Chapter Ten

1. Chapter Ten Substance-Use Disorders

2. Substance-Use Disorders • Recent trends • 21.8 million adolescents and adults (8.7% of population) use illicit drugs, including cannabis, cocaine, heroin, hallucinogens, inhalants, and illicitly-obtained prescription drugs • Increases in nonmedical use of prescription drugs • High rates of heavy drinking and marijuana use

3. Substance-Use Disorders (cont’d.) Figure 10-1 Two-Year Comparison of Past-Month Illicit Drug Use Across Age Groups In comparing 2008 and 2009, increases in the use of illicit drugs (cannabis, cocaine, heroin, hallucinogens, inhalants, and prescription drugs used nonmedically) occurred in almost all age groups. Source: Substance Abuse and Mental Health Services Administration (2010c)

4. Substance-Use Disorders (cont’d.) Figure 10-2 Comparison of Past-Month Illicit Drug Use Across Ethnic Groups In 2009, there were significant differences among ethnic groups in the use of illicit drugs (cannabis, heroin, cocaine, hallucinogens, inhalants, and prescription drugs used nonmedically) Source: Substance Abuse and Mental Health Services Administration (2010c)

5. Substance-Use Disorders (cont’d.) • Arise when psychoactive substances are used excessively • Psychoactive substances: alter moods, thought processes, or other psychological states • Heavy substance use induces changes in brain resulting in addiction • Addiction: involves compulsive drug-seeking behavior and loss of control over drug use

6. Substance-Use Disorders (cont’d.) • Withdrawal: • Adverse physical and psychological symptoms that occur after reducing or ceasing substance intake • Physiological dependence: • State of adaptation that occurs after chronic exposure to a substance • Can result in craving and withdrawal symptoms • Tolerance: • Decreases in effect of substance occurring after chronic use

7. Substance-Use Disorders (cont’d.) • Characteristics of individuals with diagnosis: • Inability to control substance use despite harmful effects • Craving for and preoccupation with obtaining and using substance • Development of tolerance • Withdrawal symptoms

8. Substance-Use Disorders (cont’d.) • DSM-5: • Differentiates disorders according to specific substance used • Disorders involve maladaptive pattern of recurrent use, extending over a period of at least 12 months • Substance abuse • Causes notable impairment or distress • Continues despite social, occupational, psychological, or physical problems

9. Substance-Use Disorders (cont’d.) • Substance abuse is twice as prevalent in males than females • Drug use is much higher among adolescents • Heroin, crack cocaine, and methamphetamine present greatest danger • Alcohol is most dangerous when personal and societal ramifications are considered

10. Substance-Use Disorders (cont’d.) Figure 10-3 Age and Gender Differences in Substance-Use Disorder Diagnosis With the exception of those aged 12 to 17, the incidence of past-year substance-use disorder diagnosis is about twice as high for males as for females. Source: Substance Abuse and Mental Health Services Administration (2010c)

11. Depressants • Cause slowing of responses and generalized depression of central nervous system • Individuals may feel relaxed and sociable due to lowered interpersonal inhibitions • Include: • Alcohol • Opioids • Sedatives, Hypnotics, and Anxiolytics

12. Depressants (cont’d.) • Alcohol: • Moderate drinking: • Lower-risk pattern of alcohol intake (one or two drinks per day) • Heavy drinking: • Chronic alcohol intake of more than two drinks per day for men and more than one drink per day for women • Binge drinking: • Episodic intake of five or more drinks for men or four or more drinks for women

13. Depressants (cont’d.) • Alcohol consumption in U.S.: • One fourth of Americans aged 12 or older binge drink • About 70 percent of adults do not drink excessively, because they either abstain or drink in moderation. • Nearly one fourth of Americans aged 12 or older binge drink, including 7 percent who binge at least five days per month. • 42% is consumed by 14% of young adults

14. Depressants (cont’d.) Figure 10-4 Comparisons of Alcohol Use Across Age Groups Almost half of those ages 18-20 reported underage alcohol use in the previous month, including 23 percent who reported binge drinking and 11 percent who were heavy alcohol users. The highest level of binge drinking and heavy alcohol use is seen in the 21-25 age group Source: Substance Abuse and Mental Health Services Administration (2010c)

15. Depressants (cont’d.) • Alcohol consumption in U.S.: • Heavy drinking in college • 5% of those who use alcohol are physiologically dependent • Withdrawal symptoms include headache, fatigue, sweating, body tremors, and mood changes • Delirium tremens: life-threatening withdrawal symptoms that can result from chronic alcohol use • Lifetime prevalence is 18%

16. Depressants (cont’d.) Figure 10-5 Trends in Heavy Alcohol Use in 18 to 22-Year-Olds There are significant differences in heavy alcohol use between 18 to 22-year-olds who attend college full time with those who attend part time or not al all, with college attendees consistently reporting more heavy drinking. Source: Substance Abuse and Mental Health Services Administration (2010c)

17. Depressants (cont’d.) • Alcohol consumption in U.S.: • Those with highest risk of becoming alcoholics: • Whites • Native Americans • Males • Younger unmarried individuals • Individuals with lower incomes • Men are twice as likely to develop disorder, but alcoholism progresses more rapidly in women

18. Depressants (cont’d.) • Effects of alcohol: • Depresses CNS functioning • Muscular coordination and judgment impaired • Alcohol poisoning • Toxic effects resulting from rapidly consuming alcohol or ingesting large quantity of alcohol • Can result in impaired breathing, coma, and death • Depends on body weight and consumption time period

19. Depressants (cont’d.) • Physiological consequences: • Tolerance • Neurological effects: • Impaired motor skills, reduced reasoning and judgment, memory deficits, distractibility, and reduced motivation • Declines in overall neurological functioning • Effects on cardiovascular system and liver • Abstinence can lead to cognitive improvement • “High functioning alcoholic”

20. Depressants (cont’d.) • Opioids: • Painkilling agents that depress the central nervous system • Illegal substances • Heroin and opium • Prescription opioids • Morphine, codeine, and oxycodone • Second leading form of drug use • The number of emergency department visits due to non-medical use of pain medications increased 111 percent between 2004 and 2008 • Highly addictive

21. Depressants (cont’d.) Figure 10-6 Emergency Department Visits Related to Illicit Use of Prescription Opioids The number of emergency department visits due to illicit use of prescription pain medications increased 111 percent between 2004 and 2008, more than doubling in all age groups and for both males and females. Source: Substance Abuse and Mental Health Services Administration (2010c)

22. Depressants (cont’d.) • Opioids: • Long-term misuse of opioids linked with significant social problems • Many began their habit with prescribed medication, eventually buying prescription drugs illegally or heroin (more lethal opioid) • Prescription drugs are considered by some to be the new “Gateway” drug: substance that leads to use of even more lethal substances • Most opioid overdose deaths are accidental and involve concurrent use of alcohol or other drugs ( Okie, 2010).

23. Depressants (cont’d.) • Effects of opioids: • Produce feelings of euphoria and drowsiness • Tolerance builds rapidly resulting in dependency and need for increased doses • Severe withdrawal symptoms • Symptoms of lethargy, fatigue, anxiety, and disturbed sleep • Drug cravings can persist for years

24. Depressants (cont’d.) • Sedatives: • Have calming effects and are used in treating agitation, muscle tension, insomnia, and anxiety • Hypnotics: induce sleep • Anxiolytics: reduce anxiety • Barbiturates and benzodiazepines have rapid anxiety-reducing effects in moderate doses and hypnotic or sleep-inducing effects in higher doses • Rohypnol is the “date rape” drug but is also used as a recreational drug in combination with alcohol, heroin, or cocaine.

25. Depressants (cont’d.) • Effects of sedatives: • Drowsiness, impaired judgment, and diminished motor skills • Excessive use can lead to accidental overdose and death • Nonmedical use of sedatives, anxiolytics, and hypnotics is highest in the 26–35 age group • Combining alcohol with sedatives increases danger • High potential for tolerance and physiological dependence with all sedatives • Withdrawal symptoms can include insomnia, nervousness, headache, and drowsiness.

26. Stimulants • Central nervous system energizer • Produce feelings of euphoria and well-being, improve mental and physical performance, reduce appetite, and prevent sleep • Include: • Caffeine • Amphetamines • Cocaine

27. Stimulants (cont’d.) • Caffeine: • Stimulant found in coffee, chocolate, tea, and soft drinks • Most widely consumed psychoactive substance in the world • In North America, 90% of adults use daily • Energy drink marketing has increased caffeine consumption • Dramatic increase in ER visits due to energy drinks, especially when combined with alcohol or other drugs. • Caffeine intoxication, tolerance, and side effects

28. Stimulants (cont’d.) • Amphetamines (“uppers”): • Speed up CNS activity • Produce feelings of euphoria and confidence but also agitation, assaultive or suicidal behavior, and delusions of persecution • 2% of U.S. adults have experienced disorder • Methamphetamine • Low cost and rapid euphoric effects • Serious health consequences

29. Stimulants (cont’d.) • Cocaine: • Substance extracted from coca plant that induces feelings of energy and euphoria • Estimated 1.6 million users, with 1.1 million demonstrating disorder • High potential for addiction: 20% of users are rapidly dependent on drug • Withdrawal causes lethargy and depression • Users often take multiple doses in rapid succession

30. Stimulants (cont’d.) • Cocaine: • Crack: • Potent form of cocaine produced by heating cocaine with other substances • Produces immediate but short-lived effects

31. Stimulants (cont’d.) • Effects of cocaine: • Constant desire for cocaine can impair social and occupational functioning • Stimulates sympathetic nervous system • Irregular heartbeat, stroke, and death may occur • Acute psychiatric symptoms • Psychosis, paranoia, and hallucinations • Chronic difficulties: • Anxiety, depression, sleep disturbances, and sexual dysfunction

32. Hallucinogens • Produces vivid sensory awareness, heightened alertness, perceptions of increased insight, and sometimes hallucinations • “Good trips” versus “bad trips” • 1.3 million people involved in 2009

33. Hallucinogens (cont’d.) • Traditional hallucinogens are derived from natural sources: • LSD from a grain fungus • psilocybin from mushrooms • mescaline from the peyote cactus • salvia from an herb in the mint family. • Effects of hallucinogens: • Vary significantly • Not addictive; dependence does not occur • Development of tolerance

34. Dissociative Anesthetics • Produce dreamlike detachment • Phencyclidine (PCP) and ketamine (Special K) highly dangerous and potentially addictive • Have dissociative, stimulant, depressant, amnesic and hallucinogenic properties • Cause disconnection, perceptual distortion, euphoria, and confusion • Delusions, hostility, and violent psychotic behavior • Delusions can persist after cessation of use • Dectromethorphan (DXM): active ingredient in many over-the-counter cough suppressants

35. Substances with Mixed Chemical Properties • Substances that have varied effects on the brain and central nervous system • Include: • Nicotine • Cannabis • Inhalants • Ecstasy

36. Substances with Mixed Chemical Properties (cont’d.) • Nicotine: • Widely-used substance found in tobacco • Stimulant in low doses; relaxant in higher doses • In 2009, almost 70 million adults and adolescents (28% of population) used tobacco, primarily cigarettes. • More males (34 percent) than females (22 percent) use tobacco, particularly noncigarette products. • Smokeless tobacco, used by 13 percent of males attending college, is increasing in popularity. • A smoker's first cigarette of the day produces the greatest stimulant effect.

37. Substances with Mixed Chemical Properties (cont’d.) Figure 10-7 Past-Month Cigarette Use Among Adolescents and Adults Across Age Groups Cigarette smoking increases significantly during late adolescence and peaks between ages 21 and 29. Source: Substance Abuse and Mental Health Services Administration (2010c)

38. Substances with Mixed Chemical Properties (cont’d.) • Nicotine: • Causes both the release of adrenaline (burst of energy) and the release of dopamine (feelings of pleasure) • Euphoric effects decrease; tolerance and withdrawal increase • Withdrawal symptoms include restlessness, anxiety, depressed mood, and irritability • 1.5 million deaths annually in U.S. • Single most preventable cause of premature death

39. Substances with Mixed Chemical Properties (cont’d.) • Cannabis: • Contains chemical THC that can produce stimulant, depressant, and hallucinogenic effects • Marijuana is derived from leaves and flower of plant, while hashish comes from pressed resin • Synthetic marijuana is increasingly popular and dangerous • Concern about the dangers of synthetic marijuana (made from a combination of herbs and chemicals) has resulted in federal efforts to ban chemicals used in its manufacture

40. Substances with Mixed Chemical Properties (cont’d.) • Marijuana is most commonly used illicit drug worldwide and in U.S. • 17 million adults and adolescents report use • Males are more likely to use • Widespread among adolescents and young adults • Most frequently associated with diagnosis of substance use disorder • Includes a unique pervasive lack of concern over consequences • considered a “gateway” drug, especially among those who begin using during adolescence

41. Substances with Mixed Chemical Properties (cont’d.) Figure 11-8 Drugs Involved in First Time Illicit Drug Use in 2009 Among the 3.1 million adolescents and adults who first used an illicit drug during 2009, over half reported their first drug was marijuana, followed by prescription medications which accounted for over 25% of first drug experiences. Source: Substance Abuse and Mental Health Services Administration (2010c)

42. Substances with Mixed Chemical Properties (cont’d.) • Marijuana produces feelings of euphoria, tranquility, and passivity combined with mild perceptual and sensory distortions • Effects of marijuana: • Increase in anxiety and depression in females • Can cause impaired memory, motor coordination, and concentration • Hallucinations and short-term psychotic reactions (may become chronic) • Adolescents who use cannabis have an increased risk of developing schizophrenia

43. Substances with Mixed Chemical Properties (cont’d.) • DSM-5 Cannabis withdrawal: • Clear patterns of withdrawal • Strong similarities with tobacco withdrawal • Clean link between severity of withdrawal symptoms and severity of cannabis dependence • Approximately 10% develop dependence • Withdrawal symptoms • Legalization efforts

44. Substances with Mixed Chemical Properties (cont’d.) • Inhalants: • Use of chemical vapors found in common household products (solvents, aerosol sprays, and compressed air products) • Most common among 12 to 17 year olds • Chronic use common among white males • Effects vary and are brief resulting in repeated “huffing” to extend intoxication

45. Substances with Mixed Chemical Properties (cont’d.) • Effects of inhalants: • Impaired coordination and judgment, euphoria, dizziness, and slurred speech • Hypoxia (oxygen deprivation) results in acute and persistent cognitive deficits • Any episode can result in stroke, acute respiratory distress, or sudden heart failure - “sudden sniffing death” • Emotional and interpersonal difficulties • Paranoia, interpersonal violence, suicidal ideation, anxiety, and depression

46. Substances with Mixed Chemical Properties (cont’d.) • Ecstasy: • Has both stimulant and hallucinogenic properties • In 2009, 1.1 million new users • Produces euphoria, mild sensory and cognitive distortion, feelings of intimacy and well-being, followed by intense depression • Drug dependence develops rapidly even among infrequent users • Withdrawal symptoms • Depression, irritability, un-social

47. Substances with Mixed Chemical Properties (cont’d.) • Effects of ecstasy: • Long-lasting damage in brain areas critical for thought and memory • Reduced ability to complete challenging cognitive tasks • May lead to death • atherosclerosis (hardening of the arteries, a condition typically associated with aging) was found in 58 percent of individuals for whom ecstasy was the cause of death.

48. Combining Multiple Substances • Synergistic effect: • The result of chemicals (or substances) interacting to multiply one another’s effects • some substances (such as alcohol) may reduce judgment, resulting in excessive (or lethal) use of other substances. • Dangerous combinations: • Tranquilizers and alcohol • Stimulants and sleeping pills • Multiple drug use involving ecstasy • Alcohol and caffeine

49. Etiology of Substance-Use Disorders • Progression from substance use to abuse • Individual decides to experiment with drugs • Drug begins to serve important purpose; consumption continues • Brain chemistry becomes altered from chronic use (physiological dependence, withdrawal symptoms, and cravings) • Lifestyle changes occur due to chronic abuse

50. Etiology of Substance-Use Disorders (cont’d.) Figure 10-9 Typical Progression Toward Drug Abuse or Dependence The progression from initial substance use to substance abuse typically begins with curiosity about a drug’s effects and casual experimentation.