Substance Abuse

 

Objectives          

1.  Identify treatment modalities available to treat addiction

2.  Describe the diagnostic criteria present for a diagnosis of substance abuse

3.  Identify signs of substance abuse

4.  Describe the models of addiction

5.  Identify the impact substance abuse has on society

6.  Describe assessment tools used to evaluate a patient level of addiction

 

Assessment, Diagnosis and Treatment

 

DSM-IV: Substance Abuse

Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following occurring within a 12-month period:

1. Failure to fulfill major role obligations

2. Recurrent substance use in situations in which it is physically hazardous

DSM-IV: SA Criteria

1. Recurrent substance-related legal problems

2. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

DSM-IV: Substance Dependence

Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 or more of the following occurring any time in the same 12-month period:

1. Tolerance

2. Withdrawal

3. Substance taken in larger amounts or over a longer period than was intended.

Overview: Did you know-

  • People that die from alcohol related illnesses and accidents lose an average of 24 years off their lives.  Approximately one half of all traffic deaths are alcohol related.  It is the single greatest cause of death among teenagers and young adults. 
  • Each year 400,000 deaths are blamed on cigarette smoking, 110,000 die alcohol related deaths and 20,000 people die from illicit drug abuse.  Alcohol and drug related deaths are higher for males than females.   
  • Heroin or cocaine is involved in 2 out of 3 drug deaths.  Often 2 or more drugs are combined with alcohol.  Forty percent of drug related deaths occur in adults ranging in age from 29 – 39.  Direct health care cost including hospitalization, physicians, nursing homes and specialized treatment centers exceeds $25 billion for alcohol and $10 billion annually for drug abuse treatment.
  • One half of the inmates in prison who committed violent crimes were under the influence of drugs or alcohol at the time they committed the crime.  Women are more likely than men to be under the influence of drugs at the time their crimes were committed.  Men are more likely to be under the influence of alcohol at the time they committed the crime.
  • One in five American households reports that drinking has caused serious problems within their homes.  The same number report having lived with an alcoholic while growing up.  One in three divorced women report alcohol contributing to the break up of their marriage.
  • Children that grow up in alcohol homes have trouble adjusting emotionally and are more likely to repeat the patterns of childhood in their adult relationships.  Children growing up in alcoholic homes are more likely to exhibit aggressive behavior, suffer from psychosomatic symptoms, have difficulty with peers and authority figures and suffer from profound bouts of depression.
  • Most alcoholics and drug users do not receive treatment for their addictions.  The reason are many including user not perceiving they have a problem, insurance companies that will not cover treatment and lack of available programs and space.

DSM-IV: Dependence

1. Persistent desire or unsuccessful efforts to cut down or control substance use

2. Great deal of time is spent in activities necessary to obtain the substance or recover from its effects

3. Important activities are given up or reduced because of substance use.

Dependence

1. The substance use is continued despite knowledge of having a persistent or recurrent physical or physiological problem caused or exacerbated by the substance

2. With physiological dependence

3. Without physiological dependence

Theories and Models of Addiction

Disease model of Addiction:

The disease model of addiction is the work of E.M. Jellinek.  He presented the disease model of alcoholism in 1960.  The American Medical Association declared alcoholism as a treatable illness in 1956. The disease model was originally applied to alcoholism and has been generalized to addiction to other drugs as well.

The disease model essentially states that addiction is more closely related to an illness of which one has little control, compared to a behavior that one chooses to enact. Recent biologically oriented research suggests a genetic component to alcohol and other addictions and points to physiological changes in the brain that result from drug use. These findings are very consistent with the disease model.

The disease model is described as progressive.  Symptoms are believed to get worse over time.  Users are not seen as being responsible for having the disease.  Symptoms of addiction can be arrested.  Addiction is seen as a harmful dependence that can be fatal if not treated.

Psychological Model:

The psychological model views heavy alcohol and drug use as problem behaviors.  An individual drinks or uses to enjoy the effects of alcohol or drugs.  Under these models a user or drinker is not bad or deficient in any way.  Anyone can become addicted to drugs or alcohol because of the way their bodies and minds work, and because of how alcohol and drugs affect their bodies and minds.

Social Learning Model:

This theory is based on results of scientific experimentation and study.  It proposes that drug or alcohol use is learned and continues because the user gets some desired outcome from it.  Users learn to drink or use in response to certain stimuli--people, places, things, events, thoughts and feelings.  Under this model, users are not bad or defective people.  This theory believes that anyone can become addicted to drugs or alcohol because of the way that alcohol and drugs affect ones mind and body.

Sociological Models

This theory believes that societies that produce high levels of tension, stress, aggression, conflict and sexual tensions have higher rates of heavy drinking and drug use.  This idea suggests that the primary role of alcohol and drug use is to reduce feelings of anxiety and stress.  Another belief is that societies that are permissive of and encourage drug or alcohol use have higher rates of problem drinking and drug use.  This model also examines the influence of those who stand to make a profit from the use of alcohol, including those who manufacture and distribute it. 

Biological Models

Biological models of addiction believe that people addicted to drugs or alcohol has a biological abnormality that causes them to become addicted.  There is something physically wrong with the individual.  It is assumed that the physical abnormality is beyond the control of the individual.  The individual is sick; the behavior is not learned nor is it a result of environmental factors. 

There is some evidence that in addicted individuals there is an inherited predisposition to become an addict.  This means that the individual can become more addicted and be more susceptible to addiction.  It does not mean that all individuals with a predisposition toward addiction will actually go on to develop alcoholism or addiction.  This model does not explain addiction in all cases; there are many substance abusers who have no family history of addiction.

This model suggest that a biological abnormality or a genetic gene caused an individuals increased desire to continue drinking after taking the first drink. It also suggests that long-term substance abuse can damage brain cells responsible for willpower and judgment.  According to these models, substance abusers have an incurable disease.  Remission in the form of abstinence is the best possible treatment and goal. 

Required Reading:  The Genetics of Alcoholism

What Is Alcoholism?    

Alcoholism, also known as “alcohol dependence,” is a disease that includes four symptoms:

Craving: A strong need, or compulsion, to drink.

Loss of control: The inability to limit one’s drinking on any given occasion.

Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, occur when alcohol use is stopped after a period of heavy drinking.

Tolerance: The need to drink greater amounts of alcohol in order to “get high.”

People who are not alcoholic sometimes do not understand why an alcoholic can’t just “use a little willpower” to stop drinking. However, alcoholism has little to do with willpower. Alcoholics are in the grip of a powerful “craving,” or uncontrollable need, for alcohol that overrides their ability to stop drinking. This need can be as strong as the need for food or water.

Although some people are able to recover from alcoholism without help, the majority of alcoholics need assistance. With treatment and support, many individuals are able to stop drinking and rebuild their lives.

Many people wonder why some individuals can use alcohol without problems but others cannot. One important reason has to do with genetics. Scientists have found that having an alcoholic family member makes it more likely that if you choose to drink you too may develop alcoholism. Genes, however, are not the whole story. In fact, scientists now believe that certain factors in a person’s environment influence whether a person with a genetic risk for alcoholism ever develops the disease. A person’s risk for developing alcoholism can increase based on the person’s environment, including where and how he or she lives; family, friends, and culture; peer pressure; and even how easy it is to get alcohol.

What Is Alcohol Abuse?

Alcohol abuse differs from alcoholism in that it does not include an extremely strong craving for alcohol, loss of control over drinking, or physical dependence. Alcohol abuse is defined as a pattern of drinking that results in one or more of the following situations within a 12-month period:

  • Failure to fulfill major work, school, or home responsibilities;
  • Drinking in situations that are physically dangerous, such as while driving a car or operating machinery;
  • Having recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk; and
  • Continued drinking despite having ongoing relationship problems that are caused or worsened by the drinking.
  • Although alcohol abuse is basically different from alcoholism, many effects of alcohol abuse are also experienced by alcoholics.

What Are the Signs of a Problem?

How can you tell whether someone may have a drinking problem? Having them answer the following four questions can help you find out:

• Have they ever felt they should cut down on your drinking?

• Have people annoyed them by criticizing your drinking?

• Have they ever felt bad or guilty about their drinking?

• Have they ever had a drink first thing in the morning (as an “eye opener”) to steady their nerves or get rid of a hangover?

One “yes” answer suggests a possible alcohol problem. If they answered “yes” to more than one question, it is highly likely that a problem exists. In either case, it is important that they see a doctor or other health care provider right away to discuss their answers to these questions. He or she can help determine whether they have a drinking problem and, if so, recommend the best course of action.

Even if they answered “no” to all of the above questions, if they encounter drinking-related problems with their job, relationships, health, or the law, they should seek professional help. The effects of alcohol abuse can be extremely serious, even fatal.

Assessment of Substance Abuse

Required Reading:      Screening for Alcohol Problems

Explore the Substance Use:

It is important to assess the patient’s current use of alcohol or drugs by exploring the frequency and quantity of use.  What kinds of drinks or what kinds of drugs are used.  Patterns of use including binge drinking and drug binging, weekend use, alone use, use at parties only or with friends.  Reasons for use including to reduce tension and stress, escape problems, reduced inhibitions or avoidance.  Ask question to determine when the substance was first used.  Understand the progression of use dating back to the first time.  Was there any periods of sobriety?   What helped them to stay sober?

Medical History: 

Are they currently or have they been on any medication?  What length of time have they used the medication and what was it prescribed for?

Patterns of Abuse in the Family of Origin:

Have parents, siblings or relatives used substances before?  Patterns of use, reason for use and end results should be explored.  Is there a history of trauma and/or abuse within the family?  Are there psychiatric problems and what treatment was prescribed.

Work and Vocational History:

What is the educational and vocational history of the patient?  Do they have difficulties seeking and maintaining employment?  What are the reasons for their difficulties?  Is it due to substance use?  Do they go to work intoxicated?  Do they drive intoxicated?  How often do they change jobs?  Do they have problems concentrating at work or school?

Legal Problems:

Do they have legal problems?  If so, are they related to the substance use?  DUI’s? Probation?  Pending litigation?  Divorce?   Why are they seeking counseling now? Is child protective services involved in the case?  Is the visit court appointed?  Is their life unmanageable?  Are they being pressured to attend?  Does the user think that they have a problem?                  

Treatment of Substance Abuse:

Levels of Care

Detoxification:

Detoxification is designed to support clients during withdrawal from alcohol and other drugs.  The treatment usually lasts from 3-7 days. Patients are monitored by qualified, staff throughout the procedure. A complete and detailed medical history and health examination is performed for each client.  Detoxification medications will be prescribes, if necessary.

Residential Treatment:  

Residential patients receive intensive treatment for addiction and alcoholism.  The treatment is goal-oriented and includes individual counseling, group therapy, educational lectures, relapse prevention groups, and specific components designed for individual clients on a case-by-case basis. Patients attend 12-Step meetings within the residential setting as well.

The goal of residential treatment is to help the client achieve and sustain long-term sobriety. Presenting problems are identified, strengths and weaknesses ascertained, and specific problem areas targeted. Family members are strongly encouraged to be involved in the treatment process and participate in family education program groups. Residential Treatment will help residents develop management skills that will not assist them during this initial stabilization period and well into the future.

Outpatient Care:

Outpatient treatment programs are designed for patients who do not require a more structured environment to maintain sobriety and who are not in acute withdrawal. Treatment includes individualized treatment planning, educational and process groups several times per week, and individual counseling. Appropriate referrals are made to community-based self help groups. Outpatient Treatment gives the individual an opportunity to interact with the real world environment while still benefiting from a peer-oriented, structured therapeutic program. Clients’ progress is assessed to help determine the length of the program for each patient.

Aftercare:

Aftercare is the care given to patients after the initial treatment has ended.  Aftercare generally lasts six to twelve months.  It includes weekly group meetings, individual counseling and case management services.  Programs are usually designed by the original treatment provider.  They are designed to prevent a relapse.

Stages of Recovery:

Initial Stage:

Physiological and biochemical changes begin to occur.  The addict received psychological care and understanding of their deep feelings of shame and relief.  They learn to adjust to their new lifestyle.  They adjust to their boredom and need for excitement.  They learn to live a substance free life.

Secondary Stage:

The initial stage of recovery fades away.  Their motivation and drive may wane.  Family and individual concerns begin to be addressed.  The deeper psychological problems that contributed to the substance abuse begin to surface.  Patients are often flooded with feelings and emotions.  Insight and working through of the problems is essential.  If the feelings are too intense, the risk of the patient dropping out of treatment will increase.

Later Stages:

Work must be continued to prevent relapse.  Traumas and everyday problems must be addressed.  Short and long term goals should be part of the continued recovery process.  Issues of intimacy continue to emerge.  Continue to place structure and control in the life of the addict.   Continue to create an atmosphere which is safe for the patient to explore their innermost feelings and concerns.

Duel Diagnosis:

Duel Diagnosis occurs when the patient suffers from more than one disorder.  In substance abuse treatment it means the patient has a substance abuse disorder coupled with a mental disorder.    The presence of a duel diagnosis decreases a successful outcome.  The poorest possible outcome occurs when the duel diagnosis includes a psychotic disorder.  Psychological and Neuropsychological testing are often needed to differentiate between the two disorders.  The need of the patient are only partial met in the treatment of substance abuse.  Medications may be needed and a complete medical evaluation is necessary when working with any substance abuse disorder. 

Co-occurring disorders are common; they affect from 7 to 10 million adults in the U.S. each year.   Children, youth, and older adults also may experience co-occurring substance abuse disorders and mental disorders. For youths, one study revealed that nearly 43 percent of youth receiving mental health services in the United States have been diagnosed with a co-occurring disorder.

Both substance abuse disorders and mental disorders have biological, psychological, and social components. Part of the complexity of treating these disorders when they co-occur is that both primarily affect the same part of the body - the brain - a factor that complicates treatment, including the use of medications.

Screening and assessment, the very first steps in the process of identifying and treating individuals with co-occurring substance abuse disorders and mental disorders, are similarly complicated. Often times these individuals minimize or deny the existence of their disorders in the first place; they do not enter the door to services willingly or often. When they do enter the service system, mental disorders may be masked by substance abuse; obversely, what appear to be mental disorders may be the product of substance abuse complicating evaluation and assessment.

12-step programs

Over the past 30 years, the peer-led, voluntary fellowship known as Alcoholics Anonymous (AA) continues to be the most widely accessed resource for people with alcohol problems.  The rationale for facilitating patients’ involvement in 12-step self-help groups stems primarily from recent AA outcome research and from developments in the management and organization of health care in the United States.

From the 1940s through the 1980s, most studies on AA did not directly evaluate AA’s effectiveness. Rather, researchers examined AA’s organizational structure and functioning; its history; and the ways in which AA participation changed members’ values, sense of identity, and spiritual outlook. The few AA outcome studies that were conducted typically did not study AA members over time or include non-AA members for comparison purposes, making conclusions about AA’s effectiveness tenuous. Given this limited empirical base, many clinicians and researchers doubted whether AA truly helped its members recover from alcohol dependence.

In the 1990s, the breadth and depth of AA research increased significantly. Recent AA outcome research, which has demonstrated the benefits of treatments intended to facilitate AA involvement, as well as of AA involvement per se, has typically employed longitudinal designs (i.e., studied AA members over time), reliable measures, comparison groups and, in some cases, random assignment to conditions. The improved methodological quality of AA research has reduced skepticism in the treatment community about AA’s effectiveness and has increased clinicians’ interest in facilitating connections between substance abuse treatment and 12-step self-help groups.

The other major factor that has enhanced interest in 12-step facilitation (TSF) interventions is the growth of managed health care. In both the public and private sectors, managed care has reduced the length and intensity of professional addiction treatment services and increased the pressure for cost-effective care.

Because managed care has reduced the amount of time available for practitioners to work with patients, clinicians are increasingly interested in facilitating patient involvement in self-help groups as an inexpensive way to achieve and maintain treatment gains.

Can Alcoholism Be Cured?

Although alcoholism can be treated, a cure is not yet available. In other words, even if an alcoholic has been sober for a long time and has regained health, he or she remains susceptible to relapse and must continue to avoid all alcoholic beverages. “Cutting down” on drinking doesn’t work; cutting out alcohol is necessary for a successful recovery.

However, even individuals who are determined to stay sober may suffer one or several “slips,” or relapses, before achieving long-term sobriety. Relapses are very common and do not mean that a person has failed or cannot recover from alcoholism. Keep in mind, too, that every day that a recovering alcoholic has stayed sober prior to a relapse is extremely valuable time, both to the individual and to his or her family. If a relapse occurs, it is very important that they try to stop drinking once again and to get whatever additional support they need to abstain from drinking.

Required Reading:      Helping Patients with Alcohol Problems             

A Closer Look at Drug Abuse

Theories of Drug Addiction

McKim (1997) describes three models of why people become addicted to drugs, or engage in substance abuse to use the modern terminology:

  • the disease model
  • the physical dependency model
  • the positive reinforcement model

At one time people with problems associated with alcohol or other drugs were regarded as sinners or criminals, and any help they might receive came via the courts or the church. Towards the end of the 19th century the medical profession began to use the word addiction as both an explanation for, and diagnosis of, excessive drug use. This idea was formalized in the 1950s when the World Health Organization (WHO) and American Medical Association (AMA) classified alcoholism as a disease. One consequence of this change in attitude is the notion that the addict is not in control of their behavior, that they require treatment rather than punishment.

One problem with the disease model is that it not clear how one catches this disease. The presence of withdrawal symptoms led to the idea that the avoidance of withdrawal symptoms was the reason people continued to self-administer drugs. This is the essence of the physical dependency model

Physical Dependency Model

Effects of heroin

Heroin withdrawal symptoms

euphoria

dysphoria

constipation

diarrhoea & cramps

relaxation

agitation

After repeated exposure to certain drugs, withdrawal symptoms appear if the drug is discontinued.

Withdrawal symptoms are compensatory reactions that oppose the primary effects of the drug. Therefore they are the opposite of the effects of the drug.

Withdrawal effects are unpleasant and reduction in these effects would therefore constitute negative reinforcement . [Negative reinforcement is the reinforcement of behavior that terminates an aversive stimulus] Negative reinforcement could explain why addicts continue to take the drug. However some addicts will endure withdrawal symptoms ( go 'cold-turkey') in order to reduce their tolerance so that they can recommence drug intake at a lower dose which costs less to purchase.

Concentrating on the role of physical withdrawal effects at the expense of other psychological factors led to the failure to recognize the addictive properties of cocaine. Cocaine does not produce physical dependency (tolerance and withdrawal symptoms) but it is more addictive than heroin.

It is also important to emphasize that reduction in withdrawal symptoms does not explain why people take drugs in the first place. Negative reinforcement may account for initial drug taking in some situations. For example, someone who is suffering from unpleasant emotions may experience a reduction in these feelings (i.e. negative reinforcement) following drug administration.

However the most likely reason for drug taking involves positive reinforcement.

Positive Reinforcement Model

The reinforcing properties of a drug are thought to be reason why most people become addicted to drugs.

Addictive drugs are positive reinforcers (Carlson, 2001). As you know positive reinforcement can lead to learning a new response, and the maintenance of existing behaviors. It follows that the behaviors associated with taking an addictive drug (i.e. injecting or smoking it) will increase in probability. One way of testing this claim is to examine the reinforcing properties of drugs in animals. We already know that conventional reinforcers support bar-pressing in animals, therefore if a drug maintains a response such as bar-pressing in an animal, it is a reinforcing stimulus.

At one time it was believed that animals could not be made addicted to drugs, but that view is now rejected because technical developments have shown that animals will learn new behaviors that cause injection of drugs into their body.

This diagram shows the apparatus used to study self-administration of drugs in laboratory animals. The rat will learn to press the lever which causes activation of the infusion pump by the program circuitry. The pump delivers drug solution through a catheter implanted into a vein.

This figure shows the daily amount of morphine self-administered by a monkey over 25 weeks. The trend line shows the progressive increase in intake which may reflect growing tolerance to the drug.

Generally drugs that are self-administered by laboratory animals are also self-administered by humans, and vice versa .

Drugs that are self-administered by laboratory animals

Drugs that are not self-administered by laboratory animals

  • alcohol
  • amphetamine
  • barbiturates
  • caffeine
  • cocaine
  • nicotine
  • opiates e.g. morphine
  • procaine
  • phencyclidine (PCP)
  • THC (active component in marijuana)
  • imipramine
  • mescaline
  • phenothiazines
  • scopolamine

 

Note that procaine (structurally similar to cocaine, normally used as a dental anaesthetic) is self-administered by laboratory animals, but it is not abused by humans. Mescaline is taken by humans, but animals will not self-administer it.

Drugs and Brain Reinforcement Systems

The most popular contemporary view of why humans self-administer potentially lethal drugs is that these chemicals activate the reinforcement system in the brain. This system is normally activated by natural reinforcers such as food, water, sex etc. Reinforcers are thought to increase the effect of dopamine at receptors in the mesolimbic system which originates in the ventral tegmental area and terminates in the nucleus accumbens . Crack cocaine is thought to cause a massive and rapid activation of dopamine receptors in this system. Crack users report that the effects are much more intense than those produced by powerful reinforcers such as ejaculation or orgasm.

Reinforcers all share one physiological effect: They increase the release of dopamine (DA) in the nucleus accumbens. This effect can be produced by addictive drugs such as amphetamine, cocaine, opiates, nicotine, alcohol, PCP, and cannabis as well as natural reinforcers such as food, water and sexual contact.

What is the role of dopamine in reward?

According to most textbooks when the dopamine pathway running from the  ventral tegmental area to the nucleus accumbens in the forebrain is activated, the  release of dopamine into the forebrain nucleus accumbens is believed to cause feelings of pleasure. However this conventional view has been challenged by Dr. Mark Wightman  and his colleagues (Garris et al, 1999) at the University of North Carolina (see Center Line (2000)). They confirmed   previous findings that:

  • Artificially stimulating the ventral tegmental area at a regular or irregular rate released dopamine in the forebrain.
  • Rats can be trained to electrically stimulate the ventral tegmental area.
  • Rats were unable to learn to self-stimulate if the stimulation produced no dopamine release
  • As predicted this self-stimulation is accompanied by the release of dopamine in the forebrain

However this effect does not last.

  • With continued training  virtually no dopamine was released in response to self-stimulation of the ventral tegmental area, even though ventral tegmental stimulation remained rewarding—the animal continued performance of the bar pressing response.

Therefore the release of dopamine may not be critical for reinforcement once the task is learned. Wightman has suggested that  dopamine may   be a neural substrate for novelty or reward expectation rather than reward itself.

Diagnostic and Statistical Manual - IV

A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  • Substance is often taken in larger amounts or over longer period than intended
  • Persistent desire or unsuccessful efforts to cut down or control substance use
  • A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects
  • Important social, occupational, or recreational activities given up or reduced because of substance abuse
  • Continued substance use despite knowledge of having a persistent or recurrent psychological, or physical problem that is caused or exacerbated by use of the substance
  •     Tolerance, as defined by either:
    • need for read amounts of the substance in order to achieve intoxication or desired effect; or
    • markedly diminished effect with continued use of the same amount
  •     Withdrawal, as manifested by either:
    • characteristic withdrawal syndrome for the substance; or
    • the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms

International Classification of Diseases – 10

[ICD-10 research criteria differ from the clinical diagnostic guide lines listed here.] Three or more of the following must have been experienced or exhibited at some time during the previous year:

  • Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use
  • A strong desire or sense of compulsion to take the substance
  • Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects
  • Persisting with substance use despite clear evidence of overtly harmful consequences, depressive mood states consequent to heavy use, or drug related impairment of cognitive functioning
  • Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses
  • A physiological withdrawal state when substance use has ceased or been reduced, as evidence by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms

Commonly Abused Drugs

Substance:
Category and Name

Examples of Commercial
and Street Names

How

Administered

Intoxication Effects/Potential Health Consequences

Cannabinoids

euphoria, slowed

 thinking and reaction

 time, confusion,

 impaired balance and coordination/cough, frequent respiratory infections; impaired memory and learning; increased heart rate, anxiety; panic attacks; tolerance, addiction

hashish

boom, chronic, gangster, hash, hash oil, hemp

I/swallowed,

smoked

marijuana

blunt, dope, ganja, grass, herb, joints, Mary Jane, pot, reefer, sinsemilla, skunk, weed

I/swallowed,

smoked

Depressants

reduced pain and

anxiety; feeling of

 well-being; lowered inhibitions; slowed

 pulse and breathing; lowered blood

 pressure; poor concentration/

confusion, fatigue; impaired coordination, memory, judgment; respiratory depression

 and arrest, addiction

Also, for barbiturates—sedation, drowsiness/depression, unusual excitement,

fever, irritability, poor judgment, slurred

speech, dizziness

for benzodiazepines—sedation, drowsiness/dizziness

for flunitrazepam

visual and

gastrointestinal disturbances, urinary retention, memory

loss for the time

under the drug's

effects

for GHB—drowsiness, nausea/vomiting, headache, loss of consciousness, loss of reflexes, seizures,

coma, death

for methaqualone—euphoria/depression,

poor reflexes, slurred speech, coma

barbiturates

Amytal, Nembutal, Seconal, Phenobarbital; barbs, reds, red birds, phennies, tooies, yellows, yellow jackets

II, III, V/injected, swallowed

Benz-

odiazepines (other than flun-

itrazepam)

Ativan, Halcion, Librium, Valium, Xanax; candy, downers, sleeping pills, tranks

IV/swallowed

Flun-

itrazepam

Rohypnol; forget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies

IV/swallowed,

snorted

GHB

gamma-hydroxybutyrate; G, Georgia home boy, grievous bodily harm, liquid ecstasy

under

consideration/

swallowed

Meth-

aqualone

Quaalude, Sopor, Parest; ludes, mandrex, quad, quay

I/injected,

swallowed

Dissociative Anesthetics

increased heart rate

and blood pressure, impaired motor function/memory

loss; numbness; nausea/vomiting

Also, for ketamine

—at high doses,

 delirium, depression, respiratory depression

 and arrest

for PCP and analogs—possible decrease in

blood pressure and

 heart rate, panic, aggression, violence/

loss of appetite,

depression

ketamine

Ketalar SV; cat Valiums, K, Special K, vitamin K

III/injected,

snorted,

smoked

PCP and analogs

phencyclidine; angel dust, boat, hog, love boat, peace pill

I, II/injected, swallowed,

smoked

Hallucinogens

altered states of

perception and feeling; nausea/chronic mental disorders, persisting perception disorder (flashbacks)

Also, for LSD and mescaline—increased

 body temperature,

 heart rate, blood pressure; loss of

appetite, sleeplessness, numbness, weakness, tremors

for psilocybin—nervousness, paranoia

LSD

lysergic acid diethylamide; acid, blotter, boomers, cubes, microdot, yellow sunshines

I/swallowed,

 absorbed through mouth tissues

mescaline

buttons, cactus, mesc, peyote

I/swallowed,

smoked

psilocybin

magic mushroom, purple passion, shrooms

I/swallowed

Opioids and Morphine Derivatives

pain relief, euphoria, drowsiness/respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness,

coma, tolerance,

addiction

Also, for codeine—less analgesia, sedation,

 and respiratory

depression than

morphine

for heroin—staggering

 gait

codeine

Empirin with Codeine, Fiorinal with Codeine, Robitussin A-C, Tylenol with Codeine; Captain Cody, Cody, schoolboy; (with glutethimide) doors & fours, loads, pancakes and syrup

II, III, IV/injected, swallowed

fentanyl

Actiq, Duragesic, Sublimaze; Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash

II/injected,

smoked,

 snorted

heroin

diacetylmorphine; brown sugar, dope, H, horse, junk, skag, skunk, smack, white horse

I/injected,

smoked,

 snorted

morphine

Roxanol, Duramorph; M, Miss Emma, monkey, white stuff

II, III/injected, swallowed,

smoked

opium

laudanum, paregoric; big O, black stuff, block, gum, hop

II, III,

 V/swallowed,

 smoked

Stimulants

increased heart rate,

 blood pressure, metabolism; feelings

of exhilaration, energy, increased mental alertness/rapid or

irregular heart beat; reduced appetite,

weight loss, heart

failure

Also, for amphetamine—rapid breathing; hallucinations/ tremor,

loss of coordination; irritability, anxiousness, restlessness, delirium, panic, paranoia,

impulsive behavior, aggressiveness,

tolerance, addiction

for cocaine—increased temperature/chest

pain, respiratory failure, nausea, abdominal pain, strokes, seizures, headaches, malnutrition

for MDMA—mild hallucinogenic effects, increased tactile sensitivity, empathic feelings, hyperthermia

/impaired memory and learning

for meth-

amphetamin

e—aggression,

 violence, psychotic behavior/memory loss, cardiac and

neurological damage; impaired memory and learning, tolerance, addiction

for methylphenidate—increase or decrease

 in blood pressure, psychotic episodes/digestive problems, loss of

appetite, weight loss

for nicotine—tolerance, addiction;additional

effects attributable to tobacco exposure - adverse pregnancy outcomes, chronic

 lung disease, cardiovascular disease, stroke, cancer

Am-

phetamine

Adderall, Biphetamine, Dexedrine; bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers

II/injected,

swallowed,

smoked, snorted

cocaine

Cocaine hydrochloride; blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot

II/injected,

smoked, snorted

MDMA

(methylene

dioxy
meth

am-

phetamine)

DOB, DOM, MDA; Adam, clarity, ecstasy, Eve, lover's speed, peace, STP, X, XTC

I/swallowed

Meth-

Am-

phetamine

Desoxyn; chalk, crank, crystal, fire, glass, go fast, ice, meth, speed

II/injected,

swallowed,

smoked, snorted

Methylphen-

idate

Ritalin; JIF, MPH, R-ball, Skippy, the smart drug, vitamin R

II/injected,

swallowed,

snorted

nicotine

bidis, chew, cigars, cigarettes, smokeless tobacco, snuff, spit tobacco

not scheduled/

smoked, snorted,

 taken in snuff and

spit tobacco

Other Compounds

anabolic steroids

Anadrol, Oxandrin, Durabolin, Depo-Testosterone, Equipoise; roids, juice

III/injected,

 swallowed,

applied to skin

no intoxication effects/hypertension,

blood clotting and cholesterol changes,

liver cysts and cancer, kidney cancer, hostility

 and aggression, acne; adolescents, premature stoppage of growth; in males, prostate

cancer, reduced sperm production, shrunken testicles, breast enlargement; in

females, menstrual irregularities,

development of beard and other masculine characteristics

inhalants

Solvents (paint thinners, gasoline, glues), gases (butane, propane, aerosol propellants, nitrous oxide), nitrites (isoamyl, isobutyl, cyclohexyl); laughing gas, poppers, snappers, whippets

not scheduled/

inhaled through

nose or mouth

stimulation, loss of inhibition; headache; nausea or vomiting; slurred speech, loss of motor coordination; wheezing/

unconsciousness,

cramps, weight loss, muscle weakness, depression, memory impairment, damage

to cardiovascular and nervous systems,

 sudden death

Schedule I and II drugs have a high potential for abuse. They require greater storage security and have a quota on manufacturing, among other restrictions. Schedule I drugs are available for research only and have no approved medical use; Schedule II drugs are available only by prescription (unrefillable) and require a form for ordering. Schedule III and IV drugs are available by prescription, may have five refills in 6 months, and may be ordered orally. Most Schedule V drugs are available over the counter.

Taking drugs by injection can increase the risk of infection through needle contamination with staphylococci, HIV, hepatitis, and other organisms.

Cocaine

Cocaine causes the body's blood vessels to become narrow, constricting the flow of blood. This is a problem. It forces the heart to work harder to pump blood through the body. (If you've ever tried squeezing into a tight pair of pants, then you know how hard it is for the heart to pump blood through narrowed blood vessels.) When the heart works harder, it beats faster. It may work so hard that it temporarily loses its natural rhythm. This is called fibrillation, and it can be very dangerous because it stops the flow of blood through the body.

Many of cocaine's effects on the heart are actually caused by cocaine's impact on the brain -- the body's control center.  Cocaine and amphetamines change the way the brain works by changing the way nerve cells communicate. Nerve cells, called neurons, send messages to each other by releasing special chemicals called neurotransmitters. Neurotransmitters are able to work by attaching to key sites on neurons called receptors.

One of the neurotransmitters affected by cocaine is called dopamine. Dopamine is released by neurons in the limbic system -- the part of the brain that controls feelings of pleasure.  Normally, once dopamine has attached to a nerve cell's receptor and caused a change in the cell, it's pumped back to the neuron that released it. But cocaine blocks the pump, called the dopamine transporter. Dopamine then builds up in the gap synapse between neurons.  The result: dopamine keeps affecting a nerve cell after it should have stopped. That's why someone who uses cocaine feels an extra sense of pleasure for a short time.

Although cocaine may make someone feel pleasure for a while, later it can damage the ability to feel pleasure. Research suggests that long-term cocaine use may reduce the amount of dopamine or the number of dopamine receptors in the brain. When this happens, nerve cells must have cocaine to communicate properly. Without the drug, the brain can't send enough dopamine into the receptors to create a feeling of pleasure.  If a long-term user of cocaine or crack stops taking the drug, the person feels an extremely strong craving for it, because without it he or she can't feel nearly as much pleasure.

Fortunately, scientists have figured out how to copy the gene that controls the dopamine transporter. This process is called cloning.  By studying copies of the transporter, scientists may learn more about how cocaine affects it -- and how to prevent those effects. These studies may even lead to the discovery of a treatment for cocaine dependency.  Scientists are already working to create fake cocaine for use as a treatment. This chemical would attach to the dopamine transporter just like real cocaine does, but it wouldn't block dopamine's normal movement back into neurons. By attaching to the transporter, the substitute would block the effects of real cocaine.

Anabolic Steroids

You may have heard that some athletes use anabolic steroids to gain size and strength. Maybe you've even seen an anabolic steroid user develop bigger muscles over time.  But while anabolic steroids can make some people look stronger on the outside, they may create weaknesses on the inside.

For example, anabolic steroids can weaken the immune system -- the body's defense against germs and diseases. They can also lead to liver damage or cancer, even in young people. They can also permanently stop bones from growing in teenagers. This means that a teenage steroid user may not grow to be his or her full adult height and will be shorter for life.

Parts of the brain that influence mood and are involved in learning and memory are called the limbic system. Anabolic steroids act in the limbic system. In animals, they have been shown to impair learning and memory. They can also lead to changes in mood, such as feelings of depression or irritability.

Anabolic steroid users may act mean to people they're normally nice to, like friends and family. Anabolic steroids in the brain may trigger really aggressive behavior. Some outbursts can be so severe they have become known in the media as "roid rages."

Anabolic Steroids Can Confuse the Brain and Body

The body's testosterone production is controlled by a group of nerve cells at the base of the brain, called the hypothalamus. The hypothalamus also does a lot of other things. It helps control appetite, blood pressure, moods, and reproductive ability.  Anabolic steroids can change the messages the hypothalamus sends to the body. This can disrupt normal hormone function.

In guys, anabolic steroids can interfere with the normal production of testosterone. They can also act directly on the testes and cause them to shrink. This can result in a lower sperm count and reproductive ability. They can also cause an irreversible loss of scalp hair.

In girls, anabolic steroids can cause a loss of the monthly period by acting on both the hypothalamus and reproductive organs. They can also cause loss of scalp hair, growth of body and facial hair and deepening of the voice. These changes are also irreversible.

Doctors never prescribe anabolic steroids for building muscle in young, healthy people.  But doctors sometimes prescribe anabolic steroids to treat some types of anemia or disorders in men that prevent the normal production of testosterone.  You may have heard that doctors sometimes prescribe steroids to reduce swelling. This is true, but these aren't anabolic steroids. They're corticosteroids.  Since corticosteroids don't build muscles the way that anabolic steroids do, people don't abuse them.

Fundamental Principles of Drug Treatment

More than two decades of scientific research has yielded a set of 13 fundamental principles that characterize effective drug abuse treatment. These principles are detailed below:

1. No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each patient's problems and needs is critical.

2. Treatment needs to be readily available. Treatment applicants can be lost if treatment is not immediately available or readily accessible.

 3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. Treatment must address the individual's drug use and associated medical, psychological, social, vocational, and legal problems.

4. At different times during treatment, a patient may develop a need for medical services, family therapy, vocational rehabilitation, and social and legal services.

5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The time depends on an individual's needs. For most patients, the threshold of significant improvement is reached at about 3 months in treatment. Additional treatment can produce further progress. Programs should include strategies to prevent patients from leaving treatment prematurely.

6. Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding non drug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships.

 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethodol (LAAM) help persons addicted to opiates stabilize their lives and reduce their drug use. Naltrexone is effective for some opiate addicts and some patients with co-occurring alcohol dependence. Nicotine patches or gum, or an oral medication, such as buproprion, can help persons addicted to nicotine.

8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.

9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification manages the acute physical symptoms of withdrawal. For some individuals it is a precursor to effective drug addiction treatment.

10. Treatment does not need to be voluntary to be effective. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase treatment entry, retention, and success.

11. Possible drug use during treatment must be monitored continuously. Monitoring a patient's drug and alcohol use during treatment, such as through urinalysis, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that treatment can be adjusted.

12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place them or others at risk of infection. Counseling can help patients avoid high-risk behavior and help people who are already infected manage their illness.

13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Participation in self-help support programs during and following treatment often helps maintain abstinence.

Prevention

Substance Abuse in the Work Place - Team Awareness Approach

Team Awareness is a workplace-training program that addresses behavioral risks associated with substance abuse among employees, their coworkers and, indirectly, their families. This program has been shown to increase employee help-seeking for and supervisor responsiveness to, troubled workers, enhance the work climate, and reduce problem drinking. These results are achieved by—

  • Promoting social health
  • Promoting increased communication between workers
  • Improving knowledge and attitudes toward alcohol- and drug-related     
  • Protective factors in the workplace (such as company policy or Employee Assistance Programs)
  • Increasing peer referral behaviors

The training consists of six modules and is conducted across two 4-hour sessions with a company or business any size. Larger companies generally require multiple training sessions. Team Awareness is highly interactive and uses group discussion, communication exercises, a board game, role play, and self-assessments. Modules cover policy ownership, enabling, stress management, listening skills, and peer referral.

Program Background

The logic and content of Team Awareness were based on Texas Christian University (TCU) survey research of over 3,000 employees from three municipalities. Findings showed that employee tolerance for coworker substance use, attitudes toward discrete policy components, and work group drinking climates were each predictive of risk for substance use-related problems. Additional findings suggested that group cohesiveness and social integration at work might buffer against substance abuse risks. Team Awareness was developed in order to address both risk and protective factors identified in this survey research

Target Population

Team Awareness is designed for use in any type of organizational setting or occupational group where employees interact with or depend on each other to get work done. The training may be particularly effective for safety-sensitive occupations (e.g., construction workers, emergency response and law enforcement personnel, machinery or equipment operators, municipalities, and transportation workers) or where tradition supports coworkers’ shared use of alcohol to handle stress or to socialize. The program has been tested on a wide variety of white- and blue-collar occupations with same- or mixed-gender compositions within two municipal work forces. Team Awareness has also been adapted for use by small businesses and community-based alcohol or drug awareness centers.

Outcomes

Employees who received Team Awareness training reported the greatest increases in involvement with the Employee Assistance Program (EAP). These findings are significant because EAP services are underutilized in workplaces where employees need psychological counseling but are concerned about confidentiality or stigma. In the high-risk sample, employees who received Team Awareness reported improvements on a number of drinking and drinking climate measures. They showed a reduction in job-related hangovers, and reported that their coworkers were more willing to discuss problem employees, less likely to stigmatize them, and less likely to drink together.

Benefits  

Reduces alcohol and drug use risk factors in the work setting

  • Improves work group climate that supports employee health and wellness
  • Increases supervisor willingness to use the Employee Assistance Program (EAP)
  • Decreases employee tendency to ignore or stigmatize coworkers with problems
  • Improves confidentiality (respect for privacy) within the work group
  • Reduces social norms that support drinking with coworkers

How It Works

Team Awareness can serve three different functions depending on the needs of a business and can be positioned as:

  • An enhanced drug-free workplace program
  • A team communication workshop
  • A work culture intervention
  • In its original design, Team Awareness has three core components:
  • Preparatory focus groups and meetings to collect policy information, establish rapport, and facilitate employee involvement
  • Supervisor training (two 4-hour sessions)
  • Employee training (two 4-hour sessions)

The training consists of six modules:

Relevance: Increases employee ownership of the importance of their role in substance abuse prevention in their work site.

Team Ownership of Policy: The Risks & Strengths Game creates positive attitudes toward company substance abuse prevention policies as tools for risk prevention.

Reducing Stigma & Tolerance and Increasing Responsiveness: Reduces risky levels of supervisor and coworker tolerance of substance use, i.e., enabling and codependence.

Work Stress, Problem Solving, and Substance Use: Identifies signs of poor coping and the role of substance use. Promotes healthy alternatives for dealing with stress.

Workplace Communication Skills: Reviews listening skills and identifies workplace communication norms.

Encouragement:  Develops peer referral skills and employee alliance with EAPs.

Many prevention models are available, depending on the type of audience to be served.  The above model shows how a structured program can benefit participants

Additional Required Reading:

Understanding Drug Abuse and Addiction: What Science Says

Methamphetamine: Abuse and Addiction

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