and tens of thousands of cases of sexual assault, including date rape, every year (NCASA, 2007; Wechsler & Wuethrich, 2002; Wechsler et al., 2000).

◗ The number of female binge drinkers among college students has increased 31 percent over the past decade.

These findings have led some educators to describe binge drinking as “the No. 1

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Testing the limits Binge drinking, similar to this display at a college campus party, has led to a number of deaths in recent years.

College Binge Drinking: An Extracurricular Crisis

•Korsakoff’s syndrome•An alcohol- related disorder marked by extreme confusion and memory impairment.

•fetal alcohol syndrome•A cluster of mental and physical problems in a child, caused by a mother’s excessive alcohol intake during pregnancy.

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Substance-Related Disorders :// 291

accidents in the United States (Ksir et al., 2008; Yi et al., 2005). Altogether, intoxicated drivers are responsible for 12,000 deaths each year. More than 30 million adults (over 13 percent) have driven while intoxicated at least once in the past year (NSDUH, 2008).

Alcoholism has serious effects on the 30 million children of persons with this disor- der. Home life for these children is likely to include much conflict and perhaps sexual or other forms of abuse. In turn, the children themselves have higher rates of psychological problems (Hall & Webster, 2002; Mylant et al., 2002). Many have low self-esteem, poor communication skills, poor sociability, and marital difficulties (Watt, 2002).

Long-term excessive drinking can also seriously damage one’s physical health (Myrick & Wright, 2008). It so overworks the liver that people may develop an irre- versible condition called cirrhosis, in which the liver becomes scarred and dysfunctional. Cirrhosis accounts for more than 27,000 deaths each year (CDC, 2008). Alcohol abuse and dependence may also damage the heart and lower the immune system’s ability to fight off cancer and bacterial infections and to resist the onset of AIDS after infection.

Long-term excessive drinking also causes major nutritional problems. Alcohol makes people feel full and lowers their desire for food, yet it has no nutritional value. As a result, long-term drinkers become malnourished, weak, and prone to disease. Their vitamin and mineral deficiencies may also cause problems. An alcohol- related deficiency of vitamin B (thiamine), for example, may lead to Korsakoff ’s syndrome, a disease marked by extreme confusion, memory loss, and other neurological symptoms (Doweiko, 2006). People with Korsakoff ’s syndrome cannot remember the past or learn new information and may make up for their memory losses by confabulating—reciting made-up events to fill in the gaps.

Finally, women who drink during pregnancy place their fetuses at risk (Finnegan & Kandall, 2008). Excessive alcohol use during pregnancy may cause a baby to be born with fetal alcohol syndrome, a pattern of abnormalities that can include mental retardation, hyperactivity, head and face deformities, heart defects, and slow growth (Grilly, 2006). It has been estimated that in the overall population around 1 of every 1,000 babies is born with this syndrome (Ksir et al.,

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Dealing with DUI To publicize, prevent, and punish intoxicated driving, Phoenix, Arizona, has created DUI chain gangs for all to see. Members of these chain gangs, men convicted of drunken driv- ing, don bright pink shirts and perform tasks such as the burial of people who have died of alcohol-related disorders.

Substance misuse and sports fans A problem that has received growing attention in recent years is excessive drinking by fans at sporting events. While two soccer players were jumping for a high ball at this 2002 playoff game in Athens, Greece, fans of the rival teams—many of them intoxicated—ripped out plastic seats, threw flares on the field, and hurled coins and rocks at the players.

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292 ://CHAPTER 10

2008). The rate may increase to as many as 29 of every 1,000 babies of women who are problem drinkers. In addition, heavy drinking early in pregnancy often leads to a miscarriage. According to surveys, around 11 percent of pregnant American women have drunk alcohol during the past month and 4.5 percent of pregnant women have had binge-drinking episodes (NSDUH, 2008).

Sedative-Hypnotic Drugs Sedative-hypnotic drugs, also called anxiolytic drugs, produce feelings of relaxation and drowsiness. At low dosages, the drugs have a calming or sedative effect. At higher dosages, they are sleep inducers, or hypnotics. The sedative-hypnotic drugs include bar- biturates and benzodiazepines.

Barbiturates First discovered in Germany more than 100 years ago, barbiturates were widely prescribed in the first half of the twentieth century to fight anxiety and to help people sleep. Although still prescribed by some physicians, these drugs have been largely replaced by benzodiazepines, which are generally safer drugs. Barbiturates can cause many problems, not the least of which are abuse and dependence. Several thousand deaths a year are caused by accidental or suicidal overdoses.

Barbiturates are usually taken in pill or capsule form. In low doses they reduce a per- son’s level of excitement in the same way that alcohol does, by attaching to receptors on the neurons that receive the inhibitory neurotransmitter GABA and by helping GABA operate at those neurons (Ksir et al., 2008; Grilly, 2006). People can get intoxicated from large doses of barbiturates, just as they do from excessive alcohol. At too high a dose, the drugs can halt breathing, lower blood pressure, and lead to coma and death.

Repeated use of barbiturates can quickly result in a pattern of abuse (Dupont & Dupont, 2005). Users may spend much of the day intoxicated, irritable, and unable to do their work. Dependence can also result. The users organize their lives around the drug and need increasing amounts of it to calm down or fall asleep. A great danger of barbiturate dependence is that the lethal dose of the drug remains the same even while the body is building up a tolerance for its sedating effects. Once the prescribed dose stops reducing anxiety or inducing sleep, the user is all too likely to increase it without medical supervision and eventually may ingest a dose that proves fatal. Those caught in a pattern of barbiturate dependence may also experience withdrawal symptoms such as nausea, anxiety, and sleep problems. Barbiturate withdrawal is particularly dangerous because it can cause convulsions.

Risks and Consequences of Drug Misuse

Risk of Risk of Risk of Severe Organ Severe Social or Long-Lasting Intoxication Dependency Damage or Economic Mental and Potential Potential or Death Consequences Behavioral Change Opioids High High Low High Low to moderate

Sedative-hypnotics Barbiturates Moderate Moderate to high Moderate to high Moderate to high Low Benzodiazepines Moderate Moderate Low Low Low

Stimulants (cocaine, amphetamines) High High Moderate Low to moderate Moderate to high

Alcohol High Moderate High High High

Cannabis High Low to moderate Low Low to moderate Low

Mixed drugs High High High High High

Source: Ksir et al., 2008; APA, 2000; Gold, 1986, p. 28.

table: 10.3

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Alcohol and Auto Fatalities: A Special Relationship Single-vehicle fatalities are more likely to involve alcohol than multiple-vehicle fatalities. <<

There are proportionately more alcohol- related vehicle fatalities during the night than during the day and during the weekends than during the week. <<

(Fatality Facts, 2004)

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Benzodiazepines Chapter 4 described benzodiazepines, the antianxiety drugs developed in the 1950s, as the most popular sedative-hypnotic drugs available. Xanax, Ativan, and Valium are just three of the dozens of these drugs in clinical use. Altogether, about 100 million prescriptions are written each year for this group of drugs (Bisaga, 2008). Like alcohol and barbiturates, they calm people by binding to receptors on the neurons that receive GABA and by increasing GABA’s activity at those neurons (Ksir et al., 2008). These drugs, however, relieve anxiety without making people as drowsy as other kinds of sedative-hypnotics. They are also less likely to slow a person’s breathing, so they are less likely to cause death in the event of an overdose (Nishino et al., 1995).

When benzodiazepines were first discovered, they seemed so safe and effective that physicians prescribed them generously, and their use spread. Eventually it became clear that in high enough doses the drugs can cause intoxication and lead to abuse or dependence (Bisaga, 2008). As many as 1 percent of the adults in North America abuse or become physically dependent on these antianxiety drugs at some point in their lives (Sareen et al., 2004; Goodwin et al, 2002) and thus become subject to some of the same dangers that researchers have identified in barbiturate misuse.

Opioids Opioids include opium—taken from the sap of the opium poppy—and the drugs de- rived from it, such as heroin, morphine, and codeine. Opium itself has been in use for thousands of years. In the past it was used widely in the treatment of medical disorders because of its ability to reduce both physical and emotional pain. Eventually, however, physicians discovered that the drug was physically addictive.

In 1804 a new substance, morphine, was derived from opium. Named after Mor- pheus, the Greek god of sleep, this drug relieved pain even better than opium did and initially was considered safe. However, wide use of the drug eventually revealed that it, too, could lead to addiction. So many wounded soldiers in the United States received morphine injections during the Civil War that morphine dependence became known as “soldiers’ disease.”

In 1898 morphine was converted into yet another new pain reliever, heroin. For several years heroin was viewed as a wonder drug and was used as a cough medicine and for other medical purposes. Eventually, however, physicians learned that heroin is even more addictive than the other opioids. By 1917 the U.S. Congress had concluded that all drugs derived from opium were addictive (see Table 10-3), and it passed a law making opioids illegal except for medical purposes.

Still other drugs have been derived from opium, and synthetic (laboratory-blended) opioids such as methadone have also been developed. All these opioid drugs—natural and synthetic—are known collectively as narcotics. Each drug has a different strength, speed of action, and tolerance level. Morphine and codeine are medical nar- cotics usually prescribed to relieve pain. Heroin is illegal in the United States in all circumstances.

Narcotics are smoked, inhaled, snorted, injected by needle just beneath the skin (“skin popped”), or injected directly into the blood- stream (“mainlined”). Injection seems to be the most common method of narcotic use, although the other techniques have been used increas- ingly in recent years (NSDUH, 2008). An injection quickly brings on a rush—a spasm of warmth and ecstasy that is sometimes compared with orgasm. The brief spasm is followed by several hours of a pleasant feeling called a high or nod. During a high, the drug user feels relaxed, happy, and unconcerned about food, sex, or other bodily needs.

Opioids create these effects by depressing the central nervous system, particularly the centers that help control emotion. The drugs attach to brain receptor sites that ordinarily receive endorphins— neurotransmitters that help relieve pain and reduce emotional tension (Kreek, 2008; Ksir et al., 2008). When neurons at these receptor sites

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•sedative-hypnotic drug•A drug used in low doses to reduce anxiety and in higher doses to help people sleep. Also called anxiolytic drug.

•barbiturates•Addictive sedative- hypnotic drugs that reduce anxiety and help produce sleep.

•benzodiazepines•The most com- mon group of antianxiety drugs, which includes Valium and Xanax.

•opioid•Opium or any of the drugs derived from opium, including morphine, heroin, and codeine.

•opium•A highly addictive substance made from the sap of the opium poppy.

•morphine•A highly addictive sub- stance derived from opium that is particularly effective in relieving pain.

•heroin•One of the most addictive substances derived from opium.

•endorphins•Neurotransmitters that help relieve pain and reduce emotional tension. They are sometimes referred to as the body’s own opioids.

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receive opioids, they produce pleasurable and calming feelings just as they would do if they were receiving endorphins. In addition to reducing pain and tension, opioids cause nausea, narrowing of the pupils (“pinpoint pu- pils”), and constipation.

Heroin Abuse and Dependence Heroin use exemplifies the kinds of problems posed by opioids. After taking heroin repeatedly for just a few weeks, users may become caught in a pattern of abuse: The drug interferes significantly with their social and occupational functioning. In most cases, heroin abuse leads to a pattern of dependence as well, and users soon cen- ter their lives on the substance, build a tolerance for it, and experience a withdrawal reaction when they stop taking it (Kreek, 2008). At first the withdrawal symptoms are anxiety, restlessness, sweating, and rapid breath- ing; later they include severe twitching, aches, fever, vomiting, diarrhea, loss of appetite, high blood pressure, and weight loss of up to 15 pounds (due to

loss of bodily fluids). These symptoms usually peak by the third day, gradually subside, and disappear by the eighth day. A person in withdrawal can either wait out the symptoms or end withdrawal by taking heroin again.

People who are dependent on heroin soon need the drug just to avoid going into withdrawal, and they must continually increase their doses in order to achieve even that relief. The temporary high becomes less intense and less important. The individuals may spend much of their time planning their next dose, in many cases turning to criminal activities, such as theft and prostitution, to support the expensive “habit” (Allen, 2005).

Surveys suggest that close to 1 percent of adults in the United States become addicted to heroin or other opioids at some time in their lives (APA, 2000). The rate of such de- pendence dropped considerably during the 1980s, rose in the early 1990s, fell in the late 1990s, and now seems to be relatively high once again (NSDUH, 2008). The number of persons currently addicted to these drugs is estimated to be as much as 323,000. The actual number may be even higher, however, given the reluctance of many people to admit an illegal activity.

What Are the Dangers of Heroin Abuse? The most immediate danger of heroin use is an overdose, which closes down the respiratory center in the brain, almost paralyzing breathing and in many cases causing death. Death is particularly likely dur- ing sleep, when a person is unable to fight this effect by consciously working to breathe. People who resume heroin use after having avoided it for some time often make the fatal mistake of taking the same dose they had built up to before. Because their bodies have been without heroin for some time, however, they can no longer tolerate this high level. Each year approximately 2 percent of persons dependent on heroin and other opioids die under the drug’s influence, usually from an overdose (Theodorou & Haber, 2005; APA, 2000).

Users run other risks as well. Often the heroin they purchase has been mixed with a cheaper drug or even a deadly substance such as cyanide or battery acid. In addition, dirty needles and other unsterilized equipment spread infections such as AIDS, hepatitis C, and skin abscesses (Batki & Nathan, 2008). In some areas of the United States the HIV infection rate among persons dependent on heroin is reported to be as high as 60 percent (APA, 2000).

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Injecting heroin Opioids may be taken by mouth, inhaled, snorted, injected just beneath the surface of the skin, or injected intravenously. Here, one addict injects another with heroin inside one of the many so-called shooting galler- ies where addicts gather in downtown San Juan, Puerto Rico.

SUMMING UP Substance Misuse and Depressants

The misuse of substances (or drugs) may lead to temporary changes such as intoxi- cation. Long-term and high use can lead to substance abuse or substance depen- dence. People who become dependent on a drug may develop a tolerance for it, experience unpleasant withdrawal symptoms when they abstain from it, or both.

BETWEEN THE LINES

Nonmedical Use of Pain Relievers In the United States, the largest increase in illicit drug use during the past few years involved the nonmedical use of medications, mostly pain relievers. <<

Around 7 million persons currently use medications nonmedically. <<

During the past year, 2 million persons used medications nonmedically for the first time. <<

23 is the average age of first-time users of pain drugs for nonmedical purposes. <<

(NSDUH, 2008, 2005)

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jjStimulants Stimulants are substances that increase the activity of the central nervous system, result- ing in increased blood pressure and heart rate, greater alertness, and sped-up behavior and thinking. Among the most troublesome stimulants are cocaine and amphetamines, whose effects on people are very similar. When users report different effects, it is often because they have ingested different amounts of the drugs. Two other widely used and legal stimulants are caffeine and nicotine.

Cocaine Cocaine—the central active ingredient of the coca plant, found in South America—is the most powerful natural stimulant now known. The drug was first separated from the plant in 1865. Native people of South America, however, have chewed the leaves of the plant since prehistoric times for the energy and alertness the drug offers. Processed cocaine is an odorless, white, fluffy powder. For recreational use, it is most often snorted so that it is absorbed through the mucous membrane of the nose. Some users prefer the more powerful effects of injecting cocaine intravenously or smoking it in a pipe or cigarette.

For years people believed that cocaine posed few problems aside from intoxication and, on occasion, temporary psychosis. Only later did researchers come to appreciate its many dangers. Their insights came after society witnessed a dramatic increase in the drug’s popularity and in problems related to its use. In the early 1960s an estimated 10,000 persons in the United States had tried cocaine. Today 28 million people have tried it, and 2.4 million—most of them teenagers or young adults—are using it currently (NSDUH, 2008). In fact, 2 percent of all high school seniors have used cocaine within the past month ( Johnston et al., 2007).

Cocaine brings on a euphoric rush of well-being and confidence. Given a high enough dose, this rush can be almost orgasmic, like the one produced by heroin. At first cocaine stimulates the higher centers of the central nervous system, making users feel excited, energetic, talkative, and even euphoric. As more is taken, it stimulates other centers of the central nervous system, producing a faster pulse, higher blood pressure, faster and deeper breathing, and further arousal and wakefulness.

Cocaine apparently produces these effects largely by increasing sup- plies of the neurotransmitter dopamine at key neurons throughout the brain (Haney, 2008; Kosten et al., 2008) (see Figure 10-2). Excessive amounts of dopamine travel to receiving neurons throughout the central

Depressants are substances that slow the activity of the central nervous system. Long-term and excessive use of these substances can lead to a pattern of abuse or dependence.

Alcoholic beverages contain ethyl alcohol, which is carried by the blood to the central nervous system, depressing its function. Intoxication occurs when the concentration of alcohol in the bloodstream reaches 0.09 percent. Among other actions, alcohol increases the activity of the neurotransmitter GABA at key sites in the brain. The sedative-hypnotic drugs, which produce feelings of relaxation and drowsiness, include barbiturates and benzodiazepines. These drugs also increase the activity of GABA.

Opioids include opium and drugs derived from it, such as morphine and heroin, as well as laboratory-made opioids. They all reduce tension and pain and cause other reactions. Opioids operate by binding to neurons that ordinarily receive endorphins.

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Figure 10-2 Biochemical euphoria The subjective experiences of euphoria after a cocaine injection closely parallel cocaine’s action at dopamine-using neurons. The peak experience of euphoria seems to occur around the same time as the peak of neuron activity (Fowler et al., 1995, p. 110; Cook et al., 1985).

•cocaine•An addictive stimulant obtained from the coca plant. It is the most powerful natural stimulant known.

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nervous system and overstimulate them. In addition, cocaine appears to increase the activity of the neurotransmitters norepinephrine and serotonin in some areas of the brain (Haney, 2008; Ksir et al., 2008).

High doses of the drug produce cocaine intoxication, whose symptoms are poor muscle coordination, grandiosity, bad judgment, anger, aggression, compulsive behavior, anxiety, and confusion. Some people experience hallucinations, delusions, or both, a condition known as cocaine-induced psychotic disorder (APA, 2000).

A young man described how, after free-basing, he went to his closet to get his clothes, but

his suit asked him, “What do you want?” Afraid, he walked toward the door, which told

him, “Get back!” Retreating, he then heard the sofa say, “If you sit on me, I’ll kick your

ass.” With a sense of impending doom, intense anxiety, and momentary panic, the young

man ran to the hospital where he received help.

(Allen, 1985, pp. 19–20)

As the stimulant effects of cocaine subside, the user experiences a depression-like let- down, popularly called crashing, a pattern that may also include headaches, dizziness, and fainting (Doweiko, 2006). For occasional users, the aftereffects usually disappear within 24 hours, but they may last longer for people who have taken a particularly high dose. These individuals may sink into a stupor, deep sleep, or, in some cases, coma.

Cocaine Abuse and Dependence Regular use of cocaine may lead to a pat- tern of abuse in which the person remains under its effects much of each day and func- tions poorly in social relationships and at work. Regular use may also cause problems in short-term memory or attention (Kubler et al., 2005). Dependence may also develop, so that cocaine dominates the person’s life, higher doses are needed to gain the desired ef- fects, and stopping it results in depression, fatigue, sleep problems, irritability, and anxiety (Barry et al., 2009). These withdrawal symptoms may last for weeks or even months after drug use has ended.

In the past, cocaine use and impact were limited by the drug’s high cost. Moreover, cocaine was usually snorted, a form of ingestion that has less powerful effects than either smoking or injection. Since 1984, however, the availability of newer, more powerful, and sometimes cheaper forms of cocaine has produced an enormous increase in abuse and dependence. Currently, close to 1 percent of all people over the age of 11 in the United States display cocaine abuse or dependence in a given year (NSDUH, 2008). Many people now ingest cocaine by free-basing, a technique in which the pure co-

caine basic alkaloid is chemically separated, or “freed,” from processed cocaine, vaporized by heat from a flame, and inhaled through a pipe. Millions more use crack, a powerful form of free-base cocaine that has been boiled down into crystalline balls. It is smoked with a special pipe and makes a crackling sound as it is inhaled (hence the name). Crack is sold in small quantities at a fairly low cost, a practice that has resulted in crack epidemics among people who previously could not have afforded cocaine, primarily those in poor urban areas (Acosta et al., 2005). Almost 2 percent of high school seniors report having used crack within the past year ( Johnston et al., 2007).

What Are the Dangers of Cocaine? Aside from cocaine’s harmful effects on behavior, the drug poses serious physical dangers (Kosten et al., 2008). Its growing use in powerful forms has caused the annual number of cocaine-related emergency room incidents in the United States to multiply by more than 100 times since 1982, from around 4,000 cases to 450,000 (SAMHSA, 2007). In addition, cocaine

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Smoking crack Crack, a powerful form of free-base cocaine, is produced by boiling cocaine down into crystalline balls and is smoked with a crack pipe.

•free-base•A technique for ingesting cocaine in which the pure cocaine basic alkaloid is chemically separated from processed cocaine, vaporized by heat from a flame, and inhaled with a pipe.

•crack•A powerful form of ready-to- smoke free-base cocaine.

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use has been linked to as many as 20 percent of all suicides by men under 61 years of age (Garlow, 2002).

The greatest danger of cocaine use is an overdose. Excessive doses have a strong ef- fect on the respiratory center of the brain, at first stimulating it and then depressing it, to the point where breathing may stop. Cocaine can also create major, even fatal, heart irregularities or brain seizures that bring breathing or heart functioning to a sudden stop (Ksir et al., 2008). In addition, pregnant women who use cocaine run the risk of

A CLOSER LOOK

Almost 30 percent of all Americans over the age of 11 regularly smoke tobacco (NSDUH, 2008). Surveys also suggest that 22 percent of all high school seniors have smoked in the past month ( Johnston et al., 2007). At the same time, 440,000 persons in the United States die each year as a result of smoking. Smok- ing is directly tied to high blood pressure, coronary heart disease, lung disease, cancer, strokes, and other deadly medical problems (George & Weinberger, 2008; Hymowitz, 2005). Nonsmokers who inhale cigarette smoke from their environment have a higher risk of lung cancer and other diseases. And the 16.4 percent of all pregnant women who smoke are more likely than nonsmokers to deliver premature and underweight babies (Ksir et al., 2008; NSDUH, 2008).

So why do people continue to smoke? Because nicotine, the active substance in tobacco and a stimulant of the central nervous system, is as addictive as heroin,

perhaps even more so (Ksir et al., 2008; Report of the Surgeon General, 1988). Indeed, the World Health Organization estimates that 1.1 billion people worldwide are addicted to nicotine (Hasman & Holm, 2004). Regular smokers develop a toler- ance for nicotine and must smoke more and more in order to achieve the same results. When they try to stop smoking, they experi- ence withdrawal symptoms—irritability, in- creased appetite, sleep disturbances, slower metabolism, cognitive difficulties, and crav- ings to smoke (Brandon et al., 2009; APA, 2000). As a stimulant, nicotine acts on the same neurotransmitters and reward center in the brain as amphetamines and cocaine (George & Weinberger, 2008).

The declining acceptability of smoking in our society has created a market for products and techniques to help people kick the habit. A fairly helpful behavioral treatment for nicotine addiction is aversion therapy. In one version of this approach, known as rapid smoking, the smoker sits in

a closed room and puffs quickly on a ciga- rette, as often as once every six seconds, until he or she begins to feel ill and cannot take another puff. The feelings of illness become associated with smoking, and the smoker develops an aversion to cigarettes (George & Weinberger, 2008).

Several biological treatments have also been developed. A common one is the use of nicotine gum, an over-the-counter product that contains a high level of nico- tine that is released as the smoker chews. Theoretically, people who obtain nicotine by chewing will no longer feel a need to smoke. A similar approach is the nico- tine patch, which is attached to the skin like a Band-Aid. Its nicotine is absorbed through the skin throughout the day, sup- posedly easing withdrawal and reducing the smoker’s need for nicotine. Studies find that both nicotine gum and the nicotine patch help people to abstain from smok- ing (George & Weinberger, 2008; Grilly, 2006). Still other popular biological prod-

ucts are nicotine lozenges, nicotine nasal spray, and the antidepressant drug bupropion (brand names Zyban and Wellbutrin).

The more one smokes, the harder it is to quit. On the positive side, however, former smokers’ risk of disease and death decreases steadily the longer they continue to avoid smoking. This assurance may be a powerful motivator for many smokers, and, in fact, around 46 percent of

regular smokers want to stop and are even- tually able to stop permanently (NSDUH, 2008). In the meantime, more than 1,000 people die of smoking-related diseases each day.

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Genetics or modeling? A man smokes a cigarette while reading to his daughter in Beijing, China. The tendency to smoke tobacco and become dependent on nicotine often runs in families. Apparently, both genetics and environment play key roles in such family trends (Rende et al., 2005).

Tobacco, Nicotine, and Addiction

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having a miscarriage and of having children with abnormalities in immune functioning, attention and learning, thyroid size, and dopamine and serotonin activity in the brain (Kosten et al., 2008).

Amphetamines The amphetamines are stimulant drugs that are manufactured in the laboratory. Some common examples are amphetamine (Benzedrine), dextroamphetamine (Dexedrine), and methamphetamine (Methedrine). First produced in the 1930s to help treat asthma, amphetamines soon became popular among people trying to lose weight; athletes seek- ing an extra burst of energy; soldiers, truck drivers, and pilots trying to stay awake; and students studying for exams through the night. Physicians now know the drugs are far too dangerous to be used so casually, and they prescribe them much less freely.

Amphetamines are most often taken in pill or capsule form, although some people inject the drugs intravenously or smoke them for a quicker, more powerful effect. Like cocaine, amphetamines increase energy and alertness and reduce appetite when taken in small doses; produce a rush, intoxication, and psychosis in high doses; and cause an emotional letdown as they leave the body. Also like cocaine, amphetamines stimulate the central nervous system by increasing the release of the neurotransmitters dopamine, nor- epinephrine, and serotonin throughout the brain, although the actions of amphetamines differ somewhat from those of cocaine (Haney, 2008; Rawson & Ling, 2008).

Tolerance to amphetamines builds very quickly, so users are at great risk of becom- ing dependent (Acosta et al., 2005). People who start using the drug to reduce their appetite and weight, for example, may soon find they are as hungry as ever and increase their dose in response. Athletes who use amphetamines to increase their energy may also find before long that larger and larger amounts of the drug are needed. So-called speed freaks, who pop pills all day for days at a time, have built a tolerance so high that they now take as much as 200 times their initial amphetamine dose. When people who depend on the drug stop taking it, they may plunge into a deep depression and extended sleep identical to the withdrawal from cocaine. Around 0.4 percent of adults

display amphetamine abuse or dependence each year (NSDUH, 2008). As many as 2 percent become dependent on amphetamines at some point in their lives (APA, 2000; Anthony et al., 1995).

One kind of amphetamine, methamphetamine (nicknamed crank), has had a major surge in popularity in recent years and so warrants special discus- sion. Almost 6 percent of all persons over the age of 11 in the United States have used this stimulant at least once. Around 0.3 percent use it currently (NSDUH, 2008). It is available in the form of crystals, also known by the street names ice and crystal meth, which are smoked by users.

Most of the nonmedical methamphetamine in the United States is made in small “stovetop laboratories,” which typically operate for a few days in a remote area and then move on to a safer location (Ksir et al., 2008). Such laboratories have increased eightfold over the past decade. A major health concern is that they expel dangerous fumes and residue (Burgess, 2001).

Since 1989, when the media first began reporting about the dangers of smoking methamphetamine crystals, the rise in usage has been dramatic. At this point, 15 million Americans have tried this stimulant at least once (NSDUH, 2008). Until recently, use of the drug was much more prevalent in western parts of the United States, but its use has now spread east as well (NSDUH, 2007). Similarly, methamphetamine-linked emergency room visits are rising in hospitals throughout all parts of the country (DAWN, 2008).

Methamphetamine is about as likely to be used by women as men. Around 40 percent of current users are women. The drug is particularly popular today among biker gangs, rural Americans, and urban gay communities and has gained wide use as a “club drug,” the term for those drugs that regularly find their way to all-night dance parties, or “raves” (Echevarry & Nettles, 2009).

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Methamphetamine dependence: spreading the word This powerful ad shows the degenerative effects of methamphetamine addiction on a woman over a four-year period— from age 36 in the top photo to age 40 in the bottom one.

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Cocaine Alert Cocaine accounts for more drug treatment admissions than any other drug (Ksir et al., 2008; SAMHSA, 2007). <<

Early in his career, Sigmund Freud was a staunch advocate of cocaine use. He proclaimed, “Cocaine brings about an exhilaration . . . an increase in self-control and . . . more vitality and capacity for work” (Freud, 1885). <<

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Like other kinds of amphetamines, methamphetamine increases activity of the neu-

rotransmitters dopamine, serotonin, and norepinephrine, producing increased arousal, attention, and related effects (Rawson & Ling, 2008). It can have serious negative effects on a user’s physical, mental, and social life (NSDUH, 2007). Of particular concern is that it damages nerve endings (Rawson & Ling, 2008). But users focus more on meth- amphetamine’s immediate positive impact, including perceptions by many that it makes them feel hypersexual and uninhibited ( Jefferson, 2005). Such perceived effects have contributed to several societal problems. For example, one-third of all men who tested positive for HIV in Los Angeles in 2004 reported having used this drug. In the area of law enforcement, one survey of police agencies had 58 percent of them reporting that methamphetamine is the leading drug they battle today.

SUMMING UP Stimulants

Stimulants are substances that increase the activity of the central nervous system. They may lead to intoxication, abuse, and dependence, including a withdrawal pattern marked by depression, fatigue, and irritability. Cocaine and amphetamines produce their effects by increasing the activity of dopamine, norepinephrine, and serotonin in the brain.

jjHallucinogens, Cannabis, and Combinations of Substances Other kinds of substances may also cause problems for their users and for society. Hallu- cinogens produce delusions, hallucinations, and other sensory changes. Cannabis substances produce sensory changes, but they also have depressant and stimulant effects, and so they are considered apart from hallucinogens in DSM-IV-TR. And many individuals take combinations of substances.

Hallucinogens Hallucinogens are substances that cause powerful changes in sensory perception, from strengthening a person’s normal perceptions to inducing illusions and hallucinations. They produce sensations so out of the ordinary that they are sometimes called “trips.” The trips may be exciting or frightening, depending on how a person’s mind interacts with the drugs. Also called psychedelic drugs, the hallucinogens include LSD, mescaline, and MDMA (Ecstasy). Many of these substances come from plants or animals; others are laboratory-produced.

LSD (lysergic acid diethylamide), one of the most famous and most powerful hallucinogens, was derived by Swiss chemist Albert Hoffman in 1938 from a group of naturally occurring drugs called ergot alkaloids. During the 1960s, a decade of social rebellion and experimentation, millions of persons turned to the drug as a way of expanding their experience. Within two hours of being swallowed, LSD brings on a state of hallucinogen intoxication, sometimes called hallucinosis, marked by a general strengthening of perceptions, particularly visual perceptions, along with psychological changes and physical symptoms. People may focus on small details—the pores of the skin, for example, or individual blades of grass. Colors may seem enhanced or take on a shade of purple. Illu- sions may be experienced in which objects seem distorted and may appear to move, breathe, or change shape. A person under the influence of LSD may also hallucinate—seeing people, objects, or forms that are not actually present.

Early LSD research Not yet recognizing how powerful and dangerous LSD can be, early investigators sometimes conducted research on this drug in a naïve and casual manner. This 1955 photo shows one researcher administering LSD to another in Emory University’s Phar- macological Department.

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•amphetamine•A stimulant drug that is manufactured in the laboratory.

•methamphetamine•A powerful amphetamine drug whose surge in popu- larity in recent years has posed major health and law enforcement problems.

•hallucinogen•A substance that causes powerful changes primarily in sensory perception, including stronger percep- tions, illusions, and hallucinations. Also called psychedelic drug.

•LSD (lysergic acid diethylamide)•A hallucinogenic drug derived from ergot alkaloids.

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Bonson, 2001). MDMA also interferes with the body’s ability to produce new supplies of serotonin. With repeated use, the brain eventually produces less and less serotonin (Baggot & Mendelson, 2001).

Ecstasy’s impact on these neurotransmit- ters accounts for its various psychological effects—and associated problems. High levels of serotonin, such as those produced after one first ingests MDMA, produce feel- ings of well-being, sociability, and even euphoria. Conversely, abnormally low sero- tonin levels are associated with depression and anxiety. This is why “coming down” off a dose of Ecstasy often produces those psychological symptoms (Malberg & Bon- son, 2001). Moreover, because repeated use of Ecstasy leads to long-term serotonin deficits, the depression and anxiety may be long-lasting. Finally, serotonin is linked to our ability to concentrate; thus the re- peated use of Ecstasy may produce prob- lems in memory and learning (Zakzanis et al., 2007).

End of the Honeymoon? The dangers of MDMA do not yet seem to outweigh its pleasures in the minds of many individuals. In fact, use of the drug is still expanding to many social settings beyond raves, dance clubs, and college scenes (Weaver & Schnoll, 2008). Clearly, despite the research indications listed here, the honeymoon for this drug is not yet over.

◗ Significant impairment of memory and other cognitive skills.

◗ Physical symptoms such as muscle ten- sion, nausea, blurred vision, faintness, and chills or sweating. MDMA also causes many people to clench and grind their teeth for hours at a time.

◗ Increases in heart rate and blood pres- sure, which place people with heart disease at special risk.

◗ Reduced sweat production. At a hot, crowded dance party, taking Ecstasy can even cause heat stroke, or hyper- thermia. Users generally try to fix this problem by drinking lots of water, but since the body cannot sweat under the drug’s influence, the excess fluid intake can result in an equally danger- ous condition known as hyponatremia, or “water intoxication.”

◗ Potential liver damage. This may happen when users take MDMA in combination with other drugs that are broken down by the same liver en- zyme, such as the cheaper compound DXM, which is commonly mixed in with Ecstasy by dealers.

How Does MDMA Operate in the Brain? MDMA works by causing the neurotransmit- ters serotonin and (to a lesser extent) dopa- mine to be released all at once throughout the brain, at first increasing and then de- pleting a person’s overall supply of the neu- rotransmitters (Ksir et al., 2008; Malberg &

PSYCH WATCH

You probably know of the drug MDMA (3,4-methylenedioxymethamphetamine) by its common street name, Ecstasy. It is also known as X, Adam, hug, beans, and love drug. This laboratory-produced drug is technically a stimulant, similar to amphet- amines, but it also produces hallucinogenic effects and so is often considered a hal- lucinogenic drug. MDMA was developed as far back as 1910, but only in the past two decades has it gained life as a “club drug”—one of the drugs that are extremely popular at all-night techno-dance parties known as “raves.” Today, in the United States alone, consumers collectively take hundreds of thousands of doses of MDMA weekly despite the drug’s illegal status (Weaver & Schnoll, 2008; McDowell, 2005). Altogether, 12 million Americans over the age of 11 have tried MDMA at least once in their lifetimes, 2 million in the past year (NSDUH, 2008). Around 6.5 percent of all high school seniors have used it within the past year ( Johnston et al., 2007).

What is Ecstasy’s allure? As a stimulant and hallucinogen, it helps to raise the mood of many partygoers and provides them with an energy boost that enables them to keep dancing and partying. How- ever, it also turns out to be a dangerous drug, particularly when taken repeatedly.

What Are the Dangers of Using Ecstasy? As MDMA has gained wider and wider use, the drug has received increasing research scrutiny. As it turns out, the mood and energy lift produced by MDMA comes at a high price (Ksir et al., 2008; Weaver & Schnoll, 2008; Wiegand et al., 2008). The problems that the drug may cause in- clude the following:

◗ Immediate psychological problems such as confusion, depression, sleep difficulties, severe anxiety, and para- noid thinking. These symptoms may also continue for weeks after ingestion of MDMA.

Club Drugs: X Marks the (Wrong) Spot

Feeling the effects Shortly after taking MDMA, this couple manifests a shift in mood, energy, and behavior. Although this drug can feel pleasurable and energizing, often it produces undesired immediate effects, includ- ing confusion, depression, anxiety, sleep difficulties, and paranoid thinking.

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Hallucinosis may also cause one to hear sounds more clearly, feel tingling or numb-

ness in the limbs, or confuse the sensations of hot and cold. Some people have been badly burned after touching flames that felt cool to them under the influence of LSD. The drug may also cause different senses to cross, an effect called synesthesia. Colors, for example, may be “heard” or “felt.”

LSD can also induce strong emotions, from joy to anxiety or depression. The percep- tion of time may slow dramatically. Long-forgotten thoughts and feelings may resurface. Physical symptoms can include sweating, palpitations, blurred vision, tremors, and poor coordination. All of these effects take place while the user is fully awake and alert, and they wear off in about six hours.

It seems that LSD produces these symptoms primarily by binding to some of the neurons that normally receive the neurotransmitter serotonin, changing the neurotrans- mitter’s activity at those sites ( Julien, 2008; Ksir et al., 2008). These neurons ordinarily help the brain send visual information and control emotions (as you saw in Chapter 7); thus LSD’s activity there produces various visual and emotional symptoms.

More than 14 percent of all persons in the United States have used LSD or another hallucinogen at some point in their lives. Around 0.4 percent are currently using it (NSDUH, 2008). Although people do not usually develop tolerance to LSD or have withdrawal symptoms when they stop taking it, the drug poses dangers for both one- time and long-term users. It is so powerful that any dose, no matter how small, is likely to produce enormous perceptual, emotional, and behavioral reactions. Sometimes the reactions are extremely unpleasant—an experience called a “bad trip.” Reports of LSD users who injure themselves or others usually involve a reaction of this kind:

A 21-year-old woman was admitted to the hospital along with her lover. He had had a

number of LSD experiences and had convinced her to take it to make her less constrained

sexually. About half an hour after ingestion of approximately 200 microgm., she noticed

that the bricks in the wall began to go in and out and that light affected her strangely. She

became frightened when she realized that she was unable to distinguish her body from the

chair she was sitting on or from her lover’s body. Her fear became more marked after she

thought that she would not get back into herself. At the time of admission she was hyper-

active and laughed inappropriately. Her stream of talk was illogical and affect labile. Two

days later, this reaction had ceased.

(Frosch, Robbins, & Stern, 1965)

Another danger is the long-term effect that LSD may have (Weaver & Schnoll, 2008). Some users eventually develop psychosis or a mood or anxiety disorder. And some have flashbacks—a recurrence of the sensory and emotional changes after the LSD has left the body (Halpern, 2003). Flashbacks may occur days or even months after the last LSD experience.

Cannabis Cannabis sativa, the hemp plant, grows in warm climates throughout the world. The drugs produced from varieties of hemp are, as a group, called cannabis. The most powerful of them is hashish; the weaker ones include the best-known form of cannabis, marijuana, a mixture derived from the buds, crushed leaves, and flowering tops of hemp plants. Of the several hundred active chemicals in cannabis, tetrahydrocannabi- nol (THC) appears to be the one most responsible for its effects. The greater the THC content, the more powerful the cannabis.

When smoked, cannabis produces a mixture of hallucinogenic, depressant, and stimu- lant effects. At low doses, the smoker typically has feelings of joy and relaxation and may become either quiet or talkative. Some smokers, however, become anxious, suspicious,

•cannabis drugs•Drugs produced from the varieties of the hemp plant Cannabis sativa. They cause a mixture of hallucino- genic, depressant, and stimulant effects.

•marijuana•One of the cannabis drugs, derived from buds, leaves, and flowering tops of the hemp plant Cannabis sativa.

•tetrahydrocannabinol (THC)•The main active ingredient of cannabis substances.

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Blinded by the Sun? In 1967 major news services reported that four California college students had suffered permanent vision loss after star- ing at the sun while under the influence of LSD. The students were said to have suffered damage to their retinas. Eight months later another news report said that six Pennsylvania college students had suffered total and permanent blindness after, again, staring at the sun during LSD trips. The stories were seized upon by medical and government officials as clear evidence of the destructive power of LSD. The stories were, in fact, hoaxes, but the incidents have continued to receive wide- spread belief to the present day. <<

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or irritated, especially if they have been in a bad mood or are smoking in an upsetting environment. Many smokers report sharpened perceptions and fascination with the intensified sounds and sights around them. Time seems to slow down, and distances and sizes seem greater than they actually are. This overall “high” is technically called cannabis intoxication. Physical changes include reddening of the eyes, fast heartbeat, increases in blood pressure and appetite, dryness in the mouth, and dizzi- ness. Some people become drowsy and may fall asleep.

In high doses, cannabis produces odd visual experiences, changes in body image, and hallucinations. Smokers may be- come confused or impulsive. Some worry that other people are trying to hurt them. Most of the effects of cannabis last two to six hours. The changes in mood, however, may con- tinue longer.

Marijuana Abuse and Dependence Until the early 1970s, the use of marijuana, the weak form of cannabis, rarely led to a pattern of abuse or dependence. Today, however, many people, including large numbers of high school students, are caught in a pattern of marijuana abuse, getting high on mari- juana regularly and finding their social and occupational or academic lives greatly affected (see Figure 10-3). Many regular users also become physically dependent on marijuana. They develop a tolerance for it and may experience flulike symp- toms, restlessness, and irritability when they stop smoking

(Chen et al., 2005). Around 1.7 percent of all persons in the United States have displayed marijuana abuse or dependence in the past year; as many as 5 percent fall into one of these patterns at some point in their lives (NSDUH, 2008).

Why have patterns of marijuana abuse and dependence increased in the last three decades? Mainly because the drug has changed. The marijuana widely available in the United States today is at least four times more powerful than that used in the early 1970s. The THC content of today’s marijuana is, on average, 8 percent, compared to 2 percent in the late 1960s (APA, 2000). Marijuana is now grown in places with a hot, dry climate, which increases the THC content.

Is Marijuana Dangerous? As the strength and use of marijuana have increased, re- searchers have discovered that smoking it may pose certain dangers. It occasionally causes panic reactions similar to the ones caused by hallucinogens, and some smokers may fear they are losing their minds (Doweiko, 2006). Typically such reactions end in three to six hours, along with marijuana’s other effects.

Because marijuana can interfere with the performance of complex sensorimotor tasks and with cognitive functioning, it has caused many automobile accidents (Ramaekers et al., 2006). Furthermore, people on a marijuana high often fail to remember informa- tion, especially anything that has been recently learned, no matter how hard they try to concentrate; thus heavy marijuana smokers are at a serious disadvantage at school or work (Lundqvist, 2005).

One study compared blood flow in the brain arteries of chronic marijuana users and nonusers (Herning et al., 2005). After one month of abstinence from smoking mari- juana, chronic users continued to display higher blood flow than nonusers. Though still higher than normal, the blood flow of light marijuana users (fewer than 16 smokes per week) and of moderate users (fewer than 70 smokes per week) had improved somewhat over the course of the abstinence month. The blood flow of heavy users, however, had shown no improvement. This lingering effect may help explain the memory and think- ing problems of long-term heavy users of marijuana.

There are indications that regular marijuana smoking may also lead to long-term health problems (Deplanque, 2005). It may, for example, contribute to lung disease.

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Figure 10-3 How easy is it for teenagers to acquire substances? Most surveyed tenth graders say it is easy to get cigarettes, alcohol, and marijuana, and around one-third say it is easy to get Ecstasy, amphetamines, steroids, and barbiturates (Johnston et al., 2007).

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Studies show that marijuana smoking reduces the ability to expel air from the lungs even more than tobacco smoking does (Tashkin, 2001). In addition, marijuana smoke contains more tar and benzopyrene than tobacco smoke (Ksir et al., 2008). Both of these substances have been linked to cancer. Another concern is the effect of regular marijuana smoking on human reproduction. Studies since the late 1970s have discov- ered lower sperm counts in men who are chronic smokers of marijuana, and abnormal ovulation has been found in female smokers (Schuel et al., 2002).

Efforts to educate the public about the growing dangers of repeated marijuana use appeared to have a major impact throughout the 1980s. The percentage of high school seniors who smoked the substance on a daily basis decreased from 11 percent in 1978 to 2 percent in 1992 ( Johnston et al., 1993). Today, however, 5 percent of high school seniors smoke marijuana daily, and 45 percent do not believe that regular use can be harmful ( Johnston et al., 2007).

Cannabis and Society: A Rocky Relationship For centuries cannabis played a respected role in medicine. It was recommended as a surgical anesthetic by Chinese physicians 2,000 years ago and was used in other lands to treat cholera, malaria, coughs, insomnia, and rheumatism. When cannabis entered the United States in the early twen- tieth century, mainly in the form of marijuana, it was likewise used for various medical purposes. Soon, however, more effective medicines replaced it, and the favorable view of cannabis began to change. Marijuana began to be used as a recreational drug, and its il- legal distribution became a law enforcement problem. Authorities assumed it was highly dangerous and outlawed the “killer weed.”

In the 1980s researchers developed precise techniques for measuring THC and for extracting pure THC from cannabis; they also developed laboratory forms of THC. These inventions opened the door to new medical applications for cannabis (Mack & Joy, 2001), such as its use in treating glaucoma, a severe eye disease. Cannabis was also found to help patients with chronic pain or asthma, to reduce the nausea and vomiting of cancer patients in chemotherapy, and to improve the appetites of AIDS patients and so combat weight loss in people with that disorder.

In light of these findings, several interest groups campaigned during the late 1980s for the medical legalization of marijuana, which operates on the brain and body more quickly than the THC capsules developed in the laboratory. Government agencies re- sisted this movement, saying that prescriptions for pure THC serve all needed medical functions. But the battle between advocates and opponents of the legalization of mari- juana for medical purposes was just beginning, and, in fact, that battle has continued to the present day.

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The source of marijuana Marijuana is made from the leaves of the hemp plant, Cannabis sativa. The plant is an annual herb, reaches a height of between 3 and 15 feet, and is grown in a wide range of altitudes, climates, and soils.

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Medicinal use Prior to the 2005 Supreme Court ruling that even medically ill marijuana smokers can be prosecuted for use of the substance, a number of medicinal cannabis shops opened throughout the United States. Here a medical marijuana patient (left), assisted by a volunteer, smells the different offer- ings at one such venue.

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In 2005, the U.S. Supreme Court ruled 6 to 3 that medically ill marijuana smokers and those who help them grow or obtain marijuana can be prosecuted, even if their physicians prescribe it and even if they live in one of the 14 states where medical mari- juana use has been declared legal. Although this ruling was initially considered a blow to the medical marijuana cause, proponents fought on, and in 2009 the U.S. Attorney General directed federal prosecutors to not pursue cases against medical marijuana users or their caregivers who are complying with state laws.

In the meantime, the Canadian government has taken a different tack. Based on re- search and trial programs, Health Canada, the country’s health care regulator, now legally permits the medical use of marijuana by individuals who are suffering from severe and debilitating illnesses, and it allows the sale of medical marijuana in select pharmacies, making Canada the second country in the world, after the Netherlands, to do so.

Combinations of Substances Because people often take more than one drug at a time, a pattern called polysubstance use, researchers have studied the ways in which drugs interact with one another. When different drugs are in the body at the same time, they may multiply, or potentiate, each other’s effects. The combined impact, called a synergistic effect, is often greater than the sum of the effects of each drug taken alone: A small dose of one drug mixed with a small dose of another can produce an enormous change in body chemistry.

One kind of synergistic effect occurs when two or more drugs have similar actions. For instance, alcohol, benzodiazepines, barbiturates, and opioids—all depressants—may severely depress the central nervous system when mixed (Ksir et al., 2008). Combin- ing them, even in small doses, can lead to extreme intoxication, coma, and even death. A young man may have just a few alcoholic drinks at a party, for example, and shortly afterward take a moderate dose of barbiturates to help him fall asleep. He believes he has acted with restraint and good judgment—yet he may never wake up.

A different kind of synergistic effect results when drugs have opposite, or antagonistic, actions. Stimulant drugs, for example, interfere with the liver’s usual disposal of barbitu- rates and alcohol. Thus people who combine barbiturates or alcohol with cocaine or

Tragic endings A number of popular performers have been victims of polysubstance misuse, including dangerous mixtures of prescription drugs, which can occur even under a physician’s supervision. The 2008 death of actor Heath Ledger (above), seen here as the Joker in the film The Dark Knight, was caused by a lethal combination of prescribed pain relievers, benzodiazepines, a sleep medication, and an antihista- mine. The 2009 death of recording artist and entertainer Michael Jackson (right) was the result of a physician-administered combina- tion of powerful sedative drugs.

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Popular Potsicles Some manufacturers are now producing marijuana-flavored lollipops with such names as Purple Haze, Acapulco Gold, Rasta, and Kronic Kandy. The candies, available at many convenience stores around the country, are legal because they are made with hemp oil, a common ingredient in health food. Drug experts have expressed outrage and deep con- cern about the message that such prod- ucts give, especially to children (Gross, 2005). <<

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amphetamines may build up toxic, even lethal, levels of the depressant drugs in their systems. Students who take amphetamines to help them study late into the night and then take barbiturates to help them fall asleep are unknowingly placing themselves in serious danger.

Each year tens of thousands of people are admitted to hospitals with a multiple- drug emergency, and several thousand of them die (SAMHSA, 2007). Sometimes the cause is carelessness or ignorance. Often, however, people use multiple drugs precisely because they enjoy the synergistic effects. In fact, polysubstance-related disorders are becoming as common as individual substance-related disorders in the United States, Canada, and Europe (Rosenthal & Levounis, 2005). As many as 90 percent of persons who use one illegal drug are also using another to some extent.

Fans still mourn the deaths of many celebrities who have been the victims of poly- substance use. Elvis Presley’s balancing act of stimulants and depressants eventually killed him. Janis Joplin’s mixtures of wine and heroin were ultimately fatal. And John Belushi’s and Chris Farley’s liking for the combined effect of cocaine and opioids (“speedballs”) also ended in tragedy.

SUMMING UP Hallucinogens, Cannabis, and Combinations of Substances

Hallucinogens, such as LSD, are substances that cause powerful changes primarily in sensory perception. Perceptions are intensified and illusions and hallucinations can occur. LSD apparently causes such effects by disturbing the release of the neu- rotransmitter serotonin.

The main ingredient of Cannabis sativa, a hemp plant, is tetrahydrocannabinol (THC). Marijuana, the most popular form of cannabis, is more powerful today than it was in years past. It can cause intoxication, and regular and excessive use can lead to abuse and dependence.

Many people take more than one drug at a time, and the drugs interact. The use of two or more drugs at the same time—polysubstance use—has become in- creasingly common. Similarly, polysubstance-related disorders have also become a major problem.

jjWhat Causes Substance-Related Disorders? Clinical theorists have developed sociocultural, psychological, and biological explana- tions for why people abuse or become dependent on various substances. No single explanation, however, has gained broad support. Like so many other disorders, exces- sive and long-term drug use is increasingly viewed as the result of a combination of these factors.

Sociocultural Views A number of sociocultural theorists propose that people are most likely to develop pat- terns of substance abuse or dependence when they live under stressful socioeconomic conditions. In fact, studies have found that regions with higher levels of unemployment have higher rates of alcoholism. Similarly, lower socioeconomic classes have substance- abuse rates that are higher than those of the other classes (Franklin & Markarian, 2005; Khan et al., 2002). In a related vein, more than 18 percent of unemployed adults cur- rently use an illegal drug, compared to around 9 percent of full-time and part-time employed workers (NSDUH, 2008).

Other sociocultural theorists propose that substance abuse and dependence are more likely to appear in families and social environments where substance use is valued, or at

•synergistic effect•In pharmacology, an increase of effects that occurs when more than one substance is acting on the body at the same time.

•polysubstance-related disorder•A long-term pattern of maladaptive behav- ior centered on abuse of or dependence on a combination of drugs.

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Celebrities Who Have Died of Drug Overdose Michael Jackson, recording artist and en- tertainer (prescription polydrug, 2009) <<

Heath Ledger, actor (prescription poly- drug, 2008) <<

Casey Calvert, guitarist, Hawthorne Heights (polydrug, 2008) <<

Anna Nicole Smith, model (prescription polydrug, 2007) <<

Ol’ Dirty Bastard, rapper, Wu-Tang Clan (polydrug, 2004) <<

Ken Caminiti, baseball player (cocaine, 2004) <<

Rick James, singer (cocaine, 2004) <<

Chris Farley, comedian (polydrug, 1998) <<

River Phoenix, actor (polydrug, 1993) <<

Janis Joplin, singer (heroin, 1970) <<

Sid Vicious, musician, Sex Pistols (heroin, 1979) <<

Jim Morrison, singer, The Doors (heroin, 1971) <<

Elvis Presley, singer (polydrug, 1977) <<

Jimi Hendrix, guitarist and singer (barbiturates, 1970) <<

John Belushi, comedian (polydrug, 1982) <<

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least accepted. Researchers have, in fact, found that problem drinking is more common among teenagers whose parents and peers drink, as well as among teenagers whose family environments are stressful and unsupportive (Ksir et al., 2008; Lieb et al., 2002). Moreover, lower rates of alcohol abuse are found among Jews and Protestants, groups in which drinking is typically acceptable only as long as it remains within clear limits, whereas alcoholism rates are higher among the Irish and Eastern Europeans, who do not, on average, draw as clear a line (Ksir et al., 2008; Ledoux et al., 2002).

Psychodynamic Views Psychodynamic theorists believe that people who abuse substances have powerful dependency needs that can be traced to their early years (Lightdale et al., 2008; Stetter, 2000). They claim that when parents fail to satisfy a young child’s need for nurturance, the child is likely to grow up depending excessively on others for help and comfort, trying to find the nurturance that was lacking during the early years. If this search for outside support includes experimentation with a drug, the person may well develop a dependent relationship with the substance.

Some psychodynamic theorists also believe that certain people respond to their early deprivations by developing a substance-abuse personality that leaves them particularly prone to drug abuse. Personality inventories and patient interviews have in fact indi- cated that people who abuse or depend on drugs tend to be more dependent, antisocial, impulsive, novelty-seeking, and depressive than other people (Ksir et al., 2008; Coffey et al., 2003). These findings are correlational, however, and do not clarify whether such personality traits lead to drug use or whether drug use causes people to be dependent, impulsive, and the like.

In an effort to establish clearer causation, one longitudinal study measured the per- sonality traits of a large group of nonalcoholic young men and then kept track of each man’s development ( Jones, 1971, 1968). Years later, the traits of the men who developed alcohol problems in middle age were compared with the traits of those who did not. The men who developed alcohol problems had been more impulsive as teenagers and continued to be so in middle age, a finding suggesting that impulsive men are indeed more prone to develop alcohol problems. Similarly, in one laboratory investigation, “impulsive” rats—those that generally had trouble delaying their rewards—were found to drink more alcohol when offered it than other rats (Poulos, Le, & Parker, 1995).

A major weakness of this line of argument is the wide range of personality traits that have been tied to substance abuse and dependence. In fact, different studies point to different “key” traits. Inasmuch as some people with a drug addiction appear to be dependent, others impulsive, and still others antisocial, researchers cannot presently conclude that any one personality trait or group of traits stands out in substance-related disorders (Chassin et al., 2001).

Cognitive-Behavioral Views According to behaviorists, operant conditioning may play a key role in substance abuse (Bradizza & Stasiewkz, 2009; Higgins et al., 2004). They argue that the temporary reduc- tion of tension or raising of spirits produced by a drug has a rewarding effect, thus in- creasing the likelihood that the user will seek this reaction again. Similarly, the rewarding effects of a substance may eventually lead users to try higher dosages or more powerful methods of ingestion. In addition, cognitive theorists argue that such rewards eventu- ally produce an expectancy that substances will be rewarding, and this expectation helps motivate individuals to increase drug use at times of tension (Chassin et al., 2001).

In support of these behavioral and cognitive views, studies have found that many people do in fact drink more alcohol or seek heroin when they feel tense (Ham et al., 2002). In one study, as participants worked on a difficult anagram task, a confederate planted by the researchers unfairly criticized and belittled them (Marlatt et al., 1975). The participants were then asked to participate in an “alcohol taste task,” supposedly

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Energy drinks: a growing trend Here a California store displays cans of energy drinks, popular high-stimulant soft drinks with edgy names such as Rockstar, Full Throttle, and Cocaine. Energy drinks, which typically contain very high levels of caffeine and other supplements, have become a major force in the soft drink industry.

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to compare and rate alcoholic beverages. The individuals who had been harassed drank more alcohol during the taste task than did the control participants who had not been criticized.

In a manner of speaking, the cognitive-behavioral theorists are arguing that many people take drugs to “medicate” themselves when they feel tense. If so, one would ex- pect higher rates of drug abuse among people who suffer from anxiety, depression, and other such problems. And, in fact, more than 22 percent of all adults who suffer from psychological disorders have been dependent on or abused alcohol or other substances within the past year (NSDUH, 2008).

A number of behaviorists have proposed that classical conditioning may also play a role in substance abuse and dependence (Haney, 2008). Objects present in the environment at the time drugs are taken may act as classically conditioned stimuli and come to produce some of the same pleasure brought on by the drugs themselves. Just the sight of a hypo- dermic needle, drug buddy, or regular supplier, for example, has been known to comfort people who abuse heroin or amphetamines and to relieve their withdrawal symptoms. In a similar manner, objects that are present during withdrawal distress may produce withdrawal-like symptoms. One man who had formerly been dependent on heroin experienced nausea and other withdrawal symptoms when he returned to the neighbor- hood where he had gone through withdrawal in the past—a reaction that led him to start taking heroin again (O’Brien et al., 1975). Although classical conditioning certainly ap- pears to be at work in particular cases or aspects of drug abuse and dependence, research has not found it to be the key factor in such patterns (Drobes et al., 2001).

Biological Views In recent years researchers have come to suspect that drug misuse may have biological causes. Studies on genetic predisposition and specific biochemical processes have pro- vided some support for these suspicions.

Genetic Predisposition For years breeding experiments have been conducted to see whether certain animals are genetically predisposed to become dependent on drugs (Kreek, 2008; Li, 2000). In several studies, for example, investigators have first identi- fied animals that prefer alcohol to other beverages and then mated them to one another. Generally, the offspring of these animals have been found also to display an unusual pref- erence for alcohol (Melo et al., 1996).

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Inhalant abuse and dependence A 13-year-old boy sniffs glue as he lies dazed near a garbage heap. In the United States, at least 6 percent of all people have tried to get high by inhaling the hydrocarbons found in common substances such as glue, gasoline, paint thinner, cleaners, and spray- can propellants (APA, 2000). Such behavior poses a number of serious medical dangers.

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Do Animals Get High? Animals may get high on substances found in nature. Llamas in Peru get frisky eating coca leaves (which contain cocaine). Grasshoppers that eat wild marijuana leaves jump unusually high. Elephants seek out fermented ripe fruit (Siegel, 1990). <<

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Similarly, some research with human twins has suggested that people may inherit a predis- position to abuse substances (Ray & Hutchi- son, 2009). One classic study found that if one identical twin abused alcohol, the other twin also abused alcohol in 54 percent of the cases, whereas among fraternal twins, the rate was only 28 percent (Kaij, 1960). Other stud- ies have found similar twin patterns (Tsuang et al., 2001). As you have read, however, such findings do not rule out other interpretations. For one thing, the parenting received by two identical twins may be more similar than that received by two fraternal twins.

A clearer indication that genetics may play a role in substance abuse and dependence comes from studies of alcoholism rates in people adopted shortly after birth (Walters, 2002; Cadoret et al., 1995; Goldstein, 1994). These studies have compared adoptees whose biological parents are dependent on alcohol with adoptees whose biological parents are not. By adulthood, the individuals whose biological parents are dependent on alcohol typically show higher rates of alcohol abuse than those with nonalcoholic biological parents.

Genetic linkage strategies and molecular biology techniques provide more direct evi- dence in support of a genetic explanation (Gelernter & Kransler, 2008). One line of investigation has found an abnormal form of the so-called dopamine-2 (D2) receptor gene in a majority of research participants with alcohol, nicotine, or cocaine dependence but in less than 20 percent of nondependent participants (Preuss et al., 2007; Blum et al., 1996, 1990). Other studies have tied still other genes to substance-related disorders (Gelernter & Kranzler, 2008; Kreek, 2008).

Biochemical Factors Over the past few decades, researchers have pieced together several biological explanations of drug tolerance and withdrawal symptoms (Kleber & Galanter, 2008; Koob, 2009, 2008). According to one of the leading explanations, when a particular drug is ingested, it increases the activity of certain neurotransmitters whose normal purpose is to calm, reduce pain, lift mood, or increase alertness. When a person keeps on taking the drug, the brain apparently makes an adjustment and reduces its own production of the neurotransmitters. Because the drug is increasing neurotransmit-

ter activity, release of the neurotransmitter by the brain is less necessary. As drug in- take increases, the body’s production of the neurotransmitters continues to decrease, leaving the person in need of more and more of the drug to achieve its effects. In this way, drug takers build tolerance for a drug, becoming more and more reliant on it rather than on their own biological processes to feel comfortable or alert. If they suddenly stop taking the drug, their natural supply of neurotransmitters will be low for a time, producing the symptoms of withdrawal. Withdrawal continues until the brain resumes its normal production of the neurotransmitters.

Which neurotransmitters are affected depends on the drug used. Repeated and excessive use of alcohol or benzodiazepines may lower the brain’s production of the

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Victims of a reward- deficiency syndrome? Theorists suspect that the brain reward centers of people who become dependent on substances are inadequately activated by events in life—a problem called the reward-deficiency syndrome. With the colors red and orange indicating greater brain activity, these PET scans show that prior to their use of drugs, the reward centers of cocaine, methamphetamine, and alcohol abusers (right) are indeed generally less active than the reward centers of nonabusers (left) (Volkow et al., 2004, 2002).

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neurotransmitter GABA, regular use of opioids may reduce the brain’s production of endorphins, and regular use of cocaine or amphetamines may lower the brain’s produc- tion of dopamine (Haney, 2008; Volkow et al., 2004, 1999). In addition, researchers have identified a neurotransmitter called anandamide that operates much like THC; excessive use of marijuana may reduce the production of this neurotransmitter (Hitti, 2004; Johns, 2001).

This theory helps explain why people who regularly take substances experience tolerance and withdrawal reactions. But why are drugs so rewarding, and why do certain people turn to them in the first place? A number of brain-imaging studies suggest that many, perhaps all, drugs eventually activate a reward center, or “pleasure pathway,” in the brain (de Wit & Phan, 2010; Haney, 2008). A key neurotransmitter in this pleasure pathway appears to be dopamine (Koob, 2009; Volkow et al., 2004). When dopamine is activated along the pleasure pathway, a person experiences pleasure. Music may activate dopamine in the reward center. So may a hug or a word of praise. And so do drugs. Some researchers believe that other neurotransmitters may also play important roles in the reward center.

Certain drugs apparently stimulate the reward center directly. Remember that cocaine and amphetamines directly increase dopamine activity. Other drugs seem to stimulate it in roundabout ways. The biochemical reactions triggered by alcohol, opioids, and marijuana probably set in motion a series of chemical events that eventually lead to increased dopamine activity in the reward center. A number of theorists suspect that people who abuse drugs suffer from a reward-deficiency syndrome: Their reward center is not readily activated by the usual events in their lives, so they turn to drugs to stimulate this pleasure pathway (Blum et al., 2000).

SUMMING UP What Causes Substance-Related Disorders?

Several explanations for substance abuse and dependence have been put forward. Together they are beginning to shed light on the disorders.

According to the sociocultural view, the people most likely to abuse drugs are those living in stressful socioeconomic conditions or whose families value or accept drug use. In the psychodynamic view, people who turn to substance abuse have

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•reward center•A dopamine-rich path- way in the brain that produces feelings of pleasure when activated.

•reward-deficiency syndrome•A condition, suspected to be present in some individuals, in which the brain’s reward center is not readily activated by the usual events in their lives.

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jjHow Are Substance-Related Disorders Treated? Many approaches have been used to treat substance-related disorders, including psycho- dynamic, behavioral, cognitive-behavioral, and biological approaches, along with several sociocultural therapies. Although these treatments sometimes meet with great success, more often they are only moderately helpful (Myrick & Wright, 2008). Today the treat- ments are typically used on either an outpatient or inpatient basis or a combination of the two (Carroll, 2008, 2005; Weiss et al., 2008) (see Figure 10-4).

Psychodynamic Therapies Psychodynamic therapists first guide clients to uncover and work through the underly- ing needs and conflicts that they believe have led to the disorder. The therapists then try to help the individuals change their substance-related styles of living (Lightdale et al., 2008). Although often applied, this approach has not been found to be particularly effective in cases of substance-related disorders (Cornish et al., 1995). It may be that drug abuse or dependence, regardless of its causes, eventually becomes a stubborn in- dependent problem that must be the direct target of treatment if people are to become drug-free. Psychodynamic therapy tends to be of greater help when it is combined with

other approaches in a multidimensional treatment program (Lightdale et al., 2008).

Behavioral Therapies A widely used behavioral treatment for substance-related disorders is aversion therapy, an approach based on the principles of classical conditioning. Individuals are repeatedly presented with an unpleasant stimulus (for example, an elec- tric shock) at the very moment that they are taking a drug. After repeated pairings, they are expected to react negatively to the substance itself and to lose their craving for it.

Aversion therapy has been applied to alcohol abuse and dependence more than to other substance-related disorders. In one version of this therapy, drinking behavior is paired with drug-induced nausea and vomiting (Owen-Howard, 2001; Welsh & Liberto, 2001). The pairing of nausea with alcohol is expected to produce negative responses to alcohol itself. Another version of aversion therapy requires people

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Sniffing for drugs A common scene in schools, airports, storage facilities, and similar settings is that of trained dogs sniffing for marijuana, cocaine, opioids, and other substances. Here one such animal sniffs lockers at a school in Texas to see whether students have hidden illegal substances among their books or other belongings.

excessive dependency needs traceable to the early stages of life. Some psychody- namic theorists also believe that certain people have a substance-abuse personality that makes them prone to drug use. The leading behavioral view proposes that drug use is reinforced initially because it reduces tensions and raises spirits, and the lead- ing cognitive view holds that such reductions of tension then lead to an expectancy that drugs will be comforting and helpful.

The biological explanations are supported by twin, adoptee, genetic linkage, and molecular biology studies, suggesting that people may inherit a predisposition to substance dependence. Researchers have also learned that drug tolerance and withdrawal symptoms may be caused by cutbacks in the brain’s production of par- ticular neurotransmitters during excessive and repeated drug use. Finally, biologi- cal studies suggest that many, perhaps all, drugs may ultimately lead to increased dopamine activity in the brain’s reward center.

BETWEEN THE LINES

Songs of Substance Substance use is a popular theme in music. Hit songs include Amy Winehouse’s “Rehab,” the Velvet Underground’s “Heroin,” Evanescence’s “Call Me When You’re Sober,” the Rolling Stones’ “Sister Morphine,” Snoop Dogg’s “Gin and Juice,” Eric Clapton’s “Cocaine,” Cyprus Hill’s “I Wanna Get High,” Eminem’s “Drug Ballad,” and Lil’ Kim’s “Drugs.” <<

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with alcoholism to imagine extremely upsetting, repulsive, or frightening scenes while they are drinking (Cautela, 2000; Kassel et al., 1999). Here the pairing of the imagined scenes with liquor is expected to produce negative responses to liquor. Here are the kinds of scenes therapists may guide a client to imagine:

I’d like you to vividly imagine that you are tasting the (beer, whiskey, etc.). See yourself

tasting it, capture the exact taste, color and consistency. Use all of your senses. After

you’ve tasted the drink you notice that there is something small and white floating in the

glass—it stands out. You bend closer to examine it more carefully, your nose is right over

the glass now and the smell fills your nostrils as you remember exactly what the drink

tastes like. Now you can see what’s in the glass. There are several maggots floating on the

surface. As you watch, revolted, one manages to get a grip on the glass and, undulating,

creeps up the glass. There are even more of the repulsive creatures in the glass than you

first thought. You realise that you have swallowed some of them and you’re very aware of

the taste in your mouth. You feel very sick and wish you’d never reached for the glass and

had the drink at all.

(Clarke & Saunders, 1988, pp. 143–144)

A behavioral approach that has been effective in the short-term treatment of people who abuse cocaine and some other drugs is contingency management, which makes in- centives (such as cash, vouchers, prizes, or privileges) contingent on the submission of drug-free urine specimens (Barry et al., 2009; Kosten et al., 2008). In one pioneering study, 68 percent of cocaine abusers who completed a six-month contingency training program achieved at least eight weeks of continuous abstinence (Higgins et al., 1993).

Behavioral interventions for substance abuse and dependence have usually had only limited success when they are the sole form of treatment (Carroll, 2008). A major problem is that the approaches can be effective only when individuals are motivated to continue with them despite their unpleasantness or demands (DiClemente et al., 2008). Generally, behavioral treatments work best in combination with either biological or cognitive approaches (Higgins & Silverman, 2008).

Number of Patients

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Figure 10-4 Where do people receive treatment? Most people receive treatment for substance abuse and dependence in a self-help group, an outpatient rehabilitation program, or a mental health center (NSDUH, 2008)

•aversion therapy•A treatment in which clients are repeatedly presented with unpleasant stimuli while performing undesirable behaviors such as taking a drug.

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Cognitive-Behavioral Therapies Two popular approaches combine cognitive and be- havioral techniques to help people gain control over their substance-related behaviors (Carroll, 2008). In one, behavioral self-control training (BSCT), applied to alcoholism in particular, therapists first have clients keep track of their own drinking behavior (Bishop, 2008; Miller et al., 1992; Miller, 1983). Writing down the times, locations, emotions, bodily changes, and other cir- cumstances of their drinking, they become more aware of the situations that place them at risk for excessive drinking. They are then taught coping strategies to use when such situations arise. They learn, for example, to set limits on their drinking, to recognize when the limits are being approached, to control their rate of drinking (perhaps by spacing their drinks or by sipping them rather than gulping), and to practice relaxation tech- niques, assertiveness skills, and other coping behaviors in situations in which they would otherwise be drinking. Approximately 70 percent of the people who complete

this training apparently show some improvement, particularly younger drinkers who are not physically dependent on alcohol (Deas et al., 2008; Ksir et al., 2008).

In a related cognitive-behavioral approach, relapse-prevention training, heavy drinkers are assigned many of the same tasks as clients in BSCT (Blume et al., 2009; Witkiewitz & Marlatt, 2007, 2004). They are also taught to plan ahead of time how many drinks are appropriate, what to drink, and under what circumstances. The ap- proach often lowers the frequency of intoxication, although the majority of clients achieve success only after repeated relapse-prevention treatments. The approach has also been used, with some success, in the treatment of marijuana and cocaine abuse as well as with other kinds of disorders such as sexual paraphilias (see Chapter 11).

Biological Treatments Biological approaches may be used to help people withdraw from substances, abstain from them, or simply maintain their level of use without further increases. As with the other forms of treatment, biological approaches alone rarely bring long-term improve- ment, but they can be helpful when combined with other approaches.

Detoxification Detoxification is systematic and medically supervised withdrawal from a drug. Some detoxification programs are offered on an outpatient basis. Others are located in hospitals and clinics and may also offer individual and group therapy, a “full- service” institutional approach that has become popular. One detoxification approach is to have clients withdraw gradually from the substance, taking smaller and smaller doses until they are off the drug completely (Wright & Thompson, 2002). A second—often medically preferred—detoxification strategy is to give clients other drugs that reduce the symptoms of withdrawal (Caldeiro et al., 2009; Ksir et al., 2008). Antianxiety drugs, for example, are sometimes used to reduce severe alcohol withdrawal reactions such as delirium tremens and seizures. Detoxification programs seem to help motivated people withdraw from drugs (DiClemente et al., 2008). However, relapse rates tend to be high for those who fail to receive a follow-up form of treatment—psychological, biological, or sociocultural—after successful detoxification (Polydorou & Kleber, 2008).

Antagonist Drugs After successfully stopping a drug, people must avoid falling back into a pattern of abuse or dependence. As an aid to resisting temptation, some people with substance-related disorders are given antagonist drugs, which block or change the effects of the addictive drug (O’Brien & Kampman, 2008). Disulfiram (Antabuse),

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Forced detoxification Abstinence is not always medically supervised or voluntary. This sufferer of alcoholism begins to experience symp- toms of withdrawal soon after being imprisoned for public intoxication.

•behavioral self-control training (BSCT)•A cognitive-behavioral approach to treating alcohol abuse and depen- dence in which clients are taught to keep track of their drinking behavior and to apply coping strategies in situations that typically trigger excessive drinking.

•relapse-prevention training•An approach to treating alcohol abuse that is similar to BSCT and also has clients plan ahead for risky situations and reactions.

•detoxification•Systematic and medi- cally supervised withdrawal from a drug.

•antagonist drugs•Drugs that block or change the effects of an addictive drug.

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BY JON PARELES, NEW YORK TIMES, JANUARY 24, 2008

It was witty . . . when Amy Winehouse sang, “They tried to make me go to rehab/I said no, no, no” on her album “Back to Black.” . . . But there was nothing amusing, and barely any surprise, in Ms. Winehouse’s recent, notorious and possibly inadvertent public appearance: on a video released by an Eng- lish tabloid, The Sun.

The homemade clip . . . shows Ms. Winehouse, with her recent blond hairdo, in her London apartment, using a glass pipe to smoke what The Sun says is crack. . . . Performers thrive on attention, and sometimes admit that it’s an addiction; now, the Internet enables that addiction all too easily. The unintended consequence is that we can now watch stars self-destruct in real time.

Images of Ms. Winehouse looking intoxicated, disheveled, half-dressed and wild-eyed are all over the tabloids and the Internet. She has appeared to be drunk onstage, barely able to get through a song. . . . Ms. Winehouse, who writes her own lyrics, . . . has often sung about harmful appetites, not just in “Rehab” but in “Addicted” (about a freeloading pot smoker) and in “Back to Black,” in which she sings, “You love blow and I love puff/And life is like a pipe.” . . .

Addiction might start with experiments by performers so young they feel invulnerable; it might seem to be, at first, a way to ease the stress of a peculiar job. It might be a way to act out the old Romantic image of the artist as daredevil. And there’s no shortage of temptation in a musician’s work environment of bars, clubs, late nights and party people. Rock stars weren’t the first musicians to drink or drug themselves to death.

What’s different, in the 21st century, is that we can watch the breakdowns almost as they happen. One day there’s a grainy video of Ms. Winehouse spreading across the Internet. . . .

In the '60s and '70s there were occasional photos of Janis Joplin hoisting a bottle of Southern Comfort, and word-of-mouth about many bands’ backstage excesses or drunken exploits, but those were occasional glimpses and dispatches. Rockers dosed themselves, mostly, behind closed doors.

Now digital video and photography, coupled with the Inter- net, can add up to near-constant surveillance. . . . There’s an en- tire industry in celebrity scandal, much of it remarkably callous.

In their times the deaths of Jim Morrison and Kurt Cobain were sudden and shocking, leaving them a legacy as handsome rock martyrs. . . . But they were pre-Internet stars. Now, there’s a sleazy symbiosis that connects instantaneous worldwide visibil- ity, publicity, marketing and narcissism. Attention addicts can get their fix with a few mouse clicks.

Why, for instance, was Ms. Winehouse letting someone shoot video, in a private setting, of her puffing that pipe in the first place? Maybe it’s some version of “keepin’ it real,” . . . Maybe it’s obliviousness, . . . Maybe she mistakenly trusted that whoever made the video would resist another temptation: the potential profit to be made providing it to a tabloid.

Perhaps Ms. Winehouse misunderstood what should be clear in the age of the Internet: Everything recorded can be dupli- cated and distributed. And possibly the video was, in its own bleary way, a kind of performance. She is keeping her audience informed if not exactly entertained.

Mostly, however, she’s just supplying material for the sphere of celebrity interaction that only wants to see idols torn down. Her fans—those of us who believe she has more superb songs yet to write—would prefer she grow less visible and consider- ably more boring. . . . [S]he would do well to disappear for a while, into rehab or private recovery, and then to hole up in a recording studio and work up some new songs. (She definitely has enough ups and downs to write about, realistically or not.) In the era of total exposure Ms. Winehouse would serve herself and her listeners best by working behind closed doors.

Copyright © 2008. Reprinted by permission of PARS International Corp. on behalf of The New York Times.

[Note: Two weeks after this article was printed, Amy Winehouse won five Grammy Awards, including ones for best new artist, song of the year (“Rehab”), and best pop vocal album (“Back to Black”).]

In Real Time, Amy Winehouse’s Deeper Descent

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for example, is often given to people who are trying to stay away from alcohol. By itself a low dose of this drug seems to have few negative effects, but a person who drinks al- cohol while taking disulfiram will experience intense nausea, vomiting, blushing, faster heart rate, dizziness, and perhaps fainting. People taking disulfiram are less likely to drink alcohol because they know the terrible reaction that awaits them should they have even one drink. Disulfiram has proved helpful, but again only with people who are motivated to take it as prescribed (DiClemente et al., 2008). In addition to disulfiram, several other alcohol antagonist drugs are now being tested (De Sousa et al., 2008).

In the realm of opioid dependence, several narcotic antagonists, such as naloxone and naltrexone, are used to treat people who are addicted to drugs of that kind (Caldeiro et al., 2009). These antagonists attach to endorphin receptor sites throughout the brain and make it impossible for the opioids to have their usual effect. Without the rush or high, con- tinued drug use becomes pointless. Although narcotic antagonists have been helpful— particularly in emergencies, to rescue people from an overdose of opioids—they can in fact be a dangerous form of treatment for opioid dependence. These antagonists must be given very carefully because of their ability to throw a person with an addiction into severe withdrawal. Recent studies indicate that narcotic antagonists may also be useful in the treatment of alcohol and cocaine dependence (Bishop, 2008; Oslin, 2006).

Drug Maintenance Therapy A drug-related lifestyle may be a greater problem than the drug’s direct effects. Much of the damage caused by heroin addiction, for ex- ample, comes from overdoses, unsterilized needles, and an accompanying life of crime. Thus clinicians were very enthusiastic when methadone maintenance programs were developed in the 1960s to treat heroin addiction (Dole & Nyswander, 1967, 1965). In these programs, people with an addiction are given the laboratory opioid methadone as a substitute for heroin. Although they then become dependent on methadone, their new addiction is maintained under safe medical supervision. Unlike heroin, methadone can be taken by mouth, thus eliminating the dangers of needles, and needs to be taken only once a day.

At first, methadone programs seemed very effective, and many of them were set up throughout the United States, Canada, and England. These programs became less popular during the 1980s, however, because of the dangers of methadone itself. Many clinicians came to believe that substituting one addiction for another is not an accept- able “solution” for substance dependence, and many persons with an addiction com- plained that methadone addiction was creating an additional drug problem that simply complicated their original one (McCance-Katz & Kosten, 2005). In fact, methadone is sometimes harder to withdraw from than heroin because the withdrawal symptoms can last longer (Ksir et al., 2008). Moreover, pregnant women maintained on methadone have the added concern of the drug’s effect on their fetus.

Despite such concerns, maintenance treatment with methadone—or with buprenor- phine, another widely used substitute drug—has again sparked interest among clinicians in recent years, partly because of new research support (Strain & Lofwall, 2008) and partly because of the rapid spread of the HIV virus and the hepatitis C virus among intravenous drug abusers and their sex partners and children (Galanter & Kleber, 2008; Schottenfeld, 2008). Not only is methadone treatment safer than street opioid use, but many methadone programs now include AIDS education and other health instructions in their services (Sorensen & Copeland, 2000). Research suggests that methadone main- tenance programs are most effective when they are combined with education, psycho- therapy, family therapy, and employment counseling (Schottenfeld, 2008; O’Brien & McKay, 2002). Today thousands of clinics provide methadone treatment across the United States (MTC, 2008).

Sociocultural Therapies As you have read, sociocultural theorists—both family-social and multicultural theorists— believe that psychological problems emerge in a social setting and are best treated in a social context. Three sociocultural approaches have been applied to substance-related

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Is methadone safe? Methadone is itself a narcotic that can be as dangerous as other opioids when not taken under safe medical supervision. Here a couple protest against a proposed methadone treatment facility in Maine. Their 19-year-old daughter, who was not an opioid addict, had died months ear- lier after taking methadone to get high.

•methadone maintenance program•An approach to treating heroin dependence in which clients are given legally and medically supervised doses of a substitute drug, methadone.

•Alcoholics Anonymous (AA)•A self- help organization that provides support and guidance for persons with alcohol abuse or dependence.

•residential treatment center•A place where people formerly dependent on drugs live, work, and socialize in a drug-free environment while undergo- ing treatment. Also called a therapeutic community.

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disorders: (1) self-help programs, (2) culture- and gender-sensitive programs, and (3) community prevention programs (Ritvo & Causey, 2008).

Self-Help and Residential Treatment Programs Many people who abuse drugs have organized among themselves to help one another recover without profes- sional assistance. The drug self-help movement dates back to 1935, when two Ohio men suffering from alcoholism met and wound up discussing alternative treatment possibili- ties. The first discussion led to others and to the eventual formation of a self-help group whose members discussed alcohol-related problems, traded ideas, and provided support. The organization became known as Alcoholics Anonymous (AA).

Today AA has more than 2 million members in 113,000 groups across the United States and 180 other countries (AA World Services, 2008). It offers peer support along with moral and spiritual guidelines to help people overcome alcoholism. Different members apparently find different aspects of AA helpful (Tonigan & Connors, 2008). For some it is the peer support; for others it is the spiritual dimension. Meetings take place regularly, and members are available to help each other 24 hours a day.

By offering guidelines for living, the organization helps members abstain “one day at a time,” urging them to accept as “fact” the idea that they are powerless over alcohol and that they must stop drinking entirely and permanently if they are to live normal lives (Nace, 2008). Related self-help organizations, Al-Anon and Alateen, offer support for people who live with and care about persons with alcoholism (Galanter, 2008). Self- help programs such as Narcotics Anonymous and Cocaine Anonymous have been developed for other substance-related disorders.

Many self-help programs have expanded into residential treatment centers, or therapeutic communities—such as Daytop Village and Phoenix House—where people formerly dependent on drugs live, work, and socialize in a drug-free environment while undergoing individual, group, and family therapies and making a transition back to community life (Brook, 2008; De Leon, 2008).

The evidence that keeps self-help and residential treatment programs going comes largely in the form of individual testimonials. Many tens of thousands of persons have revealed that they are members of these programs and credit them with turning their lives around. Studies of the programs have also had favorable findings, but their numbers have been limited (De Leon, 2008; Moos & Timko, 2008; Tonigan & Connors, 2008).

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Fighting drug abuse while in prison Inmates at a county jail in Texas exercise and meditate as part of a drug and alcohol rehabilitation program. The program also includes psychoeducation and other interventions to help inmates address their substance abuse problems.

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AA: Reaching Out As many as 9 percent of adults in the United States have been to an Alcoholics Anonymous meeting at some time in their lives. <<

More than 3 percent have been to a meeting within the last year. <<

(Moos & Timko, 2008)

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Culture- and Gender-Sensitive Programs Many persons who abuse sub- stances live in a poor and perhaps violent setting. A growing number of today’s treatment programs try to be sensitive to the special sociocultural pressures faced by drug abusers who are poor, homeless, or members of minority groups (Cabaj, 2008; Westermeyer & Dickerson, 2008). Therapists who are sensitive to their clients’ life challenges can do more to address the stresses that often lead to relapse.

Similarly, therapists have become more aware that women often require treatment methods different from those designed for men (Brady & Back, 2008). Women and men often have different physical and psychological reactions to drugs, for example. In addition, treatment of women who abuse substances may be complicated by the impact of sexual abuse, the possibility that they may be or may become pregnant while taking drugs, the stresses of raising children, and the fear of criminal prosecution for abusing drugs during pregnancy (Finnegan & Kandall, 2008). Thus many women with such disorders feel more comfortable seeking help at gender-sensitive clinics or resi- dential programs; some such programs also allow children to live with their recovering mothers.

Community Prevention Programs Perhaps the most effective approach to substance-related disorders is to prevent them (Sloboda, 2009; Clayton et al., 2008; Ksir et al., 2008). The first drug-prevention efforts were conducted in schools. Today preven- tion programs are also offered in workplaces, activity centers, and other community settings, and even through the media (NSDUH, 2008). Over 11 percent of adolescents report that they have participated in substance use prevention programs outside school within the past year. Around 80 percent have seen or heard a substance use prevention message. And almost 60 percent have talked to their parents in the past year about the dangers of alcohol and other drugs.

Prevention programs may focus on the individual (for example, by providing educa- tion about unpleasant drug effects), the family (by teaching parenting skills), the peer group (by teaching resistance to peer pressure), the school (by setting up firm enforcement of drug policies), or the community at large (by public service announcements such as the “Just say no” campaign of the 1980s and 1990s). The most effective prevention efforts focus on several of these areas to provide a consistent message about drug abuse in all areas of individuals’ lives (Clayton et al., 2008; Ksir et al., 2008). Some prevention pro- grams have even been developed for preschool children.

Listen to my story A prisoner stands shackled before students at an Ohio high school and discusses his drunk-driving conviction (his intoxicated driving resulted in a fatal automobile crash). Such high school visits by inmates are part of the school’s “Make the Right Choice” prevention program.

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Student Athletes and Alcohol As many as 88 percent of college athletes in the United States drink alcohol to some degree (O’Brien & Lyons, 2000). <<

College athletes (both male and female) are more likely to drink, drink heavily, and binge-drink than college students who are not athletes (Hildebrand et al., 2001; Nelson & Wechsler, 2001). <<

In one survey, one-third of student ath- letes reported missing classes throughout the school year because of alcohol use (Perkins, 2002). <<

White American student athletes display more alcohol consumption patterns than student athletes from minority groups (Perkins, 2002). <<

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PUTTING IT... together New Wrinkles to a Familiar Story In some respects the story of the misuse of drugs is the same today as in the past. Sub- stance use is still rampant, often creating damaging psychological disorders. New drugs keep emerging, and the public goes through periods of believing, naively, that they are “safe.” Only gradually do people learn that these drugs, too, pose dangers. And treat- ments for substance-related disorders continue to have only limited effect.

Yet there are important new wrinkles in this familiar story. Researchers have begun to develop a clearer understanding of how drugs act on the brain and body. In treatment, self-help groups and rehabilitation programs are flourishing. And preventive education to make people aware of the dangers of drug misuse is also expanding and seems to be having an effect. One reason for these improvements is that investigators and clinicians have stopped working in isolation and are instead looking for intersections between their own work and work from other models. The same kind of integrated efforts that have helped with other psychological disorders are bringing new promise and hope to the study and treatment of substance-related disorders.

Perhaps the most important insight to be gained from these integrated efforts is that several of the models were already on the right track. Social pressures, personality characteristics, rewards, and genetic predispositions all seem to play roles in substance- related disorders, and in fact to operate together. For example, some people may inherit a malfunction of the biological reward center and so may need special doses of external stimulation—say, intense relationships, an abundance of certain foods, or drugs—to stimulate their reward center. Their pursuit of external rewards may take on the char- acter of an addictive personality (Ebstein & Kotler, 2002). Such individuals may be es- pecially prone to experimenting with drugs, particularly when their social group makes the drugs available or when they are faced with intense social and personal stress.

Just as each model has identified important factors in the development of substance- related disorders, each has made important contributions to treatment. As you have seen, the various forms of treatment seem to work best when they are combined with approaches from the other models, making integrated treatment the most productive approach.

These recent developments are encouraging. At the same time, however, enormous and increasing levels of drug use continue. New drugs and drug combinations are dis- covered almost daily, and with them come new problems and the need for new research and new treatments. Perhaps the most valuable lesson is an old one: There is no free lunch. The pleasures derived from these substances come with high psychological and biological costs, some not yet even known.

SUMMING UP How Are Substance-Related Disorders Treated?

Treatments for substance abuse and dependence vary widely. Usually several ap- proaches are combined. Psychodynamic therapies try to help clients become aware of and correct the underlying needs and conflicts that may have led to their use of drugs. A common behavioral technique is aversion therapy, in which an unpleasant stimulus is paired with the drug that the person is abusing. Cognitive and behavioral techniques have been combined in such forms as behavioral self-control training (BSCT) and relapse-prevention training. Biological treatments include detoxification, antagonist drugs, and drug maintenance therapy. Sociocultural treatments approach substance-related disorders in a social context by means of self-help groups (for example, Alcoholics Anonymous), culture- and gender-sensitive treatments, and community prevention programs.

BETWEEN THE LINES

Drugs and the Law There are more than 230,000 drug-law violators incarcerated in state prisons and local jails and 60,000 in federal prisons (Beck, 2004). <<

Fifty-seven percent of state prisoners and 45 percent of federal prisoners in the United States report using illicit drugs in the month before committing their offense (Bureau of Justice Statistics, 1999). <<

BETWEEN THE LINES

Celebrities Who Have Acknowledged Past Substance Abuse or Dependence Amy Winehouse, singer/songwriter <<

Lindsay Lohan, actress <<

Pete Doherty, rock musician <<

David Crosby, musician <<

Eminem, rapper <<

Christian Slater, actor <<

Drew Barrymore, actress <<

Scott Weiland, rock singer <<

Robert Downey Jr., actor <<

Ron Wood, guitarist <<

Melanie Griffith, actress <<

Nick Cave, rock singer <<

Juliette Lewis, actress <<

Greg Allman, rock singer <<

Dr. John, rock singer <<

Charlie Sheen, actor <<

Whitney Houston, singer <<

James Hetfield, singer <<

Matthew Perry, actor <<

Pat O’Brien, interviewer <<

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318 ://CHAPTER 10

1. Various kinds of club drugs (e.g., Ecstasy and crystal meth), drugs used at all-night dance parties called “raves,” seem to fall in and out of favor rather quickly. Why might young people readily move from one such drug to another? pp. 298–299, 300

2. What effects might the use of drugs by some rock, rap, and other musical performers have on teenagers and young adults? Who has the greater impact on the drug behaviors of teenagers and young adults: perform-

ers who speak out against drugs or performers who praise the virtues of drugs? pp. 304–305, 313, 317

3. What different kinds of issues might be confronted by drug abusers from different ethnic groups or genders, and how might such issues influence their efforts at recovery? pp. 305– 306, 316

4. Popular talk show host Oprah Winfrey has revealed, with great emotion, that she was physically dependent on cocaine in the

mid-1970s. What impact might admissions like Winfrey’s have on people’s willingness to seek treatment for substance abuse? pp. 310–316

5. Since the major dangers of heroin come from overdose, unsterilized needles, and a criminal lifestyle, society has periodically tried legal, medically supervised use of heroin (in Great Britain) or a heroin substitute (in the United States) to combat this drug problem. In many cases, such approaches have had limited effec- tiveness. Why? p. 314

CRITICAL THOUGHTSC

intoxication, p. 286 hallucinosis, p. 286 substance abuse, p. 286 substance dependence, p. 286 tolerance, p. 286 withdrawal, p. 286 alcohol, p. 287 delirium tremens (DTs), p. 289 cirrhosis, p. 291 Korsakoff’s syndrome, p. 291 fetal alcohol syndrome, p. 291 sedative-hypnotic drug, p. 292 opioid, p. 293 endorphins, p. 293 cocaine, p. 295

free-basing, p. 296 crack, p. 296 amphetamine, p. 298 hallucinogen, p. 299 lysergic acid diethylamide (LSD), p. 299 cannabis drugs, p. 301 marijuana, p. 301 tetrahydrocannabinol (THC), p. 301 synergistic effect, p. 304 polysubstance-related disorder, p. 305 substance-abuse personality, p. 306 dopamine-2 (D2) receptor gene, p. 308 reward center, p. 309 aversion therapy, p. 310 contingency management, p. 311

behavioral self-control training (BSCT), p. 312 relapse-prevention training, p. 312 detoxification, p. 312 antagonist drug, p. 312 disulfiram (Antabuse), p. 312 narcotic antagonist, p. 314 methadone maintenance program, p. 314 self-help program, p. 315 Alcoholics Anonymous (AA), p. 315 residential treatment center, p. 315 culture- and gender-sensitive program, p. 316 community prevention program, p. 316

KEY TERMSK

1. How does alcohol act on the brain and body? What are the problems and dangers of alcohol misuse? pp. 287–292

2. Describe the features and problems of the misuse of barbiturates and benzodiazepines. pp. 292–293

3. Compare the various opioids (opium, heroin, morphine). What problems may result from their use? pp. 293–294

4. List and compare two kinds of stimu- lant drugs. Describe their biological

actions and the problems caused by each of them. pp. 295–299

5. Why has cocaine use become a major problem in recent years? pp. 295–298

6. What are the effects of hallucino- gens, particularly LSD? pp. 299–301

QUICK QUIZ

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Substance-Related Disorders :// 319

7. What are the effects of marijuana and other cannabis substances? Why is marijuana a greater danger today than it was 30 years ago? pp. 301–304

8. What special problems does polysub- stance use pose? pp. 304–305

9. Describe the leading explanations for substance-related disorders. How well supported are these explanations? pp. 305–309

10. What are the leading treatments for substance-related disorders? How effective are they? pp. 310–316

cyberstudy <<>> SEARCH

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▲ Chapter 10 Video Cases Craving for Cocaine Using Marijuana for Medicinal Purposes Hallucinogens and the Brain

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