Uppers, Downers, All Arounders, 7th Edition – Instructors Manual

Uppers, Downers, All Arounders, 7th Edition – Instructors Manual

Chapter 1 – History Chapter Overview The first part of this chapter provides a historical survey of the pharmacologic and political influences on the use of psychoactive substances and compulsive behaviors in all civilizations. The second part presents a system for classifying these psychoactive substances along with major legislation impacting use of drugs and treatment of addictions. Throughout the last 10,000 years, humans have used psychoactive drugs to alter their perception of reality for a variety of reasons. By studying the history of drug use and abuse, a number of historical themes become apparent. 1.

There is a basic need of human beings to cope with their environment and enhance their existence.

2.

Human brain chemistry can be affected by psychoactive drugs, behavioral addictions, and mental illness to induce an altered state of consciousness.

3.

The ruling classes, governments, and businesses have always been involved in trying to control the drug trade, often using it as a source of revenue through trade and taxes.

4.

Technological advances in refining, synthesizing, and manufacturing psychoactive drugs have increased their potency and abuse liability.

5.

Users and researchers have discovered new ways of taking drugs so they reach the brain faster, thus increasing their abuse liability.

For example, opium was used originally for medicinal and spiritual purposes. Once people discovered that opium created mental effects because of the way it manipulated the brain's own natural chemicals especially endorphins, the body's own painkillers, they used it to change their mental/emotional state. Legal, social, and health problems multiplied after people began to smoke it, when it became a lucrative source of income for governments and trading companies, when it was refined to the stronger morphine and heroin and when it could be delivered directly into the bloodstream using a hypodermic needle. The discovery of psychoactive plants (opium poppy, coca bush, coffee bean, Cannabis, and the tobacco plant) and the subsequent synthesis of hundreds of other psychoactive substances, has led to a medicine chest full drugs, most useful and some desirable but all causing problems when abused. Today alcohol, tobacco, marijuana, cocaine, opioids (especially prescription drugs), crystal meth, and ecstasy are the most widely used drugs. The recent development of synthetic marijuana sold as “herbal incense” and synthetic stimulants sold as “bath salts” represent a great potential for a renewed proliferation of traditionally dangerous “designer drugs.” Behavioral addictions (gambling, internet, shopping, sex, compulsive eating disorder) are now formally recognized as addictions that affect the same natural brain chemicals and neural pathways as addictive substances. The popularity of abusing specific psychoactive substances is cyclical; cocaine in the 1880s, the 1910s and '20s, and the 1970s to '80s; opiates, beginning thousands of years ago and continuing through numerous cycles to the present. By viewing these cycles and the themes of drug use through the lens of history, we can understand the enormous influence psychoactive drugs had on the development of civilizations. CLASSIFICATION Psychoactive drugs include those substances that affect the central nervous system. This book classifies drugs according to their effects: stimulants (uppers), depressants (downers), and psychedelics (all arounders). Other groups of drugs include inhalants, sports drugs (e.g., anabolic

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steroids), and psychiatric medications such as Haldol® and Prozac®. Also included are compulsive behaviors (e.g., gambling, eating disorders, etc.) that can be acted out in an addictive manner.

Chapter 1 – History Outline INTRODUCTION I. FIVE HISTORICAL THEMES OF DRUG USE 1. 2. 3. 4. 5.

Human need to cope with the environment A susceptible brain chemistry Business & government involvement Technological advances in making drugs More efficient methods of putting drugs into the body

HISTORY OF PSYCHOACTIVE DRUGS II. PREHISTORY & THE NEOLITHIC PERIOD (8500–4000 B.C.) III. ANCIENT CIVILIZATIONS (4000 B.C.A.D. 400) A. B. C. D. E. F.

Alcohol Opium Cannabis (Marijuana) Mescal Bean, San Pedro & Peyote Cacti (Mescaline) In Mesoamerica Psychedelic Mushrooms in India, Siberia, & Mesoamerica Tobacco & Coca Leaf in Mesoamerica

IV. MIDDLE AGES (400–1400) A. B. C. D. E. F.

Psychedelic “Hexing Herbs” Psychedelic Mold-Ergot (St. Anthony’s Fire) From Medicine, to Psychoactive Drug, To Poison Alcohol & Distillation Islamic Substitutes for Alcohol Coffee, Tea & Chocolate (Caffeine)

V. RENAISSANCE & THE AGE OF DISCOVERY (1400–1700) A. B. C. D. E.

Alcohol Coca & the Conquistadors Tobacco Crosses the Oceans Coffee & Tea Consumption Spreads Opium Returns

VI. THE AGE OF ENLIGHTENMENT & THE EARLY INDUSTRIAL REVOLUTION(1700– 1900) A. B. C. D.

Distilled Liquors & The Gin Epidemic Tobacco, Hemp, & The American Revolution Ether, Nitrous Oxide, Other Anesthetics, & Other Inhalants Opium to Morphine To Heroin 1. Opium Smoking 2. Morphing 3. Hypodermic Needle 4. Heroin 5. Opium Wars E. From Coca to Cocaine

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F. Temperance & Prohibition Movements G. Opiates & Cocaine in Patent Medicines & Prescription Drugs

VII. TWENTIETH CENTURY A. From Pipes & Smokeless Tobacco to Cigarettes B. Drug Regulation C. Alcohol Prohibition & Treatment D. Marijuana: From Ditchweed to Sinsemilla E. Amphetamines in War & Weight Loss F. Sports & Drugs G. Sedative-Hypnotics & Psychiatric Medications H. LSD & the New Psychedelics I. Methadone J. Heroin & Vietnam K. Preventing & Treating Drug Abuse L. Cocaine & the Crack Epidemic

VIII. TODAY & TOMORROW A. Geopolitics of Drugs 1. Heroin 2. Cocaine B. HIV, AIDS, & Hepatitis C C. From Club Drugs to Synthetic Drugs D. Marijuana (Cannabis) & Health E. Tobacco, Health, & The Law F. Amphetamine, Methamphetamine & Ecstasy G. Other Stimulants H. Prescription Drug Abuse I. Buprenorphine J. Alcohol Hangs On K. Steroids & Sports L. Behavioral Addictions M. Court-Referred Treatment N. Co-Occurring Disorders

IX. CONCLUSIONS

CLASSIFICATION OF PSYCHOACTIVE DRUGS X. WHAT IS A PSYCHOACTIVE DRUG? A. Definition B. Chemical, Trade, & Street Names C. Classification by Effects

XI. MAJOR DRUGS A. Uppers (Stimulants) 1. Physical Effects 2. Mental/Emotional Effects

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B. Downers (Depressants) 1. Physical Effects 2. Mental/Emotional Effects C. All Arounders (Psychedelics) 1. Physical Effects 2. Mental/Emotional Effects

XII. OTHER DRUGS & ADDICTIONS A. Inhalants (Deliriants) 1. Physical Effects 2. Mental/Emotional Effects B. Anabolic Steroids & Other Sports Drugs 1. Physical Effects 2. Mental/Emotional Effects C. Psychiatric Medications D. Compulsive Behaviors 1. Physical Effects 2. Mental/Emotional Effects

XIII. CONTROLLED SUBSTANCES ACT OF 1970

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Chapter 1 – Extended Outline INTRODUCTION (pp. 1.2− −1.3) Presidential attitudes towards psychoactive drugs have changed over the years due more to the political climate rather than the actual effects of the drugs. As a result, the War on Drugs expenditures went from $3.7 million to $15.6 billion over the last 40 years Certain historical themes are evident in the way societies perceive and use drugs.

I. FIVE HISTORICAL THEMES OF DRUG USE (P. 1.3−1.5) 1. Human beings have a basic need to cope with their environment and enhance their existence. Early man lived in a dangerous and mysterious environment, they found that ingesting certain plants could ease fear, reduce pain, treat some illnesses, give pleasure, and help them connect with their gods. 2. Human brain chemistry can be affected by psychoactive drugs, behavioral addictions, and mental illness to induce an altered state of consciousness. If psychoactive drugs and behavioral addictions did not affect human brain chemistry in a desirable manner, they would not be used voluntarily. 3. The ruling class, government, business and criminal organizations have been involved in growing, manufacturing, distributing, taxing, and prohibiting drugs. Ongoing struggles to control the supplies through colonization, exportation and the sale of drugs along with excise taxes to support governments are documented throughout history. Control of the drug trade has financed revolutionary and terrorist movements. 4. Technological advances in refining, synthesizing, and manufacturing drugs have increased the potency of these substances. Over the centuries various cultures have learned how to distill alcoholic beverages, refine opium and coca, synthesize methamphetamines and LSD, use the sinsemilla growing technique, and produce MDMA. These and other techniques enable drug users to deliver more of a drug’s active psychoactive ingredients into the body at one time. 5. The development of faster and more efficient methods of delivering drugs into the body intensified the effects. Technological and pragmatic discoveries have taught users to mix alcohol and opium, absorb more juice from the chewed coca leaf, inhale nitrous oxide, inject heroin, smoke crack cocaine, and crush and inject time-release medications. The availability of rapid-play poker machines increased the number of pathological gamblers; online pornography increased the level of sexual addiction

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II. PREHISTORY & THE NEOLITHIC PERIOD (8500−4000 B.C.) (p. 1.3) Over 4,000 plants yield psychoactive substances, 60 or so have been in continuous use. The shaman, used both naturally induced (e.g., fasting and dancing) and drug-induced altered states of consciousness.

III. ANCIENT CIVILIZATIONS (4000 B.C.−A.D. 400) (p. 1.3−1.9)

The earliest crops were wheat and barley, used to make bread and beer. In Asian civilizations, rice was used to make wine (sake). Some ancient cultures also cultivated the opium poppy and the hemp plant (Cannabis). A. ALCOHOL (pp. 1.5−1.6) Many ancient cultures considered alcohol, particularly wine, a gift from the gods. Workers drank beer, the pharaohs and members of the upper class drank wine. Because alcoholic was desirable, most civilizations throughout history have placed religious, social, and legal controls on its use. The temperance of later Greek society gave way to binge drinking in Roman society, encouraged by Bacchus. B. OPIUM (pp. 1.6−1.7) Remnants of ancient poppy plantations in Spain, Greece, northeast Africa, Egypt, and Mesopotamia are evidence of the widespread early use of opium. It was used both for its medicinal properties of pain relief, cough suppression, and diarrhea control as well as for its sedation and euphoria. C. CANNABIS (MARIJUANA) (p. 1.7) Cannabis was prized as a source of oil and fiber, for its edible seeds, as a medicine, and as a psychedelic. It is referenced in ancient texts as a medication (for constipation, dysentery, analgesic,) as well as a substance with stupefying and hallucinogenic properties. Most ancient civilizations, (e.g., Greece, Rome, and England), used Cannabis (hemp) as a fiber. D. MESCAL BEAN, SAN PEDRO & PEYOTE CACTI (mescaline) IN MESOAMERICA (p. 1.8) Dozens of indigenous hallucinatory plants in North and South America were used in complex ceremonies overseen by shamans, who had positions of spiritual influence. Some South American cultures boiled peyote and San Pedro cacti for up to seven hours and drank the potion to produce hallucinations and communicate with the supernatural. E. PSYCHEDELIC MUSHROOMS IN INDIA, SIBERIA & MESOAMERICA (pp. 1.8−1.9) Archeology suggests that the sacramental use of mushrooms began about 7,000 years ago during Paleolithic times. The mushrooms used include the Amanita muscaria in India and Psilocybe in Aztec and Mayan cultures in pre-Columbian Central America.

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F. TOBACCO & COCA LEAF IN MESOAMERICA (p. 1.9) Plants with stimulant alkaloids (nicotine and cocaine) have been around for 65 million to 250 million years. Humans started drinking, chewing, snorting, and smoking tobacco for rituals and stimulation around 5000 B.C. They chewed the coca leaf for stimulation, nutrition, and appetite control.

IV. MIDDLE AGES (400−1400) (p. 1.9−1.10) A. PSYCHEDELIC “HEXING HERBS” (p. 1.9) Psychedelics used over the centuries include those members of the nightshade family that contain atropine and scopolamine. In the Middle Ages, the nightshade varietals were sometimes used by medicine men and women who were later accused of witchcraft. Drugs included datura, henbane, belladonna, and the mandrake root. B. PSYCHEDELIC MOLD—ERGOT (Saint Anthony's Fire) (p. 1.9−1.10) Ergot, a brownish purple fungus (Claviceps purpurea), grows on infected rye and wheat plants. The active ingredient is lysergic acid diethylamide (LSD). Over the centuries there have been numerous outbreaks of ergot poisoning. Hallucinations, convulsions, insanity, and a burning sensation in the feet and hands were common symptoms. C. FROM MEDICINE, TO PSYCHOACTIVE DRUG, TO POISON (p. 1.10) Most drugs can be used as a medicine, a desirable psychoactive drug, or a deadly poison. Opium suppresses pain at low doses, causes euphoria at a higher dose, and stops breath at very high doses. D. ALCOHOL & DISTILLATION (p. 1.10) In the eighth to fourteenth centuries, knowledge of distillation techniques became widespread. Evaporation raised the alcohol content of beverages from 14% to 40%. The increased strength caused cultural attitudes to shift from abstention to temperance to bingeing. E. ISLAMIC SUBSTITUTES FOR ALCOHOL (pp. 1.10−1.11) In the Qur’an (Koran), the holy book of Islam, drinking wine was frowned upon because it made a drinker forget his religious duties. Muslims searched for alternatives. Opium for the relief of pain, both physical and mental, was seen as an acceptable substitute for alcohol along with tobacco, hashish, khat, and coffee. F. COFFEE, TEA & CHOCOLATE (CAFFEINE) (p. 1.11) The coffee plant Coffea Arabica was found growing wild in Ethiopia, about A.D. 850. Potency was increased when the beans were roasted then ground. Tea from the leaves of the Thea sinensis (chinensis) bush was used in China 4,700 years ago. Today, tea remains at the heart of social and religious ceremonies in Japan, England, and a number of other countries. Approximately 60 plants contain caffeine, including guarana, maté, yoco, kola, and the cacao tree (chocolate) .

V. RENAISSANCE & THE AGE OF DISCOVERY (1400–1700) (PP. 1.11−1.14)

Exploration, trade, and colonization by Portugal, Spain, England, France,

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and the Netherlands put Europeans in contact with diverse cultures and the unfamiliar psychoactive plants that they then brought home. A. ALCOHOL (p. 1.11− −1.12) Laws limiting alcohol were based on the effects of overuse and were aimed at temperance rather than prohibition because distilled beverages produced hefty tax revenues. Ships involved in the slave trade introduced rum to cultures where mild beer and wine were the strongest beverages previously available. Rum caused more harmful side effects. B. COCA & THE CONQUISTADORS (p. 1.11− −1.12) Economic and political needs transform the way a psychoactive substance is used.The Spanish conquistadors who colonized Peru in the 1500s took control of the Incas’ coca plantations to ensure a steady supply of leaves that were supplied to their coerced labor force to keep them working. Coca chewing increased dramatically as did revenue to support the colony. C. TOBACCO CROSSES THE OCEANS (p. 1.12− −1.13) When Christopher Columbus arrived in America in 1492; he noted the natives’ use of tobacco in pipes, cigars, cigarettes, nasal snuff, and chew tobacco. Shamans in South America used tobacco to induce trancelike states. It was also used as a medicine for a wide variety of ailments. Soon the Spaniards and the British were exporting tobacco from their North American colonies to Europe. Sir Walter Raleigh brought tobacco to the court of Queen Elizabeth I. The abuse of tobacco by the clergy led to vigorous attacks by authorities, including King James I of England. However, the craving for tobacco overwhelmed most calls for prohibition, as did the rich revenues it generated for many governments. D. COFFEE & TEA CONSUMPTION SPREADS (p. 1.13− −1.14) historically, coffee and tea were first perceived as drugs and medications and then as social lubricants. Coffee drinking became widespread in Europe, and became the center of social interaction and a ritualistic part of family life. Cortez, sampled chocolate in Montezuma II’s court in the Aztec’s Mexican Empire and brought it back to Europe. E. OPIUM RETURNS (p. 1.14) During the Renaissance the use of opium returned to favor when the works of the second-century Greek physician, Galen, and the eleventhcentury Moorish physician, Avicenna, became widely taught in medical education causing a revival of theriac, one of the opium preparations mentioned by both physicians. In 1524, Paracelsus returned to Western Europe with the secret of laudanum, a tincture of opium in alcohol used as a cure-all. A medicine that could kill pain and make one feel euphoric was highly prized.

VI. AGE OF ENLIGHTENMENT & THE EARLY INDUSTRIAL REVOLUTION (1700–1900) (PP. 1.14−1.15)

The development of refined forms of psychoactive drugs, new methods of use, improved production techniques, and government and merchants’ economic motives all played a role in leading more people to use. More

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users resulted in more mental and physical problems, including abuse and addiction. A. DISTILLED LIQUORS & THE GIN EPIDEMIC (pp. 1.14− −1.15) When the English Parliament encouraged the production and consumption of gin, urban alcoholism skyrocketed. The London Gin Epidemic (1710 to 1750) illustrated how unlimited availability of a desirable substance causes excess use. Only stiff taxes and the strict regulation of sales brought the epidemic under control. About the same time, rum was the chief medium of exchange in the slave trade and, along with whiskey, one of the mainstays of the economy of colonial America. B. TOBACCO, HEMP & THE AMERICAN REVOLUTION (p. 1.15− −1.16) Tobacco (Nicotiana tabacum or Virginia leaf) was introduced to the Jamestown colony in 1612, the harvested leaves were shipped to England over the next century and a half. It was a financial mainstay for the southern colonies. Virtually all of it was chewed or smoked in cigars and pipes. In 1764, King George III of England encouraged the planting of hemp (Cannabis) in the new American colonies for the fiber. The financial viability of the crop depended on slave labor and it ceased to be profitable post Civil War. C. ETHER, NITROUS OXIDE, OTHER ANESTHETICS & OTHER INHALANTS (p. 1.16) In 1275 ether was discovered; 300 years later Paracelsus discovered its hypnotic effects. 200 years later, a liquid form of ether called anodyne was used as an anesthetic. Joseph Priestly discovered nitrous oxide (laughing gas) in 1776. Chloroform was discovered in 1831. Both men and women participated in “gas frolics” in the 1830s. Beginning in the nineteenth century, volatile solvents were used as inhalants. D. OPIUM TO MORPHINE TO HEROIN (p. 1.16− −1.17) Scientific developments, changes in methods of use, economic innovation, and political expediency escalated the use, abuse, and addiction of opiates. 1. Scientific Developments In 1804, morphine was refined from opium. It was about 10 times more powerful than opium, which led to a more-rapid development of tolerance and therefore greater dependence. After scientists discovered active alkaloids in many other plants (e.g., cocaine in the coca leaf), more concentrated forms of a number of drugs were produced. In 1874 heroin was derived by chemically altering morphine. It was marketed for coughs, chest pain, and tuberculosis. Heroin use led to a more rapid progression to abuse and addiction. 2. Changes in Methods of Use Opium smoking was first introduced to China around 1500.

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In 1855, the reusable hypodermic needle was invented. This method of introducing drugs into the body bypasses the natural barriers that protect the body from infection. 3. Economic & Political Developments During the Opium Wars in the 1800s, colonial powers vied for the right to sell opium in China. The British government grew opium in India to trade with China for silver in order to buy tea. Brittan prevailed, forcing China to grant greater trade concessions, an unacknowledged right to sell opium, and Hong Kong became a British colony. E. FROM COCA TO COCAINE (p. 1.17) In 1859, Albert Niemann isolated the alkaloid cocaine from the coca leaf. The leaf was chewed or chopped and absorbed on the gums. The mild excitement of the coca leaf became an intense cocaine rush, particularly when injected, smoked, or snorted. The physician Karl Koller found that cocaine was a strong topical anesthetic; Angelo Mariani popularized his cocaine wine (Vin Mariani) as a medicinal tonic; Sigmund Freud published his treatise, Über Coca, and suggested cocaine’s use for a number of ailments. Freud and others also used cocaine to feel better and relieve depression. The possibility of negative consequences was minimized. F. TEMPERANCE & PROHIBITION MOVEMENTS (p. 1.18) The first temperance movement in the United States began around 1785 spearheaded by Dr. Benjamin Rush, a noted physician and reformer. The first national temperance organization, the American Temperance Society, was created in 1826; it was supported by businessmen who needed sober and industrious workers. After the Civil War, the Women’s Crusade, the Woman’s Christian Temperance Union and the Anti-Saloon League (1893) led the temperance movement. G. OPIATES & COCAINE IN PATENT MEDICINES & PRESCRIPTION DRUGS (p. 1.18) At the turn of the 20th century, hundreds of patent medications were available, many loaded with opium, morphine, cocaine, Cannabis, and alcohol. Listing a product’s ingredients was not required, and manufacturers were not held to any claims they made to sell their product. During the Victorian era physicians’ over prescribed psychoactive medications for patients (mostly women) causing dependency (iatrogenic addiction). From 1886 until 1903, Coca-Cola® contained about 5 mg of cocaine, or one-third to one-half of a “line.”

VII. TWENTIETH CENTURY (PP. 1.19−1.26)

A. FROM PIPES & SMOKELESS TOBACCO TO CIGARETTES (p. 1.19− −1.20) As governments and businesses exploited psychoactive substances, especially tea, coffee, alcohol, and tobacco, they became more readily available to the public. The Bonsack automatic cigarette-rolling machine was invented in 1884 and the price of cigarettes dropped. A more

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plentiful and milder strain of tobacco, aggressive advertising and marketing, vastly increased the number of smokers. By the 1930s taxes on cigarettes were providing a rich source of revenue for state and federal governments. Warnings of the health hazards of smoking were issued as early as 1945. In 1964 and 1967, the U.S. Surgeon General issued reports that concluded, “Cigarette smoking is a health hazard.” Smoking in the United States decreased through the 1960s, rose during the 1970s, and went into a decline that continues into the present. B. DRUG REGULATION (pp. 1.20− −1.21) 1906-The Pure Food and Drug Act; 1909-The Opium Exclusion Act; 1914-The Harrison Narcotic Act; 1920-Volstead Act or prohibition; 1933-Prohibition was repealed; 1937-Marijuana Tax Act; 1965-Drug Abuse Control Amendments; 1970-Comprehensive Drug Abuse Prevention and Control Act 1984- Drinking age was raised to 21 years; . 2000- The Substance Abuse & Crime Prevention Act, (California Prop. 36) 1996–present-Laws legalizing the medical use of marijuana were passed in 16 states and the District of Columbia. C. ALCOHOL PROHIBITION & TREATMENT (pp. 1.21− −1.22) The Eighteenth Amendment (Prohibition) was ratified in 1920, and repealed 13 years later. Prohibition created other serious problems (criminal organizations) but helped control many serious health/social issues. Alcoholics Anonymous (AA), is a spiritual program that teaches 12 steps to recovery. Today there are 52,050 groups in the United States with a membership of 1,068,516. Other programs use the 12-step model to help narcotics addicts (NA), overeaters (OA), gamblers (GA), and dozens of other addictions. The belief that alcoholism is a disease and not a moral weakness changed treatment practices. D. MARIJUANA: FROM DITCHWEED TO SINSEMILLA (pp. 1.22− −1.23) Marijuana smoking wasn’t common in the United States until about 1910. Gradually, it spread to the Southwest and the West. The federal response was the 1937 Marijuana Tax Act, which banned Cannabis sativa. The ban on growing and using occurred despite its use in numerous medicines for more than 5,000 years. In the 1960s a new generation ignored prohibitions against marijuana and used it as a symbol of youthful rebellion against parents, authority, and the war in Vietnam. In the 1970s, the sinsemilla growing technique (which increased the concentration of THC) was widespread and the price skyrocketed. E. AMPHETAMINES IN WAR & WEIGHT LOSS (p. 1.23) Amphetamine was first synthesized in 1887 in Germany, and methamphetamine was created in 1919 in Japan. In the 1930s amphetamine’s stimulating effects on the CNS become widely known and

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exploited. During World War II, American, British, German, and Japanese army doctors routinely dispensed amphetamines (speed) to “elevate the fighting spirit.” The appetite-suppressant effects led to the massive use of amphetamines as diet drugs in the fifties and sixties. They also fueled the hippie movement in the late sixties. As a reaction, Congress passed the Comprehensive Drug Abuse Prevention and Control Act of 1970. F. SPORTS & DRUGS (pp. 1.23− −1.24) The Cold War politicized athletic competition between the Free World and the Communist-bloc countries , particularly during the Olympics. The use of anabolic androgenic steroids, stimulants, and other performanceenhancing drugs became widespread. By 1968, the International Olympic Committee began drug testing. The National Collegiate Athletic Association (NCAA) began drug testing in 1986. G. SEDATIVE-HYPNOTICS & PSYCHIATRIC MEDICATIONS (p. 1.24) Drug companies discovered a way to synthesize medications rather than having to rely on extracts from natural products. Sedatives, such as bromides and chloral hydrate, gave way to barbiturates. Benzodiazepines dominated the prescription downer market because of a lower overdose liability. The recognition that brain chemical imbalances cause almost all mental illnesses spurred the development of psychiatric medications (antipsychotics, antidepressants, anxiolytics, and mood stabilizers). Research also led to the development of medications to treat drug abuse and addiction, including aids for detoxification, long-term abstinence, and relapse prevention. H. LSD & THE NEW PSYCHEDELICS (p. 1.25) Lysergic acid diethylamide (LSD) is the active ingredient in ergot fungus. It was isolated and extracted in 1938 by Swiss scientist Albert Hoffman and was considered as a potential treatment for mental illness. The army and the CIA experimented with it and other psychedelics as mind-control drugs. Dr. Timothy Leary publicly supported its use and encouraged the youth of the sixties to “turn on, tune in, and drop out.” Starting in the 1960s, a flood of synthetic psychedelic drugs (MDA, DMT, PCP, 2CB, and CBR), and rediscovered natural psychedelic substances, (peyote, psilocybin, salvia divinorum, and MDMA [ecstasy]), were tried. I. METHADONE (p. 1.25) Methadone, a long-acting opioid designed as a legal substitute for heroin, is an early example of harm reduction that was targeted to benefit society. More than 1,235 clinics supply methadone to about 285,000 heroin addicts. With more and more people using prescription opioid painkillers, methadone maintenance is now a treatment for more than just the heroin addict. J. HEROIN & VIETNAM (p. 24) A new group of heroin addicts, both at home and abroad, was created during America’s involvement in the Vietnam War. Only 5% continued their heroin use after the war.

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K. PREVENTING & TREATING DRUG ABUSE (p. 1.26) Attempts to address the problems of drug abuse, and crime brought on by the misuse of drugs focused on: •

supply reduction—interdiction plus stricter laws concerning use

•

demand reduction—prevention coupled with treatment

•

harm reduction—reducing the harm caused by abuse (methadone maintenance, free needle distribution).

The discovery of brain chemicals (endorphins) that act like psychoactive drugs expanded the understanding of the process of addiction. The treatment of addiction became a medical as well as a social science. L. COCAINE, THE CRACK EPIDEMIC & ICE (p. 1.26) Heavy cocaine use occurred from 1880 to1905 and 1920to1930. New ways of preparing and using the drug made cocaine fashionable again beginning in the 1970s. A smokable form of cocaine, known as “freebase,” gave way to smokable crystals called “crack.” Over the years, crack use moved to the inner city, and heavy use became more prevalent among minorities. In the late 1980s, a slightly altered smokable methamphetamine called “ice” came onto the scene. Most methamphetamine seized by law enforcement consists of this form of the drug (called “crystal meth”).

VIII. TODAY & TOMORROW (PP. 1.26−1.35)

Worldwide, 76 million people have an alcohol use disorder, 180 million abuse illicit drugs, 1 billion use tobacco, and 147 million smoke marijuana. 30% to 60% of all hospital beds are occupied by patients suffering from the medical consequences of drug abuse, such as heart disease and cirrhosis of the liver. The Mexican drugs wars claimed more than 34,000 lives over the last five years, problem gambling and electronic addictions are growing, and synthetic drugs are making a splash among drug users. The positives include new diagnostic imaging techniques, genetic research, new medications to control craving, and better treatment techniques. A. GEOPOLITICS OF DRUGS (pp. 1.27− −1.29) The monetary value of drugs is often part of government’s economic plan. 1. Heroin Although four geographic regions grow and export heroin, 90% of the world’s supply is from Afghanistan. Currently in the United States, Colombian white heroin, Mexican black tar and brown heroin, and Afghani white are the most common. Various terrorist groups use the profits from the drug trade to fund insurgencies.

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2. Cocaine All cocaine is grown in South America, in Colombia, Peru, and Bolivia. About 65% of the cocaine smuggled into the United States comes across the U.S.-Mexican border. Colombian and Mexican cartels control the trade. B. HIV, AIDS & HEPATITIS C (p. 1.29) Worldwide, more than 25 million people have died of AIDS while over 30 million are living with the disease, the majority in sub-Saharan Africa with growing numbers in Asia. In the U.S., more than 600,000 have died while one million are living with the disease. About 4 million Americans suffer from hepatitis C (HCV), a liver infection that can be fatal. A test for HCV was developed and prevention efforts lowered the rate of infections among IV drug users. C. FROM CLUB DRUGS TO SYNTHETIC DRUGS (pp. 1.29− −1.30) Raves, clubs and music parties are keeping alive the tradition of mixing music and psychoactive drugs. The most common drug used at these venues, MDMA (ecstasy), is a psychedelic, also referred to as a psychostimulant. One dose runs from $20 to $30. The development of synthetic marijuana (K-2,® Spice) and synthetic cocaine/methamphetamine has drawn the attention of the DEA. Other club drugs include GHB, a sedative, and dextromethorphan (DXM), found in many cough and cold medications. DXM can induce psychedelic effects when abused. D. MARIJUANA (CANNABIS) & HEALTH (p. 1.30) As of May 2011, medical marijuana is legal in 16 states and the District of Columbia. There are conflicts between state and federal laws that remain unresolved. Sinsemilla cultivation techniques have made high-potency marijuana widely available which has increased the compulsive liability and the need for treatment. E. TOBACCO, HEALTH & THE LAW (pp. 130− −131)) Smoking prevention and cessation efforts have increased worldwide. Between 1966 and 2009, the number of U.S. smokers declined from 44% to 23%. However, smoking among women multiplied lung cancer deaths past those from breast cancer. In an attempt to sustain revenues, tobacco companies are focusing on foreign markets, primarily in third world countries. They are also releasing new products (strips, tablets, electronic cigarettes, and flavored tobacco) to attract and retain customers. In 1998, the biggest class-action lawsuit settlement in history ordered the major tobacco companies to pay $246 billion over a period of 25 years to 46 states for prevention and treatment of tobacco-related illnesses. Recent lawsuits have focused on secondhand smoke, and smoking in public places. The U.S. Family Smoking Prevention and Tobacco Control Act enacted in 2009 gave the FDA more control over tobacco products. F. AMPHETAMINES, METHAMPHETAMINES & ECSTASY (pp. 1.311.32) Worldwide, an estimated 35 million people use amphetamines, half that number use cocaine. Newer and cheaper ways of manufacturing methamphetamines continue to proliferate. A significant portion of the

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manufacture and wholesale is controlled by Mexican trafficking organizations in Mexico and the United States. A number of states, including Hawaii, Idaho, Iowa, and Oregon, have restricted OTC sales of cold medications containing meth precursors. From 1998 to 2008, admissions to drug treatment facilities for meth rose from 56,000 to 123,000. In the Philippines, Thailand, and other parts of Asia, small methamphetamine pills called “yaa baa” are more popular than ecstasy. G. OTHER STIMULANTS (p. 1.32) There has been a huge growth in the number of coffee outlets, caffeinated soft drinks, and energy drinks (Red Bull® ,Rockstar®). The use of khat and betel nuts, in countries outside the United States has also expanded. H. PRESCRIPTION DRUG ABUSE (pp. 1.32-1.33) The abuse of prescription and over-the-counter medications especially by adolescents has reached alarming levels. “Generation X” of the rave and club drug scene had morphed into “Generation Rx,” cohorts who share their diverted prescription drugs at “pharming parties.” Pharmaceuticals are now available at the click of a mouse on the Internet. The most widely abused (and most often diverted) prescription opioids are pain medications like OxyContin® and hydrocodone (Vicodin®). Methadone is now used for pain control as well as for methadone maintenance programs, which has led to increased abuse and diversion of the drug resulting in large numbers of overdoses. I. BUPRENORPHINE (p. 1.33) Administering buprenorphine in a doctor’s office to treat opioid craving, rather than exclusively at a drug clinic, is becoming more widespread. Physicians must complete special training to qualify to provide this service to clients. An increase in treatment referrals often results. J. ALCOHOL HANGS ON (p. 1.33) Alcohol kills more than 75,000 people a year in the United States and 1.8 million worldwide. An estimated 17.6 million Americans have an alcohol use disorder. The latest research includes a focus on the genetic components of susceptibility, neurobiology of satiation, pharmacological interventions to reduce cravings, and refining treatment techniques. K. STEROIDS & SPORTS (p. 1.33) There have been a number of drug-use allegations, positive tests, and drug use suspensions in various sports especially competitive cycling. The World Anti-Doping Agency was created in 1999 to promote, coordinate, and monitor doping in sport. L. BEHAVIORAL ADDICTIONS (pp. 1.33-1.34) Behavioral addictions include compulsive gambling and shopping/buying, food addictions, electronic addictions, and compulsive sexuality. Forty-eight states sponsor or allow legalized lotteries, poker machines, and/or off-track betting. There are also 300-plus Indian gaming

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establishments throughout the United States. The federal government passed legislation to make online gambling for money illegal. The main eating disorders are anorexia, bulimia, and binge-eating disorder. Fast-food-rich environments aggravate eating disorders, particularly compulsive overeating. Food companies foster these disorders by manufacturing foods that are more addictive because of the excessive amount of salt, fat, and sugars they contain. Electronic media is the newest source of addiction in a technological age; television watching, MMORPG game playing (World of Warcraft® and Farmville®), and social media. M. COURT-REFERRED TREATMENT (p. 1.35) The current emphasis on demand reduction led to the creation of drug courts in all 50 states. First-time offenders are diverted from jail to treatment. There are more than 2,140 drug courts nationwide. N. CO-OCCURRING DISORDERS (p. 1.35) An increased effort to recognize and treat patients with co-occurring disorders (a substance-abuse disorder and a serious mental illness) has resulted in more frequent use of psychiatric medications. About one-third of those with a mental illness have a substance abuse problem and viceversa, one-third of those with a substance abuse problem have a mental illness. Continuing concern exists regarding the overuse of psychiatric medications for children.

IX. CONCLUSIONS (p. 1.35) Historically, drug abuse and addiction have altered government policies, created new social structures, and hijacked personal priorities. The drive to alter states of consciousness is as essential to human nature as the drive to survive and procreate. The higher the potency of a drug, the more overwhelming is the brain's ability to rebalance itself, which leads to neurochemical changes. Research leads to changes in treatment techniques.

X. WHAT IS A PSYCHOACTIVE DRUG? (PP. 1.35−1.37) A. DEFINITION (p. 1.36) Any substance that directly alters the normal functioning of the central nervous system is considered a psychoactive drug. This definition could be expanded to include any behaviors (e.g., gambling) that directly activate the brain’s alcohol and drug addiction pathways. B. CHEMICAL, TRADE & STREET NAMES (p. 1.36) Drugs have chemical names, trade names, and street names, e.g., alprazolam, Xanax, and “xannies.” C. CLASSIFICATION BY EFFECTS (p. 36) A practical way to classify these substances is by their overall effects:

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“uppers” for stimulants, “downers” for depressants, and “all arounders” for psychedelics. Other substances can be defined by their purpose, e.g., performance-enhancing sports drugs, inhalants, and psychiatric medications.

XI. MAJOR DRUGS (P. 1.37) A. UPPERS (STIMULANTS) (p. 1.37) Uppers, or CNS stimulants, include cocaine, amphetamines, amphetamine congeners, plant stimulants, look-alike stimulants, caffeine, and nicotine 1. Physical Effects Small doses stimulate the central nervous system, creating insomnia, energized muscles, increased heart rate, and decreased appetite. Frequent use depletes the body’s energy chemicals. Large amounts can cause heart, blood vessel, and seizure problems. 2. Mental/Emotional Effects Stronger stimulants increase confidence and excitement and can cause a rush and/or high. Larger doses can cause extreme nervousness, anxiety, and anger. Prolonged use causes intense anxiety, paranoia, mental confusion, and sometimes a psychosis. B. DOWNERS (DEPRESSANTS) (p. 1.37) The four categories of CNS depressants are: Opiates and opioids: opium, morphine, heroin, oxycodone, hydrocodone, methadone, and buprenorphine. Sedative-hypnotics: benzodiazepines, e.g., Xanax,® Valium,® barbiturates, and Z-hypnotics, e.g., zolpidem (Ambien®). Alcohol: beer, wine, and hard liquors. Others: antihistamines, skeletal muscle relaxants, look-alike sedatives, and bromides. 1. Physical Effects Small doses depress the central nervous system. They can slow heart rate and respiration, induce sleep, dull the senses, and most important, diminish pain. Excessive drinking or sedative-hypnotic use can slur speech and cause digestive problems. Sedative-hypnotics and alcohol in large doses, or in combination with other depressants, can cause dangerous respiratory depression and coma. 2. Mental/Emotional Effects Initially, small doses act like stimulants because they lower inhibitions thus inducing freer behavior. With excess use, depressant effects begin to dominate. Certain downers can also induce euphoria or a sense of well-being. Long-term use can cause psychological and physical dependence. C. ALL AROUNDERS (PSYCHEDELICS) (p. 1.37) Psychedelics are substances that can distort perceptions. They are extracted from plants or synthesized.

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Indole Psychedelics: LSD, psilocybin mushrooms, ayahuasca, DMT Phenylalkylamines: peyote (mescaline), ibogaine, MDMA, MDA, 2CB Cannabinoids: marijuana, hashish. Others: ketamine, PCP, nutmeg, Amanita mushrooms. 1. Physical Effects Most hallucinogenic plants, cause nausea and dizziness. Marijuana increases appetite and makes the eyes bloodshot. LSD raises the blood pressure and causes sweating. MDMA and LSD act like stimulants. The physical effects are not as dominant as the mental effects in this class of substances. 2. Mental/Emotional Effects Psychedelics distort sensory messages to and from the brain stem so many external stimuli are intensified or altered (illusions). Psychedelics can also trigger hallucinations along with distorted thinking (delusions).

XII. OTHER DRUGS & ADDICTIONS (PP. 1.37−1.38)

Three other groups of drugs can stimulate, depress, or confuse the user: inhalants, anabolic steroids and other sports drugs, and psychiatric medications. A. INHALANTS (DELIRIANTS) (pp. 1.37− −1.38) Inhalants are gaseous or liquid substances that are inhaled and absorbed through the lungs. They include organic solvents, volatile nitrites, and anesthetics, especially nitrous oxide. 1. Physical Effects Most often there is CNS depression causing dizziness, slurred speech, unsteady gait, and drowsiness. Heavy use can cause stupor, coma, and asphyxiation. Organic solvents can be toxic to cells in the lung, and other tissues. 2. Mental/Emotional Effects Small amounts commonly cause impulsiveness, excitement, mental confusion, and irritability. Some inhalants cause a rush through a variety of mechanisms. Larger amounts can cause delirium and hallucinations.

B. ANABOLIC STEROIDS & OTHER SPORTS DRUGS (p. 1.38) Anabolic-androgenic steroids are the most common performanceenhancing drugs. Others include stimulants (e.g., amphetamines, ephedrine, and caffeine), human growth hormone (HGH), human chorionic gonadotropin (HCG), herbal/nutritional supplements (e.g., creatine and androstenedione), and some therapeutic drugs (e.g., painkillers, beta blockers, and diuretics). 1. Physical Effects Anabolic steroids increase muscle mass and strength. Prolonged use can cause acne, high blood pressure, shrunken testes, and masculinization in women.

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2. Mental/Emotional Effects Anabolic steroids often cause a stimulant-like high, increased confidence, and aggression. Prolonged large-dose use can be accompanied by outbursts of anger known as “roid rage.” C. PSYCHIATRIC MEDICATIONS (p. 1.38) Psychiatric medications are used to try to rebalance irregular brain chemistry that has caused mental problems, drug addiction, and other compulsive disorders. The most common are antidepressants (e.g., Tofranil,® Prozac®), antipsychotics (e.g., Risperidol,® Zyprexa®), and antianxiety drugs (e.g., Xanax® and BuSpar®) including panic disorder drugs (e.g., Inderal®). These drugs are prescribed more frequently today, despite the fact that the national incidence of the disorders has remained fairly constant over the past 30 years. 1. Physical Effects Psychiatric medications have a wide variety of physical side effects, particularly on the heart, blood, and skeletal-muscular systems. 2. Mental/Emotional Effects Antidepressants elevate mood, antipsychotics control schizophrenia, thought difficulties, and hallucinations, antianxiety drugs inhibit anxiety-producing thoughts. D. COMPULSIVE BEHAVIORS (p. 1.38) Behaviors such as eating disorders, compulsive gambling, sexual compulsion, Internet addiction, and compulsive shopping affect many of the same areas of the brain that are affected by psychoactive drugs. 1. Physical Effects The major physical effects are generally confined to neurological and chemical changes in the brain’s reward pathway. The exception is eating disorders, excessive or extremely limited food intake can lead to cardiovascular problems, diabetes, nutritional diseases, and/or obesity. 2. Mental/Emotional Effects The development of tolerance, psychological dependence, and in some cases, withdrawal symptoms occur due to compulsive behaviors. The compulsion to gamble or overeat is every bit as strong as drug-seeking behavior.

XIII. CONTROLLED SUBSTANCES ACT OF 1970 (PP. 1.38−1.39)

The Comprehensive Drug Abuse Prevention and Control Act of 1970, was enacted to reduce the burgeoning availability and use of psychoactive drugs.

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The act consolidated and updated most drug laws that had been passed in the twentieth century. The Schedule of Psychoactive Drugs •

Schedule I - have a high abuse potential and supposedly no accepted medical use. (LSD, marijuana)

•

Schedule II - have a high abuse potential with severe psychic or physical dependence liability even though they have medical uses. (cocaine, methamphetamine, opium, morphine).

•

Schedule III - have less abuse potential (Tylenol® with codeine).

•

Schedule IV - have low abuse potential (the benzodiazepines).

•

Schedule V - have very low abuse potential. Some of these drugs are sold over the counter (Lomatil®).

Chapter 1 - Discussion Topics

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1.

How have people throughout history used psychoactive drugs to cope with their environment?

2. Discuss natural highs and rushes that humans can induce without the use of psychoactive drugs (sustained aerobic exercise like running which produces elevated levels of endorphins, thrill-seeking activities that mimic the adrenaline rush of stimulants). 3. Give examples of governmental involvement in the drug trade or behavioral addictions such as gambling. 4. Discuss the different ways technological advances have increased the addictive liability of specific drugs (development of the sinsemilla growing technique for marijuana which have increased the THC levels). 5.

Describe how the development of time-release medications changed the abuse of oxycodone.

6. Discuss ways that psychoactive drugs have been used for spiritual and religious purposes. 7. Discuss the development of different ways of refining and using opium in the nineteenth and twentieth century. 8. What were the nineteenth- and twentieth-century developments that led to different ways of refining and using cocaine? 9. What drug problems do we face today that our ancestors did not have to face and why? 10.

What technical developments and marketing strategies have made tobacco the health problem it is today?

11.

How did the battle between prohibition, temperance, and drinking affect the evolution of laws regulating the use of alcohol?

12.

Discuss the reasons drugs have three types of names 1. Street or slang 2. Scientific, 3. trade

13.

Have the students list 10 or more reasons people use psychoactive drugs and discuss the reasons as they relate to the following: a. Identify the major age groups in western society (pre-teens, teenagers, young adults, middle age, elderly) and determine if the reasons for use are relevant or the same for all age groups. If they are not the same, how do they differ? b. Identify different cultures within North America and across the globe (Native Americans, British, Islamic, Arabic, Thai) and determine if the reasons for use are relevant or the same for all cultures. Take into consideration the type of use (ceremonial, recreational etc.), and the overall “cultural acceptance” of use.

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Critical Thinking & Class Exercises 1. Have the class collectively construct a timeline that illustrates how governments have been involved in the drug trade. 2. Hold a mock public hearing in class to determine if marijuana should be legalized or remain illegal. Use historical examples and current factual information to support the pro and con positions. There are three historical timeframes the students can consider: a. Historical timeframe - A hearing limiting the arguments to the information that was available in 1937 when the Marijuana Tax Act was enacted. b. Informed historical timeframe – a hearing conducted in 1937 including in the arguments all of the information available today - to determine if marijuana should remain legal, become illegal or be given a status of decriminalization. c. Current day public hearing to determine whether l marijuana should be decriminalized or legalized and under what controls in a state in which marijuana is not currently decriminalization and in which medical marijuana is not legal. 3.

Have the students play the role of a U.S. Congressional member in 1830. Have the “legislators” discuss and debate whether laws to limit the use of alcohol should be established in support of one of three views of the time; 1.) temperance, 2.) prohibition, 3.) no regulations.

4. Discuss how the lessons of history could suggest solutions to current alcohol and other drug problems. 5. Ask students to collect articles in newspapers and select magazines (online or print) which discuss any one of the five historical themes listed below. Have the students write a brief summary on ways the articles selected illustrate one of the five themes 1. Human’s basic need to cope with their environment and enhance their existence. 2. Human brain chemistry can be affected by psychoactive drugs, behavioral addictions, and mental illness to induce an altered state of consciousness. 3. The ruling classes, governments, and industry, along with criminal organizations, have long been involved in growing, manufacturing, distributing, taxing, and prohibiting drugs. 4. Technological advances in refining, synthesizing, and manufacturing drugs have increased the potency of these substances. 5. The development of faster and more efficient methods of delivering drugs into the body has intensified the effects.

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6. Ask students to present historical justification for or against the use of medical marijuana, including current federal and state court rulings, particularly in their own state. 7. Have students create a display of images (printed from online sources) that relate to the history of alcohol and other psychoactive drugs – they should be prepared to present a brief description. Suggested image sources include the archives of the National Library of Medicine, the DEA, and the National Archives among others.

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Uppers, Downers, All Arounders, 7th Edition - Instructors Manual Chapter 2 - HEREDITY, ENVIRONMENT & PSYCHOACTIVE DRUGS Chapter Overview HOW PSYCHOACTIVE DRUGS AFFECT PEOPLE This chapter examines how drugs reach the brain and the ways in which they affect brain chemistry. Drugs can be inhaled, injected, swallowed or absorbed through mucous membranes or through the skin. Once a drug is introduced to the body it travels through the circulatory system until it reaches the brain where it has the greatest effect. Drugs are principally metabolized by the liver and then excreted from the body in urine, exhaled breath, or sweat. The body’s nervous system consists of the peripheral nervous system (autonomic and somatic) and the central nervous system (the brain and spinal cord). Using evolutionary terminology, psychoactive drugs affect both the old (primitive, survival) brain and the new (common sense, thinking) brain. The key circuit of the brain that drugs affect is the reward/control pathway, especially the nucleus accumbens septi, which serves as the brain’s “go switch” and the amygdala. Drugs cause their effects by mimicking or modifying neurotransmitters (e.g., dopamine, serotonin, norepinephrine, endorphins, GABA). Problems occur when the stop switch located in the orbital frontal cortex of the brain’s control circuit that normally shuts off the craving becomes dysfunctional. Drugs affect the nervous system at the cellular level, particularly the synaptic gap where they are mistaken for or disrupt natural brain chemistry. An individual’s drug tolerance, tissue dependence, withdrawal, and metabolism determine additional effects. New research indicates there are “stay-stopped” switches in the brain which compromise abstinence and lead to slips and relapse. FROM EXPERIMENTATION TO ADDICTION In addition to the desired effects of drugs, such as getting high, self-medicating, creating energy, relieving pain, zoning out, or altering consciousness, undesirable side effects occur, some of them minor, some major, and some fatal. The level of drug use - abstinence, experimentation, social/recreational use, habituation, abuse, and addiction - depends on the amount, frequency, and duration of use as well as a person’s susceptibility to addiction as determined by heredity and environment. The continued use of a psychoactive drug also affects a person’s vulnerability to develop addiction. All these factors cause alterations in brain chemistry known as allostasis that can affect a person for a few hours, a few days, or even a lifetime. Many of these alterations can be seen with the assistance of new imaging techniques such as SPECT, CAT, MRI, fMRI, DTI, and PET brain scans. Compulsive behaviors, such as gambling and compulsive eating, also affect brain chemistry. Compulsion curves that illustrate the contributions of heredity, environment, and the use of psychoactive drugs or the practice of compulsive behaviors to addiction are useful when trying to design methods of treatment that will lead to recovery.

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Chapter 2 - HEREDITY, ENVIRONMENT & PSYCHOACTIVE DRUGS Chapter Outline HOW PSYCHOACTIVE DRUGS AFFECT PEOPLE I.

INTRODUCTION

II. HOW DRUGS GET TO THE BRAIN A. ROUTES OF ADMINISTRATION & DRUG ABSORPTION 1. Inhaling 2. Injecting 3. Mucous Membrane Absorption 4. Oral Ingestion 5. Contact Absorption B. DRUG DISTRIBUTION 1. The Blood-Brain Barrier C. METABOLISM & EXCRETION III. THE NERVOUS SYSTEM A. PERIPHERAL NERVOUS SYSTEM 1. Autonomic System 2. Somatic System B. CENTRAL NERVOUS SYSTEM C. OLD BRAIN-NEW BRAIN 1. Old Brain 2. New Brain D. MEMORY E. THE REWARD/CONTROL PATHWAY 1. The "Go" & "Stop" Circuits 2. Hijacking the Reward/Control Pathway 3. Nucleus Accumbens 4. "Stop" Circuit F. MORALITY & THE REWARD/CONTROL CENTER IV. NEUROANATOMY A. NERVE CELLS & SYNAPSES B. NEUROTRANSMITTERS & RECEPTORS 1. Major Neurotransmitters 2

2. Monoamines (e.g. catecholamines), Acetylcholine 3. Opioid Peptides 4. Amino Acids 5. Tachykinin 6. Endocannabinoids 7. Pituitary Peptide 8. Gas 9. Hormones 10. Receptors for Neurotransmitters 11. Advanced Neurochemistry 12. Agonist & Antagonist C. SYNAPTIC PLASTICITY, EPIGENETICS & ALLOSTASIS V. PHYSIOLOGICAL RESPONSES TO DRUGS A. TOLERANCE 1. Kinds of Tolerance B. TISSUE DEPENDENCE C. PSYCHOLOGICAL DEPENDENCE D. WITHDRAWAL 1. Kinds of Withdrawal E. THE STAY-STOPPED CIRCUIT & RELAPSE FROM EXPERIMENTATION TO ADDICTION VI.

DESIRED EFFECTS VS. SIDE EFFECTS A. DESIRED EFFECTS B. SIDE EFFECTS C. POLYDRUG ABUSE

VII. LEVELS OF USE A. ABSTINENCE B. EXPERIMENTATION C. SOCIAL/RECREATIONAL D. HABITUATION E. DRUG ABUSE F. ADDICTION

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G. CLASSIFICATION 1. DSM-IV-TR 2. WHO International Classification of Diseases

VIII. THEORIES OF ADDICTION A. ADDICTIVE DISEASE MODEL B. BEHAVIORAL/ENVIRON-MENTAL MODEL C. ACADEMIC MODEL D. DIATHESIS-STRESS THEORY OF ADDICTION

BEHAVIORS A. HEREDITY 1. Twin & Retrospective Studies 2. Alcoholism-Associated Genes B. ENVIRONMENT 1. Environment, Brain Development & memory networks C. PSYCHOACTIVE DRUGS D. COMPULSIVE BEHAVIORS X. ALCOHOLIC MICE & SOBER MICE XI. COMPULSION CURVES

IX. HEREDITY, ENVIRONMENT, PSYCHOACTIVE DRUGS, & COMPULSIVE

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Chapter 2 - HEREDITY, ENVIRONMENT, PSYCHOACTIVE DRUGS Extended Outline HOW PSYCHOACTIVE DRUGS AFFECT PEOPLE I. INTRODUCTION (P. 2.3) Almost 80 years ago, Doctor William Silkworth wrote in the Alcoholics Anonymous Big Book that alcoholism [and addiction] is a combination of an obsession of the mind combined with an allergy of the body. Modern imaging techniques, genetic research, neurochemical insights along with social, psychological, and physiological research continue to affirm his insights. II. HOW DRUGS GET TO THE BRAIN (PP. 2.4−2.9) Psychoactive drugs directly affect the central nervous system (the brain and the spinal cord) Factors that determine their effects and abuse potential (pharmacokinetics) include: • route of administration, • speed of transit to the brain, • affinity for nerve cells and neurotransmitters. The more rapidly a psychoactive drug reaches its target in the central nervous system, the greater its reinforcing effect. A. ROUTES OF ADMINISTRATION & DRUG ABSORPTION (pp. 2.4−2.7) The five most common ways drugs are introduced to the body are: 1. Inhaling Smoking a drug like marijuana or inhaling a substance like nitrous oxide delivers the vaporized drug to the lungs where it is rapidly absorbed through capillaries lining the air sacs (alveoli) of the bronchi (air passages). Inhaling acts more quickly than any other method of use (7 to 10 seconds before the drug reaches the brain). 2. Injecting Substances, such as heroin and cocaine, can be injected by three methods: intravenous (IV, or “slamming”)—directly into the bloodstream by way of a vein (15-30 seconds to the brain) intramuscular (IM, or “muscling”)—into a muscle mass 3 to 5 minutes) subcutaneous (“skin popping”)—under the skin (3 to 5 minutes). Shooting up is most likely to produce an intense rush. Injecting is the most dangerous method of use because it bypasses most of the body’s natural defenses against infections such as hepatitis C or AIDS.

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3. Mucous Membrane Absorption Powdered drugs can be snorted into the nose (insufflation) and then absorbed by the capillaries. Mucous membranes can also absorb drugs under the tongue (sublingually) or between the gums and cheek (buccally) effects begin in 3 to 5 minutes. Morphine suppositories take 10 to 15 minutes for effects to begin. 4. Oral Ingestion An ingested drug passes through the esophagus and the stomach to the small intestine, where it is absorbed into the capillaries which carry it to the liver to be partly metabolized before being pumped back to the heart and subsequently to the rest of the body. The effects of drugs taken by mouth are delayed 20 to 30 minutes. 5. Contact Absorption Drugs can be applied to the skin through saturated adhesive patches (e.g., nicotine, fentanyl) that allow the drug to be passively absorbed for up to seven days. It can take one or two days for therapeutic effects to begin. B. DRUG DISTRIBUTION (pp. 2.6−2.7) A drug is distributed by the bloodstream to the rest of the body. The bioavailability is the degree to which a drug becomes available to the target tissue. There, it will cause a direct effect, be ignored, be stored or be biotransformed. Within 10 to 15 seconds after entering the bloodstream, the drug reaches the blood-brain, blood-cerebral spinal fluid barriers, and the placental barrier. 1. The Blood-Brain, Blood-Cerebral Spinal Fluid & Placental Barriers Psychoactive drugs infiltrate the blood-brain barrier (a series of tightlypacked cells that protect the brain) and because the brain is essentially fatty, it readily absorbs fat-soluble substances (most psychoactive drugs are fat-soluble). The blood-cerebral spinal fluid barrier prevents unwanted substances from entering the subarachnoid space, ventricles, and spinal cord. There is also a placental barrier that provides some protection to a developing fetus. C. METABOLISM & EXCRETION (pp. 2.7−2.9) Metabolism is the body’s mechanism for processing, using, and inactivating a foreign substance. The liver is the key metabolic organ because it is able to break down drugs. Excretion is the body’s mechanism for eliminating foreign substances and their metabolites. The kidneys, the key excretory organ, filter the metabolites, water, and other waste from the blood

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Some drugs, such as Valium,® are “prodrugs”, these are transformed by the liver’s enzymes into three or four metabolites that are themselves active. A drug’s half-life is the measure of time it takes a drug to be inactivated or eliminated by the body. The half-life can be extended by polydrug use, e.g., alcohol and cocaine. A number of factors affect the metabolism (and the half-life) of drugs: age, race, heredity, gender, health, emotional state, allergy to the drug, and the presence of other drugs. III. THE NERVOUS SYSTEM (PP. 2.9−2.25) The central nervous system or CNS (brain and spinal cord) consists of 100 billion nerve cells and 100 trillion connections. The CNS is half of the complete nervous system. The peripheral nervous system or PNS (the autonomic and somatic subsystems) is the other half. It connects the CNS with its internal and external environments. A. PERIPHERAL NERVOUS SYSTEM (pp. 2.9−2.10) The autonomic part controls involuntary internal functions such as circulation, digestion, and respiration. It consists of the sympathetic, parasympathetic, and enteric divisions. The somatic part transmits sensory information and then transmits any instructions from the CNS back to skeletal muscles. B. CENTRAL NERVOUS SYSTEM (p. 2.10) The central nervous system analyzes messages from the peripheral nervous system, and then sends responses. The CNS also facilitates reason and the ability to make judgments about the environment. Psychoactive drugs can alter this information. −2.14) C. OLD BRAIN–NEW BRAIN & MEMORY (pp. 2.10− Looking at the brain from an evolutionary perspective sense, the physiological changes can be interpreted as survival adaptations. The evolutionary concept also theorizes that psychoactive drugs have an affinity for natural survival mechanisms and initially cause desirable effects. The net result is that psychoactive drugs hijack and subvert the brain’s survival mechanisms. The two major parts of the brain are defined as the old brain and the new brain. 1. Old Brain The old brain consists of the brainstem, cerebellum, and mesocortex or midbrain which contains the limbic system (the emotional center). The spinal cord is considered part of this old-brain system. The old brain regulates physiological functions, experiences basic emotions and

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cravings, and imprints survival memories. It is the old brain that orchestrates euphoric recall that become addiction memories. 2. New Brain The new brain, also called the neocortex (cerebrum and cerebral cortex), processes information from the senses and other parts of the brain. The new brain allows humans to speak, reason, create, and remember. Because the craving to use a psychoactive drug almost always resides in the old brain, the desire for the pleasure, pain relief, and excitement that drugs promise can be very powerful, overriding the new brain’s rational arguments. D. MEMORY (2.11−2.14) The old and new brains carry out functions by creating, storing, and utilizing memories. Memories are the heart of an obsession to use drugs. The other element of addiction, the allergy or extra sensitivity to a drug, is reflected in neurochemical and anatomical changes to the brain. Memories are stored in dendritic spines which are formed on the dendrites of nerve cells. It takes a thousand or more memory spines to make one memory. Most of them last a lifetime. Emotionally-charged or drug-charged memories are more deeply ingrained and influential, they lead to euphoric recall which is a remembrance of positive experiences with drugs which can trigger craving and relapse. E. THE REWARD/CONTROL PATHWAY (pp. 2.14−2.17) The reward/control pathway encourages a human to repeat a survival action, it has two parts: a “go” switch (also called a more switch) and a “stop” switch. The “go” part of this circuit communicates the following: • the action is necessary for survival, • remember how the action was achieved. • continue the action again, and again. The “stop,” or satiation, part of this circuit, signals when the craving has been satisfied and shuts down the “continue the action” message. 2. Hijacking the Reward/Control Pathway When a psychoactive drug activates this circuit, the “go” or “more” switch becomes overactive and the “stop” switch becomes dysfunctional. The user gets no instruction to stop so the need to continue use gains intensity. The "do it again" (continue the action) message becomes so powerful that it causes drug-seeking behavior and addiction. The greater responsiveness to psychoactive drugs diminishes the responsiveness to normal everyday activities so the user becomes more dependent on the drug or behavior for any kind of satisfaction and pleasure. 7

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Recovery requires reintegrating the functions of the old brain and new brain so one doesn't overwhelm the other.

1. Nucleus Accumbens (Septi) The NAc was discovered by Dr. Robert Olds and Dr. Robert Heath in the 1950s and serves as a powerful motivator (reinforcer) for normal survival activities. When psychoactive drugs are used, the NAc becomes stimulated, hijacking its functions. The longer someone uses, the stronger the do-it-again message becomes. The brain reacts in a certain way, not because of a bad environment, but because of the way the brain is designed. The effect of the alteration in the brain chemistry has to do with the reaction to the drug itself as well as the anticipation of using. This phenomenon may be the manifestation of an allergy which differentiates these people, and sets them apart. 2. “Stop” (Satiation) Switch The stop/satiation circuit is crucial to keeping craving and satiation in balance. Alcohol and other drugs have the ability to turn genes on or off which changes the network of cells. The increase in neural alterations results in heightened sensitivity to a drug which increases the risk of relapse even after use stops. There are a number of theories on ways psychoactive drugs disrupt the on/off switches of the reward/control pathway and the satiation circuits of the brain: • there is no satiation point, • the on/off switches are ignored or overridden • psychoactive substances disrupt communication between the two brains • the fasciculus retroflexus which communicates from the new brain to the old brain is damaged preventing stop messages from reaching the old brain. The disruption of the on/off switches due to a behavioral addiction is identical to that of drug addiction. The longer a drug is used or a behavior practiced, the more the brain changes and the harder it becomes to restore a healthy balance (homeostasis). E. MORALITY & THE REWARD/ CONTROL PATHWAY (pp. 2.17− −2.18) Throughout human history our primal urges, desires, and intense emotional memories that mostly reside in the old brain, have been pitted against reason, common sense, and morality that mostly resides in the new brain. In many addicts this conflict is more pronounced, but “the old brain rules!”

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Because the "go" circuit of the reward/control pathway reacts more quickly and intensely than the neocortex, it takes a powerful, conscious effort to override cravings and desires generated by the old brain. Christian, Buddhist, Islamic, and almost all theologies teach that one must resist most primal cravings (including psychoactive drugs) to live a moral or fulfilling life.

IV. NEUROANATOMY (PP. 2.18−2.35) A. NERVE CELLS & SYNAPSES (PP. 2.18− −2.19) When one of the five senses is activated, a signal is sent through a network of nerve cells first to the old brain for an instant reaction and then to the thalamus where it is forwarded to the new brain for a more complete reaction. Nerve impulses might fire up to 1,000 pulses per second. Each nerve cell has four essential parts: dendrites, which receive signals, the cell body, which nourishes the cell, the axon, which carries the message to the terminals, and terminals, which relay the message to the next cell. A synaptic gap exists between the terminals of each nerve cell preventing them from touching each other. When an electrical message arrives at the synaptic gap it releases neurotransmitters which trigger another electrical signal in the adjoining nerve cell. This electrical-chemicalelectrical-chemical transmission continues until the message reaches the appropriate section of the brain or body. B. NEUROTRANSMITTERS & RECEPTORS (pp. 2.19−2.24) The discovery in the mid-1970s of endorphins and enkephalins provided an understanding of how psychoactive drugs work in the brain and the body. These neurotransmitters are called endogenous opioids, meaning “originating within the body.” Morphine, heroin, and opioids originate outside the organism. Over the next 30 years researchers identified and y and associated dozens of psychoactive drugs with the neurotransmitters they affect. Sensations or feelings that can’t be triggered by a natural neurotransmitter in the body cannot be created by a psychoactive drug. Humans can naturally create virtually all of the sensations and feelings they seek by using drugs. Some examples are: • a terrifying experience forces the release of adrenaline that mimics part of a cocaine rush. • sleep or sensory deprivation can produce true hallucinations through the same neurotransmitters and mechanisms affected by peyote. Natural sensations have no side effects, drug-induced sensations do. Drug/Neurotransmitter Relationships Drug Neurotransmitters Directly Affected 9

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Alcohol GABA, met-enkephalin, serotonin Benzodiazepines GABA, glycine Marijuana Anandamide, 2AG, noladin ether, acetylcholine, dynorphin Heroin Endorphin, enkephalin, dopamine Cocaine & meth Dopamine, epinephrine, norepinephrine, serotonin, Some people are drawn to certain drugs because they have a neurochemical imbalance and use the drug to self-medicate. 1. Major Neurotransmitters Acetylcholine, the first neurotransmitter discovered, is most active at nerve/muscle junctions. Norepinephrine (NE) and epinephrine (E) function as stimulants. Epinephrine has a greater effect on energy, norepinephrine on confidence and feelings of well-being. Dopamine (DA) is the most crucial neurotransmitter involved in drug use and abuse. It is often called the “reward chemical.” Serotonin helps control mood stability, e.g., depression, anxiety, appetite, and sleep. Enkephalins, endorphins, and dynorphins are involved in pain, stress control, and euphoria. GABA, an amino acid, is the brain’s main inhibitory neurotransmitter. Substance P conveys pain impulses. Anandamide is responsible for the integration of emotional sensory experiences as well as those controlling learning, motor coordination, and memory. It is mimicked by THC in marijuana. At least 100 more neurotransmitters have been discovered. 2. Receptors for Neurotransmitters A receptor is designed to receive a compatible neurotransmitter. Each nerve cell produces and sends only one type of neurotransmitter; but a single nerve cell can have receptors for several different types of neurotransmitters. 3. Advanced Neurochemistry Excitatory neurotransmitters increase cell firings while inhibitory neurotransmitters reduce cell firings. Many mechanisms are involved in this transmission process, e.g., first messenger system and second messenger system. Up regulation and down regulation (where excessive drug use will lower the number of available receptors causing a dampening of message transmission) is a crucial mechanism in creating addiction. Other mechanisms that help regulate neurotransmitters are active transport pumps, autoreceptors, and reuptake ports. 10

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4. Agonist & Antagonist Drugs that mimic or facilitate the effects of neurotransmitters are called agonists; drugs that block neurotransmitters are called antagonists; drugs that partly mimic the effects of neurotransmitters are called partial agonists; Drugs that stabilize the receptor in its inactive state (so that it cannot react) are called inverse agonists. Psychoactive drugs can: • block the release or force the release of neurotransmitters, or prevent them from being reabsorbed; • inhibit enzymes that help synthesize or metabolize neurotransmitters • interfere with the storage of neurotransmitters. Example: cocaine forces the release of norepinephrine and dopamine, heroin inhibits the release of substance P, the pain neurotransmitter. LSD alters the user’s perception of messages received from the external environment. C. SYNAPTIC PLASTICITY. EPIGENITICS, & ALLOSTASIS (pp. 2.24− −2.25) Synaptic plasticity is the ability of the synapse to change in strength and function when a synaptic pathway is overused or underused, often due to constant stress or the use of psychoactive drugs. Changes can last for weeks, months, or years. Epigenetics is the field of research that studies changes in genes, also called gene expressions. Allostasis is the overall process of achieving and maintaining functionality and balance by physiological and behavioral change through synaptic plasticity, altered neurotransmitters, and other physiological processes. V. PHYSIOLOGICAL RESPONSES TO DRUGS (PP. 2.25−2.30) A. TOLERANCE (pp. 225− −227) As drug use continues over a long period, the body changes to adapt to the toxin, developing a tolerance to the substance. The user must take larger and larger amounts of a drug to achieve the same effect. The body's hedonic set point (an individual's preferred level of effects from a drug) rises. 1. Kinds of Tolerance Dispositional Tolerance. The body speeds up the breakdown (metabolism) of the drug to eliminate it. Pharmacodynamic Tolerance. Nerve cells become less sensitive to the effects of the drug. Behavioral Tolerance. The brain learns to compensate for the effects of the drug by using those parts of the brain not affected. 11

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Reverse Tolerance. The user becomes more sensitive and therefore less able to handle even moderate amounts. Acute Tolerance (tachyphylaxis). The brain and the body begin to adapt almost instantly to the toxic effects of the drug. Select Tolerance. The body develops tolerance to mental and physical effects at different rates. Inverse Tolerance (kindling). The body becomes more sensitive to the effects of the drug as the brain chemistry changes. Cross-Tolerance. Once a person develops tolerance to one drug, a tolerance to similar drugs occurs. B. TISSUE DEPENDENCE (p. 2.27) Tissue dependence is the biological adaptation of the body due to prolonged use of drugs. Tissues and the organs come to depend on the drug to stay functional. Cross-Dependence. Once tissue dependence to a specific drug occurs, the body will develop a dependence on similar drugs. C. PSYCHOLOGICAL DEPENDENCE (p. 2.27) Psychological dependence has been recognized as an important factor in the development of addictive behavior. Drugs cause an altered state of consciousness and distort perceptions pleasurable to the user. Drugs also have the innate ability to guide and virtually hypnotize the user into continual use (called the “positive reward-reinforcing action of drugs”). Addictive drug taking is further reinforced via drug automatism, negative reinforcement, and social reinforcement. −2.29) D. WITHDRAWAL (pp. 2.27− Withdrawal is defined as the “body’s attempt to rebalance itself after cessation of prolonged use of a psychoactive drug.” Many compulsive users continue use due to the fear of withdrawal. 1. Kinds of Withdrawal Nonpurposive withdrawal consists of objective physical signs that are a direct result of the tissue dependence and are directly observable upon cessation of drug use by an addict. Purposive Withdrawal results either from addict manipulation or from a psychic conversion reaction (an emotional expectation of physical effects that have no biological explanation). Protracted Withdrawal (environmental triggers & cues) is a flashback or recurrence of withdrawal symptoms and a triggering of heavy craving for the drug long after an addict has been detoxified. Post-Acute Withdrawal Symptoms (PAWS) is the persistence of subtle, yet significant, emotional and physical problems that can last 12

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for three to six months into recovery, e.g., cognitive impairment, memory problems, and emotional over-reaction. E. THE STAY-STOPPED CIRCUIT & RELAPSE (2.29− −2.30) In 2005, scientists discovered decreased activity in five discrete areas of the brain's neocortex that correlated to a high risk of relapse in meth addicts who graduated from a 28-day residential program. More research is necessary before these findings can be used to determine if an addict will relapse and how to design a program tailored to their susceptibility to relapse. FROM EXPERIMENTATION TO ADDICTION People take psychoactive drugs for the mental, emotional, and physical effects they induce. Most often it is the memory of what that drug did in specific emotional situations that prompts continued use. IV. DESIRED EFFECTS VS. SIDE EFFECTS (PP. 2.30− −2.31) A. DESIRED EFFECTS (pp. 2.30− −2.31) People use drugs to get high, for curiosity, self-medication, confidence, energy, psychological pain relief, anxiety control, peer pressure, disinhibition, boredom, altered consciousness, to deal with life problems, oblivion, and to gain a competitive edge. B. SIDE EFFECTS (p. 2.31) Drugs also trigger mild, moderate, dangerous, and sometimes fatal side effects. This conflict between the emotional/physical effects that users seek and the consequences of dangerous side effects is the dilemma presented by the use of psychoactive drugs. In addition to the physical and psychological side effects of drug use, social side effects, including legal, relationship, financial, and career consequences can be equally damaging. C. POLYDRUG ABUSE (pp. 2.31− −2.32) If an addict can’t get the desired effect from one drug, they will try almost any other substance, behavior, or combination of both to attain the change of mood and physical condition they seek. Some patterns of polydrug use include • replacement; using another drug when the desired drug is not available; • multiple drug use; taking several drugs to attain different feelings. Other patterns include cycling, stacking, mixing, sequentialing, and morphing (using one drug to counteract the unwanted effects of another).

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VII. LEVELS OF USE (PP. 2.32− −2.35) It is necessary to know the amount, frequency, and duration of psychoactive drug use in order to judge the impact the drug use has on the individual’s life and determine treatment needs. A. ABSTINENCE (p. 2.32) Abstinence is abstaining from the intentional use of any psychoactive substance. B. EXPERIMENTATION (p. 2.33) Experimentation occurs when a person’s curiosity about the effects of a drug prompts them to try it if/when it becomes available. No pattern of use develops, and there are limited negative consequences unless large amounts are used at one time, the person has an allergic reaction, the person has a pre-existing physical or mental condition, she is pregnant, etc. C. SOCIAL/RECREATIONAL USE (p. 2.33) A person seeks out a known drug and wants to experience a known effect, but there is no established pattern. D. HABITUATION (p. 2.33) There is a definite pattern of use (the person regularly uses a particular drug) but use does not affect his or her life in negative ways. E. ABUSE (p. 2.33) This pattern is marked by the continued use of a drug despite negative consequences, e.g., poor social life, chaotic finances, poor legal status, ill health, lost job, poor grades, or emotional confusion. F. ADDICTION (pp. 2.33− −2.34) Addiction comprises the four Cs, the cornerstones of addictive behavior: loss of control, compulsive drug use, powerful cravings for drugs, continued use despite increasing negative consequences associated with use. G. CLASSIFICATION (pp. 2.34) 1. DSM-IV-TR, DSM-V & ICD The American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines drug related illnesses as: Substance-related disorders are divided into two general categories: substance use disorders and substance-induced disorders. Substance use disorders involve patterns of drug use and are divided into substance dependence and substance abuse.

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Substance dependence is a pattern of repeated selfadministration that can result in tolerance, withdrawal, and compulsive drug-taking behavior. Substance abuse is “a maladaptive pattern of substance use leading to clinically significant impairment or distress;” i.e., continued use despite adverse consequences. Substance-induced disorders include conditions that are caused by use of specific substances, e.g., intoxication, withdrawal, certain mental disorders, 2. The World Health Organization (WHO) International Classification of Diseases classifies addictions under Mental and Behavioural Disorders. VIII. THEORIES OF ADDICTION (PP. 2.35− −2.36) Historically addiction was often perceived as a moral failure. Today, addiction is viewed through the lens of the addictive disease model, the behavioral/environmental model, the academic model, and the diathesisstress theory. A. ADDICTIVE DISEASE MODEL (p. 2.35) This medical model, maintains that the disease of addiction is a chronic, progressive, relapsing, incurable, and potentially fatal condition that is primarily a consequence of genetic irregularities in brain chemistry and anatomy, which may be activated by the particular drugs. B. BEHAVIORAL/ENVIRONMENTAL MODEL (pp. 2.35− −2.36) This theory emphasizes the overriding significance of environmental and developmental influences in leading a user to addictive behavior. Animal and human studies show that environmental factors can change brain chemistry as surely as drug use or heredity. C. ACADEMIC MODEL (p. 2.36) In this model, addiction occurs when the body adapts to the toxic effects of drugs at the biochemical and cellular levels, marked by the development of tolerance, tissue dependence, withdrawal symptoms, and psychological dependence. D. DIATHESIS-STRESS THEORY OF ADDICTION (p. 2.36) A diathesis (predisposition to addiction), is the result of genetic and environmental influences, such as stress. When a person becomes stressed or challenged by the use of psychoactive drugs or the practice of certain behaviors, neurochemistry and brain function are changed to a point where return to normal use or normal behavior is extremely difficult. IX. HEREDITY, ENVIRONMENT, PSYCHOACTIVE DRUGS & COMPULSIVE BEHAVIORS (PP. 2.36− −2.41) The reasons for drug addiction are a combination of heredity, environment, and the use of psychoactive drugs −2.38) A. HEREDITY (pp. 2.36− Many physical traits as well as many behaviors seem to have a heritable component. There are many genes that affect addiction; more than 100 15

Chapter 2 – Heredity, Environment & Psychoactive Drugs

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have been associated with drug abuse. The more addiction-related genes the person has, the more susceptible they are to drug abuse and addiction. 1. Twin & Retrospective Studies Identical twins raised in different environments have been studied to see if addiction still occurs. Fraternal twins are compared to identical twins raised in similar environments to study the influence of environment. The influence of parents are studied by reviewing the biological family records of alcoholics 2. Addiction-Associated Genes A number of specific genes associated with addiction have been identified. One of the first was the DRD2 A1 allele gene, found in more than 70% of severe alcoholics. Although the gene only indicates a shortage of dopamine (D2) receptors, it also indicates a tendency towards alcoholism, drug addiction, and compulsive behaviors. In practical terms, people with one or more marker genes are more susceptible to developing addiction once they begin drinking or using. Conversely, genes can also help prevent dependence from developing. There are a number of other genes implicated in dependency or resistance to dependency. P300 ERP (event-related potential) wave relates to a person’s cognition, decision-making, and processing of shortterm memory signals a propensity to alcohol addiction. B. ENVIRONMENT (pp. 2.38− −2.39) Sexual/physical/emotional abuse, stress, love, nutrition, living conditions, and family relationships, all determine how a person uses psychoactive drugs. 1. Environment, Brain Development & Memory Networks Environment helps mold the brain’s architecture and neurochemistry, thus altering the way the brain reacts to outside influences. It takes at least 20 years for the brain to become “hardwired.” Our brains remember emotionally charged events, e.g., abuse, accidents, or wartime trauma. Some youngsters begin using drugs, gambling or overeating —anything to temper pain or discomfort from their environment. The brain remembers the counter-behavior just as it remembers the stress and the pain. Other environmental influences include stress in the home, peer pressure to drink or use, lack of practice, malnutrition, and persuasive alcohol and tobacco marketing. −2.40) C. PSYCHOACTIVE DRUGS (pp. 2.39− Excessive, frequent, or prolonged use of alcohol or other drugs inevitably modifies many of the same nerve cells and neurochemistry that are affected by heredity and environment. 16

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The development of tolerance, tissue dependence, withdrawal, and psychological dependence are signs that the drugs are causing physical and chemical changes in the body, creating a motivation to increase use. Finally, animal studies confirm that some drugs have greater power to compel continued use than other drugs (positive reinforcement). Psychoactive drugs cause both temporary and permanent changes in various parts of the brain that can be imaged by new techniques including a SPECT, PET, CAT, MRI, fMRI, & DTI scans. These changes are due to synaptic plasticity and the brain’s need to achieve allostasis, a new balance. D. COMPULSIVE BEHAVIORS (p. 2.41) Certain behaviors, such as eating, shopping, gambling, engaging in sexual activity, playing video games, and Internet use can become compulsive in ways that mimics compulsive drug use. Compulsive behaviors are recognized as actual dysfunctions of brain chemistry. Compulsive behaviors are different from obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder. X. ALCOHOLIC MICE & SOBER MICE (PP. 2.41− −2.43) Years ago two genetic strains of mice were created - one strain loved alcohol, the other hated alcohol. When the alcohol-loving mice, whose genetics made them prefer alcohol were given unlimited access to alcohol, they drank themselves to death. When the alcohol-hating mice were injected with high levels of alcohol, they preferred alcohol after a few weeks. Another group of the alcohol-hating mice were subjected to environmental stress and within a few weeks, this group of sober mice also came to prefer alcohol over water. Another group of alcohol-hating mice had vitamin B and some proteins subtracted from their diets. This limited nutrition also resulted in increased alcohol use after several months. When the forced drinking, stress, and malnutrition were stopped, the once genetically sober mice did not return to their normal nondrinking habits. They had been transformed into alcohol-loving mice and if given the chance to drink, would be alcoholic mice. When the brains of the four groups of mice were examined, all had similar brain cell changes and neurotransmitter imbalances that made them prefer alcohol even though they were born with different neurochemical balances. XI. COMPULSION CURVES (PP. 2.43− −2.45) Compulsion/susceptibility help explain the connection between heredity, environment and the use of psychoactive drugs or compulsive behaviors. Each person is born with a different genetic susceptibility. The contribution of heredity to drug addiction is from 30% to 60%. 17

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The susceptibility to addiction is further molded by environment. A person may have experienced low, medium, or high environmental contributions toward a susceptibility to drug addiction. The final factor that pushes a person towards abuse and addiction is the use of psychoactive drugs or the practice of compulsive behaviors. The drugs that push the hardest and the quickest toward addiction are (from fastest to slowest): • smoking tobacco, crack, heroin; • injecting heroin and meth; • snorting cocaine, • ingesting opioid painkillers, amphetamines, and sedative hypnotics; • drinking alcohol, • smoking marijuana, When use stops, an individual drops below critical susceptibility but they have a higher risk of relapse. The addiction has permanently altered their brain cells and circuitry. If stress continues and the person remains near maximum susceptibility, just one drink, snort, bet, or piece of cake can retrigger compulsive use. If stress is reduced, environmental cues are avoided, attendance at selfhelp groups is routine and addiction memories are overcome, a person has a chance at continued recovery. XII. CONCLUSIONS (P. 2.45) Recent research shows, through brain imaging and a variety of other research techniques, that there are actual chemical and anatomical changes that force a person into compulsive behavior. Irresistible cravings and messages are permanently imprinted on the brain in emotionally charged addiction memories created by the excessive use of psychoactive drugs over a period of time. It is necessary to understand these physiological and psychological changes and devise strategies that take these neurochemical changes into account; however, any study of addiction should focus on the totality of people’s lives.

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Chapter 2 - HEREDITY, ENVIRONMENT, PSYCHOACTIVE DRUGS Classroom or Small Group Discussion Topics 1. Discuss the different methods of introducing drugs into the body and the factors that would make someone choose one method or another. 2. As a class, list the human functions controlled by the old brain. Give reasons why they are old-brain functions rather than new-brain functions. 3.

Discuss the evolutionary functions of the reward/control pathway in animals and humans and how it operates as a survival mechanism.

4.

Describe how a message is sent from a sensory organ, to the brain, and then to another part of the body.

5. 6.

Describe, in detail, how a message crosses a synaptic gap. Describe the difference between what cocaine does at a synapse and what heroin does at a synapse.

7. List and discuss natural activities that create an effect similar to various psychoactive drugs. 8. Discuss how a desired effect of a drug can also be an unwanted effect in a different situation (e.g., a painkiller such as codeine deadens pain but also can keep the person from sensing damage that could be aggravated by exercise.). 9. Think about food you regularly eat (sweets, spicy flavors, carbs) and how your capacity for use (tolerance) may have increased over time and then compare that to the increase in tolerance for psychoactive drugs. 10.

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Ask the students to identify an activity they or a friend pursue to excess and describe the process from experimenting with the behavior, up through the levels of use, and finally to an obsession with the activity.

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Chapter 2 - HEREDITY, ENVIRONMENT, PSYCHOACTIVE DRUGS Critical Thinking & Class Exercises 1. Divide the class into five groups and ask each group to determine ways • experimenters • social/recreational users • habitual users • abusers • addicts would acquire (a.) an illicit drug, (b.) a legal or licit substance used illegally (alcohol for underage drinkers, recreational use of prescription drugs) 2. Ask students to interview a friend or relative and ask the interview subjects to describe their physical and mental feelings (a.) after drinking coffee/tea/cola (stimulant), (b.) after a cigarette (stimulant), and/or (c.) after drinking alcohol. Compare the reactions for each stimulant such as heart rate, alertness, physical coordination, clarity of thought, and problem-solving abilities. 3. Ask students to make a list of five heredity factors and five environmental factors that might make them more susceptible to drug abuse. Then list five heredity factors and five environmental factors that would make them less susceptible. (if this is too personal – the exercise could focus on general factors – What would make a person susceptible…) 4. Have the students redraw the reward/control pathway on page 2.17 (Figure 2-8) and briefly describe the three phases of brain activity that comprise the reward/control pathway and label the specific areas that are involved at each step. 5. Have small groups discuss and then report to the class the following: What drugs are most attractive to people in their age group, and why? What drugs are most attractive to people in their home community, and why?

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Uppers, Downers, All Arounders, 7th Edition - Instructors Manual Chapter 3 – UPPERS Overview This chapter surveys the various stimulants, their history, effects and side effects, and the social context of their use. General Effects Uppers are stimulants that initially increase energy and alertness. These are the world’s most widely used psychoactive drugs. Some give an intense rush while others are only mildly stimulating. These drugs vary in strength from cocaine and amphetamines (strong) to caffeine and nicotine (weaker). Stimulants also include drugs used to treat attention-deficit/hyperactivity disorder, diet pills, and plant stimulants such as khat, betel nut, ephedra, and yohimbe. New illicit stimulants include MDPV, mephedrone and cathinone deceptively sold as “bath salts”. Stimulants can cause severe health problems when they are abused. It is the rapid development of tolerance and the disrupting effect on brain chemistry that encourage abuse and addiction. Cocaine & Amphetamines Cocaine and amphetamines are the strongest stimulants; they release excess neurotransmitters, principally epinephrine, norepinephrine, and dopamine. At lower doses, stimulation, confidence, aggressiveness, lack of hunger or thirst, increased heart rates, raised blood pressure, and alertness are the desired effects. At high doses or with prolonged use, neurotransmitter depletion, exhaustion, paranoia, psychosis, dehydration, unhealthy weight loss, and uncontrolled heart rates are common. The method of use can increase the abuse potential; smoking cocaine in its freebase chemical form known as “crack” is more addicting than snorting the drug. Amphetamine Congeners Amphetamine congeners are drugs that are related to amphetamines but are not as strong. The most well known is methylphenidate, used to treat attention-deficit/hyperactivity disorders. There is much controversy over their use. Amphetamines such as Adderall are also used to treat ADHD. The other well-known amphetamine congeners are also used as diet pills such as dexfenfluramine, pemoline, and phentermine. Plant Stimulants Worldwide, plant stimulants such as betel nuts and khat are used recreationally with the same frequency as coffee or cigarettes are used in the United States. Khat is popular in eastern Africa, the Middle East, and southern Arabia. Betel nuts have been used for more than two millennia; anywhere from 200 to 450 million people use betel nuts. Other plant and synthetic stimulants like ephedra, yohimbe, cathinone and pseudoephedrine have similar effects as methamphetamine. Caffeine The most widely used stimulant, caffeine, is found in coffee, tea, caffeinated soft drinks and energy drinks. “Speedball” cocktails (mixing energy drinks with liquor) are currently popular in the western world. Worldwide, more people drink tea than coffee. Excess caffeine use can cause tolerance, withdrawal when use is stopped, and a mild dependence. Caffeine use disorder will be added to the Diagnostic and Statistical Manual of Mental Disorders in 2013. Tobacco This stimulant kills 440,000 Americans each year either directly or through secondhand smoke. The addicting ingredient in tobacco is nicotine. The nicotine in tobacco was manipulated in the 1950’s by major tobacco companies (nicotine freebase) to make it more addictive. Smokers continue to smoke to maintain their blood- nicotine level. Tobacco first stimulates and then relaxes the body. Nicotine and other tobacco additives or smoking byproducts are toxic to every organ in the human body. Its use is linked to respiratory problems, cardiovascular disease, and cancer. Laws controlling the use, lawsuits against the tobacco companies, and higher public awareness of the dangers have cut cigarette use in half in this country, but worldwide, smoking rates are almost twice that of the United States.

Chapter 3 – UPPERS Outline

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I.

GENERAL CLASSIFICATION

II. GENERAL EFFECTS A. BORROWED ENERGY 1. Crash & Withdrawal B. REWARD/CONTROL PATHWAY C. WEIGHT LOSS D. CARDIOVASCULAR SIDE EFFECTS E. EMOTIONAL/MENTAL SIDE EFFECTS F. TOLERANCE &ADDICTION LIABILITY III. COCAINE A. BOTANY, CROP YIELDS & REFINEMENT B. SMUGGLING &THE STREET TRADE C. HISTORY OF USE 1. Chewing the Leaf 2. Coca to Cocaine 3. Drinking Cocaine 4. Injecting Cocaine 5. Snorting Cocaine 6. Mucosal & Contact Absorption 7. Smoking D. PHYSICAL &MENTAL EFFECTS 1. Metabolism 2. Medical Use 3. Neurochemistry & the Central Nervous System 4. Sexual Effects 5. Aggression, Violence, & Cocaethylene 6. Cardiovascular Effects 7. Neonatal Effects 8. Tolerance 9. Withdrawal, Craving, & Relapse 10. Overdose 11. Miscellaneous Effects 12. Cocaine Psychosis & Other Mental Problems E. OTHER PROBLEMS WITH COCAINE USE 2

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1. Polydrug Use 2. Adulteration & Contamination F. COMPULSION

IV. SMOKABLE COCAINE (crack, freebase) A. PHARMACOLOGY OF SMOKABLE COCAINE B. EFFECTS &SIDE EFFECTS 1. Respiratory Effects 2. Polydrug Abuse 3. Overdose C. OTHER CONSEQUENCES OF CRACK USE 1. Economic Consequences 2. Drug Gangs 3. Social Consequences D. COCAINE VS.AMPHETAMINES V. AMPHETAMINES A. CLASSIFICATION B. HISTORY OF USE 1. Discovery 2. Japanese Epidemic 3. Diet Pills 4. Street Speed 5. “Ice” C. CURRENT USE. D. METHAMPHETAMINE MANUFACTURING E. EFFECTS 1. Routes of Administration F. NEUROCHEMISTRY G. PHYSICAL & SIDE EFFECTS H. NEONATAL EFFECTS G. MENTAL & EMOTIONAL EFFECTS

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A. ADHD, METHYLPHENIDATE (RITALIN©) & CONCERTA 1. Diagnosis of ADHD 2. Epidemiology 3. Pharmacotherapy for ADHD 4. Concerns Regarding ADHD Pharmacotherapy B. DIET PILLS VII. LOOK-ALIKE & OTC STIMULANTS A. LOOK-ALIKES B. OTHER OVER-THE-COUNTER STIMULANTS VIII. MISCELLANEOUS PLANT STIMULANTS A. KHAT & METHCATHINONE 1. Khat (“qat,” “shat,” “miraa”) 2. Methcathinone B. BETEL NUTS C. YOHIMBE D. EPHEDRA (EPHEDRINE) 1. Herbal Ecstasy® & Herbal Nexus® IX. CAFFEINE A.HISTORY OF USE 1. Tea 2. Coffee 3. Cocoa 4. Caffeinated Soft Drinks (colas) 5. Energy Drink Phenomenon 6. Other Plants Containing Caffeine B. PHARMACOLOGY C. PHYSICAL &MENTAL EFFECTS D. TOLERANCE, WITHDRAWAL, & ADDICTION

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X. NICOTINE A. HISTORY 1. American Indians & Tobacco 2. Growth of Cigarette Smoking 3. Smokeless Tobacco B. BOTANY & PHARMACOLOGY 1. Nicotine 2. Freebase Nicotine 3. Other Reasons for Continued Use C. TOLERANCE, WITHDRAWAL, & ADDICTION 1. Tolerance 2. Withdrawal 3. Addiction D. AGE OF FIRST USE E. EPIDEMIOLOGY F. SIDE EFFECTS 1. Longevity 2. Cardiovascular Effects 3. Respiratory Effects 4. Cancer 5. Smokeless Tobacco Effects 6. Fetal Effects G. BENEFITS FROM QUITTING H. TREATMENT FOR TOBACCO ADDICTION I. THE TOBACCO INDUSTRY &TOBACCO ADVERTISING 1. The Business of Tobacco 2. Advertising 3. Laws & Lawsuits 4. Second Hand Smoke J. 2004 & 2008 SURGEON GENERAL’S REPORT ON SMOKING

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Chapter 3 – PSYCHOACTIVE DRUGS: HISTORY & CLASSIFICATION Extended Outline I. GENERAL CLASSIFICATION (PP. 3.2-3.4) Last year, 5.3 million Americans used cocaine, 850,000 used methamphetamine non-medically, 70 million smoked cigarettes, 150 million drank coffee, and 47 gallons of soft drinks (most caffeinated) were consumed per capita. Worldwide, 200 million people used betel nut, Southeast Asians ingested yaa baa (a form of amphetamine) at a record pace, the majority of the male population in Ethiopia, Somalia, and Yemen used khat, and 1.3 billion smoked cigarettes. Stimulants are the drugs of choice in the restless world of the twenty-first century. Some stimulants are found in plants: the coca shrub (cocaine), the tobacco plant (nicotine), the khat bush (cathinone), the ephedra bush (ephedrine), the betel nut palm (arecoline), and the coffee plant (caffeine). Other stimulants are synthesized in legal plants or street laboratories; methamphetamines, diet pills, methylphenidate (Ritalin®), MDMA,MDPV, and methylmethcathinone. II. GENERAL EFFECTS (P. 3.5) All stimulants increase the chemical and electrical activity in the central and peripheral nervous systems. Stimulants are used clinically to treat narcolepsy, obesity, and attention-deficit/ hyperactivity disorder (ADHD). They are used illegally to fend off drowsiness, keep the user energized, increase confidence, reduce weight, and induce euphoria. The major effects of stimulants result from the way they manipulate the brain’s natural energy chemicals. They cause addiction because they activate the brain’s reward/control pathway. A. BORROWED ENERGY (p. 3.5) Neurotransmitters responsible for most of the stimulants effects are epinephrine (E), norepinephrine (NE), and to a lesser extent, serotonin (5HT) and dopamine (DA). The nervous system naturally releases extra energy chemicals when the body needs energy. In contrast, stimulants force the release of these chemicals and infuse the body with excessive amounts of energy regardless of the need. The extra energy is manifested through physical activity, talking, and hyper vigilance. The effect is multiplied when strong stimulants (e.g., cocaine and amphetamines) are used because they block the natural reabsorption and metabolism of the energy chemicals that are released. 1. Crash & Withdrawal If stimulants are taken in excess, the energy supplies become depleted and the body is left without reserves. With stronger stimulants, this crash and its subsequent withdrawal symptoms and severe depression, can last for days, weeks, or occasionally months. B. REWARD/CONTROL PATHWAY (p. 3.6) 4

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All stimulants have some effect on the reward/control pathway. Normally, this center serves as a survival mechanism, giving a surge of pleasure when a physiological or psychological need is being satisfied (e.g., hunger, thirst, or sexual desire). Stronger stimulants release two to ten times as much dopamine as normal activities artificially over stimulating this pathway and falsely signal the brain that hunger, thirst, and /or other needs are being satisfied. Dopamine is the neurotransmitter most often involved in triggering these feelings of pleasure or satisfaction. C. WEIGHT LOSS (p. 3.6) Stimulants fool the body into thinking that hunger has been satisfied even though no food has been consumed - causing weight loss, which is one of the main reasons for their use. Tobacco also decreases appetite because of this effect. D. CARDIOVASCULAR SIDE EFFECTS (p. 3.6) Many stimulants, including nicotine and caffeine, constrict blood vessels, thus decreasing blood flow to tissues and organs, including the skin. The stronger stimulants can damage blood vessels, raise blood pressure and heart rate, and raise the risk of stroke. E. EMOTIONAL/MENTAL SIDE EFFECTS (p. 3.6− −3.7) Stimulants initially increase confidence and induce euphoria, but as use continues talkativeness, restlessness, irritability, insomnia, and eventually, paranoia, aggression, and violence increase. High-dose or prolonged methamphetamine/cocaine use can cause drug-induced paranoia and psychosis by altering the levels of dopamine in the brain. F. TOLERANCE &ADDICTION LIABILITY (p. 3.7) Tolerance develops rapidly due many processes including downregulation, or decreased number of dopamine and serotonin receptors in the brain. While the physical dependence of extended cocaine and methamphetamine use is not quite as severe as it is with heroin, the psychological dependence is just as powerful. Tolerance and dependence can also develop with methamphetamine congeners, caffeine, nicotine, and other milder stimulants. III. COCAINE (P. 3.7− −3.17) Cocaine epidemics occur every few generations - the 1890s, 1920s, 1970s 1980s, and the 2000s. The development of crack, a smokable form of cocaine led to the most recent use epidemic.

A. BOTANY, CROP YIELDS & REFINEMENT (p. 3.7− −3.8) 5

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Cocaine grows mainly on the slopes of the Andes Mountains in South America (Peru, Bolivia, Ecuador, and mainly Colombia). The leaves of the coca bush contain 0.5% to 1.5% by weight of the alkaloid cocaine. The cocaine refinement technique is a multi-step process. B. SMUGGLING &THE STREET TRADE (pp. 3.8− −3.9) In spite of a reported 18% reduction in Colombia’s coca crop, cocaine prices have remained stable and the purity has improved. This is partly due to Colombia grows about two-thirds of the world’s coca crop. Two-thirds of the cocaine smuggled into the United States in recent years has been trafficked by drug gangs and cartels centered in Mexico. An estimated 200 to 400 metric tons flooded the U.S. market in 2007. It is estimated that about 865 metric tons of cocaine were produced in the Andean region in 2005, while Americans spent an estimated $36.1 billion (retail) on the drug in 2007. Street prices vary from $50 to $200 per gram of powdered cocaine hydrochloride. “Rocks” of crack cocaine sell for $10 to $20. The 2008 National Household Survey on Drug abuse estimated 1,411,000 dependent cocaine users in the U.S. The Drug Use Forecasting Program estimates at least twice that many. C. HISTORY OF USE (p. 3.9− −3.11) Many landmarks in the history of coca and cocaine use coincide with the changing methods of use and the refinement of the substance. 1. Chewing the Leaf (p. 3.9) The Incas chewed the leaf for the juice, adding some lime or ash to increase absorption. 16th century, Spanish conquistadors conquered the Incan Empire and controlled the trade. Today 90% of Indians living in coca-growing regions of South America chew coca leaf.. 2. Coca to Cocaine (p. 3.9) Cocaine hydrochloride, synthesized in 1859, is 200 times more powerful by weight than the coca leaf. Karl Koller discovered its anesthetic properties and Sigmund Freud promoted its medical and psychiatric uses 3. Drinking Cocaine (p. 3.10) In the late 1860s, cocaine wines were popular in France and Italy( Vin Mariani). It takes 15 to 30 minutes for the cocaine in wine to reach the brain. In the 1880s and 1890s, patent medicines laced with cocaine, opium, morphine, heroin, Cannabis, and alcohol became the rage.

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4. Injecting Cocaine (p. 3.10) Large doses could be injected into the body with the invention of the hypodermic needle in 1853. Injecting intravenously results in an intense rush within 30 seconds and produces the highest bloodcocaine level. If injected subcutaneously or intramuscularly, the high is delayed three to five minutes and is not as intense. 5. Snorting Cocaine (p. 3.10) This method delivers the drug to the nasal mucosa and into the brain in three to five minutes. Peak effects take a few more minutes to occur. Due to capillary constriction, snorting cocaine is self-limiting, the more snorted the slower the absorption. 6. Mucosal & Contact Absorption (p. 3.11) Cocaine can also be absorbed through mucosal tissues in the gums, cheeks, rectum, and vagina. It has topical anesthetic effects on all tissues it contacts. 7. Smoking Cocaine (p. 3.11) When street chemists converted cocaine hydrochloride to freebase cocaine, it lowered the vaporization point to 98°C and made the drug smokable. When absorbed through the lungs, it reaches the brain in only 5 to 8 seconds. This method leads to an extreme binge pattern of use. D. PHYSICAL & MENTAL EFFECTS (p. 3.11−3.16) 1. Metabolism (p. 3.11) Cocaine is metabolized very rapidly so effects quickly dissipate. The half-life of cocaine in the body is 30 to 90 minutes. A metabolite of cocaine is detectable in the urine for up to 36 hours. 2. Medical Use (p. 3.11− −3.12) Cocaine is the only naturally occurring topical anesthetic, it is used in aerosol form to numb the nasal passages when inserting breathing tubes, to numb the eye or throat during surgery, and to deaden the pain of chronic sores. 3. Neurochemistry & the Central Nervous System (p. 3.12) Cocaine prevents the reabsorption of epinephrine, norepinephrine, serotonin, and dopamine thus increasing their concentration in the synapse and intensifying their effects. The Crash. By blocking the reabsorption of stimulant neurotransmitters, cocaine leaves them vulnerable to continued metabolism leading to the rapid depletion energy chemicals. So the crash after using cocaine can be intensely depressing. This depression can last a few hours, several days, or even weeks until the brain replenishes its stimulant neurotransmitters. 4. Sexual Effects (p. 3.12) Cocaine at low doses enhances sexual desire, delays ejaculation, and is considered an aphrodisiac by many users. With higher doses and chronic use, sexual dysfunction becomes more common and the likelihood of high-risk sexual behavior and unusual sexual practices increases. 7

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5. Aggression, Violence & Cocaethylene (p. 3.12− −3.13) Cocaine use is associated with increased aggression and violence, especially in those prone to violence. Emotional triggers and the fright center are overstimulated, inhibitory functions in the cortex are suppressed. Cocaethylene, a byproduct of alcohol and cocaine together, increases violence as well as cardiovascular dangers. Its half-life is more than three times that of cocaine alone. Autopsies showed that 31% of all homicide victims in New York in the early 1990s had cocaine in their bodies. 6. Cardiovascular Effects (p. 3.13) Physiologically, it is the cardiovascular system that is most affected by long-term cocaine use, raising the heart rate and constricting blood vessels, causing a 20- to 30-unit rise in blood pressure. Use leads to cellular changes, including damage to heart muscles (known as constriction bands), coronary arteries, and other blood vessels. Stroke is a possibility. 7. Neonatal Effects (p. 3.13, 3.14) Cocaine use exposes the fetus to the drug within seconds. Miscarriage, premature birth, fetal stroke, placental separation, sudden infant death syndrome (SIDS), and blood vessel malformations are increased. Many infant abnormalities have more to do with the mother’s lifestyle rather than the drug itself. Good prenatal and postnatal care results in a toddler’s emotional and physical development catching up to noncocaine-exposed children. 8. Tolerance (p. 3.14) Tolerance to the euphoric effects can begin to develop after the first injection or smoking session. Tolerance is partly related to the adaptation of the brain to a reduction of dopamine in the nucleus accumbens, which in turn diminishes the rewarding effects of the drug. 9. Withdrawal, Craving & Relapse (p. 3.14) Although similar to the crash, withdrawal effects can last months or years. Symptoms include • anhedonia, anergia, emotional depression, • loss of motivation, anxiety, insomnia, agitation, and an intense craving. A typical cycle of compulsive cocaine (or amphetamine) use is • the crash • a few days later, the user feels much better (euthymia); • a week or 10 days later, craving builds and emotional depression increases; • two to four weeks after vowing to abstain, craving and depression build to a fever pitch often leading to a slip and relapse.

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10. Overdose (p. 3.15) Cocaine was involved in 32% of ER visits in major cities in 2007; most often, an overdose was not fatal. In 2,000 to 3,000 U.S. cases every year, death occurs, usually within 40 minutes to five hours after exposure (occasionally the next morning). “Kindling” effects of cocaine causes increased risk for toxic effects the longer it is used. 11. Miscellaneous Effects (p. 3.15) Formication refers to sensations on or under the skin that feel like hundreds of tiny bugs (“coke bugs”). Dental Erosion is caused by malnutrition, poor dental hygiene, the erosive effects of acidic cocaine, and oral dehydration. Seizure occurs in 2% to 10% of regular cocaine users. Gastrointestinal Complications. include gastric ulcerations, tract perforations, colonic ischemia, etc., “Crack or Meth Dancing” is involuntary writhing, flailing, jerky, and sinuous movement, of the hands, arms and sometimes legs. 12. Cocaine Psychosis & Other Mental Problems (pp. 3.15− −3.16) Because cocaine increases dopamine, repeated use can trigger stimulant-induced paranoid psychosis. It is difficult for clinicians to differentiate between a pre-existing psychosis and a cocaine-induced psychosis. Symptoms usually disappear after a period of abstinence. E. OTHER PROBLEMS WITH COCAINE USE (p. 3.16) 1. Polydrug Use Cocaine’s stimulating effects can be so intense that the user needs a downer to take the edge off, e.g., alcohol, heroin, or a sedativehypnotic. Cocaine combined with a downer is known as a “speedball”. Cigarette smokers are 22 times more likely to also use cocaine. 2. Adulteration & Contamination Street cocaine is usually adulterated so when the drug is used intravenously, diluents, bacteria, and viruses are also injected. The hepatitis C infection rate for IV drug users is 50% to 90%. In 2009, 69% of U.S. street cocaine samples contained levamisole, a dangerous veterinary de-worming medicine. F. COMPULSION (pp. 3.16− −3.17) The reasons for compulsive use including • recapturing the initial rush • avoiding the crash • avoiding life’s problems • controlling the symptoms of a mental illness. 9

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There is a hereditary predisposition to use; the drug induces alteration of brain chemistry that causes cravings and manifests a binge pattern of use. IV. SMOKABLE COCAINE (crack, freebase) (PP. 3.17− −3.20) The smokable-cocaine epidemic began in 1981 when a cheap chemical process to make cocaine smokable was developed. The addictive nature of smokable cocaine was the primary reason for the epidemic. The media has lost interest in reporting about crack but it is still a serious problem. The epidemic waned in the 1990s but smokable cocaine is still a problem and 72% of all those admitted for cocaine treatment are crack smokers. A. PHARMACOLOGY OF SMOKABLE COCAINE (pp. 3.17− −3.18) Making cocaine suitable for smoking (freebasing, “basing,” or “baseballing”) involves precipitating out pure cocaine freebase crystals. “Cheap basing” or “dirty basing” involves baking soda, water, and heat until clumpy crystals precipitate out (“crack”); there are more impurities with this method. The converted freebase cocaine, made by either method 1. has a lower melting point than the powdered form, 2. reaches the brain faster, 3. is more readily absorbed by fat cells of the brain, and 4. delivers a much higher dose of cocaine in the system over a short period of time. Crack and freebase are just different chemical forms of cocaine that makes them smokable. Smoking results in more addiction problems. In those treated for cocaine addiction, 70% are crack smokers though more cocaine users snort or inject the drug. B. EFFECTS &SIDE EFFECTS (pp. 3.18− −3.19) The rush from smoking crack lasts as little as 5 to 10 seconds and a subsequent euphoria, excitation, and arousal lasts several minutes more. Crack is always used in an intense binge pattern. Physical side effects include thirst, coughing, tremors, dry skin, slurred speech, and blurred vision. As use becomes chronic, chest pains, sore throat, black or bloody sputum, hypertension, weight loss, insomnia, tremors, and heart damage can occur. Other effects include crack keratitis, crack thumb, and torch burns to the face and hands. Unwanted psychological effects of chronic use include paranoia, intense craving, asocial behavior, hyperexcitability, hallucinations, etc. 1. Respiratory Effects Chest pains, pneumonia, cough, crack lung, hemorrhage, respiratory failure, and death due to the drug’s effect on the respiratory control center of the brain can occur. Crack lung is defined by pain, breathing problems, and fever that resemble pneumonia. Respiratory problems are further aggravated when the user also smokes cigarettes. 10

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2. Polydrug Abuse Some smokers combine freebase and marijuana (“champagne,” “caviar”), crack with PCP or ketamine (“space basing,” “whack”), freebase cocaine and smokable tar heroin (“hot rocks”), and cocaine and wine coolers (crack coolers), etc. 3. Overdose Usually overdose is marked by a very rapid heartbeat and hyperventilation, often accompanied by a feeling of impending death. Most people survive, but several thousand die usually from cardiac arrest, seizure, stroke, respiratory failure, or severe hyperthermia. C. OTHER CONSEQUENCES OF CRACK USE (pp. 3.19− −3.20) 1. Economic Consequences Crack is not cheaper per gram than cocaine hydrochloride; it is just sold in smaller units. One gram of cocaine sells for about $100. Onetenth of a gram converted to a crack rock sells for about $20. Successful dealers become addicted to the money and the lifestyle that comes with dealing. 2. Drug Gangs The majority of small-time cocaine dealers make just enough money to support their own habit. The large scale economic potential is so great that gangs (e.g. Bloods, Crips, Jamaican, Colombian and Mexican) are organized around its sale and distribution. Along with homicide and other crime associated with gang activity, cocainerelated arrests account for 42% of all U.S. drug arrests. Federal penalties changed in late 2010 to reduced the disparity between crack and powder cocaine sentencing because a disproportionate number of minorities were being imprisoned for cocaine trafficking. 3. Social Consequences Addictive use of the drug has social ramifications, e.g., high rates of neglect, abandonment, and child abuse. There is also a high rate of crime associated with crack use that has a major negative impact on families in many inner-city communities. D. COCAINE VS. AMPHETAMINES (p. 3.20) Price. Cocaine is more expensive. Quality of the Rush or the High. Many users report that the rush and the high from cocaine is greater than that from amphetamines but amphetamines release greater amounts of energy. Duration of Action. Cocaine’s major effects last about 40 minutes; amphetamine’s effects last four to six hours. Manufacture. Cocaine is plant derived; amphetamines are synthetic. Methods of Use. Snorting, smoking, and shooting (injecting) are the preferred methods of use for both, methamphetamines can also be ingested. 11

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Addiction Rate. Methamphetamine leads users into addiction more quickly than cocaine and users enter treatment sooner.

V. AMPHETAMINES (PP. 3.20− −3.28) A. CLASSIFICATION (p. 3.20) Amphetamines are a class of powerful synthetic stimulants with effects similar to cocaine but lasting much longer. Amphetamines are usually snorted, injected, or taken orally. There are several different types of amphetamines: amphetamine, metham-phetamine, dextroamphetamine, and dextro isomer methamphetamine (or “crystal meth,” the most common). All produce similar effects. B. HISTORY OF USE (p. 3.21− −3.24) Worldwide more than 35 million people used amphetamines and methamphetamines in 2009, compared to 18 million cocaine users, 18 million heroin users, and 165 million marijuana users. 1. Discovery Amphetamine was synthesized in 1887 and methamphetamine in 1919. The drugs’ stimulant qualities and medical applications were not utilized until the 1930s when Methedrine® and Benzedrine® inhalers were marketed as bronchodilators. The drugs were taken to energize the user, counter low blood pressure, reduce the need for sleep, and suppress appetite. Amphetamine tablets were widely used during World War II by Allied, German, and Japanese forces to keep pilots and soldiers alert. More than 225 million doses were handed out during the Vietnam conflict. Amphetamines were also used to treat narcolepsy (a chronic sleep disorder), some cases of epilepsy, and depression. 2. Japanese Epidemic Abuse of amphetamines in Japan continued after World War II, There are 1 to 2 million amphetamine abusers in Japan. 3. Diet Pills In 1970, an estimated 6% to 8% Americans used prescription amphetamines, for weight loss. 4. Street Speed The peak of the “speed” craze occurred in the late 1960’s. The hippy/counter culture movement was fueled by both diverted and illegally manufactured amphetamines.

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In response to the amphetamine epidemic, the Comprehensive Drug Abuse Prevention and Control Act of 1970 classified amphetamines as Schedule II drugs, making them difficult to obtain. The most popular form of street speed was the “crosstop” tablet smuggled into the U.S. from Mexico. In the late 1980s and 1990s there was a resurgence in abuse of illicit methamphetamines, particularly “crank” (methamphetamine sulfate), and “crystal meth” (dextro isomer methamphetamine hydrochloride). 5. “Ice” In the 1990s, “crystal meth” (“ice,” “glass,” “batu,” or “shabu”), was trending toward major abuse. Many Asian countries saw severe abuse problems with this drug (“shabu,” “batu,” “ya ba”, etc). In Arab countries, phenethylline (Captagon®) a drug that is metabolized in the body into amphetamine has seen recent abuse. C. CURRENT USE Licit Use. Amphetamines are used to treat attention-deficit/hyperactivity disorder, narcolepsy, and obesity. Illicit Use. Historically, stimulant epidemics last 10 to 15 years. Due to the intensity of the high and the severity of the side effects, meth abuse eventually becomes self-limiting. The current cycle began in the 1980’s and continues into 2011, the number of admissions for amphetamine addiction has doubled in the past 10 years. The typical user is a white male between the ages of 19 and 40. Meth use is particularly rampant in the gay community. The number of HIV/AIDS cases in the gay community exceeds that of other populations due to high-risk sexual behavior and the use of contaminated needles. D. METHAMPHETAMINE MANUFACTURING Meth was originally manufactured by biker gangs, today Mexican gangs and drug cartels are involved in its manufacture and distribution. There are more than 300 ways to manufacture methamphetamine using ephedrine and pseudoephedrine. Super labs run by Mexican cartels manufacture most of the meth available in the U.S. To control mom and pop meth labs, many states enacted laws requiring pharmacies to limit the amount of pseudoephedrine-containing cold tablets that could be purchased at one time. The Federal Combat Meth Act of 2005 limits access to meth precursors. The international controls placed on meth precursors by Mexico and other countries have caused the drug gang to smuggle in new precursors like P2P to produce meth. The price of a gram is $200 to $300. The chemicals used in the manufacturing process are dangerous to the environment. In 2005 in the United States, 12,484 polluted methamphetamine laboratories and dumpsites were seized and decontaminated, primarily by the DEA and state law enforcement agencies. 13

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Recently “ya ba,” manufactured in Thailand, Laos, and Myanmar, has become a problem. These little brightly colored methamphetamine pills are being smuggled into the United States and other countries in everincreasing amounts. E. EFFECTS (p. 3.24− −3.25) 1. Routes of Administration Snorting methamphetamine causes irritation and pain to the nasal mucosa. Intravenous use causes a more intense high than snorting or swallowing; however, it often causes pain in the blood vessels. Oral ingestion fell out of favor because of the drug’s bitter taste and the length of time it takes to reach the brain. Smoking “crank” or “ice” is similar to smoking freebase cocaine (in a pipe). Regardless of the route of administration – the effects last four to six hours compared to 10 to 90 minutes for cocaine. F. NEUROCHEMISTRY (p. 3.25) Amphetamines increase norepinephrine, epinephrine, and dopamine in three ways: • they force the release of these neurotransmitters in nerve terminals • intake pumps reverse function and spit out extra neurotransmitters • they block the enzymes that metabolize the excess neurotransmitters. Prolonged amphetamine use alters brain chemistry in a way that increases craving. This process also occurs with cocaine. In one study the brains of meth users showed an average loss of 11.3% of their limbic gray matter, particularly the hippocampus, areas associated with craving, emotions, mood, and memory. Users with a strong tendency to relapse have subdued activity in five different regions of the brain. This implies that those with a tendency to relapse have an impaired decision-making ability and find it hard to refuse a craving. G. PHYSICAL EFFECTS & SIDE EFFECTS (p. 3.25− −3.26) Small-to-moderate doses create extra energy, increase heart rate, raise body temperature, trigger rapid respiration, raise blood pressure, dilate bronchial vessels, and suppress appetite. Methamphetamine abusers go on binges, or “runs,” remaining awake and active for 3, 4, or 10 days at a time. Tolerance to amphetamines is pronounced. Users go from 15 to 30 mg per day to 5,000 mg after months of use. Long-term use can cause sleep deprivation, heart and blood vessel toxicity, and severe malnutrition. Malnutrition, cravings for sweet foods,

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poor dental hygiene, and severe oral dehydration often result in bad gums and rotted teeth. Withdrawal from methamphetamine or cocaine results in physical and emotional depression, extreme irritability, nervousness, anergia, anhedonia, and craving, Large amounts can cause an overdose, resulting in convulsions, hyperthermia, stroke, cardiovascular overstimulation, and collapse. H. NEONATAL EFFECTS (p. 3.26− −3.27) In the United States, almost half of all methamphetamine abusers are women. Damage to the fetus of a pregnant drug abuser can stem from the direct effects of the drug as well as the consequences of a chaotic lifestyle. Risks include • irritable baby syndrome at birth; • premature delivery and congenital deformities; • placental separation; • intrauterine stroke; • higher risk for HIV and hepatitis B or C. Developmental risks include: • growth and developmental delays • learning disabilities • increased incidence of ADHD • increased risks for rage disorder • greater incidence of SIDS. I. MENTAL & EMOTIONAL EFFECTS (p. 3.27− −3.28) Amphetamines initially produce a mild-to-intense euphoria, a sense of well-being and confidence, alertness, and sexual impulsivity. After prolonged use, irritability, paranoia, anxiety, aggression, mental confusion, poor judgment, impaired memory, and hallucinations can result from unbalanced neurotransmitters. Amphetamines release neurotransmitters that mimic sexual gratification so they are sometimes used to augment sexual activity. The increased suspiciousness, paranoia, and overconfidence created by the use of meth leads to misinterpretations of others’ actions which sometimes leads to violent reactions. Excess methamphetamine or cocaine use can trigger amphetamine/cocaine psychosis. Symptoms include hallucinations, loss of contact with reality, and pressed speech that is almost indistinguishable from true schizophrenia or paranoid psychosis. The disturbed user will usually return to some semblance of normalcy after the brain chemistry has been rebalanced which takes a few days or weeks.

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Dextromethamphetamine (“ice,” or “crystal meth”) stimulates the brain more than other amphetamines, resulting in more overdoses and a quicker disruption of neurotransmitters.

VI. AMPHETAMINE CONGENERS (p. 3.28−3.30) Amphetamine congeners are stimulant drugs that are chemically dissimilar but pharmacologically related to amphetamines and that produce many of the same effects. A. ADHD, METHYLPHENIDATE (Ritalin®) & CONCERTA® (p. 3.28− −3.29) Methylphenidate (Ritalin®) is the most widely used amphetamine congener. Although it is prescribed as both a mood elevator and a treatment for narcolepsy, it is most often prescribed for attentiondeficit/hyperactivity disorder. Amphetamines such as Adderall® and Dexedrine® are also widely prescribed for ADHD. 1. Diagnosis of ADHD There is no explicit diagnostic test for ADHD. Controversy surrounding the extent and the severity of the disorder continues. Some physicians use brain-imaging techniques to look for telltale signs. One of the main deficits is in the executive control part of the brain Classification. In the United States, the 3 subtypes of ADHD according to the DSM-IV-TR are: • ADHD, combined type • ADHD, predominantly inattentive type (also known as Attention Deficit Disorder, ADD) • ADHD, predominantly hyperactive-impulsive type 2. Epidemiology Between 3% and 7.4% of all school age children in the United States could be diagnosed with ADHD; it is two to three times more prevalent in boys than girls. 2.9% to 16.4% of adults could be diagnosed with ADHD. 3. Pharmacotherapy for ADHD Stimulants are prescribed to treat ADHD. Dopamine depletion is one of the main causes, and amphetamines or amphetamine congeners release dopamine (and serotonin). More than 22 million prescriptions per year are issued for ADHD stimulants: • methylphenidate (Ritalin,® Focalin XR, and Concerta®) (10 million prescriptions per year); • d-amphetamine (Adderall®) (7.7 million prescriptions) 16

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• • •

lisdexamfetamine (Vyvanse®) atomoxetine (Strattera®) and guanfacine (Intuniv,® Tenex®), nonstimulant ADHD medication (5.8 million prescriptions); and pemoline (Cylert®)

Other therapies include dietary and lifestyle changes, education, exercise, behavior modification, and psychotherapy. Some research has shown methylphenidate alone worked as well as methylphenidate and therapy for ADHD. 4. Concerns Regarding ADHD Pharmacotherapy The FDA has received reports of psychosis or mania and hallucinations among patients treated with ADHD medications. Increased abuse of these substances was seen in the mid-2000s due to diversion of methylphenidate and Adderall® to nonmedical use. Methylphenidate, has strong addictive liability. It has been sold on the street and used as a party drug. The U.S. military bars anyone who used methylphenidate in adolescence from military service. There are also grave concerns about the long-term effects of giving strong stimulants to children. There is a high occurrence of ADHD in drug abusers with an increased risk for substance abuse in adults with untreated ADHD. One study of boys with ADHD who were treated with stimulants, including Ritalin,® were 84% less likely to abuse drugs and alcohol when they get older compared with those who are not treated. Research supports the need to treat ADHD patients with medications throughout their lives. B. DIET PILLS (p. 3.31) At any given time, 24% of men and 38% of women in the United States are trying to lose weight. Presently only 2% to 3% use diet pills. In the fifties, sixties, and seventies, amphetamine based diet pills saturated the market. In addition to aiding weight loss, they also caused heart problems, malnutrition, and dependence. Amphetamine congeners, diet pills like Adipex® and Obetrol® with similar side and toxic effects were the next generation that saturated the market. American Home Products has paid approximately $4.8 billion to settle claims brought against two amphetamine congener diet pills— fenfluramine and dexfenfluramine (fen-phen)—that caused heart-valve damage. Other amphetamine congeners like pemoline and atomoxetine can cause liver damage. Diet pills (amphetamines and amphetamine congeners) are recommended only for short-term use.

VII. LOOK-ALIKE & OVER-THE-COUNTER (OTC) STIMULANTS (PP. 3.31−3.32)

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A. LOOK-ALIKES (p. 3.31) In the 1980s the look-alike stimulants contained ephedrine and occasionally pseudoephedrine (anti-asthmatics), phenylpropanolamine (PPA a decongestant and mild appetite suppressant), and caffeine (a stimulant). In the early 1980s the FDA banned the OTC sale of products containing two or more of these ingredients. When overused, these products are somewhat toxic, especially when combined. B. OTHER OVER-THE-COUNTER STIMULANTS (p. 3.32) Pseudoephedrine and phenylpropanolamine, which have decongestant, mild anorexic, and stimulant effects, were previously found in hundreds of allergy and cold medications. After restrictions were placed on pseudoephedrine and warnings about phenylpropanolamine surfaced, drug manufacturers turned to other drugs, such as phenylephrine, that couldn’t be made into amphetamines and had fewer stimulant or other unwanted side effects. Caffeine has been sold as an OTC stimulant for years, e.g., NoDoz® and Vivarin. ® VIII. MISCELLANEOUS PLANT STIMULANTS (P. 3.32−3.35) Worldwide, dozens of plants or their extracts with stimulant properties have been used for centuries by hundreds of millions of people; plants include khat, betel nut, yohimbe, and ephedra. A. KHAT &METHCATHINONE (p. 3.32−3.33) 1. Khat (“qat,” “shat,” & “miraa”) Khat is the driving economic force in Somalia, Yemen, and a few other countries in eastern Africa, southern Arabia, and the Middle East. The khat shrub is 10 to 20 ft. tall. The fresh leaves and tender stems are chewed and the juice is swallowed. Dried leaves and twigs are crushed for tea or made into a chewable paste. The main psychoactive ingredient, cathinone, has a half-life of about 90 minutes. It produces a mild euphoric effect along with exhilaration, talkativeness, hyperactivity, wakefulness, aggressiveness, enhanced selfesteem, and loss of appetite. Side effects of excess use include anorexia, tachycardia, hypertension, dependence, chronic insomnia, and gastric disorders. Withdrawal from chronic abuse results in similar symptoms as seen with amphetamine addiction. 2. Methcathinone, methylmethcathinone and MDPV Methcathinone, also known as methylmethcathinone and mephadrone is a synthetic version of cathinone that was originally synthesized in 1957 in the United States, but it was rejected for production due to side effects. The formula became widely available in Russia, and by the early 1980s, methcathinone manufacturing and illicit use were widespread. It has been estimated that 20% of illicit-drug abusers in the Russian Republic use methcathinone. There has been a dramatic increase in abuse of this drug 18

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in Europe. In the US, mephadrone and another analog of cathinone, methylenedioxypyrovalerone (MDPV) was sold as synthetic cocaine or synthetic amphetamine and disguised as “bath salts” Side effects include nervousness, labored respiration, and lack of coordination. B. BETEL NUTS (p. 3.33−3.35) Specific references to betel nuts (seeds of the betel palm, Areca catechu) date back 23 centuries. The nut has been widely used in India, Pakistan, the Arab world, Taiwan, Malaysia, the Philippines, New Guinea, Polynesia, southern China, and some countries in Africa. Today anywhere from 200 million to 450 million people worldwide use betel nuts as a recreational drug and as a medication. The main active ingredient, arecoline, increases levels of epinephrine and norepinephrine. The effects of betel are similar to those of nicotine or strong coffee and include a mild euphoria, excitation, and a decrease in fatigue. The betel nut (husk and/or meat) is usually chewed in combination with another plant leaf (such as peppermint or mustard) and slaked lime. The juice of this mixture stains the teeth and the mouth dark red over time. Tissue damage to mucosal linings of the mouth and the esophagus is common. Gutkha is a commercial betel nut product, heavily marketed in India. “Betel quids” are commercially prepared betel nut product in Taiwan. C. YOHIMBE (p. 3.35) Yohimbine, a bitter spicy extract from the African yohimbe tree, can be brewed into a stimulating tea or used as a medicine. It is reported to be a mild aphrodisiac. The yohimbine in the bark is extracted and formulated into either tablets or a tincture for oral ingestion. Yohimbine has been reported to produce a mild euphoria and occasional hallucinations; in large doses it can be toxic and cause death by respiratory paralysis. D. EPHEDRA (Ephedrine) (p. 3.35) The ephedra bush (Ephedra equisetina) contains the drug ephedrine. This mild-to-moderate stimulant is used medicinally to treat asthma, narcolepsy, allergies, and low blood pressure. Extract of ephedra has been used by athletes for an extra energy boost, but overuse can lead to heart and blood vessel problems. The National Football League banned ephedrine use by players because of the potential risk of cardiovascular damage. Ephedra is sold as an herbal stimulant in a wide variety of tablets and capsules. Natural ephedra, synthetic ephedrine, and pseudoephedrine are also the main ingredients in the synthesis of methamphetamine and methcathinone. Laws are in place that reduce the importation and sale of these precursors. IX. CAFFEINE (P. 3.35) 19

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Caffeine is the most popular stimulant in the world. It is found in coffee, tea, chocolate, soft drinks, energy drinks, 60 different plants, and hundreds of OTC and prescription medications. A. HISTORY OF USE (p. 3.36−3.38) 1. Tea After water, tea is the most widely consumed beverage in the world. It was present in China as early as 2700 B.C. The tea ceremony was and still is an important ritual in Japanese homes. The Boston Tea Party in 1774 reflected the importance of this psychoactive substance in colonial life as irate Bostonians threw tea into Boston Harbor to protest a tax on tea. Today the primary exporters of tea are India, China, and Sri Lanka. Black tea comprises 75% of the world’s tea, green tea 22%. 2. Coffee Coffee was first cultivated in Ethiopia around A.D. 650. Use spread to Arabia in the thirteenth century and finally to Europe by the fifteenth century. Coffee and tea generated huge revenues. The drink was so stimulating that many cultures banned it as too intoxicating. Each coffee drinker in the U.S. consumes about 20 lbs. of coffee per year. There has been an incredible growth in the number of specialty coffeehouses. As of 2009, Starbucks® operated 16,680 stores in 49 countries. 3. Cocoa Cocoa is the product of the roasted and ground beans of the cacao tree (Theobroma cacao) it was first used in the New World by Mayan and Aztec royalty as an unsweetened drink, a spice, as food, as a stimulant, and a currency. There is a small amount of caffeine in chocolate. 4. Caffeinated Soft Drinks (colas) The average American consumed the equivalent of 780 eight-ounce glasses of soft drinks (most caffeinated) in 2009. Caffeinated soft drinks (colas) often use caffeine extracted from the process of decaffeinating coffee. Dental and obesity problems are related to the high sugar contents of soft drinks. 5. Energy Drink Phenomenon With 80 mg of caffeine, Red Bull® has more than twice the amount of caffeine in a 12 oz. Coca Cola® (35 mg) but less than half that of 8 oz. of brewed coffee (135 mg). In addition to caffeine, Red Bull® also contains taurine, ginseng, guarana, glucose or glucuronolactone, B-complex vitamins, minerals, and carbohydrates to provide a quick energy boost. Rockstar,® Blast,® Zoom,® Killer Buzz,® and Cocaine® are other brands. 20

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Some countries banned the sale of energy drinks because of cardiovascular concerns and excess dehydration. The practice of mixing alcoholic beverages with energy drinks to create a type of “speedball cocktail” is responsible for intoxication and compromised health. 6. Other Plants Containing Caffeine Other plants containing caffeine include guarana, mate, and yoco, all are found in South America. Guarana is the national drink of Brazil; maté is the most popular caffeinated drink in Argentina. B. PHARMACOLOGY (p. 3.38) Caffeine is an alkaloid of the chemical class called xanthines. Its half-life in the body is 3 to 7 hours, so it takes 15 to 35 hours before 95% of the caffeine is excreted. 20% of U.S. adults consume more than 350 mg. of caffeine per day. 3% consume more than 650 mg. daily. Caffeine Content of Various Drinks & Medications (table 3-2 p. 3.37) Brewed coffee (8 oz.) 135 mg 5-minute tea brew 60 mg Mountain Dew® 54 mg Coca-Cola® 35 mg Milk chocolate (4 oz.) 24 mg Red Bull® energy drink (8 oz) 80 mg Dexatrim® (1 capsule) 200 mg NoDoz® Max. (1 tablet) 200 mg U.S. per-capita consumption of caffeine is 211 mg per day (about two cups of regular coffee plus a cola); in Sweden its 425 mg and in the United Kingdom, 445 mg. In the U.S. Tea is responsible for 17% of the per-capita daily consumption of caffeine, 16% soft drinks, and 60% coffee. C. PHYSICAL &MENTAL EFFECTS (p. 3.39) Medically, caffeine is used as a bronchodilator in asthma patients. It can counteract a sudden drop in blood pressure and is found in a number of OTC preparations. Nonmedically, caffeine is a mild stimulant. In low doses (100 up to 300 mg), it can increase alertness, dissipate drowsiness or fatigue, and facilitate thinking. It releases the brain’s stimulants and inhibits adenosine. At doses of more than 350 mg (3 to 4 cups of coffee) per day, anxiety, insomnia, gastric irritation, high blood pressure, nervousness, and flushed face can occur. Caffeine is lethal at about 10 grams (100 cups of coffee). People who are prone to panic attacks should avoid caffeine. Coronary heart disease, ischemic heart disease, heart attacks, intestinal ulcers, diabetes, and some liver problems are occasionally seen in longterm, high-dose caffeine users. 21

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D. TOLERANCE, WITHDRAWAL &ADDICTION (p. 3.41) Tolerance to the effects of caffeine does occur. PET scans of habitual coffee drinkers indicated a need to drink coffee to activate their brain to a normal state. Withdrawal symptoms appear in 12 to 24 hours, peak in 24 to 48 hours, and last two to seven days. The most common withdrawal symptom is a throbbing headache. Lethargy, depression, decreased alertness, sleep disturbances and irritability are other symptoms. Dependence can occur with daily intake levels of 500 mg. (about 5 coffees or 10 colas) or more. Coffee creates a milder dependency than do amphetamines or cocaine. X. NICOTINE (PP. 3.41− −3.55) Although the number of smokers in the U.S. has been on the decline in recent years, about 22% of Americans are regular smokers. Rates of regular tobacco use in other countries are higher. Hospitals estimate that 15% to 40% of patients have tobacco-related diseases. A. HISTORY (p. 3.41) 1. American Indians & Tobacco Tobacco was venerated as a sacred; it was used in spiritual and health rituals in ancient Mesoamerica. The use of tobacco didn’t reach Europe and Asia until the late 1400s when it was introduced by Columbus and other explorers. Europeans used it for recreation and as a medicine. Smoking tobacco in a pipe several times a day was the most common form of use in early America, but in the eighteenth century chewing tobacco and snuff became popular until the end of World War I. 2. Growth of Cigarette Smoking The technical and social developments that increased the use of tobacco included: • the cigarette rolling machine • a milder strain of tobacco • lower prices • aggressive advertising and marketing • freebase nicotine (a more addictive form of the chemical) Today, the average heavy smoker in the U.S. smokes 20 to 40 cigarettes per day, or more than 10,000 per year. In 2008 • 36.9 million Americans smoked cigarettes every day • 13.1 million smoked cigars, 1.88 million smoked pipes • 8.67 million used smokeless tobacco. 22

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3. Smokeless Tobacco Moist snuff, the most popular form of smokeless tobacco in America, is finely chopped tobacco that is placed in the mouth next to the gums. Gutka, a form of moist snuff popular in India, consists of betel nuts, betel leaves, tobacco paste, clove oil, glycerin, spearmint, menthol, and camphor. Powder snuff (dry snuff) is a fine powder that is most often gently inhaled or rubbed on the gums. Loose-leaf tobacco is stuffed into the mouth and chewed to release the nicotine-laden juice. New smokeless tobacco products were introduced in the mid 2000s featured tobacco in pouches, and nicotine Strips, Orbs and Sticks. These products were developed as a socially acceptable alternative to smoking. Some believe they were developed to capture young people’s interest in using tobacco products. B. PHARMACOLOGY (p. 3.43) 1. Nicotine Nicotine, a central nervous system stimulant, disrupts the balance of endorphins, epinephrine, dopamine, and acetylcholine. Acetylcholine affects heart rate, blood pressure, memory, learning, reflexes, aggression, sleep, sexual activity, and mental acuity. The release of dopamine makes a smoker feel satisfied and calm thus resulting in tranquilizing as well as stimulating effects. The average tobacco leaf contains 2% to 5% nicotine, the principle ingredient responsible for cardiovascular and psychoactive effects. Smoking delivers nicotine to the brain in 5 to 8 seconds; chewing tobacco or snuff in 3 to 8 minutes. The average cigarette contains 10 mg of nicotine but delivers only 1 to 3 mg of that to the lungs due to side stream smoke. Smoking accounts for 90% of all tobacco use in the U.S. In India chewing tobacco is more popular (85% of all men) 2. Freebase Nicotine Internal tobacco industry memos discovered in the 1990s provided evidence of an awareness of the addictive quality of nicotine which was referred to as its “impact” on users. The memos released by the Tobacco Settlement Act of 1999 revealed that cigarette manufactures began adding ammonia compounds to tobacco in cigarettes as early as the 1960s. The compounds altered the nicotine released into a freebase form of the molecule which made tobacco more addictive in much the same way altering cocaine to freebase cocaine increases its addictive potential. Manufacturers could decrease the nicotine content of their products while making them more addictive. In 2009 the FDA was granted authority to regulate tobacco for the first time in history. 3. Other Reasons for Continued Use

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Social context, ritual aspects of lighting up, perception of smoking as an adult activity • Desire to manipulate mood • Rebellion • Perception that smoking is sexually attractive • Craving and addiction The two most common reasons are weight control and self medication for depression. Weight Controll. Nicotine suppresses appetite and increases metabolism. On average, smokers weigh 6 to 9 lbs. less than nonsmokers. Fear of regaining weight prevents many smokers from quitting. Self-Medication. Major depression occurs twice as often in smokers than in non-smokers. Smokers who have experienced at least one episode of major depression are 50% less likely to quit than those who exhibit no major depression. •

C. TOLERANCE, WITHDRAWAL &ADDICTION (p. 3.45−3.47) 1. Tolerance Physiological adaptation to the initial effects of nicotine develops quite rapidly. A few hours of smoking are sufficient for the body to begin learning how to handle these new toxins. Tolerance does not continue to build as it does with other stimulants. 2. Withdrawal Withdrawal from a one or two pack-a-day habit can cause headaches, nervousness, fatigue, hunger, severe irritability, poor concentration, depression, increased appetite, sleep disturbances, and intense nicotine craving. The severity of these symptoms, particularly craving, is the main cause of relapse. A true physiologic dependence or tissue dependence develops through increased acetylcholine nicotinic receptors resulting in withdrawal when nicotine levels drop in brain. A smoker smokes to avoid unpleasant withdrawal symptoms. This process is known as negative drug reinforcement. The sense of relaxation and well-being that most smokers receive from a cigarette is, in fact, the sensation of the withdrawal symptoms being subdued. Smokers try to maintain a constant level of nicotine in the bloodstream and the brain. 3. Addiction Studies show that in the U.S. 25% of those who try a cigarette become daily habitual users. Only 1/10 of those who try alcohol become daily abusers. 80% of smokers say they want to quit, and another 10% want to limit the amount they smoke. Nicotine provides much less pleasure than other addictive drugs but significantly more people who try nicotine (compared to other drugs) become daily abusers. In many countries the 24

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rate of daily use is higher: 50% in China, 40% in England, and 50% in Japan. Globally, 12% of women and 47% of men smoke. Craving is a “self-determined nicotine state of consciousness” or “state dependence.” State dependence describes a person’s desire to achieve a certain mental and physical state that may be neither pleasurable nor objectionable but it is a state with which they are familiar and therefore comfortable. Teen surveys have found that an adolescent smoker is 3 times more likely to also abuse alcohol, 8 times more likely to abuse marijuana, and 22 times more likely to abuse cocaine. Studies indicate that outcomes from drug addiction treatment are more positive when tobacco cessation is included in the overall treatment strategy. D. AGE OF FIRST USE (p. 3.47) The age of first use of any addictive substance is the most significant indicator that an individual will become habituated to that substance in adulthood. Those who began tobacco or other addictive drug use at age 8 to 12 are five times more likely to become an addict that those who began use at age 18 or 19. Those who delay their first use until after 19 are 18 times less likely to develop an addiction. Prevention should be targeted at delaying first use as long as possible. E. EPIDEMIOLOGY (p. 3.47) In 2009, 170 million Americans (over half of the U.S. population) had tried tobacco at some time in their lives and 60 million had used in the past 30 days. Most of were cigarette smokers but 8.7 million were smokeless tobacco users. Use of smokeless tobacco has declined in twelfth-graders from 12.2% in 1995 to 8.4% in 2009. The incidence of tobacco use is highest among American Indians or Native Alaskans (47.7%) and lowest in Asian Americans 2.7%. Among Blacks, 27.8%, Whites 26.6%, and Hispanic or Latino Americans (21.1%) use tobacco. F. SIDE EFFECTS (p. 3.47−3.50) Tobacco contains 4,000 to 4,800 chemicals; 400 are toxins, and 69 are known cancer-causing substances (e.g. cadmium, hydrogen cyanide, and arsenic). Cigarette smoke contains fine particles of carcinogenic tar and nitrosamines. In 2000, tobacco smoking was estimated to have caused 5.4 million premature deaths worldwide, 392,000 in the U.S. alone. Most of these deaths are from lung cancer, heart disease, and lung disease. Another 50,000 U.S. nonsmokers die from secondhand smoke. About 8.6 million U.S. residents have at least one serious illness caused by smoking. For every smoking-related death, 20 more live a lower quality of life. The health–related economic losses in the U.S. due to smoking cost $193 billion every year. 25

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1. Longevity In the U.S. adult smokers lose an average of 14 years of life from smoking. U.S. premature deaths caused by smoking and secondhand smoke totaled 443,000 in 2008. A British study found that smoking shortened a life by an average of 10 years. 2. Cardiovascular Effects Smoking accelerates plaque formation and hardening of the arteries, the major cause of heart attacks. In 2008 in the United States, one-third of the 442,000 deaths from smoking-related illnesses were due to cardiovascular disease. Worldwide 11% of all cardiovascular deaths are due to smoking. A 2009 report showed that limiting secondhand smoke in the U.S. cut the incidence of heart attacks by 5% to 47%. 3. Respiratory Effects Cigarette smokers have a high rate of bronchopulmonary disease, such as emphysema, chronic bronchitis, and chronic obstructive pulmonary disease (COPD). Approximately 80% to 90% of COPD deaths (from emphysema and chronic bronchitis) are due to smoking. 4. Cancer Men who smoke are 22 times more likely to develop lung cancer than men who don’t; women who smoke are 12 times more likely. Approximately 85% of men with lung cancer and 75% of women with lung cancer smoke. The most likely culprits are the tars and other byproducts of combustion that a smoker inhales. Pipe and cigar smokers are more likely to get cancers of the larynx, mouth, and esophagus in addition to lung cancer. 5. Smokeless-Tobacco Effects The effects of chewing are almost identical to the effects of smoking, including a slight increase in energy, alertness, blood pressure, and heart rate. One health advantage of smokeless tobacco over cigarettes is the lack of lung involvement; however, smokeless tobacco delivers more nicotine into the body than smoking cigarettes. Smokeless tobacco irritates the tissues of the mouth and the digestive tract. Gums can become inflamed, causing dental problems and the risks of oral, pharyngeal, and esophageal cancers are increased. Users have a 50% higher risk factor for developing cheek and gum cancer than nonusers. Cardiovascular problems are just as severe with smokeless tobacco. 6. Fetal Effects If a woman smokes during pregnancy less oxygen is available for her fetus which contributes to a lower than average birth weight and a higher 26

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incidence of crib death (SIDS). Pregnant smokers are also twice as likely to miscarry and have spontaneous abortions as nonsmokers. G. BENEFITS FROM QUITTING (pp. 3.50−3.51) • Within 20 minutes of quitting blood pressure, pulse rate, and the temperature of hands and feet drop to normal levels. • Within 8 hours, carbon monoxide levels drop and oxygen levels increase to normal • Within 24 hours, the risk of a sudden heart attack decreases. • Within 1 week the risk of heart attack decreases, breathing improves and blood vessels began to relax. • Within 2 to 12 weeks, circulation improves, lung function increases up to 30%, and the complexion improves • Within 5 years, the heart disease death rate returns to that for a nonsmoker and the lung cancer death rate decreases 50%. • Within 10 to 15 years, the risk of all major diseases caused by smoking decreases to nearly that of someone who never smoked.

H. TREATMENT FOR TOBACCO ADDICTION (p. 3.51) Medications approved to suppress cravings for nicotine during cessation include varenicline (Chantix®) and bupropion (Zyban®). These have been shown to have initial success rates of 44% and 30.5% respectively when used along with counseling. The other medical treatment consists of nicotine replacement products to prevent cravings and shift use of nicotine into non-smoking exposures. These include nicotine patches, inhalers, gums, nasal sprays, and lozenges. I. THE TOBACCO INDUSTRY &TOBACCO ADVERTISING (pp. 3.51−3.54) 1. The Business of Tobacco In 2008 U.S. cigarette sales were at their lowest point in 58 years, about 16 billion packs. As American sales declined tobacco companies shifted their focus to increasing sales overseas, producing cheap generic brands, smokeless tobacco products, and adding more nicotine per cigarette. These efforts raised the number of tobacco users worldwide to 1.3 billion. Three companies control almost 90% of the U.S. market. The Altria Group (Marlboro®, Virginia Slims®, and Basic®) captures 49.2% of all tobacco sales. After higher taxes made cigarettes more expensive, the tobacco industry responded by adding flavorings and marketing cheaper generic products aimed at younger smokers. Hand-rolled, flavored bidi cigarettes from India contain three times the nicotine content of American cigarettes.

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Electronic cigarettes heat a nicotine solution in a cigarette-shaped device into vapor thus avoiding combustion and smoke. These are alleged to be safer than smoking but no research confirms this allegation. 2. Advertising Tobacco advertising, including premiums, promotional allowances to retailers, and other expenditures, exceeds $13 billion a year, about $290 for every adult smoker. In 2008 the top cigarette brands and their share of their market were Marlboro,® 41%; Newport,® 9.7%, Camel, ® 6.7%, Doral,® 3.8%, Basic,® 3.5%, and Winston,® 3.2%. White and Hispanic smokers prefer Marlboro® (42% and 60%) over Newport® (16.5% and 18.6%). Black smokers prefer Newport® (44%) over Marlboro® (8.1%). Studies show that teen smoking is more addictive to the user than starting during adulthood. Comprehensive bans on all tobacco advertising in other nations have had a significant effect on reducing tobacco consumption. 3. Laws & Lawsuits Lawsuits on behalf of dead or living smokers with cancer are expanding and many are successful. In 2010 every state had laws regarding smoking in public spaces and buildings. The major tobacco companies agreed to pay states $246 billion in settlements to help pay for the medical costs of tobacco-induced illnesses and to finance smoking-prevention campaigns. Many state governments redirected the funds allocated for antismoking campaigns. The Family Smoking Prevention and Tobacco Control Act of 2009 prohibit adding anything to tobacco or smoke that would result in a characterizing flavor. This is to prevent children and teens from trying tobacco products at a young age. Menthol was exempted from the bill. 4. Secondhand Smoke The battle over secondhand smoke began in the 1990s. It is estimated that one person dies from secondhand smoke (usually from cardiovascular disease) for every eight-smoker deaths. This represents 40,000 to 50,000 deaths each year. Side stream smoke from a smoldering cigarette contains up to 4 times the amount of toxins found in smoke directly inhaled through a filtered or nonfiltered cigarette.

J. THE 2004 & 2006 SURGEON GENERAL’S REPORT ON HEALTH CONSEQUENCES OF SMOKING (p. 3.54−3.55) Since the first Surgeon General’s Report in the 1960s, the number of U.S. smokers has diminished by half and men’s cancer deaths have declined. The report reiterates, however, that smoking remains the leading preventable cause of disease and premature death in the United States. Smoking is shown to harm every organ of the body. The report determined that the lack of progress in tobacco control is attributable 28

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more to the failure to implement proven strategies than to a lack of knowledge about what to do. XI. CONCLUSIONS (P. 3.55) Compare the use of stimulants to gain energy and confidence with natural methods, where energy supplies are replenished through sleep, relaxation, exercise, nutrition, and a healthy lifestyle. Natural methods create energy supplies before they are needed and provide for replenishment. Chemical methods drain the body causing it to shut down to recover and allow tolerance and psychological dependence to develop. The resulting excess use damages neurochemistry and most body systems.

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Chapter 3 - UPPERS Classroom or Small Group Discussion Topics 1. Considering the serious health risks associated with powerful stimulants, like cocaine and amphetamines, what would make a person use? Are the negative side effects simply discounted or could they believe the feelings they get from using will outweigh the dangers? 2. Identify the social and political factors that contributed to the cocaine and crack epidemic in the 1980’s? 3. Identify the physical/medical/behavioral signs and symptoms indicating a person is under the influence of each of the following drugs: • cocaine • amphetamines • nicotine • caffeine What are some behavioral and physical signs and symptoms indicating a person is dependent on each of the following drugs? • cocaine • amphetamine • nicotine • caffeine 4. Create a grid (example below) with three columns. Ask students to identify a stimulant drug for each column (legal/licit or illegal/illicit) and provide information and explain the differences between the effects, consequences and patterns of use for substances in each category. In what ways is the information in each column similar or different? Legal/Licit Stimulant Illegal/Illicit Stimulant Psychological Effects Physical Effects Legal Consequences Social Consequences Patterns of Use Patterns of Abuse

5. Discuss the cyclical patterns of popular substances of abuse. Provide the students with a timeframe of stimulant drug epidemics from 1970 to present day. • Since 1970 when has cocaine use has been at epidemic levels? Note specific trends for powder cocaine and crack cocaine.

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When has amphetamine use been at epidemic levels? Note specific trends for various types of amphetamines including “speed”, methamphetamine, Adderall, Ritalin, etc. • Give examples of generational amnesia (forgetting the severe problems associated with widespread drug use). 6. Discuss the use of plant based stimulant drugs in cultures around the world. • Where and how is Catha edulis (Khat/Quat/Ghat) used and how do the societies that use it structure their day around this plant based stimulant? • Where and how are betel nuts used and how does it fit within the cultures and societies that use it? • Where and how is unrefined coca leaf used and how does it fit within the cultures and societies that use it? • Discuss ways mild plant based stimulant use might be similar to or different from the use of coffee or colas in the U.S. 7. Discuss how the expansion of amphetamine use can affect a community (e.g., crime, environmental pollution, and violence). 8. Ask the students to discuss ways smokers who are concerned about the health hazards of smoking could reduce the harm of smoking to themselves and to those around them. Is quitting the only solution? •

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Chapter 3 - UPPERS Critical Thinking & Class Exercises 1.

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Provide students with materials to build a model or illustrate how cocaine affects neurotransmitters in the brain (e.g., markers and paper, to make drawings, or marbles and glue, clay etc for an assemblage). Show how the use of amphetamines initially stimulates an individual but ultimately results in decreased energy. Break into small groups and discuss the repercussions of “synthetic cocaine and amphetamine” sold in head shops and online as plant food and bath salts. Referencing specific ads or marketing campaigns, ask students to analyze how audiences are targeted to sell cigarettes, energy drinks, and coffee through the use of language, graphic imagery, emotional overtones, implied promises, product endorsements, etc. Have students discuss how various cultures have developed in relation to the types of stimulant drugs (licit or illicit) readily available, e.g. khat in Somalia, cocaine in Columbia, coffee and tobacco in the United States. Collect ads for energy drinks and evaluate whether or not the copy used to describe the benefits of an energy drink could be used to advertise amphetamines or another stimulant. Log on to the Phillip Morris web site http://www.philipmorrisusa.com/en/health_issues/default.asp Read their information on the health consequences of smoking. Is this a sincere effort or a strategy to avoid further litigation and legal restrictions on their product? How does cigarette marketing differ in other countries? Their international web site: http://www.pmi.com/eng/our_products/pages/our_brands.aspx http://www.pmi.com/eng/tobacco_regulation/pages/tobacco_regulatio n.aspx Review the recent legislation that exempts menthol from the Family Smoking Prevention and Tobacco Control Act of 2009. Explore the different points of view including the issue of the disproportionate use of menthol cigarettes by African Americans. Why does secondhand smoke through side-stream smoke exposure contain four times more toxins than directly inhaled mainstream smoke?. Should smoking cigarettes, E-Cigarettes, cigars, and pipes be completely banned from all public places? Why? Why not?

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Uppers, Downers, All Arounders, 7th Edition - Instructors Manual Chapter 4 – DOWNERS: OPIATES/OPIOIDS & SEDATIVE-HYPNOTICS Chapter Overview The three major classes of downers (depressants), include opiates/opioids, sedative-hypnotics, and alcohol. The four minor classes are skeletal muscle relaxants, antihistamines, over-thecounter depressants, and look-alike depressants. OPIATES/OPIOIDS Desired effects include pain relief, sedation, anxiety control, muscle relaxation, suppression of inhibitions, and drowsiness. Undesired effects include depressed respiration, slowed heart rate, constipation, and slurred speech. When grossly misused the drugs’ effects can include unconsciousness, coma, and death. Opiates/opioids work by either inhibiting pain or stimulatory neurotransmitters or by mimicking the body’s natural sedating neurotransmitters. A prescription drug epidemic of depressant drugs (opioid painkillers and benzodiazepine sedatives) that begin in the 2000s is responsible for an increase in diversion, overdoses, and addiction. This chapter surveys the different types of opiates and opioids (e.g., heroin, codeine, morphine, methadone, buprenorphine, fentanyl, Vicodin® and OxyContin®), history, effects, side effects, and addictive qualities. SEDATIVE HYPNOTICS The sedative-hypnotics covered in this chapter include benzodiazepines, barbiturates, GHB, and z-hypnotics, their effects, side effects, drug interactions, synergism, addictive qualities, cross-dependence, and cross-tolerance. Alcohol is covered in Chapter 5. OTHER PROBLEMS WITH DEPRESSANTS Other problems with depressants include drug interactions, misuse, and diversion. The chapter also covers prescription drugs, over-the-counter medications and the pharmaceutical industry’s role in the depressant prescription drug epidemic and our prescription drug-dependent society.

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Chapter 4 - DOWNERS: OPIATES/OPIOIDS& SEDATIVE-HYPNOTICS Chapter Outline GENERAL CLASSIFICATION I. MAJOR DEPRESSANTS A. OPIATES/OPIOIDS B. SEDATIVE-HYPNOTICS C. ALCOHOL (see Chapter 5) II. MINOR DEPRESSANTS A. SKELETAL MUSCLE RELAXANTS B. ANTIHISTAMINES C. OVER-THE-COUNTER DOWNERS D. LOOKALIKE DOWNERS III. PRESCRIPTION DRUG EPIDEMIC OPIATES/OPIOIDS IV. INTRODUCTION V. CLASSIFICATION A. OPIUM, OPIATES, & OPIOIDS VI. HISTORY OF USE (see Chapter 1) A. ORAL INGESTION B. SMOKING C. REFINEMENT OF MORPHINE, CODEINE, & HEROIN D. INJECTION USE E. PATENT MEDICINES F. SNORTING G. TWENTIETH CENTURY H. HEROIN - A WORLD VIEW 1. Mexican Heroin & Mexican Cartel VII. EFFECTS OF OPIOIDS A. PAIN & PLEASURE 1. Opioids & Receptor Sites 2. Pain 3. Pleasure B. FROM PLEASURE TO PAIN C. COUGH SUPPRESSION & DIARRHEA CONTROL

VIII. SIDE EFFECTS OF OPIOIDS A. PHYSICAL SIDE EFFECTS

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B. TOLERANCE, TISSUE DEPENDENCE, WITHDRAWAL 1. Tolerance 2. Tissue Dependence 3. Withdrawal IX. ADDITIONAL PROBLEMS WITH HEROIN & OTHER OPIOIDS A. NEONATAL EFFECTS B. OVERDOSE C. DIRTY & SHARED NEEDLES 1. Hepatitis C & HIV 2. Abscesses & Other Infections D. DILUTION & ADULTERATION E. COST F. POLYDRUG USE X. FROM EXPERIMENTATION TO ADDICTION 1. The Vietnam Experience 2. The Iraqi/Afghani Experience 3. The Russian Experience XI. PAIN CONTROL & SPECIFIC OPIOIDS A. THERAPEUTIC PAIN CONTROL B. MORPHINE C. CODEINE D. HYDROCODONE (Vicodin,® Hycodan,® Tussend,® Norco®) E. OXYCODONE (OxyContin,® Percodan®) F. METHADONE (Dolophine®) G. BUPRENORPHINE (Buprenex,® Suboxone®) Subutex,® H. FENTANYL I. HYDROMORPHONE (Dilaudid®) J. MEPERIDINE (Demerol,® Pethidine®) K. PENTAZOCINE (Talwin NX®) L. PROPOXYPHENE (Darvon,® Darvocet,® &

M. LAAM® (l-alpha acetylmethadol) N. NALOXONE (Narcan®) P. CLONIDINE (Catapres®) Q. BUTORPHANOL (Stadol) & TRAMADOL (Ultram®)

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R. ULTRARAPID OPIOID DETOXIFICATION S. KRATOM SEDATIVE-HYPNOTICS XII. CLASSIFICATION XIII. HISTORY XIV. USE, MISUSE, ABUSE, & ADDICTION XV. BENZODIAZEPINES A. MEDICAL USE OF BENZODIAZEPINES B. NONMEDICAL USE OF BENZODIAZEPINES C. NEUROCHEMISTRY & GABA D. TOLERANCE, TISSUE DEPENDENCE, & WITHDRAWAL 1. Tolerance 2. Tissue Dependence 3. Withdrawal 4. Overdose F. MEMORY IMPAIRMENT

XVI. BARBITURATES A. EFFECTS B. TOLERANCE, TISSUE DEPENDENCE & WITHDRAWAL

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XVII. OTHER SEDATIVE-HYPNOTICS A. PREGABALIN (Lyrica®) B. RAMELTEON (Rozerem) C. ESZEPLONE (Lunesta®) D, ZALEPLON (Sonata,®), ZOPLICLONE (Imovane®) & ZOLPIDEM (Ambien®) E. BUSPIRONE (BuSpar®) F. ETHCHLOVYNOL (Placidyl®) G. GHB (gamma hydroxybutyrate) H. GBL (gamma butyrolactone or 2[3H]furanone dihydro) & BD (1,3 butanediol) I. METHAQUALONE (Quaalude,® Mandrax®) J. QUETIAPINE (Seroquel®) OTHER PROBLEMS WITH DEPRESSANTS XVIII. DRUG INTERACTIONS A. SYNERGISM B. CROSS-TOLERANCE & CROSSDEPENDENCE XIX. PRESCRIPTION DRUGS & THE PHARMACEUTICAL INDUSTRY A. RESEARCH/DEVELOPMENT & MARKETING

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Chapter 4 - DOWNERS: OPIATES/OPIOIDS& SEDATIVE-HYPNOTICS Extended Outline −4.5) GENERAL CLASSIFICATION (PP. 4.2− The abuse of prescription painkillers such as hydrocodone and oxycodone, along with prescription sedative hypnotics are widespread. Downers (depressants) depress the overall functioning of the central nervous system to induce sedation, muscle relaxation, drowsiness, and if used to excess - coma. Some downers also induce a rush or high and often cause disinhibition of impulses and emotions. I. MAJOR DEPRESSANTS (P. 4.3) A. OPIATES/OPIOIDS (p. 4.3) These are refinements and synthetic versions of the active ingredients in the opium poppy, e.g., opium, morphine, codeine, hydrocodone (Vicodin®), oxycodone (OxyContin®), methadone, and heroin. They were developed for the treatment of acute pain, diarrhea, coughs, and a number of other illnesses. B. SEDATIVE-HYPNOTICS (p. 4.3) Sedative-hypnotics include a wide range of synthetic chemical substances developed to treat anxiety and insomnia. Barbiturates were the standard for years, but now benzodiazepines and most recently Zhypnotics are the most widely prescribed and often abused. C. ALCOHOL (p. 4.3) Alcohol, the natural by-product of fermented plant sugars or starches, is the oldest psychoactive drug in the world. It is often used in combination with other downers, especially opioids and sedative hypnotics. II. MINOR DEPRESSANTS (p. 4.3− −4.4) A. SKELETAL MUSCLE RELAXANTS (p. 4.3) Centrally acting skeletal muscle relaxants are synthetic CNS depressants aimed at areas of the brain responsible for muscle coordination and activity. They are used to treat muscle spasms and pain. Recently, carisoprodol (Soma®) has been detected in the drug-screening urine tests of a number of addicts, often in combination with other drugs, particularly benzodiazepines. In San Francisco it is used as a recreational drug of abuse by young Asian Americans resulting in hundreds of overdoses and dozens of deaths. These are usually due to combining drugs, either another depressant such as alcohol or a stimulant to get a "speedball effect."

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B. ANTIHISTAMINES (pp. 4.3− −4.4) Antihistamines, found in hundreds of prescription and OTC cold and allergy medicines (including Benadryl,® Actifed,® and Tylenol P.M. Extra®), are synthetic drugs that were first developed during the 1930s and 1940s to treat allergic reactions. Antihistamines are occasionally abused for their depressant effects. C. OVER-THE-COUNTER DOWNERS (p. 4.3) These include nonprescription depressants, such as Nytol,® Sleep-Eze,® and Sominex®. D. LOOK-ALIKE DOWNERS (p. 4.4) In the early 80s unscrupulous drug manufacturers sold products that looked like prescription downers. These companies took legally available antihistamines and packaged them in tablets that resembled Quaalude,® Valium,® Seconal,® etc. They are rarely available today, but are still advertised in a few magazine ads. III. PRESCRIPTION DRUG EPIDEMIC (PP. 4.4− −4.5) Many prescription drug users are hospitalized or die of prescription drug overdose; celebrities are not immune, e.g., Michael Jackson, Heath Ledger, and Anna Nicole Smith. Over 3 billion prescriptions are filled each year for legal drugs. The consequences of misuse can be as deadly as any street drug. Almost two-thirds of prescription drug abusers receive them from friends or relatives, 17% from physicians and 4.3% from street dealers. Other ways to obtain prescription drugs include diversion, forgery and theft. Males 18 to 25 are most likely to abuse opioid analgesics. Others demographics prefer sedative-hypnotics such as the benzodiazepines or the newer Z-hypnotics like Ambien.® Abuse of prescription drugs produces toxic effects, adverse drug reactions, and other negative physical and emotional consequences. OPIATES/OPIOIDS (PP. 4.5-4.29) IV. INTRODUCTION (PP. 4.5− −4.6) Opiates/opioids are one of the oldest and best-documented groups of drugs and are the principal drugs used to treat pain, diarrhea, and coughs. A debate continues over the use of opioids to control pain because they have a high addiction liability. The discovery in the 1070s of the body’s own natural painkillers— endorphins and enkephalins—significantly changed our understanding of this class of drugs. V. CLASSIFICATION (PP. 4.6− −4.7)

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A. OPIUM, OPIATES & OPIOIDS (p. 163) Opioids are fully synthetic versions of opiates which come from opium, the milky fluid contained in unripe seedpod of the opium poppy plant (Papaver somniferum). There are more than 25 known alkaloids in opium, but the two most prevalent are morphine (10% to 20% of the milky fluid) and codeine (0.7% to 2.5%). • Opiates include opium, morphine, codeine, and thebaine. • The semisynthetic opiates include heroin, hydrocodone (Vicodin®), oxycodone (OxyContin®), and hydromorphone (Dilaudid®). • Fully synthetic opiate-like drugs include meperidine (Demerol®), methadone, and propoxyphene (Darvon®). • Synthetic opioid antagonists (naloxone and naltrexone) block the effects of opiates and opioids. VI. HISTORY OF USE (PP. 4.7− −4.12) The first cultivation of opium poppies occurred in ancient Mesopotamia, Egypt, and Greece around 3400 B.C. and spread eastward to Asia. Ancient civilizations used it as a cure-all, a pleasure-inducing substance, and a poison. Over the centuries, experimentation with different methods of use, development of new refinements of the drug, synthesis of molecules that act like the natural opiates, and time-release versions of the drugs have slowly increased the benefits of these substances as well as their potential for abuse. A. ORAL INGESTION (p. 4.8) Opium, from the Greek word opòs, meaning “juice” or “sap,” was originally chewed, eaten, or blended in various liquids and swallowed. The abuse potential of opium was relatively low due to its bitter taste, low concentration of active ingredients, and limited supply. When taken orally, it reaches the brain in 20 -30 minutes. In ancient writings opium is listed as an ingredient in more than 700 remedies. Other opiate medicines over the centuries included theriac, laudanum, and paregoric. B. SMOKING (p. 4.8) In the sixteenth century, the introduction of smoking opium in a pipe (from North America to Europe and by Portuguese traders to Asia) set the stage for the widespread nonmedical use. Vaporized opium reaches the brain in 7 to 10 seconds and produces a stronger sense of euphoria than oral ingesting. China banned the practice in the 1700s but the British were unwilling to stop the opium trade which led to the Opium Wars. Britain and other Western countries prevailed, won trade concessions; and China ceded control of Hong Kong to Britain.

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Opium smoking was introduced to the United States by some of the 70,000 Chinese workers who built the railroads. In the twentieth century, heroin smoking gained in popularity.

−4.9) C. REFINEMENT OF MORPHINE, CODEINE & HEROIN (pp. 4.8− • In 1805, morphine was isolated from opium. It is10 times as strong • In 1832, codeine, the other major component of opium, was isolated. • In 1874, heroin (diacetylmorphine) was refined from morphine. Heroin crosses the blood/brain barrier more rapidly than morphine. The rush (and the subsequent euphoria) comes on more quickly and is more addicting. D. INJECTION USE (p. 4.9) The development of the hypodermic needle in 1853, enable high doses of the drug to be injected directly into the bloodstream. It takes 15 to 30 seconds to affect the central nervous system. Injection under the skin or in a muscle delays effects by five to eight minutes. When injected intravenously an intense rush occurs making addiction more likely. E. PATENT MEDICINES (pp. 4.9− −4.10) During the 1800s opiates were so popular that hundreds of tonics and medications containing the drug became available. Working-class adults used opium-laced mixtures to ease their aches and pains. Members of the upper class, especially women, were prescribed excessive amounts by their physicians, which often led to addiction (iatrogenic addiction). The use of opioids for pleasure also came into vogue as the number of opium parlors, doctors willing to prescribe for flimsily reasons, and new opiate mixtures increased. F. SNORTING (p. 4.10) It takes five to eight minutes for the drug to enter the nasal capillaries and reach the central nervous system and 10 to 15 minutes for peak effects to occur. More than half of all heroin addicts entering treatment began their use by insufflations (snorting). Opioid pills can be crushed and snorted. G. TWENTIETH CENTURY (p. 4.10) Casual nonmedical use of opiates was declared illegal at the beginning of the twentieth century by the United States through the Pure Food and Drug Act in 1906 and the Harrison Narcotics Act in 1914. The gradual proliferation of laws also increased the prison population even though opioid addiction was considered a medical problem in the early 1900s and was treated by physicians. Legal restrictions limited supplies and made opium and heroin valuable commodities. Growing, processing, and distributing heroin became a

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major source of revenue for criminal organizations worldwide. Diversion of legal prescription opiates/opioids, through theft, forged prescriptions, and easy Internet accessibility has created an expanding illegal market of prescription opioids. Currently, an estimated 4.7 million Americans use prescription opiates/opioids illicitly every month compared with 136,000 to 800,000 heroin abusers. H. HEROIN: A WORLD VIEW (pp. 4.11− −4.12) There are 5 to 10 million regular heroin users worldwide. The United States consumes approximately 3% of the world’s heroin supply. Afghanistan grows over 90% of the world’s opium supply; most is used in Europe and Asia. Opium supports most of the Taliban counterinsurgency in Afghanistan. The Golden Triangle (Myanmar, Thailand, and Laos) is the other significant grower of illicit opium. Most heroin in the United States comes from Mexico and Colombia. Since the 1940s, Mexico has been a major supplier. Drug wars are devastating Mexico and challenging the Mexican government’s efforts to wipe out the drug gangs. Since the 1980s “tar” or “black tar” heroin from Mexico has taken over a large part of the western U.S. market. In the early 1990s, a number of Colombian cocaine cartels diversified and started to grow and distribute opium/heroin (in addition to coca). VII. EFFECTS OF OPIOIDS (PP. 4.12− −4.15) Medically, physicians most often prescribe opioids to: • deaden pain, • suppress cough, • control diarrhea. Nonmedically, users self-prescribe opioids to: • drown out emotional pain, • get a rush, • induce euphoria, and • prevent withdrawal symptoms. −4.14) A. PAIN & PLEASURE (pp. 4.12− 1. Opioids & Receptor Sites Humans have many natural (endogenous) opioids, particularly endorphins, enkephalins, and dynorphins which produce effects similar to those from opioid drugs. They both affect pain and pleasure at receptor sited on the dendrites of adjoining nerve cells. 2. Pain

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Pain is a warning signal that damage has occurred. The pain message is transmitted from nerve cell to nerve cell by a neurotransmitter called substance P. If the pain is too intense the body releases its own painkillers (endorphins and enkephalins) to block pain transmission. Natural opioid receptor sites for the body’s own endorphins and enkephalins help block pain. The main receptors are µ (mu), κ (kappa), δ (sigma), and nociceptin. Opioid medications relieve unbearable pain because they act like the body’s endogenous (naturally occurring) painkillers (endorphins and enkephalins) and slot into the same receptor sites; causing more-intense reactions. Mental pain such as fear and anxiety is also subdued. Even though all opioids relieve pain, small alterations in the molecular structure can produce dramatic differences in the strength, duration, and side effects. 3. Pleasure The other major effect of opioids involves endorphins and dopamine and their effect on the reward/control pathway. The normal activation of this system produces a surge of pleasure that encourages repeating the action, such as eating or having sex. Dopamine released in this pathway helps the brain remember the details of the action so it can be repeated in the future. Some people try opioids in search of a high or to relieve pain because the drugs activate the reward/control pathway. Of the various opioids, heroin has the strongest effect on the reward/control pathway. Normally, natural endorphins and enkephalins activate the stop signal/switch when the need is filled (the body has had enough to eat, it is relaxed after sex, etc. ). Powerful psychoactive drugs like heroin disrupt this cutoff or stop switch (fasciculus retroflexus and habenula), the individual continues the behavior or activity which serves to reinforce the desire to continue. B. FROM PLEASURE TO PAIN (4.14− −4.15) The same area of the brain that signals pleasure/reward also signals alleviation of pain. Drug abusers will keep using past the point of pain relief searching for a high or simply because they are unable to stop. C. COUGH SUPPRESSION & DIARRHEA CONTROL (p. 4.15) Opioids suppress a cough by controlling the activation of the cough center in the brainstem that signals the body to cough when the respiratory tract is irritated. Opiods control diarrhea because they affect areas in the brainstem that inhibit gastric secretions and depress the activity of intestinal muscles. Constipation can become a severe problem for surgical patients or for those with intractable pain who use opioids over a long period. VIII. SIDE EFFECTS OF OPIOIDS (PP. 4.15− −4.17) 9

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A. PHYSICAL SIDE EFFECTS (pp. 4.15− −4.16) Unwanted side effects include • insensitivity to pain as a warning signal; • lowered blood pressure, pulse, and respiration; • confusion; • droopy eyelids and nodding head • slurred, slowed speech, and a raspy or hoarse voice; • slowed gait and lack of coordination • pinpoint pupils that do not react to light; • dry, itchy skin • lack of sexual desire, often to the point of indifference; • hindered phlegm clearance; • nausea • delayed/erratic menstrual periods B. TOLERANCE, TISSUE DEPENDENCE & WITHDRAWAL (pp. −4.17) 4.16− 1. Tolerance Tolerance occurs when the body tries to neutralize heroin by speeding up the metabolism, desensitizing nerve cells, excreting the drug more rapidly, or altering the brain and body chemistry to compensate for the effects of the drug. There is almost no limit to the development of opioid tolerance. Tolerance develops at different rates for different body systems so a desire for stronger mental effects might be accompanied by excessive respiratory depression. 2. Tissue Dependence A strong opioid can temporarily and sometimes permanently alter brain chemistry. When chronic heroin use is stopped, the body has less ability to produce its own dopamine and therefore less ability to feel elated or normal. This depletion intensifies the desire to use the drug again because the body relies on it to stay normal. 3. Withdrawal For powerful opioids there are three withdrawal phases: acute, postacute, and protracted. • Acute withdrawal occurs as the body tries to return to normal too quickly. • Protracted withdrawal (extended withdrawal symptoms) lasts for months after abstinence has begun.

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•

Post–acute withdrawal syndrome (PAWS) is the persistence of subtle emotional and physical symptoms that can last for 3 to 6 months and in some cases up to 18 months.

Short-acting opioids (2 to 3 hours), like heroin and morphine result in more-acute withdrawal symptoms which begin 8 to 12 hours after cessation of chronic use, reach peak intensity within 48 hours, and then subside over a period of 5–7 days. Long-acting opioids such as methadone activate withdrawal symptoms within 36 to 72 hours. Withdrawal symptoms include, bone, joint, and muscular pain, insomnia, anxiety, sweating; runny nose; stomach cramps, vomiting, diarrhea, hyper reflexes, and muscle cramps, all accompanied by fever, chills, and goose flesh. Severe withdrawal is rarely life threatening (except in infants) although the fear of withdrawal becomes an even greater trigger for continued use than does the desire to repeat the rush. IX. ADDITIONAL PROBLEMS WITH HEROIN & OTHER OPIOIDS −4.29) (PP. 4.18− A. NEONATAL EFFECTS (p. 4.18) Most opioids can cross the placental barrier between the fetus and the mother and deliver large doses of the drug to the developing infant. Babies born to addicted mothers are also addicted; withdrawal can be fatal. The amount of prenatal care received by a pregnant opioid addict is crucial to the health of her fetus and neonate. Infants born addicted often have to be medically managed. B. OVERDOSE (p. 4.18) Of 1.3 million drug-related emergency department (ED) visits in 2008, about 200,000 involved heroin compared with 482,000 for cocaine, 91,000 for methamphetamine, and 657,000 involving alcohol. Approximately 367,000 cases involved prescription opioids. Each year 5,000 to 6,000 people die from opioid overdoses alone or in combination with other depressants. Severe respiratory depression is the major cause of overdose deaths. An overdose can be counteracted by a shot of an opioid antagonist—naloxone (Narcan®)—to block and reverse the life-threatening effects. C. DIRTY & SHARED NEEDLES (pp. 4.18− −4.20) Heroin users can unknowingly inject adulterants, infectious bacteria or virus, including those that cause hepatitis B or C, endocarditis, malaria, syphilis, flesh-eating bacteria, gangrene, and HIV. 1. Hepatitis C & HIV

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From 50% to 90% of all needle-using heroin addicts carry hepatitis C. IV users carry infections that can be spread to their partners or co-users. More than half of IV drug users carry HIV, although the percentages vary radically from city to city. 70% of children infected with HIV had mothers who were IV drug users or had sexual contact with an IV drug user. Worldwide, 60 million people have been diagnosed with HIV and 25 million have died. By 2007, about 576,000 Americans had died from AIDS and a million carry the virus. 2. Abscesses & Other Infections Septic abscesses and ulcerations caused by soft-tissue infections are common among IV drug users. Other signs of IV drug use are lesions or “tracks,” (scars on the skin) often caused by constant inflammation at the injection site and hyperpigmentation. One particularly gruesome infection is necrotizing fasciitis, an infection that destroys large areas fascia and subcutaneous tissue. Other infections include • endocarditis, an infection of heart valves; • cotton fever, caused by endotoxins (which thrive in cotton), • D. DILUTION & ADULTERATION (p. 4.20) Street drugs vary radically in purity from 0% to 99% pure. If a user is expecting 3% heroin and gets 30%, the results could be fatal. One reason for the increased purity is the influx of large amounts of unadulterated Southeast Asian and South American heroin. E. COST (p. 4.20) The majority of heroin users (79%) are gainfully employed; however, many users must turn to illegal activities to pay for their habit. The cost of a heroin habit can range from $20 to $200 a day. 60% of the cost of supporting a habit is acquired through consensual crime, including prostitution and drug dealing. −4.21) F. POLYDRUG USE (pp. 4.20− Multiple Drug Use. Heroin in the morning can lead to speed at night. Mixing cocaine or amphetamine with heroin is called a “speedball” and can enhance the euphoric and painkilling effects of both drugs. OxyContin® is often mixed with other drugs to simulate a heroin-like high. Users often use an opioid or alcohol to come down from meth or cocaine. X. FROM EXPERIMENTATION TO ADDICTION (PP. 4.21-4.22) It takes an average of one year of sporadic heroin use for someone to develop a daily habit. Over time, the pain of withdrawal often exceeds whatever pain the user might have been trying to avoid by taking the drug, so the motivation to continue use is reinforced. Treating addiction is a physiological as well as a psychological process. Physically the addict must be detoxified from the heroin or other opioid, 12

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often with the use of medications. Cravings must be controlled to maintain abstinence. Psychologically the addict has to learn a new way of living. 1. The Vietnam Experience During the Vietnam War (1965 to 1973) almost half the GIs experimented with opium or heroin; 20% became physically addicted and reported withdrawal symptoms. Only 5% of those who had become addicted in Vietnam relapsed within 10 months of their return to the United States (environmental influence). 2. The Iraqi/Afghani Experience A 2007 survey found that 7.1% of veterans met the criteria for substance use disorders. The Department of Defense is allotting more money for mental health and drug treatment and protecting the careers of those who voluntarily seek help. The Russian Experience The number of Russian heroin addicts ballooned during and after their occupation of Afghanistan. Six times as many Russians died from heroin overdose as Americans. XI. PAIN CONTROL & SPECIFIC OPIOIDS (4.22− −4.29) A. THERAPEUTIC PAIN CONTROL (pp. 4.22− −4.23) An estimated 50 million Americans have chronic pain. About half of those take a prescription drug and many are afraid of becoming dependent. Physician concerns include; • fear that addiction might develop or a recovering addict will relapse; • the possibility that the opioid will mask clues to a serious disease; • the chance that the patient is faking symptoms. These concerns keep some physicians from prescribing sufficient pain medication even when it is appropriate. Problems caused by OxyContin,® hydrocodone, and methadone make adherence to medically sound prescribing practices challenging. Most of the problems with moderatestrength prescription opioids come from long-term use. By relying on the drug to relieve the pain, the patient becomes more sensitive to pain because the body produces fewer of its own painkillers and downregulates its own opioid receptors. Ongoing research is focusing on non-opioid pain medications. Lines of inquiry include glial cells and cannabinoid receptors.

B. MORPHINE (pp. 4.23− −4.24)

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Morphine remains the standard by which effective pain relief is measured. It is processed from opium into white crystal hypodermic tablets, capsules, suppositories, oral and injectable solutions. Three to six times more morphine must be taken orally to achieve the same effects as injecting. C. CODEINE (p. 4.24) Codeine is extracted directly from opium or refined from morphine. It is one-fifth as strong and is generally used to relieve moderate pain. It is also commonly used to control a severe cough (Robitussin A-C® and Cheracol®). Codeine was formerly the most widely prescribed and abused prescription opioid in the United States, today it is hydrocodone (Vicodin®). D. HYDROCODONE (Vicodin,® Hycodan,® Tussend,® Norco®) (p. 4.24) More than 120 million prescriptions were written for hydrocodone in 2006, the most of any prescription drug (4 times as many as codeine). In addition to pain relief, hydrocodone is also used in cough preparations, called antitussives. About 600 deaths are reported each year from hydrocodone overdose, more occur when it is used with other depressants. E. OXYCODONE (Oxycontin,® Percodan®) (pp. 4.24− −4.25) This semisynthetic derivative of codeine is used for the relief of moderateto-severe pain. Purdue Pharma introduced OxyContin® in 1995. Abusers chew, crush, and inject the drug or they crush and sniff the time-release formulation that holds the oxycodone. Once the time-release action is destroyed a higher blood level of oxycodone is achieved. Heroin and other opioid abusers describe the high as similar to heroin. Robberies and diversion of legitimate supplies are on the rise. Patients with legitimate prescriptions recognize a financial opportunity and sell their supplies. Heightened media coverage is responsible for the public’s increased l knowledge of the drug. F. METHADONE (Dolophine®) (pp. 4.25− −4.26) Methadone is a legal opioid used to treat heroin addiction through a program known as “methadone maintenance.” There are approximately 288,000 heroin addicts involved in methadone treatment in more than 1,132 methadone treatment programs nationwide. This long-acting synthetic opioid reduces drug craving and blocks withdrawal symptoms for 24 to 72 hours. Like heroin, methadone is addicting and must be monitored closely to prevent diversion into illegal channels. More frequent prescriptions of methadone as a pain reliever in recent years has increased the street supply of the drug and the number of inadvertent overdoses; 4,462 deaths in 2005. In 2009 Oregon reported more overdose deaths from methadone than heroin.

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G. BUPRENORPHINE (Buprenex,® Subutex,® Suboxone®) (pp. 4.26− −4.27) Buprenorphine is a powerful opioid agonist at low doses and an opiate antagonist at high doses. In low doses it is approved as an analgesic alternative to morphine. At high doses, it blocks the opioid receptors. It has been approved as an alternative to methadone for detoxification, buprenorphine maintenance, and as a transition away from methadone maintenance. It can be prescribed and administered by an approved physician in addition to being available daily at specialized treatment clinics. Two drugs, Subutex® and Suboxone,® were approved in 2002 for treatment of patients with opioid dependence. Buprenorphine doesn’t mitigate all withdrawal symptoms so clients have slightly unrealistic expectations about the effectiveness of the drug. H. FENTANYL (Sublimaze®) (p. 4.27) Even in its milder therapeutic formulation, fentanyl, introduced in 1968, is the most powerful of the opioids—50 to 100 times as strong as morphine on a gram-for-gram basis. It is used intravenously during and after surgery for severe pain. The drug is diverted from normal channels in pill form, liquid suspension, or in a patch. The street versions of fentanyl (alpha, 3-methyl) and meperidine (MPPP) are illegally manufactured and are often more potent than the drugs they are imitating. Sold as “China white,” these drugs attest to the growing sophistication of street chemists. I. HYDROMORPHONE (Dilaudid®) (pp. 4.27− −4.28) Hydromorphone, a short-acting semisynthetic opioid, can be taken orally or injected. Hydromorphone is refined from morphine using a process that makes it 7 to 10 times more potent gram-for-gram than morphine. A 4 mg tablet of Dilaudid® costs $30 to $70 on the street. J. MEPERIDINE (Demerol,® Pethidine,® Mepergan®) (p. 4.28) A synthetic phenylpiperidine derivative, this short-acting opioid is one of the most widely used analgesics for moderate-to-severe pain. Though less potent by weight than morphine, it is the opioid most often abused by medical professionals. K. PENTAZOCINE (Talwin NX,® Fortwin,® Talacen®) (p. 4.28) Talwin NX,® prescribed for chronic or acute pain, comes in tablets, has a fraction of the potency of morphine, and acts as a weak opioid antagonist as well as an opioid agonist. In the past, this drug was frequently combined and injected with pyrabenzamine, an antihistamine drug (“Ts and blues”) for the heroin-like high.

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L. PROPOXYPHENE (Darvon,® Darvocet,® Propacet,® Wygesic®) (p. 4.28) Used for the relief of mild-to-moderate pain, this odorless white crystalline powder is often prescribed by dentists. More than 23 million prescriptions were written for propoxyphene in 2005. It was removed from the U.S. market in 2010 because it was found to cause heart problems. M. LAAM® (Levomethadyl Acetate) (p. 4.28) LAAM® is another long-acting opioid that was used for heroin replacement therapy. It prevented withdrawal symptoms and lasted 2 to 3 days. By the early 2000s, a number of cardiac arrhythmias were documented in patients treated with LAAM. ® In response, Roxanne Pharmaceuticals voluntarily ceased production of the medication in 2003, it is still referenced in current research. N. NALOXONE (Narcan®), Nalone, Narcanti) & NALTREXONE (Revia,® Depade,® Vivitrol,® Trexan®) (p. 4.28-4.29) Naloxone and naltrexone are opioid antagonists. They block the effects of heroin, hydrocodone, and other opioids as well as blocking endorphins and enkephalins. Naloxone (Narcan®) is effective in treating heroin/opioid drug overdose. When a heroin overdose victim is injected with naloxone, the heroin’s effects are immediately halted and the person regains consciousness in a matter of seconds. Naltrexone (Revia®) is used to prevent relapse and to help break the cycle of addiction to opioids. Taking naltrexone daily effectively blocks the effects of heroin and any other opioid. It is also used to reduce cravings for alcohol and cocaine. Naltrexone has proven effective in smokingcessation programs, particularly among female smokers. Vivitrol® is the time-release version. P. CLONIDINE (Catapres®) (p. 4.29) This nonopioid, originally prescribed for the treatment of hypertension, is often used to diminish opioid withdrawal symptoms such as nausea, anxiety, and diarrhea. It can also alleviate opioid craving. Because it acts on norepinephrine receptors to control their overactivity (one of the main causes of severe opioid withdrawal symptoms), it can shorten withdrawal time from t a month to a couple of weeks. When used in combination with naltrexone it shortens severe withdrawal symptoms to about five days in a process called rapid opioid detoxification. Q. BUTORPHANOL (Stadol®) & TRAMADOL (Ultram®) (p. 4.29) These newer synthetic opioid analgesics were originally developed to be less abusable and addictive than older opioids. Butorphanol became just as abused as other opioids and is now a Schedule IV drug.

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R. ULTRARAPID OPIOID DETOXIFICATION (p. 4.29) In this medically supervised process naltrexone is given orally or intravenously to a patient who is either heavily sedated or under general anesthesia to avoid the pain of acute withdrawal symptoms precipitated by the opioid antagonist. There is much controversy about this process. S. KRATOM (p. 4.29) The kratom tree is native to Southeast Asia. Its leaves are used in low doses as a stimulant and in high doses for diarrhea control and as a sedative, a painkiller, a treatment for opiate addiction, and a recreational drug. SEDATIVE-HYPNOTICS Prescription drugs have been called the middle and upper classes’ abusable drugs of choice. America has gone through several periods of sedative-hypnotic abuse as each new drug or family of drugs was released. Reports exist of barbiturate abuse in the 1930s and 1940s, Miltown® abuse in the 1950s, benzodiazepine abuse in the 1970s through the present. Prescription drug abuse, particularly among younger users, is increasing. XII. CLASSIFICATION (PP. 4.29− −4.30, 4.31) Americans spent $300 billion on prescription drugs in 2009, which amounts to 3.8 billion prescriptions at an average of $70 to $80 per prescription. More than 85 million of those prescriptions were for sedative-hypnotics (mostly benzodiazepines). Psychiatric medications have taken over a significant part of the sedative-hypnotics market share. Approximately 164 million prescriptions were written for psychiatric medications in 2008. Almost all sedative-hypnotics are available in pill, capsule, or tablet form. The three main groups of sedative-hypnotics are benzodiazepines, barbiturates, and a number of nonbenzodiazepine, nonbarbiturate sedative-hypnotics, especially the Z-hypnotics. The effects of sedative-hypnotics are similar to those of alcohol (e.g., lowered inhibitions, physical depression, sedation, and muscular relaxation). The basic difference between the two is their potency. Sedatives are calming drugs, e.g., alprazolam (Xanax®). They are also called “minor tranquilizers.” Hypnotics are sleep inducers, i.e., short-acting barbiturates and benzodiazepines such as Halcion® that work on the brainstem. They also depress most body functions, including breathing and muscular coordination. Some sedatives are used as hypnotics and some hypnotics are used as sedatives. XIII. HISTORY (PP. 4.30, 4.32) Calming and sleep-inducing drugs have been around for centuries. In ancient cultures, natural plant-derived substances or products of

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fermentation were used/. Since the mid 1800s all sedative-hypnotics have been developed in the laboratory. At the beginning of the twentieth century, bromides, chloral hydrate, and paraldehyde were commonly used. Though chemically quite different, they all depress the central nervous system. Barbiturates were developed at the end of the nineteenth century and slowly grew in popularity; they peaked in the 1930s and 1940s. Phenobarbital, secobarbital, and pentobarbital were among the hundreds of compounds synthesized from barbituric acid. The toxic potential of barbiturates instilled an apprehension about use. Meprobamate (Miltown®) was developed in the late 1940s and 1950s. Known as “mother’s little helper,” this long-acting sedative replaced many long-acting barbiturates. Glutethimide (Doriden®) was tested as a barbiturate substitute, but it had many of the same disadvantages. Benzodiazepines were discovered in 1954 (Librium®) in a deliberate search for a safer class of sedative-hypnotics. Over the years more than 3,000 compounds were developed, but less than two dozen were marketed and released. Benzodiazepines still dominate the market for sedative-hypnotics. Other sedative-hypnotics are being developed in an attempt to improve this class of drugs, e.g., Lunesta,® BuSpar,® Rozerem,® Lyrica,® and Ambien.® XIV. USE, MISUSE, ABUSE & ADDICTION (PP. 4.32− −4.33) Half of all Americans use at least one prescription drug a day. When used properly, sedative-hypnotics can be beneficial therapeutic adjuncts for treatment of a variety of psychological and physical conditions. When misused they can cause undesirable side effects, dependence, abuse, addiction, and death. Sedative-hypnotic misuse or abuse can occur when patients overuse the drug or use them in combination with other psychoactive drugs MENTIONS OF DRUG PROBLEMS IN U.S. EMERGENCY ROOMS, 2004 & 2008. Drug Drug Mentions 2004 Alcohol 674,914 264,759 Narcotics (hydrocodone, OxyContin®) Cocaine 475,425 Marijuana 281,619 ® ® Benzodiazepines (Xanax, Klonopin ) 170,471 Heroin 214,432 Aspirin, acetaminophen, etc. 102,076 Methamphetamine, amphetamines 166,661 Barbiturates 12,919

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2008 656,892 593,956 482,188 374,475 330,235 200,666 138,446 95,500 10,808

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More than one drug is found in many incoming patients XV. BENZODIAZEPINES (PP. 4.33− −4.36) Benzodiazepines are the most widely used sedative-hypnotics in the United States. This class of drugs was developed in the 1950s as an alternative to barbiturates. Benzodiazepines are recommended for shortterm use for specific conditions. The most widely used benzodiazepines are alprazolam (Xanax®), lorazepam (Ativan®), clonazepam (Klonopin®), diazepam (Valium®), and temazepam (Restoril®). A. MEDICAL USE OF BENZODIAZEPINES (pp. 433-436) Medically, benzodiazepines are used to treat • symptoms of anxiety and panic disorders; • anxiety in surgical patients; • sleep disorders; • spasms and seizures; • acute alcohol withdrawal symptoms. B. NONMEDICAL USE OF BENZODIAZEPINES(p. 4.34) Because the desirable emotional and physical effects of benzodiazepines are very similar to those of alcohol, people use them for the same reason they drink. Benzodiazepines can be abused alone but they are most often abused in conjunction with other drugs. Methamphetamine and cocaine abusers take them to come down from excess stimulation. Most benzodiazepine abusers are over 30 years of age, White, well educated, and female. C. NEUROCHEMISTRY & GABA (p. 4.34) Benzodiazepines increase the effects of GABA (gamma amino butyric acid), the most important inhibitory neurotransmitter, so when a benzodiazepine increases the actions of GABA, it subsequently inhibits anxiety-producing thoughts and over stimulating neural messages The metabolites of benzodiazepines can be as or more active than the original drug. Specific benzodiazepines have been developed to treat specific conditions. For example: Xanax® for symptoms of generalized anxiety disorder, panic disorder, and depression; or triazolam (Halcion®) for shortterm (7 to 10 days) treatment of insomnia;

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D. TOLERANCE, TISSUE DEPENDENCE & WITHDRAWAL (pp. 4.34− −4.36) 1. Tolerance Tolerance to benzodiazepines develops as the liver becomes more efficient in processing the drug. A younger person can tolerate higher doses of benzodiazepines than someone older. 2. Tissue Dependence Physical addiction to a benzodiazepine can develop if a patient takes 10 to 20 times the normal dose daily over a couple of months, or takes a normal dose for a year or more. 3. Withdrawal Withdrawal symptoms can be severe with symptoms lasting 7 to 20 days for short-acting benzodiazepines and up to 28 days for those long-acting. It takes several months to taper off of the drug. Symptoms can include recurrence or magnification of the symptoms that were being treated, headaches, tremors, muscle twitches, nausea and vomiting, anxiety, restlessness, yawning, tachycardia, cramping, hypertension, sleep disturbances, and life-threatening convulsions. Symptoms can come and go in cycles separated by 2 to 10 days; can be bizarre, sometimes life threatening, and are complicated by the cyclical nature of benzodiazepine withdrawal. 4. Overdose Benzos have a high margin of safety but the margin is significantly diminished when benzodiazepines are taken in combination with alcohol, other benzodiazepines, phenothiazines, MAO inhibitors, barbiturates, opioids, or other antidepressants. E. MEMORY IMPAIRMENT (p. 4.36) Benzodiazepines disrupt the transfer of information from short- to longterm memory. The amnesic effect of benzodiazepines is medically known as either retrograde or anterograde amnesia. Sexual predators sometimes count on this effect so their victims will forget they were sexually assaulted. Rohypnol® was associated with date rape until 1996 when the FDA banned all imports of the drug even for personal use. XVI. BARBITURATES (PP. 4.36-4− −37) Barbituric acid was first synthesized in 1863. In 1903, the molecule was modified to create barbital (Veronal®). Phenobarbital was synthesized in 1913, and since then approximately 50 of the 2,000 barbiturates created have been marketed. Since the peak of their use in the 1940s and 1950s and their abuse in the 1950s, 1960s, and 1970s, their licit and illicit use has declined dramatically.

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A. EFFECTS (pp. 4.36− −4.37) • Long-acting barbiturates (e.g., Phenobarbital) last 12 to 24 hours and are used mostly as daytime sedatives or to control seizures. • Intermediate-acting barbiturates (e.g., butabarbital), are used as longer-acting sedatives and last 6 to 12 hours. • Short-acting compounds, (e.g., butalbital and, in the past-Seconal®) last 3 to 6 hours and are used to induce sleep. • Very short-acting barbiturates (Pentothal®) are used for anesthesia. Barbiturates affect GABA, therefore acting as a brake on inhibitions, anxiety, and restlessness. Because they can induce a feeling of disinhibitory euphoria, barbiturates have an initial stimulatory effect. Their effects are very similar to those of alcohol. B. TOLERANCE, TISSUE DEPENDENCE & WITHDRAWAL (p. 4.37) Dispositional tolerance results from the physiologic conversion of liver cells to more-efficient cells that metabolize or destroy barbiturates more quickly. Pharmacodynamic tolerance causes affected nerve cells and tissues to become less sensitive. Tissue dependence to barbiturates occurs after 8 to 10 times the normal dose is taken daily for 30 days or more. Within 6 to 8 hours after stopping heavy use of short-acting barbiturates, users will begin to experience anxiety, agitation, loss of appetite, nausea, vomiting, increased heart rate, excessive sweating, abdominal cramps, and tremulousness. Convulsions can occur 12 hours to a week after the last dose. XVII. OTHER SEDATIVE-HYPNOTICS(PP. 4.37− −4.39) ® A. PREGABALIN (Lyrica ) (p. 4.37) Pregabalin is FDA approved to treat nerve pain from shingles or diabetes as well as to help treat seizures. In 2007 the FDA was considering approving Lyrica® for the treatment of anxiety and sleep or mood disorders. It can cause dizziness, drowsiness, lethargy, and memory problems. Euphoria has also been associated with its use and there is a mild potential for abuse and dependence. B. RAMELTEON (Rozerem®) (p. 4.37) This medication is a new approach to treating insomnia. Ramelteon directly activates the brain’s melatonin receptors. It is recommended for short-term treatment of sleep problems. Abuse and dependence have not been associated with its use; however, ramelteon taken with alcohol has additive toxic effects. C. ESZOPICLONE (Lunesta®) (p. 4.37) This drug is a hypnotic agent prescribed for insomnia, it affects GABA. When used longer than a few weeks at a high dose, it can cause

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dependence. There is a cumulative effect when it is taken with other sedatives or opioids. D. ZALEPLON (Sonata®), ZOPICLONE (Imovane®) & ZOLPIDEM −4.38) (Ambien®) (pp. 4.37− ® Zaleplon (Sonata ), zopiclone (Imovane®), and zolpidem (Ambien®) are known as the Z-hypnotics because they have similar actions and their chemical names all began with the letter Z. Eszopiclone (Lunesta®) is also considered a Z-hypnotic. The Z-hypnotics are short acting and work by activating the benzodiazepine receptor to enhance the effect of GABA in the brain. Excess use can cause nausea, diarrhea, headaches, dizziness, and drowsiness the following day. The Z-hypnotics can cause memory, performance, and learning impairment, they have a high therapeutic index and rarely cause overdose deaths except when taken in combination with other depressants. E. BUSPIRONE (BuSpar®) (p. 4.38) This sedative-hypnotic medication is most often used as an anxiolytic or anti-anxiety medication but is also used in combination with SSRI antidepressant medications to treat depression. It does not produce abuse, addiction, or withdrawal symptoms. Because most people (and especially addicts) expect a high or buzz from a sleeping pill or an antianxiety medication, it has a low-use rate.

F. ETHCHLORVYNOL (Placidyl®) & CHLORAL HYDRATE (Noctec,® −4.39) Somnos,® Aquachloral®) (pp. 4.38− Ethchlorvynol and chloral hydrate are used to induce sleep, and both have a long history of toxic overdoses and patterns of addictive use. G. GHB (Gamma Hydroxybutyrate) (p. 4.38) GHB is a strong, rapidly acting CNS depressant that was used as a sleep inducer in the 1960s and 1970s. It is thought to increase the body’s levels of human growth hormone (HGH). It also induces effects similar to alcohol (sedation and disinhibition), ecstasy (empathy and sensory enhancement), and heroin intoxication (euphoria), making it a popular club drug. By the 1990s, the FDA took GHB off the market because of health risks. A dose of GHB costs $5 to $10 on the street and the effects last three to six hours. Because GHB causes a mild euphoria and lowers inhibitions, it has been used by sexual predators to lower the defenses of their victims. H. GBL (Gamma Butyrolactone or 2[3H]-Furanone Dihydro) & BD (1,3 Butanediol) (p. 4.39) Increased legal scrutiny of GHB has resulted in the abuse of GBL and BD. GBL and BD are prodrugs (they are metabolized to GHB in the

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body). These elixirs are sold under the trade names Blue Nitro® and Insom-X®. I. METHAQUALONE (Quaalude,® Mandrax®) (p. 4.39) Methaqualone was developed in India in 1955 as a safe barbiturate substitute. The disinhibitory effect is similar to that caused by alcohol and can last 60 to 90 minutes; the sedating effects last 6 to 10 hours. In 1984 it was classified as a Schedule I drug. This change led to a tremendous increase in the illicit production of Quaalude®. There is no guarantee that street versions of Quaalude® contain actual methaqualone. J. QUETIAPINE (Seroquel®) (4.39) Quetiapine was approved to treat schizophrenia and bipolar disorders. It has benzodiazepine-like effects; abuse has increased in recent years. OTHER PROBLEMS WITH DEPRESSANTS XVIII. DRUG INTERACTIONS (PP. 4.39− −4.40) Pharmacologic research has found that more than 150 prescription and OTC medications interact negatively with alcohol. This is a particular problem in those over 65. −4.40) A. SYNERGISM (pp. 4.39− When more than one depressant drug is used, the polydrug combination can cause a much greater reaction than simply the sum of the effects. Exaggerated respiratory depression presents the most serious danger, often caused by the use of alcohol and another depressant. Approximately 19,000 deaths per year are due to this effect, and 275,000 people are treated in ERs because of adverse reactions to nonmedical use of multiple drugs. B. CROSS-TOLERANCE & CROSS-DEPENDENCE (p. 4.40) Cross-tolerance is the development of tolerance to other drugs due to the continued exposure and development of tolerance to the initial drug. Cross-dependence occurs when an individual becomes addicted or develops tissue dependent on one drug, resulting in biochemical and cellular changes that support an addiction to another drug. XIX. PRESCRIPTION DRUGS & THE PHARMACEUTICAL INDUSTRY (PP. 4.40− −4.41) In 2009, Americans spent about $300 billion on prescription medications. Legal psychoactive drugs, including psychiatric medications, account for approximately 10% to 12% of prescriptions written in the United States. There has been a significant increase in prescription medications for children.

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From the industry perspective, the high cost of prescription drugs is justified. The cost of developing a new medication is enormous and patents are good for only 17 years. The industry is trying to limit the purchase of drugs online causing consumers to claim that they are being denied access to cheaper versions of the drugs they need. Advertising dollars aimed at consumers for pharmaceuticals has gone from $2 million in 1980 to $1.85 billion in 1999, to $4.43 billion in 2008, while overall promotion budgets are four to five times that amount. Of the 1,035 new drugs approved by the FDA between 1989 and 2000, more than half showed "no significant clinical improvement" over older and/or cheaper drugs. When free enterprise is at odds with unprofitable public policy, heavy political contributions, inaction and delaying tactics are often the result, usually to the detriment of the general public.

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Chapter 4 - DOWNERS: OPIATES/OPIOIDS & SEDATIVE-HYPNOTICS Classroom or Small Group Discussion Topics 1. Discuss the similarity between pleasure and relief from pain. Will a person strive harder to gain pleasure or relieve pain? 2. Discuss the subjective nature of pain. Note that people have different pain thresholds or levels of tolerance for pain and therefore require different amounts of a painkiller for the same injury. 3. Compare the use of legally prescribed drugs for the treatment of opiate addiction ( a.) heroin( b.) methadone (c.) Suboxone/Subutex . What are the pros and cons of each of these drugs from the perspective of (a.) crime prevention, (b.) ethics, and (c.) effective recovery. 4. How does growing and selling opium in Afghanistan affect the war efforts? Have we looked the other way rather than prosecute those involved in the drug war for fear of interfering with attempts to defeat the insurgency? 5. Compare Valium® addiction to heroin addiction, physically, mentally, financially, and criminally. Which of these drugs have a higher risk of death during withdrawal particularly if a patient is not medically monitored (a.) heroin or( b.) Valium®. 6. Discuss which drugs are likely to be prescribed or recommended for a person presenting with one of the complaints listed below. a. “I can't sleep at night.” b. “Since my partner died, I always feel low.” c. “These headaches are killing me.” d. “I have debilitating anxiety attacks in social situations.” •

What is the most likely prescription or suggested therapy for a woman with the presenting complains? For a man?

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What are the potential benefits and drawback?

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What nondrug therapies could be substituted?

7. How has advertising prescription medications changed the doctor patient relationship in the United States.

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Chapter 4 - DOWNERS: OPIATES/OPIOIDS& SEDATIVE-HYPNOTICS Critical Thinking & Class Exercises 1. Have the students create a human interactive model that illustrates how neurotransmitters move from one nerve cell across the synapse to a secondary terminal when pain is transmitted (Substance P). Then integrate students into positions on the secondary terminal to show how opioids block the transmission of pain signals. 2. Ask the students to compare the descriptions of several regularly prescribed sedatives (Xanax®, Valium®, etc.) in the Physicians’ Desk Reference with advertisements for those drugs in professional medical journals. • How are the ads designed to encourage physicians to prescribe the drugs? • How are patients portrayed in the ads? • What characteristics of the drugs are not emphasized in the ads? 3. Have the class discuss what social factors may affect the medical prescribing patterns of benzodiazepines (e.g., Valium®, Xanax®) Are benzodiazepines prescribed equally for men and women? Is there a disparity? 4. Have students discuss how various cultures have developed in relation to the types of depressant drugs licit or illicit drugs they have available, e.g. opium in China, heroin in Afghanistan, whiskey and valium in the United States, vodka in Russia. 5. Invite a pharmacist or emergency room physician to visit your class and share his or her experiences dealing with people who abuse prescription drugs trying by “doctor shopping ” or feigning an illness or injury in order to obtain a prescription or access to a controlled substance.Note this may also include over-the-counter drugs with ephedrine (e.g. Sudaphed®). Applied Learning- Case Study Break the students into small groups (2 to 4 students) and have each group of students review Case Study # 9 which focuses on a person with a heroin problem. Ask the students to identify the following:

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What evidence indicates that the subject used heroin habitually, abusively, and/or addictively?

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What drives the person to continue using heroin? What was their initial draw, what is their desired effect from heroin?

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What side effects or undesired effects did they experience from the drug?

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What role did heredity and the person’s environment play in the subject’s heroin problem?

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Uppers, Downers, All Arounders, 7th Edition – Instructors Manual

Chapter 5 – DOWNERS: ALCOHOL Chapter Overview Alcohol is the oldest and most widely used psychoactive drug in the world. Throughout history, societies’ attitudes towards beer, wine, and distilled liquors has wavered between prohibition, temperance, and free use. It is legal in most countries; Islamic countries prohibit its use. This chapter surveys the chemistry of alcohol, its pharmacology (including effects on the brain’s neurotransmitters), and physiological/psychological effects and reviews the classification of beverages containing alcohol. Although the absorption and distribution of alcohol via the circulatory system varies among individuals (and genders) everyone’s metabolism eliminates the alcohol at a fairly fixed rate. Blood alcohol concentration (BAC) correlates to the severity of alcohol effects. The desired effects of alcohol are dose dependent and include relaxation, lowering of inhibitions, and a certain high. The side effects include decreased alertness, exaggerated emotions, slurred speech, unsteady gait, heart problems, cirrhosis of the liver, and neurological damage. Alcohol causes more health, domestic, social and legal problems than any other psychoactive drug, especially for heavy and/or long term drinkers. Between 15% and 25% of emergency room patients test positive for alcohol and 40% of industrial fatalities involve alcohol. Binge drinking has increased at colleges. Many freshmen continue their high school drinking patterns their first year of college, by their senior year most have learned how to control their drinking. A movement known as the Amethyst Initiative advocates lowering the legal drinking age in the U.S. despite the problems student drinking causes such as lower grades, binge drinking, and “second-hand” drinking (exposure of non-drinkers to violence, unwanted sexual advances and vandalism). Polydrug abuse, mental health complications, violent behaviors, impaired driving, and damage to a fetus during pregnancy are some of many negative consequences associated with alcohol abuse Drinking patterns vary depending on the culture of the individual. Research shows that as people assimilate into American culture, their drinking patterns change. The road to alcoholism varies depending on family history, childhood abuse, peer pressure, and the availability of alcohol.

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Chapter 5 - DOWNERS: ALCOHOL I. OVERVIEW A. Introduction B. History (also see chapter 1)

II. ALCOHOLIC BEVERAGES A. The Chemistry of Alcohol B. Types of Alcoholic Beverages 1. Beer 2. Wine 3. Distilled Spirits (liquor) 4. Other Alcoholic Beverages

III. ABSORPTION, DISTRIBUTION, & METABOLISM A. Absorption & Distribution B. Metabolism 1. Blood Alcohol Concentration (BAC)

IV. DESIRED EFFECTS, SIDE EFFECTS, & HEALTH CONSEQUENCES A. Levels Of Use 1. Abstention 2. Experimentation 3. Social/Recreational Use 4. Habituation 5. Abuse 6. Addiction

B. Low-To-Moderate-Dose Episodes 1. Physical Effects 2.: Psychological Effects 3. Neurotransmitters Affected by Alcohol 4. Sexual Effects

C. High-Dose Episodes 1. Physical Effects of Intoxication 2. Mental & Emotional Effects 3.: Alcohol Poisoning (overdose) 4.: Blackouts 5. Hangover 6.: Sobering Up

D. Chronic High-Dose Use 1. Digestive System & Liver Disease 2. Other Digestive Organs 3. Cardiovascular Disease 4. Nervous System 5. Sexual Desire & the Reproductive System 6. Cancer

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7. Systemic Problems 8. Mental/Emotional Effects

E. Mortality V. Addiction (Alcohol Dependence/Alcoholism) A. Classification 1. Early Classifications 2. E. M. Jellinek 3. Modern Classifications 4. The Disease Concept of Alcoholism

B. Heredity, Environment, & Psychoactive Drugs 1. Heredity 2. Environment

C. Tolerance, Tissue Dependence & Withdrawal 1. Tolerance 2. Withdrawal

D. Directions In Research Vi. Other Problems with Alcohol A. Polydrug Abuse B. Alcohol & Mental Problems C. Alcohol & Pregnancy 1. Maternal Drinking 2. Fetal Alcohol Spectrum Disorders (FASD) 3. Paternal Drinking

D. Aggression & Violence E. Driving Under The Influence 1. Injuries & Suicide

Vii. Epidemiology A. Patterns Of Alcohol Consumption B. Population Subgroups 1. Men & Women 2. Adolescents 3. College Students & Learning 4. Older Americans 5. U.S. Military 6. Homeless

C. Underrepresented Populations 1. African Americans 2. Hispanics

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3. Asian & Pacific Islanders (APIS) 4. American Indians & Alaskan Natives

Viii. Conclusions

−5.5) I. OVERVIEW (PP. 5.2− A. INTRODUCTION (pp. 5.2− −5.3) Worldwide: • There are 2 billion drinkers worldwide. Alcohol is consumed in all but Islamic countries. • China’s alcohol consumption has doubled, India's has risen 50% in the last 20 years; • Russian men consume the equivalent of six to seven bottles of vodka per capita per year. • Approximately 2 million people die annually due to alcohol and 76 million have an alcohol use disorder. In the United States: • last month about 129 million Americans had at least 1 drink; 16 million of this group are considered heavy drinkers; • 25% to 30% of hospital admissions are due to complications from alcohol • about half of all murder victims and murderers were drinking alcohol at the time of the crime. B. HISTORY (p. 5.3) Alcohol is the oldest known and, at present, the most widely used psychoactive drug in the world. People were drawn to alcohol for the mental/emotional effects. Thirsty farmers discovered that grapes as well as the starch in potatoes, rice, corn, fruit, and grains could be fermented into alcohol (beer or wine). The first civilized settlements were created to ensure a regular supply of grain for food and beer, grapes for wine, and poppies for opium. 1. The Legal Drug Throughout history alcohol has been used as a reward, a food (grain-rich beer), a cure-all, a sacrament, a substitute for water, a social lubricant, a tranquilizer, and as a source of revenue from taxes. Almost every country has periods in its history when alcohol use was restricted or banned. Those prohibitions were usually rescinded.

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The Gin Epidemic in England in the 1700s illustrated how poverty, unrestricted use, and industrial despair coupled with the higher concentration of distilled alcohol cause abuse and, for many, addiction. Efforts to curtail abuse included increased taxes and severe limits on production. In colonial America, alcohol was a part of everyday life. The founding fathers encouraged the cultivation, manufacture, and sale of whiskey and rum and used the taxes to finance the American Revolution (and the slave trade). In 1920 the U.S. government officially prohibited the production and sale of alcohol but widespread flouting of the Prohibition amendment and pressure by those who wanted to drink (and those who wanted the revenue from excise taxes) led to the repeal of Prohibition 13 years later. −5.8) II. ALCOHOLIC BEVERAGES (PP. 5.5− A. THE CHEMISTRY OF ALCOHOL (p. 5.5) There are hundreds of different alcohols • ethyl alcohol (ethanol, grain alcohol) is the least toxic and is found in all alcoholic beverages; • methyl alcohol (wood alcohol), isopropyl alcohol (rubbing alcohol, shellac, etc.); • butyl alcohol, used in many industrial processes Other components produced during fermentation, known as congeners, contribute to the distinctive tastes, aromas, and colors of alcoholic beverages. Ethyl alcohol and carbon dioxide are produced from the fermentation that occurs when airborne yeast feeds on sugars in mash. B. TYPES OF ALCOHOLIC BEVERAGES (pp. 5.5− −5.8) • Beer is produced from fermented grain. • Wine is produced from fermented fruit. • Distilled spirits with different concentrations of alcohol are made from fermented grains, tubers (e.g., potatoes), vegetables, and other plants. They can also be distilled from wine or other fermented beverages. 1. Beer Brewing beer and making bread date back about 10,000 years to Neolithic times. Beer includes ale, stout, porter, malt liquor, lager, and bock beer. The differences among beers have to do with the type of grain used, the fermentation time, and whether they are top- or bottom-fermenting beers. The alcohol content of most lager beers is 4% to 5%; ales, 5% to 6%; ice beers, 5% to 7%; malt liquors, 6% to 9%; light beers are only 3.4% to 4.2% alcohol. CONSUMPTION OF BEER - Liters per Capita 5

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Beer Wine Germany 131 22 England 103 13 United States 95 20 France 40 60 Italy 103 59 2. Wine In some early cultures, beer was the beverage of common people and wine was the drink of priests and nobles. Most wines are made from the extracted juices of grapes, though some are made from berries, other fruits or starchy grains (e.g., Japanese saké rice wine). European wines contain 8% to 12% alcohol; U.S. wines have 12% to 14% alcohol content. New techniques can produce wine with 16% alcohol. Wine coolers are usually diluted with juice and contain an average of 6% alcohol. 3. Distilled Spirits (liquor) Beverages with greater than 14% alcohol were not available outside of Asia until about A.D. 800 when the Arabs discovered distillation, the process of liquid separation by evaporation and condensation. This eventually led to the production of distilled spirits such as brandy, whiskey, vodka, and gin. Brandy is distilled from wine, rum from sugar cane or molasses, whiskey and gin from grains, and vodka from potatoes. The higher the alcohol proof, the quicker the drinker becomes inebriated. PERCENTAGE OF ALCOHOL BY VOLUME WINE Unfortified (red, white) 12–16% Fortified (sherry, port) 17–21% Wine cooler 6% BEER Regular beer 4–5% Light beer 3.4–4.2% Malt liquor 6–9% LIQUORS & WHISKEYS Bourbon, whiskey, Scotch, vodka, gin, brandy 40–50% ® 95% Everclear 4. Other Alcoholic Beverages These include the high potency mixed drinks favored by young adults (shooters like Flaming Dr. Pepper) and alcoholic energy drinks.

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III. ABSORPTION, DISTRIBUTION & METABOLISM (PP. 5.8− −5.10) A. ABSORPTION & DISTRIBUTION (p. 5.8) Absorption of alcohol into the bloodstream occurs at various sites along the gastrointestinal tract, including the stomach, the small intestines, and the colon. In men, 10% to 20% of the alcohol is absorbed by the stomach. Most of the alcohol enters the capillaries in the walls of the small intestines through passive diffusion. Women register higher blood alcohol concentrations than men from the same amount of alcohol. Thus chronic alcohol use causes greater physical damage to women than to men. Female alcoholics have death rates 50% to 100% higher than male alcoholics. Alcohol is absorbed into the bloodstream and partially metabolized by the liver. The highest levels of blood alcohol concentration occur 30 to 90 minutes after drinking. Factors that speed absorption: • increasing the amount consumed • drinking on an empty stomach • heating the alcohol Factors that slow absorption: • eating before or while drinking • consuming high fat/ high calorie foods B. METABOLISM (pp. 5.8− −5.10) About 90% to 98% of alcohol is neutralized through metabolism (mainly oxidation) by the liver and then by excretion through the kidneys and the lungs as water and carbon dioxide. The variation in people’s reactions to alcohol is due in part to hereditary factors that affect the metabolic efficiency of ADH and ALDH. 1. Blood Alcohol Concentration (BAC) Metabolism occurs at a relatively defined continuous rate. About 1 oz. of pure alcohol (1.5 drinks) is eliminated from the body every three hours. An individual’s reaction and level of impairment depends on their drinking history, behavioral tolerance, mood, and a dozen other factors. It takes 30 to 90 minutes after ingestion to reach maximum blood alcohol concentration. A BAC table measures the concentration of alcohol in an average drinker’s blood. For purposes of law enforcement a BAC of 0.08 is considered legal intoxication in all 50 states.

IV. DESIRED EFFECTS, SIDE EFFECTS & HEALTH −5.19) CONSEQUENCES (PP. 10− 8

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A. LEVELS OF USE (pp. 5.10-5.11) Escalating patterns of use: 1. Abstention (nonuse) 2. Experimentation (use for curiosity with no subsequent seeking behavior) 3. Social/Recreational Use (sporadic infrequent use - no established pattern) 4. Habituation (established pattern of use with no major negative consequences) 5. Abuse (continued use despite negative consequences) 6. Addiction (compulsion to use, inability to stop use, major life dysfunction with continued use) The effects of alcohol depend on the amount, the frequency, and the duration of use. B. LOW-TO-MODERATE-DOSE EPISODES (pp. 5.11− −5.13) Most studies show that small amounts of alcohol and infrequent mild intoxication episodes do not have negative health consequences. The exceptions include women who are pregnant and men or women who have preexisting physical/mental health problems, have a history of addiction, are allergic to alcohol, and/or have a high genetic/environmental predisposition to addiction. 1. Low-to-Moderate-Dose Use: Physical Effects Therapeutic Uses. Alcohol is used as a topical disinfectant and as a body rub to reduce fever. Systemically, ethanol is used to treat methanol and ethylene glycol poisoning. Desired Effects. Some people enjoy the taste, have found that the drinks quench their thirst, relax muscle tension, stimulate the appetite, lower inhibitions, and reduce the incidence of heart disease and plaque formation thus lowering the risk of stroke. Sleep. Alcohol is often used as a sleep aid, particularly if anxiety is causing insomnia. However, disturbances in sleep patterns can occur, decreasing daytime alertness, and impairing performance. Chronic 2. Low-to-Moderate-Dose Use: Psychological Effects For some people alcohol lowers inhibitions, increases selfconfidence, and promotes sociability. It calms, relaxes, sedates, and reduces tension. If someone is lonely, depressed, angry, or suicidal, the depressant and disinhibiting effects of alcohol can deepen negative emotions. Vehicular crashes, legal conflicts, and high-risk sexual activity are some of the consequences.

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3. Neurotransmitters Affected by Alcohol Alcohol causes GABA to lower psychological inhibitions and eventually slow down all of the brain processes. The release of serotonin raises mood then depletes it causing depression. Dopamine release gives a surge of pleasure. Glutumate intensifies the effects of dopamine. The release of endorphins and anandamides enhances the reinforcing effect. 4. Low-to-Moderate-Dose Use: Sexual Effects Alcohol’s physical effects on sexual functioning are closely related to blood alcohol levels. In low doses alcohol usually increases desire in females and males but slightly decreases erectile ability and delays ejaculation. More than half of college students believe that alcohol facilitates sexual opportunities. C. HIGH-DOSE EPISODES (pp. 5.13− −5.15) 1. High-Dose Use: Physical Effects Intoxication is the result of the amount and speed with which alcohol is consumed as well as the psychological mood, expectation, mental/ physical tolerance, and past drinking experience of the drinker. Binge drinking is defined as consuming five or more drinks at one sitting for males and four or more for females. About 44% of college students say they are binge drinkers and 21% (of the totals) say they binge regularly. Heavy drinking is defined as five or more drinks in one sitting at least five times a month. After enough drinks are consumed, the depressant effects of the alcohol take over. Blood pressure is lowered, motor reflexes are slowed, digestion and absorption of nutrients become poor, body heat is lost as blood vessels dilate, and sexual performance is diminished.

Level of Impairment vs. Rising Blood Alcohol Concentration 0.50 Blood Alcohol Concentration Death from lung and heart failure Coma 10

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Life-threatening unconsciousness Difficulty in rousing Incapacitation, loss of feeling Confused speech Inability to walk without help Slurred speech Exaggerated emotions Argumentative and often hostile behavior Unsteadiness standing or walking Clumsiness, exaggerated emotions Slowed reaction time Further loss of coordination Impaired ability to drive Reduced social inhibitions Decreased alertness Some loss of muscular coordination Lowered inhibitions, feelings of relaxation 0.01 Blood Alcohol Concentration 2. High-Dose Use: Mental & Emotional Effects Mental confusion, mood swings, loss of judgment, and emotional turbulence at higher doses are common along with slurred speech, progressive mental confusion and loss of emotional control. Sleep becomes disturbed and erratic. 3. High-Dose Use: Alcohol Poisoning (overdose) When large amounts of alcohol are consumed the drinker is at risk for depression of the central nervous system (CNS) possibly leading to respiratory and cardiac failure, then to unconsciousness (passing out), coma, and death. Some clinicians use a BAC level of 0.40 as the threshold for alcohol poisoning. When other depressants are used, the danger is greatly increased. 4. High-Dose Use: Blackouts About one-third of all drinkers report experiencing at least one blackout. During a blackout a person acts normally and is awake and conscious but afterward cannot recall anything that was said or done afterward. When a drinker has only partial recall of events, it is known as a brownout. A possible indicator of susceptibility to blackouts is a dampening of the P3 or P300 brain wave that affects cognition, decisionmaking, and processing of short-term memory. This dampening is found in alcoholics and their young sons. 5. High-Dose Use: Hangovers The effects of a hangover can be most severe many hours after alcohol has been eliminated from the system. Typical effects include nausea, occasional vomiting, headache, etc. More severe withdrawal symptoms usually occur with chronic high-dose users. 6. High-Dose Use: Sobering Up

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Alcohol is eliminated from the system at a constant rate. Coffee, exercise, or a cold shower will not speed up the process nor cure a hangover. Feeling better comes only after rest and sufficient recovery time. D. CHRONIC HIGH-DOSE USE (pp. 5.15− −5.19) 1. Digestive System & Liver Disease The main impact of alcohol on the digestive system is caused by its direct effects on organs and tissues. Chronic drinking inevitably compromises the liver. Fatty liver - the accumulation of fatty acids in the liver can occur after just a few days of heavy drinking. Approximately 10% to 35% of heavy drinkers develop alcoholic hepatitis and 10% to 15% develop cirrhosis. Alcoholic hepatitis causes inflammation of the liver, areas of fibrosis (formation of scar-like tissue), necrosis (cell death), and damaged membranes. It usually takes months or years of heavy drinking to develop this condition. Cirrhosis occurs once alcohol kills too many liver cells and causes scarring. It is the most advanced form of liver disease caused by drinking and is the leading cause of death among alcoholics. Alcohol Use vs. Cirrhosis It is estimated that alcoholic cirrhosis is a major factor in about 80% of all cases of cirrhosis in the United States. About 13,000 Americans die from cirrhosis each year. Heavy-drinking countries such as France and Germany have rates of cirrhosis two to three times higher than the United States. Country Rate of Cirrhosis per 100,000 Germany 15.4 Italy 13.9 Spain 12.2 France 12.1 United States 7.7 Japan 7.2 United Kingdom 6.4 2. Other Digestive Organs Excessive amounts of alcohol can cause acid stomach and diarrhea. Gastritis (stomach inflammation) is common among heavy drinkers as are inflammation and irritation of the esophagus, small intestine, and pancreas (pancreatitis). Other serious disorders include ulcers, stomach hemorrhage, gastrointestinal bleeding, and the increased risk of cancer. Alcoholics may suffer from primary malnutrition, including vitamin B1 deficiency. Alcohol can also cause hypoglycemia (too little

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sugar [glucose]) or hyperglycemia (too much sugar) depending on nutrition. 3. Cardiovascular Disease Chronic heavy drinking is associated with a variety of heart diseases, including hypertension (high blood pressure) and cardiac arrhythmias. Cardiomyopathy—an enlarged, flabby, and inefficient heart—is found in some chronic heavy drinkers. The risk of stroke and other intracranial bleeding increases within 24 hours of a drinking binge. 4. Nervous System Chronic high-dose use causes direct damage to nerve cells which can have far-reaching consequences in susceptible individuals. Dementia (deterioration of intellectual ability, faulty memory, disorientation, and diminished problem-solving ability) is another consequence of heavy drinking. Two serious diseases due to brain damage cause by chronic alcoholism and thiamine (vitamin B1) deficiency are Wernicke’s encephalopathy and Korsakoff’s psychosis. 5. Sexual Desire & the Reproductive System Female. Although light drinking lowers inhibitions, prolonged use decreases desire, the intensity of orgasm and causes sexual dysfunction. Male. Though low-to-moderate levels of alcohol can lower inhibitions and enhance the psychological aspects of sexual activity, the depressant effects soon kick in. Over time, alcohol abuse can lead to an inability to experience normal sexual relationships. 6. Cancer Breast Cancer. The association between heavy drinking and breast cancer is clear. The evidence linking drinking small amounts of alcohol and the incidence of breast cancer is less compelling. Other Cancers. The risk of cancer of the mouth, throat, larynx, and esophagus is six times greater for heavy alcohol users, seven times greater for smokers, and an astonishing 38 times greater for smokers who also drink alcohol. Liver cancer is also a risk in those with long-standing cirrhosis. 7. Systemic Problems Musculoskeletal System. Alcohol leeches minerals from the body causing a risk of fractures. Direct toxic effects can cause myopathy (painful swollen muscles). Dermatologic Complications. The reddish complexion and other skin conditions of chronic alcoholics is caused by dilation of blood vessels near the skin, malnutrition, jaundice, thinning of the skin,

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and liver problems. Acne rosacea, psoriasis, eczema, and facial edema are also common. Immune System. Heavy drinking may disrupt white blood cells and in other ways weaken the immune system, resulting in greater susceptibility to infections. 8. Chronic High-Dose Use: Mental/Emotional Effects With chronic high-dose use, almost any mental, emotional, or psychiatric symptom could occur including hallucinations, paranoia, severe depression, insomnia, intense anxiety, and problems with memory. E. MORTALITY (p. 5.19) Heavy drinkers are likely to shorten their life span by 15 years. SOME ALCOHOL-RELATED CAUSES OF DEATH Diseases Diseases Injuries, etc. (direct cause) (indirect cause) (indirect cause) Alcoholic psychoses Tuberculosis Accidents; plane, Alcoholism Cancer: mouth, cars, etc. Seizure activity liver, stomach Homicides Nerve degeneration Diabetes Falls Heart disease Hypertension Drowning Alcoholic gastritis Suicides V. ADDICTION (alcohol dependence/ alcoholism) −5.24) (PP. 5.19− 10% to 12% of the 140 million adult drinkers in the U.S. are alcohol dependent. Alcoholism is 2 to 3 times more prevalent in men. A. CLASSIFICATION (pp. 5.19-5.21) 1. Early Classifications Classifications are developed to serve as a framework by which an illness or a condition can be studied systematically. Early pioneers in alcohol research were Dr. Benjamin Rush, Dr. Thomas Trotter, Alcoholics Anonymous, Yale’s Laboratory of Applied Psychology, etc. 2. E. M. Jellinek Jellinek, in his landmark book The Disease Concept of Alcoholism, proposed five types of alcoholism: alpha, beta, gamma, delta, and epsilon. Gamma and delta alcoholics were considered true alcoholics. 3. Modern Classifications

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Four scientific developments led to a deeper understanding of alcoholism: • discovery of the nucleus accumbens, the reward pathway in the 1950s; • discovery of endogenous neurotransmitters, e.g., endorphins, in the 1970s; • genetic research tools developed in the 1980s and 1990s provided insights into hereditary influences; • imaging techniques became more sophisticated in the 1990s and 2000s; scientists could actually see the brain on drugs.

• •

Current classifications include: Type I & Type II Alcoholics. (Cloninger & colleagues) Type A & Type B Alcoholics. (Dr. T. F. Babor and colleagues at the University Of Connecticut School Of Medicine).

4. The Disease Concept of Alcoholism Much of the current research in the treatment of alcoholism is based on the disease concept. The American Society of Addiction Medicine and the National Council on Alcoholism and Drug Dependence defined alcoholism as follows: “Alcoholism is a primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestation. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug (alcohol), use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic.” B. HEREDITY, ENVIRONMENT & PSYCHOACTIVE DRUGS (p. 5.21− −5.22) 1. Heredity Family studies, twin studies, animal studies, and adoption studies show strong genetic influences particularly in severe alcoholics. It is widely accepted that several genes have an influence on a person’s susceptibility to alcoholism and other drug addictions. Other markers for a strong genetic influence are a tendency to have blackouts, a greater initial tolerance to alcohol, an impaired decision-making area of the brain, a major shift in personality while drinking, an impaired ability to learn from mistakes, retrograde amnesia, and a low level of response (LR) to alcohol. 2. Environment Environmental factors that have overwhelming influences are: alcohol and/ or other drug–abusing parents, friends, and/or relatives; chaotic familial relationships; peer pressure; and

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extreme stress. Sexual, physical, and/or emotional abuses experienced at a young age are the most powerful environmental factors. 3. Alcohol & Other Drugs Once genetic and environmental factors have determined susceptibility, the toxic effects of alcohol and other drugs that change neurochemistry come into play. C. TOLERANCE, TISSUE DEPENDENCE & WITHDRAWAL (pp. 5.22− −5.23) 1. Tolerance Tolerance is a process through which the brain defends itself against the effects of alcohol. Dispositional (metabolic) tolerance occurs when the body changes so that it metabolizes alcohol more efficiently. The liver eventually becomes less able to metabolize the alcohol, a process called reverse tolerance. Pharmacodynamic tolerance means brain cells become more resistant to the effects of alcohol. Behavioral tolerance means drinkers learn how to “handle their liquor” by modifying their behavior. Acute tolerance starts to develop with the first drink. Select tolerance means that tolerance does not develop equally to all the effects of alcohol. 2. Withdrawal Hangovers can occur with any level of drinking, from experimentation to addiction. More-severe withdrawal symptoms occur with chronic high-dose use. About 85% to 95% of those who experience withdrawal have only minor rather than life-threatening symptoms. Major withdrawal symptoms usually develop after 48 to 87 consecutive days of heavy drinking. Minor symptoms include rapid pulse, sweating, increased body temperature, hand tremors, anxiety, depression, insomnia, and nausea or vomiting. Major symptoms include tachycardia; transient visual, tactile, or auditory hallucinations and illusions; psychomotor agitation; grand mal seizures; and delirium tremens. Medical care for a chronic alcohol abuser must be considered in any course of treatment. In less than 1% of serious cases of alcohol withdrawal, full-blown delirium tremens, called “the DTs,” occurs. Neurotransmitters & Withdrawal. Initially alcohol increases the effectiveness of GABA. Over time the brain decreases the number of GABA receptors, resulting in hyperarousal causing anxiety, 16

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increased muscular activity, tachycardia, hypertension, and occasionally, seizures. Kindling. Kindling, also known as inverse tolerance, actually intensifies subsequent withdrawal symptoms and can cause seizures. D. DIRECTIONS IN RESEARCH (pp. 5.24− −5.25) Heredity research is seeking to identify the genes that make a user more susceptible to addiction (e.g., DRD2A1 allele, ALDH2). Research into environmental causes of alcoholism is evaluating specific changes in an addict’s surroundings that will decrease the use of alcohol and other drugs. Examining drug-caused physiological and psychological changes that occur with chronic and high-dose use also keeps many researchers occupied. VI. OTHER PROBLEMS WITH ALCOHOL (PP. 5.25− −5.32) A. POLYDRUG ABUSE (p. 5.25) Most users of illicit drugs also drink alcohol, and most alcohol abusers use other drugs. Alcohol can be used to come down off a three-day methamphetamine run. Compulsive gamblers drink while gambling or gamble while drinking. Polydrug abuse has become so common that treatment centers must often treat simultaneous addictions. B. ALCOHOL & MENTAL PROBLEMS (pp. 5.25− −5.26) Alcohol is often used to change one’s mood or mental state. The mood could be mild anxiety, confusion, boredom, or sadness. The mental state could be symptoms of a pre-existing mental illness such as depression or a personality disorder. The incidence of major depression among alcoholics is about 28% and anxiety 37%. Excess alcohol or withdrawal can induce symptoms of mental illness. Heavy drinking raises the levels of neurochemicals that cause tension and depression. Any psychiatric diagnosis must take into account the possibility of drug- and alcohol-induced symptoms. A client with co-occurring disorders often continues to relapse because the psychiatric problems have not been addressed. Both conditions must be treated to achieve an effective recovery. The actual incidence of personality disorders, particularly borderline personality disorder and antisocial personality disorder is under debate. C. ALCOHOL &PREGNANCY (pp. 5.26− −5,29) 1. Maternal Drinking

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Alcohol use during pregnancy is the leading cause of mental retardation in the United States. Excess drinking during pregnancy is responsible for increases in the number of miscarriages and infant deaths, causes more problem pregnancies, and results in smaller and weaker newborns. A survey of pregnant women in the United States found that 12.4% consumed alcohol at some point in their pregnancy, 4% used in a binge pattern, and 0.7% were heavy drinkers; In a survey of mothers with fetal alcohol syndrome (FAS) babies, about 89% used alcohol with at least two other drugs during pregnancy. Most of the women had been physically or sexually abused and often there was a history of alcohol or drug abuse in the family. In another study, 69% of the mothers of FAS babies died before their children reached adolescence. 2. Fetal Alcohol Spectrum Disorder (FASD) Diagnosticians look to four factors to diagnose alcoholinvolved problems: retarded growth, facial deformities and problems with the heart and limbs, CNS involvement e.g., delayed intellectual development and behavioral problems, and prenatal alcohol exposure by the mother. Fetal alcohol spectrum disorder (FASD) refers to the whole range of alcohol affected births. • FAS (fetal alcohol syndrome) involves all four mentioned problems. • PFAS (partial fetal alcohol syndrome) is like FAS without growth or facial anomalies. • ARND (alcohol-related neurodevelopmental disorder) is marked by CNS abnormalities; • ARBD (alcohol-related birth defects) is marked by any number of physical anomalies. • FAE (fetal alcohol effects) is now ARND and ARBD. Alcohol kills cells and changes the wiring of a fetal brain. Huge gaps during brain development destroy natural connections that can never be regained. FAS IQ scores range from 20 to 120 with an average of 79. For the other syndromes it ranges from 49 to 142 with an average of 90. Other problems include: • difficulty with short-term memory, • problems storing and retrieving information, • difficulty making good judgments, forming relationships, etc. These cognitive/behavioral deficits are not unique to alcohol exposure. Many other substances and physiological conditions

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can cause similar symptoms in children so FASD diagnoses are often missed. Studies estimate that FAS births occur in 0.33 to 2.9 cases per 1,000 live births worldwide. Critical Period. The brain is most vulnerable to alcohol in weeks 3 through 8, at the onset of embryogenesis (formation of the embryo). Critical Dose. One study concludes that seven standard drinks per week or less by pregnant mothers will not trigger neurobehavioral effects. However, a single prolonged contact with alcohol lasting four hours or more is enough to kill vast numbers of brain cells. In truth, there is no way to determine if a baby might be at risk from even very low levels of alcohol exposure. 3. Paternal Drinking There is now evidence that some of the detrimental effects of alcohol on the fetus may also be transmitted by paternal alcohol consumption. Adolescent male rats subjected to high alcohol intake produced both male and female offspring suffering from abnormal development. Observations of male children of alcoholic fathers indicate no gross physical deficits but do show an association with intellectual and functional deficits. D. AGGRESSION &VIOLENCE (pp. 5.29− −5.31) Most research suggests that some people have an inherent tendency toward violence. Alcohol has been shown to increase aggression by interfering with GABA (the main inhibitory neurotransmitter) in ways that provoke intoxicated people with pre-existing aggressive tendencies. Alcohol encourages the release of pent-up anger, hatred, and desires In addition, low serotonin decreases impulse control. Misjudging intentions can also cause a person to perceive a threat where none exists, leading to a violent overreaction. Based on victim reports, 15% of robberies, 26% of aggravated assaults, and 50% of all homicides involve alcohol use. About 30% of the victims of violent crime reported that the offender had been drinking alcohol at the time of the offense. Any type of violence can cause permanent biochemical changes in the victim, changes that can make them more susceptible to drug abuse and other emotional problems. Depending on the study, 34% to 74% of sexual assault perpetrators had been drinking as had 30% to 79% of the victims. E. DRIVING UNDER THE INFLUENCE (pp. 5.31− −5.32) In 2009, one-third of traffic fatalities and one-third of vehicle accidents involved alcohol, down from 2005.

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If a driver’s BAC (blood alcohol concentration) registers above the legal limit of 0.08, no additional impairment testing is required to determine guilt. Officers often check eye movement if a driver is suspected of being impaired because alcohol causes the eyes to start jerking if they try to follow a moving object (nystagmus test). Two-thirds of those arrested for DUI have never been arrested before. More disturbing is the fact that only one driver is arrested for every 300 to 1,000 drunk-driving trips. Prevention strategies including lowering the BAC limit from 0.10 to 0.08, the threat of license revocation. losing revoking a license, raising the drinking age, a zero-tolerance policy for those under 21, impounding vehicles, educating bar tenders, waiters, anyone who serves alcohol, and requiring treatment for convicted drivers have reduced the number of alcohol-related traffic fatalities and injuries over the years 1. Injuries & Suicide 15% to 25% of emergency room patients tested positive for alcohol or reported alcohol use, with relatively high rates among those involved in fights, assaults, and falls. Alcoholics are 16 times more likely to die in falls and 10 times more likely to become burn or fire victims; 31% of those involved in boating fatalities had a BAC of .10 or more; 40% of industrial fatalities and 47% of injuries involved alcohol. Compared to the general population, the suicide rate for adult alcoholics is twice as high. VII. EPIDEMIOLOGY (PP. 5.33− −5.42) A. PATTERNS OF ALCOHOL CONSUMPTION (p. 5.33− −5.34) A person’s culture is one of the primary determinants of their drinking behavior. Different drinking patterns are found in wet and dry drinking cultures (excluding non-drinking Muslim countries). • Wet drinking cultures (e.g., Austria, France, and Italy) sanction almost daily use and integrate social drinking into everyday life. • Dry drinking cultures (e.g., Denmark, Norway, and Sweden) restrict the availability of alcohol and tax it more heavily. • Canada, England, Germany, Ireland, and the United States exhibit combinations of both wet and dry cultures. Patterns such as binge drinking in social situations are common. Other cultural patterns. • Alcohol plays a very minor role in China. • In Japan, most of the men and half of the women drink. • In Russia, vodka is traditionally consumed in large quantities between meals.

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•

In England, 70% drink regularly, beer accounts for 66% the alcohol consumption.

B. POPULATION SUBGROUPS (p. 5.34− −5.39) 1. Men & Women In all age groups, men drink more per drinking episode than women do, regardless of the culture. Men also have more adverse social and legal consequences and develop problems with alcohol abuse or alcohol dependence at a higher rate than women although proportionally, more women than men die from cirrhosis. ALCOHOL ABUSE WITHIN THE PAST MONTH (2009) Males Females Any alcohol use 57.7% 45.9% Binge drinkers 31.6% 15.4% Heavy drinkers 10.8% 3.4% Alcohol problems become greater for women in their thirties, men’s become greater in their twenties. Alcohol-dependent women, as a group, drink about one-third less alcohol than alcohol-dependent men. WOMEN & ALCOHOL PROBLEMS Less At Risk More At Risk Younger women Older women (60+) Loss of role (mother, job) Multiple roles Never Married Married Divorced, separated Widowed White women Black women Childhood sexual abuse The rate of alcoholism in relatives of females diagnosed with alcoholism is somewhat higher than in relatives of male alcoholics. Proportionally, more women than men die from cirrhosis of the liver, circulatory disorders, suicide, and accidents. Because society is more accepting of men who are alcoholics than it is of women who are alcoholics, women are less likely to seek treatment.

3. Adolescents The younger an individual starts drinking, the more likely he or she will have a problem later in life.

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In a major survey of students, Monitoring the Future, the percentages of teenagers who had been drunk in the past month were: Grade 1999 2009 • eighth grade 9.4% 5.4% • tenth grade 22.5% 15.5% • twelfth grade 32.9%. 27.4% Adolescent binge drinkers were also 17 times more likely to smoke than nonbinge drinkers. Alcohol can encourage unsafe sexual practices, which lead to higher rates of unplanned pregnancies, sexual aggression, and sexually transmitted diseases. When an adolescent is heavily involved is alcohol, their emotional growth becomes limited. 4. College Students & Learning Drinking usually has negative effects on learning and maturation. 47% of college students admit to binge drinking at least once every two weeks. Grade Average Drinks per Week Males Females Overall A 5.4 2.3 3.3 B 7.4 3.4 5.0 C 9.2 4.1 6.6 D or F 14.6 5.2 10.1 • •

•

Male students binge more than female students (48.6% to 40.9%); White students (50.2%) are more likely to binge than Hispanic (34.4%), Asian/Pacific Islander (26.2%), or Black (21.7%) students; Residents of fraternity houses (75.4%) drink more than dormitory residents (45.3%), off-campus residents (54.5%), or married residents (26.5%).

Binge drinking in college leads to about 1,700 deaths per year, 696,000 physical assaults, 599,000 injuries, and 97,000 sexual assaults. 5. Older Americans People 65 and older have the lowest prevalence of problem drinking and alcoholism due to spontaneous remission with age, limited resources, a body less able to handle alcohol, and more illness that exaggerate the effects of alcohol. By 2020, 34 million Americans will be 65 or older. The percentage of undiagnosed heavy drinkers among the elderly is high because of secrecy. 22

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Research indicates that patterns of drinking persist into old age. In nursing homes as many as 49% of the patients have drinking problems. The average 65+ American takes two to seven prescription medications daily, making alcohol/prescription drug interactions common. More than 150 prescription and over-the-counter medications interact negatively with alcohol. About one-third of elderly alcohol abusers are of the late-onset variety. Diagnosis of drug or alcohol problems in the elderly is made more difficult because of the coexistence of other physical or mental problems. It is often a patient’s physician who recognizes an alcohol problem while providing treatment for other medical conditions. A brief intervention by the physician is can direct the patient to get the help he or she needs. People 65 and older have the lowest prevalence of problem drinking and alcoholism. 6. Homeless There are several kinds of homeless: • situationally homeless (lost job, bankruptcy, divorce); • street people, who have made the streets their home; • chronic mentally ill, squeezed out of inpatient mental facilities; and • homeless substance abusers, particularly alcohol abusers. Estimates of the total number of homeless people range from 754,000 in one study to 1.5 million in another. The average length of homelessness is six months. The homeless population is made up of : • 47% single males, 16% single females; • 34% are families with children; • 17% are employed, 18.7% are veterans, and 23% disabled; • 45% African American, 5.7% Hispanic, and 41.1% White. It is estimated that: • 8% have HIV or AIDS, • 23% could be considered mentally ill, • 30% have serious substance-abuse problems. One common denominator among all of these groups is a lack of affiliation with any kind of support system. A comprehensive program to alleviate drug and mental problems among the homeless must involve outreach. Nationwide, there are 438,000 emergency and transitional yearround beds for the homeless. C. UNDERREPRESENTED POPULATIONS (pp. 5.39− −5. 42)

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Diverse cultural traditions make a great contribution to alcohol use and abuse patterns. 1. African Americans In 2008, heavy use of alcohol was lower among African Americans (5%) than among Whites (8%) and Hispanics (5%) as in previous years. Use on a monthly basis by African American men (42%) is also less than that by White men (57%). Peak drinking for African Americans occurred after the age of 30, whereas drinking among Whites peaked at a younger age. A long history of spirituality along with a strong matriarchal family structure, are two factors which limit abuse and aid in treatment. Medical problems brought on by heavy drinking among African Americans are more severe. 2. Hispanics In 2010 there were 47 million Hispanics in the United States, or about 15.5% of the total population. Hispanic cultures include Mexican American (60%), Puerto Rican (9.5%), Cuban American (3.2%), and dozens of other Spanish-speaking cultures. Drinking increases in the Hispanic community among both sexes as education and income increase. One of the problems with alcohol abuse and addiction in the Hispanic community is a lack of culturally relevant treatment facilities and personnel. Hispanic women drink considerably less than Hispanic men. In treatment, positive outcomes depend on strong family involvement plus an appreciation of the values of dignidad, respeto, y cariño (dignity, respect, and love). 3. Asians & Pacific Islanders (APIs) Asians and Pacific Islanders (APIs) are the fastest-growing ethnic group in the United States. They currently constitute only about 4.5% of the total population. Asians and Pacific Islanders are reported to have the lowest rate of drinking and drug use in the U.S. As APIs became more highly acculturated, drinking increases but culture helps deter heavy drinking. In one study in Los Angeles, Filipino Americans and Japanese Americans were twice as likely to be heavy drinkers as Chinese Americans. Korean Americans have the highest number of abstainers. Fewer APIs seek treatment because of the stigma involved in admitting that there is a problem. Treatment centers with API counselors on staff and specific API programs in place have a higher a API treatment population. 4. American Indians & Alaskan Natives The 2.7 million American Indians and Alaskan Natives in the United States represent more than 300 tribal or language groups.

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In general, drinking patterns vary widely among these tribes who make up about 1% of the population. Some tribes are mostly abstinent, some drink moderately, and some have high rates of heavy drinking and alcoholism. It is the pattern of heavy binge drinking among males in various tribes, especially on reservations, which accounts for the highly visible American Indian alcoholic. Historically, American Indians drank only weak beers or other fermented beverages and usually just for ceremonial purposes. When distilled alcoholic beverages were introduced, most American Indian cultures did not have time to develop ethical, legal, and social customs to handle the stronger drinks. The abuse of alcohol accounts for 5 of the 10 leading causes of death in most American Indian tribes. One study in Oklahoma found that alcohol-related causes of death varied from less than 1% to 24% among the 11 tribes surveyed, compared with 2% for African Americans and 3% for Whites. VIII. CONCLUSIONS (PP. 5.42) Because alcohol causes many serious health and societal problems, its use has often been restricted or banned by almost every country. Most restrictions are ultimately overturned because of demand and the lure of tax revenues by governments. It can take three months or 30 years to become an alcoholic —or it may never occur. Alcohol is a psychoactive drug that can cause irreversible physiological changes, making the user susceptible to alcoholism with heavy continued use.

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Chapter 5 – DOWNERS: ALCOHOL Discussion Topics 1. What kinds of provisions have societies made to control the problems of excess alcohol use? 2. How could someone use the BAC table to plan an evening of drinking? Using the BAC table, give some specific examples. 3. Ask students to summarize their perception of the various stages of alcohol use. Include frequency, amount, effects, and thought processes at each of these stages. a. experimental b. social/recreational c. habituation d. abuse e. addiction 4. Should safe drinking be taught in the home and/or at school even though it is illegal for underage people to drink? 5. What kinds of programs have been, or could be, effective in reducing binge and heavy drinking on campus? 6. What benefits or effects do college students seek from drinking? What negative consequences are most commonly experienced by college students who drink? 7. What are the effects of secondhand drinking, i.e., effects experienced by those who come in contact with drinkers? 8. What are some specifically male expectations when they drink? What are some specifically female expectations when they drink? 9. Discuss how culturally relevant alcohol and other drug treatment might work for several underrepresented populations (e.g., Native American, Hispanic). How would treatment differ? What aspects of traditional, non-culturally relevant treatment would be difficult for the client?

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Chapter 5 – DOWNERS: ALCOHOL Critical Thinking & Class Exercises 1. Have students write arguments for and against prohibition of alcohol as if they had to argue it in a court of law, discussing such aspects as legality, enforcement, cost, and effectiveness. 2. Have students collect 10–20 alcohol and cigarette ads and discuss what attitudes and values are being presented in relation to the advertiser’s product. 3. Ask students to develop 10 rules for responsible alcohol consumption (a “drinking etiquette”) that will both prevent harm to, and respect the rights of, the drinker, others around the drinker, and society at large. 4. Have groups of students create an informative and entertaining ad that stresses moderate and safe drinking and have the groups explain the rationale behind the message. 5. Ask students to describe their first drinking experiences. a. Was alcohol the focus of, or incidental to, the experience? b. What did they feel during the experience, immediately after? c. How did they view the experience at the time, today? 6. In the context of a discussion of alcohol binge drinking and abuse, ask students to give examples of excuses or statements indicating denial. a. rationalization (“In college everyone drinks.”); b. denial (“I can stop anytime I want.”); c. projection (“I don’t have a problem with my drinking, you do.”); d. excuse (“I drink only when I’ve had a hard day.”); e. misinformation (“I’m not an alcoholic, I only get bombed on the weekends.”).

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Uppers, Downers, All Arounders, 7th Edition – Instructor's Manual Chapter 6 – ALL AROUNDERS Overview This chapter summarizes the history, pharmacology, epidemiology, and the physical/ psychological effects of psychedelic drugs. The botany, compulsive qualities, and legal complications of marijuana use along with an examination of the medical marijuana controversy is also explored. Psychedelics have been used for thousands of years for religious, social, ceremonial, and medical purposes. They originally came from some of the 4,000 plants that have psychoactive effects. In more modern times, many psychedelics have been synthesized. LSD, MDMA, and hundreds of psycho-stimulants are created every day by street chemists. Psychedelics or “All Arounders” are generally classified into five major categories: • indoles: e.g., LSD, psilocybin mushrooms, ibogaine, DMT; • phenylalkylamines: e..g., mescaline (peyote), MDMA (ecstasy), MDA; • anticholinergics: e.g., belladonna, henbane, mandrake & datura; • miscellaneous psychedelics: e.g., PCP, DXM, Salvia divinorum; and • cannabinoids: marijuana. All psychedelics cause intensified and confused sensations as well as illusions, delusions, and hallucinations. Many of the psychedelics also cause stimulation, impaired judgment, and faulty reasoning. Marijuana is the most widely used psychedelic; 160 million people worldwide use Cannabis. The use of phenylalkylamines, also known as psycho-stimulants, particularly MDMA (ecstasy) has decreased slightly in recent years. Club drugs such as ecstasy, mephedrone and MDPV are used to enhance the music party/club/rave experience. Other so-called club drugs popular in the music scene include ketamine, GHB, and nitrous oxide. The other psychedelics are used at a fraction of the rate that marijuana is used. LSD use has gone down substantially since its heyday in the 1960s and ‘70s. Synthetic analogs of marijuana’s most psychoactive chemical, THC were sold legally as “herbal incense” with trade names like K2® or Spice® until 2011 when five of these chemicals were classified as Schedule I drugs of abuse. Most states have banned the sale of these incense products. Powerful synthetic stimulants sold as “bath salts” with trade names like Ivory Wave® or Cloud 9® were still legal under federal law in 2011 but several states have classified them as Schedule I illegal drugs.

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Chapter 6 – ALL AROUNDERS Chapter Outline I.

HISTORY

VI. ANTICHOLINERGIC PSYCHEDELICS (belladonna, henbane, mandrake & datura

II. CLASSIFICATION III. GENERAL EFFECTS A. ASSESSING THE EFFECTS 1. Physical & Mental Effects 2. Illusions, Delusions, & Hallucinations

IV. LSD, PSILOCYBIN MUSHROOMS, & OTHER INDOLE PSYCHEDELICS A. LSD (lysergic acid diethylamide) 1. History (also see Chapter 1) 2. Manufacture of LSD 3. Epidemiology 4. Pharmacology 5. Physical & Mental Effects 6. Bad Trips (acute anxiety reactions) 7. Mental Illness & LSD 8. Dependence B. “MAGIC MUSHROOMS” (psilocybin & psilocin) 1. Pharmacology 2. Effects C. OTHER INDOLE PSYCHEDELICS 1. Ibogaine 2. Morning Glory Seeds (ololiuqui) 3. DMT (dimethyltryptamine) 4. Ayahuasca (yage) 5. Foxy (5-methoxy-N, N-disopropyltryptamine [5-Me-DIPT)

V. PEYOTE, MDMA & OTHER PHENYLALKYLAMINE PSYCHEDELICS A. PEYOTE (mescaline) 1. Effects B. PSYCHO-STIMULANTS & Club Drugs 1. MDMA (ecstasy) 2. Parties, Festivals, Raves, & Music Clubs 3. 2C-T-7 & 2C-T-2 4. Nexus (2C-B or 4-bromo-2,5-dimethoxy phenylethylamine) 5. PMA (4-MA or paramethoxyamphetamine) 6. STP (DOM) (2,5-dimethoxy-4-methylamphetamine) 2

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VII. PCP, KETAMINE, SALVIA DIVINORUM & OTHER PSYCHEDELICS A. PCP B. KETAMINE 1. Effects C. SALVIA DIVINORUM (salvinorin A) D. AMANITA MUSHROOMS E. DEXTROMETHORPHAN F. NUTMEG & MACE G. BROMO-DRAGONFLY H. LEONOTIS LEONURUS I. EFAVIRENZ (Sustiva: HIV/AIDS medication)

VIII. MARIJUANA & OTHER CANNABINOLS A. HISTORY OF USE B. EPIDEMIOLOGY IN THE UNITED STATES C. BOTANY 1. Species 2. Sinsemilla & Other Forms of Marijuana 3. Growers D. SYNTHETIC MARIJUANA 1. Synthetic THC E. PHARMACOLOGY 1. Marijuana Receptors & Neurotransmitters F. SHORT-TERM EFFECTS 1. Physical Effects 2. Mental Effects 3. Novelty 4. Memory & Learning G. LONG-TERM EFFECTS 1. Respiratory Complications 2. Immune System 3. Acute Mental Effects H. TOLERANCE, WITHDRAWAL, & ADDICTION 1. Tolerance 2. Withdrawal 3. Addiction I. MARIJUANA (Cannabis) & THE LAW 1. Marijuana, Driving, & Drug Testing J. MEDICAL USE OF MARIJUANA 1. Epidemiology & Dispensaries 2. Medical Effects © 2011, CNS Productions, Inc.

3. Rationale For & Against Medical Marijuana

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Chapter 6 – ALL AROUNDERS Extended Outline I. INTRODUCTION & HISTORY (PP. 6.2−6.3) Psychedelics dramatically alter a user’s sensory perceptions and create a world in which reason takes a back seat to intensified sensations by creating illusions, delusions, and hallucinations. More than 4,000 plants have psychedelic (hallucinogenic) or psychoactive properties but only a few dozen are used. Some of these plants have been around for 250 million years. The initial objective of use was to alter one’s consciousness and perception of reality rather than to induce an immediate rush. Most psychedelics are grown and used in the Americas, Europe, and Africa; the major exception is marijuana which is grown and used throughout the world. People have used peyote, psilocybin mushrooms, yage, marijuana, and morning glory seeds for religious, social, ceremonial, and medical purposes. Other than marijuana, psychedelics are more popular among young White users, followed by Hispanics. Per-capita use among African Americans is the lowest.

II. CLASSIFICATION (P. 6.3) There are five main chemical classifications of psychedelics: • indoles (e.g., LSD, psilocybin mushrooms); • phenylalkylamines (e.g., peyote, MDMA) • anticholinergics (e.g., belladonna, datura); • others (e.g., ketamine, PCP, Salvia divinorum, dextromethorphan [DXM]); • cannabinoids found in marijuana (Cannabis) plants.

III. GENERAL EFFECTS (PP. 6.3−6.12) A. ASSESSING THE EFFECTS (pp. 6.3−6.5) Much of the information about the effects of psychedelics is anecdotal rather than the result of extended scientific testing. Most plant-based psychedelics contain more than one active ingredient. The duration and intensity of the effects depend on • the toxicity of the psychedelic • the dose • the users experience with the drug, • the basic emotional makeup of the user, • the users mood/mental state at the time of use, • the existence of any mental illnesses • the surroundings in which the drug is taken.

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1. Physical & Mental Effects LSD, ecstasy, and most other hallucinogens stimulate the sympathetic nervous system, raising pulse rate and blood pressure and causing sweating and nausea. Psychedelics’ effects on serotonin alter sensory perception. The stimulation of the brainstem overloads the sensory pathways, making the user acutely aware of all sensation. Disruption of visual and auditory centers can confuse perception. An auditory stimulation such as music might jump to a visual pathway, causing the music to be “seen.” This crossover or mixing of the senses is known as synesthesia. 2. Illusions, Delusions & Hallucinations An illusion is a mistaken perception of an external stimulus. A delusion is a mistaken idea or belief that is not swayed by reason or other contradictory evidence. A hallucination is a sensory experience that doesn’t come from external stimuli.

IV. LSD, PSILOCYBIN MUSHROOMS & OTHER INDOLE PSYCHEDELICS (PP. 6.5−6.12) Indole psychedelics are also known as serotonin-like psychedelics because they seem to exert many of their effects through interactions with serotonin receptors, particularly those designated 5HT2A. In addition to affecting mood, sleep, and anxiety, serotonin influences areas of the brain that are most likely to generate hallucinations and illusions. A. LYSERGIC ACID DIETHYLAMIDE (LSD) (pp. 6.5−6.9) 1. History LSD (lysergic acid diethylamide) is a semisynthetic form of an ergot fungus toxin that infects rye and other cereal grasses. The brownish purple fungus was responsible for many outbreaks of ergot poisoning and thousands of deaths over the centuries due to farmers and town folk accidentally injesting the infected grain. Gangrenous ergotism, also known as “Saint Anthony’s Fire,” is marked by feverish hallucinations and gangrenous extremities rotting away. Convulsive ergotism is marked by visual and auditory hallucinations, painful muscular contractions, delirium, convulsions, etc. Dr. Albert Hoffman first extracted LSD in 1938. He discovered the hallucinogenic properties of the new drug after accidentally ingesting a dose. LSD was studied as a potential therapy for mental illnesses and alcoholism, and as a key to investigating thought processes. In the early 1950s the CIA conducted a number of experiments using LSD as a potential truth drug or mind-control drug in a program code-named MKULTRA. 5

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Harvard psychologists Drs. Timothy Leary and Richard Alpert popularized LSD-25. Dr. Leary’s slogan “Turn on, tune in, and drop out,” was used endlessly in newspaper articles and TV news shows and served as the rallying cry for the youth of the 1960s and 1970s. LSD was made illegal on February 1, 1966. All scientific research on the drug ceased in the early seventies, recently research on LSD and MDMA has been renewed. 2. Manufacture of LSD The majority of LSD was manufactured in the San Francisco Bay Area. Eleven pounds of LSD is the nation’s annual consumption. The end product of the initial synthesis, crystalline LSD, is dissolved in alcohol. The solution is dropped on blotter paper and chewed or swallowed. 3. Epidemiology Young Americans used LSD in the early 1990s, but use dropped by the early 2000s due to the popularity of ecstasy and federal efforts to restrict the manufacture of LSD (by 95%). Price also became an issue, a single hit went from $5 to $20 or more. In the 1990s and 2000s, young teens said they tried LSD to get high or to augment the effects of ecstasy, GHB, or ketamine at raves, clubs and parties. Standard drug tests usually do not screen for LSD which contributed to the brief resurgence in use. 4. Pharmacology LSD (C20H25N3O) is remarkable for its potency. Doses as low as 25 µg, or 25 millionths of a gram, can cause stimulatory as well as mental effects. Effects appear 15 to 60 minutes after ingestion, peak at 2 to 4 hours, and last 6 to 8 hours. The user returns to the pre-drug state 10 to 12 hours after ingestion. The usual psychedelic dose of LSD is 150 to 300 µg. Tolerance develops very rapidly to the psychedelic effects of LSD. Withdrawal usually mental and emotional rather than physical. 5. Physical Effects & Mental Effects LSD can cause a rise in heart rate and blood pressure, a higher body temperature, dizziness, dilated pupils, and some sweating. 6. Mental Effects LSD overloads the brainstem, the sensory switchboard for the mind, causing sensory distortions (seeing sounds, feeling smells, or hearing colors [synesthesia]), dreaminess, depersonalization, altered mood, impaired concentration, and weakened motivation. One of the greatest dangers of use is impaired reasoning and loss of judgment. This loss, coupled with slowed reaction time and visual distortions, can make driving a car a recipe for disaster. 7. Bad Trips (acute anxiety reactions)

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Because LSD affects the emotional center in the brain and distorts reality, some novice users are subject to the extremes of euphoria and panic. Depersonalization and lack of a stable environment can trigger acute anxiety, paranoia, fear of loss of control, and delusions of persecution. 8. Mental Illness & LSD Proponents of psychotherapeutic use claim that drug-stimulated insights provide some patients with a shortcut through psychotherapy, a process in which uncovering traumas and conflicts from the subconscious helps the patient heal. Users with a preexisting mental illness or instability can aggravate those conditions, creating more-severe mental disturbances. Some otherwise normal users can experience a temporary, but prolonged, psychotic reaction or severe depression that requires extended treatment. Flashbacks & Hallucinogen Persisting Perception Disorder (HPPD). A number of users experience mental flashbacks of sensations, or of a bad trip they had while under the influence of LSD. Most flashbacks are provoked by some sensory stimulus: sight, sound, odor, or touch. The other type of HPPD is the intermittent or continuous experience of LSD-like visual and perceptual disturbances that chronically occur. This type of HPPD may disappear within five years or may persist indefinitely. A number of psychedelics have the capacity to cause HPPD (e.g., LSD, MDMA, MDA, mescaline, DMT, PCP, marijuana, and psilocybin). Flashbacks are experienced by 23% to 64% of regular LSD users. A number of medications have been tried on HPPD but with limited success. 9. Dependence The 500 or more LSD trips reported by some users are probably due to a psychological dependence rather than a physical dependence even though tolerance does develop rapidly. B. “MAGIC MUSHROOMS” (Psilocybin & Psilocin) (pp. 6.9−6.10) Psilocybin and psilocin are the active ingredients in a number of psychedelic mushrooms found in the Americas, Southeast Asia, and Europe. These mushrooms were especially important to Indian cultures in Mexico and in the pre-Columbian Americas; they were used in ceremonies dating as far back as 1000 B.C. and are still used today. Persecution by the Spanish Conquistadores in the sixteenth and seventeenth centuries drove the ceremonial use of mushrooms underground for hundreds of years. Shamans use the mushrooms to induce visions that would help them treat illnesses, resolve problems, or communicate with the spirit world.

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1. Pharmacology Psilocybin and psilocin are found in about 100 different species of mushroom. The chemical structure of psilocybin is similar to that of LSD. Both wild and cultivated mushrooms vary greatly in strength, so a single potent mushroom might have as much psilocybin as 10 weak ones. Psychic effects are obtained from doses of 10 to 60 milligrams (mg) and generally last three to six hours. 2. Effects Most mushrooms containing psilocybin cause nausea and other physical symptoms before the psychedelic effects take over. The effects include visceral sensations, changes in sight, hearing, taste, and touch, and altered states of consciousness. Psilocybin does not create as much disassociation or panic as does LSD. One of the major dangers of “’shroom” harvesting is mistaking poisonous mushrooms for those containing psilocybin. C. OTHER INDOLE PSYCHEDELICS (pp. 6.10−6.12) 1. Ibogaine Produced by the African Tabernanthe iboga shrub and other plants, ibogaine in low doses acts as a stimulant; in higher doses it produces long-acting psychedelic effects and a self-determined catatonic reaction that can be maintained for up to two days. There is research on the use of ibogaine to treat heroin, alcohol, and cocaine addiction. 2. Morning Glory Seeds (ololiuqui) Seeds from the morning glory plant or Hawaiian baby woodrose contain several LSD-like substances, particularly lysergic acid amide, which is about one-tenth as potent as LSD. It takes several hundred seeds to get high, that quantity magnifies the drug’s nauseating properties. Commercially sold morning glory seeds are dipped in a toxin that induces vomiting. 3. DMT (dimethyltryptamine) DMT is found naturally in South American trees, vines, shrubs, and mushrooms (e.g., yopo beans) and is synthesized by street chemists. DMT is a psychedelic substance similar in structure to psilocin. It can also be snorted or injected. South American tribes have used it for more than 400 years. It is prepared from several different plants as a snuff called “yopo,” “cohoba,” etc. DMT causes intoxication, intense visual rather than auditory hallucinations, and often a loss of awareness of surroundings lasting 30 to 60 minutes or less. The short duration of action gave rise to its nickname, “businessman’s special.” 8

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4. Foxy (5-methoxy-N, N-diisopropyltryptamine [5-Me-DIPT]) & AMT (alphamethyltryptamine) These two psychedelic tryptamines appeared in the early 2000s, today they are listed as scheduled drugs. Effects include hallucinations, euphoria, empathy, visual and auditory disturbances (illusions), formication, paranoia, and emotional distress. The effects can last 12 to 24 hours, smaller doses last only 3 to 6 hours. 5. Ayahuasca (yage) Ayahuasca, also known as yage, is a psychedelic drink made from the leaves, bark, and vines of Amazon jungle vines. Drinking this preparation causes intense vomiting, diarrhea, and then a dreamlike condition that lasts up to 10 hours. The active ingredient is the indole alkaloid harmaline. Native cultures often mix yage with DMT plant extracts to intensify the effects. Over the past few years, cults using ayahuasca as the focus of their beliefs have sprung up in Brazil.

V. PEYOTE, MDMA & OTHER PHENYLALKYLAMINE PSYCHEDELICS (PP. 6.12−6.17) This class of psychedelics is chemically related to adrenaline and amphetamine, although many of the effects are quite different. Phenylalkylamines take several hours to reach their peak. A. PEYOTE (MESCALINE) (pp. 6.12-6.14) Mescaline is the active component of the peyote cactus (Lophophora williamsii) and the San Pedro cactus (Trichocereus pachanoi). The use of the peyote cacti goes back to at least 3700 B.C. Over the centuries the Aztecs, Toltecs, Chichimecas, and several Meso-American cultures included it in their rituals. There have been many challenges to the legality of using a psychedelic substance for a religious ceremony. In 1996 the U.S. Supreme Court ruled that the use of peyote during religious ceremonies by Native Americans is protected by the Constitution, and individual states cannot ban its use. The Native American Church of North America has a claimed membership of 250,000 and uses peyote. Peyote cacti are eaten in spiritual ceremonies by the tribes in northern Mexico. 1. Effects The gray-green crowns of the peyote cactus are cut at ground level or uprooted and are used fresh or dried. The effects of mescaline last approximately 12 hours and are very similar to LSD with an emphasis on colorful visions and hallucinations. A peyote ceremony might consist of ingesting 8-12 peyote buttons, then singing, drumming, and chanting to seek a spiritual experience through psychedelic visions. 9

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Use of a mind-altering substance in a structured ceremonial setting can induce a higher level of spirituality than use at a rock concert. Peyote’s connection to spiritual matters limits abuse. B. PSYCHO-STIMULANTS (MDA, MDMA, 2C-B, PMA, 2C-T-7, 2C-T-2, ET AL.) & CLUB DRUGS (pp. 6.14−6.17) Psycho-stimulants are chemically defined as phenylethylamine derivatives similar to mescaline.

1. MDMA (ecstasy) The psycho-stimulant MDMA, chemical name 3, 4-methylenedioxymethamphetamine, is shorter acting than MDA (4 to 6 hours vs. 10 to 12). It can be swallowed, snorted, or injected, much like methamphetamine, though it is usually sold as a capsule, tablet, or powder. MDMA is taken at parties, raves, and music clubs because users claim it creates a strong desire to move about, dance, and interact with other people. History. The German pharmaceutical company, Merck, first discovered MDMA in 1914 as an intermediate chemical step in its synthesis of MDA. The first published human study of MDMA in 1969 described the personal insight the drug produced and recommended its use to a number of therapists to help their patients tap into their emotions and repressed memories. Some therapists continued to experiment with MDMA as a treatment for psychological disorders. After a series of hearings, starting in 1985, MDMA was banned in 1988 in the United States as a Schedule I drug, making it impossible to legally continue psychotherapeutic experimentation. Prior to its ban, up to 50,000 tablets a week were legally sold. Trafficking in this psycho-stimulant continues but not at the rate of a few years ago. Use & Cost. Ecstasy is often stuffed into a Tootsie Roll, users call it “rolling”. Vicks® inhalants and other pungent substances that are said to be pleasingly enhanced by the use of “E” are also found at rave clubs. A capsule, a tablet, or an equivalent powder packet (75 to 125 mg) costs about $25, sometimes as high as $70. A DEA report found that 30% to 50% of the tablets sold as MDMA at raves contain no MDMA but rather other illicit drugs such as PCP and/or methamphetamine. Physical Effects. MDMA has stimulant effects similar to amphetamines. The onset usually consists of tightening muscles with generalized spasms, trismus (jaw muscle spasm), and bruxism (clenching of the teeth) prior to the psychic effects. For occasional users of low or moderate amounts, most of the physical effects are relatively benign. More serious MDMA effects include dehydration, blurred vision, headaches, agitation, nausea, anorexia, dangerous heart arrhythmias and, in a few cases, seizure activity, stroke, cardiovascular failure, coma, and malignant hyperthermia (high body temperature). 10

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Mental/Emotional Effects. Twenty minutes to an hour after ingestion and continuing for 3 to 4 more hours, MDMA induces feelings of happiness, clarity, peace, pleasure, and altered sensory perceptions. Users also report experiencing increased nonsexual empathy for others, more self-awareness, and heightened self-esteem, open mindedness, acceptance, and intimacy in their interactions. For the first few hours of use, ecstasy continues to overwhelm the vesicles and forces them to discharge their reservoirs of serotonin. It can take up to a week or more to produce a sufficient amount of serotonin to re-experience similar feelings. Due to this excessive stimulation, serotonin receptors retreat into the cell membrane to avoid damage. This process, called “down regulation,” Following an ecstasy experience, some users have been known to become extremely depressed and suicidal. MDMA Polydrug Combinations. Ecstasy is often ingested simultaneously with a number of prescription and street drugs. • LSD with ecstasy is said to prolong and intensify the effects of both drugs. • OxyContin, ® heroin, or GHB with ecstasy are Generation X speedball combinations. • Nitrous oxide with ecstasy is used to intensify the inhalant rush. • MDMA with Viagra® used enhance sexuality is called “sextacy.” 2. Parties, Festivals, Raves & Music Clubs Raves are gatherings where patrons dance to loud computer-generated techno or electronic trance beat music, light shows and laser light effects are performed, and, at many, both club drugs and drug paraphernalia are condoned. Today some of the clubs have permanent locations and some are nomadic. The most popular drugs at these gatherings are ecstasy, nitrous oxide (“laughing gas”), GHB or GBL, and occasionally dextromethorphan, ketamine, PCP, and nexus (2C-B). More traditional street drugs are also available, especially methamphetamine and marijuana. Alcohol is always available along with various prescription medications. Most who attended these gatherings do not suffer adverse effects, they are there to enjoy the music, dance, and socialize. Incidents do sometimes occur including harmful physical reactions to drugs, overheating, falling injuries, passing out, bad psychedelic experiences, and mental destabilization. 3. 2C-T-7 & 2C-T-2 The common effects of these phenethylamine psycho-stimulant drugs are their ability to induce delirium, heighten sensitivity, and increase awareness in the user. Use can also cause dangerous cardiovascular effects and even death when taken in high doses. 11

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The abuse of 2C-T-2, spread through “smart shops” in the Netherlands, Sweden, Germany, and Japan, led to its ban in the Netherlands in 1999. 4. Nexus (2C-B [CBR] or 4-bromo-2,5-dimethoxy phenylethylamine) The effects of 2C-B are dependent on the amount taken: mild stimulation at low doses and intense psychedelic experiences at high doses. A number of users combine 2C-B and MDMA to intensify the experience. 5. PMA (4-MA or paramethoxyamphetamine) Recently, PMA has been found in pills smuggled in from Europe purporting to be ecstasy. Effects of this short short-acting drug materialize after an hour and include a sudden rise in blood pressure, distinct afterimages, and tingly sensations similar to pins-and-needles, a chill or hair standing on end. 6. STP (DOM) (2,5-dimethoxy-4-methylamphetamine) STP, also called the “serenity,” “tranquility,” or “peace” pill, is similar to MDA. It causes a 12-hour intoxication characterized by intense stimulation and several mild psychedelic reactions. It was used in the 1960s and 1970s but is rarely used today because of the high incidence of bad trips.

VI. ANTICHOLINERGIC PSYCHEDELICS (Belladonna, henbane, mandrake & datura [jimson weed, thornapple]) (PP. 6.17−6.18) From ancient Greek times through the Middle Ages and the Renaissance, these plants, which contain hyoscyamine, atropine, and scopolamine, have been used in magic ceremonies, sorcery, witchcraft, and religious rituals. They have also been used as a narcotic, a diuretic, a sedative, an antispasmodic, a poison, to mimic insanity, and a beauty aid. The drugs block acetylcholine receptors causing a form of delirium and compromising the ability to visually focus. They also speed up the heart, cause intense thirst, and raise the body temperature to dangerous levels. Anticholinergics also create hallucinations, a separation from reality, and cause the user to fall into a deep sleep for up to 48 hours Jimson weed is a bristly plant with coarse green leaves and white flowers that induces jerky movements, tachycardia, hypotension, and severe halluci-nations such as imaginary snakes, spiders, and lizards. Few users try the drug twice.

VII. KETAMINE, PCP & OTHER PSYCHEDELICS (PP. 6.18−6.22) Other lesser-known psychedelics fall in and out of favor depending on the generation and how strong their memory is of the reasons people originally quit using these drugs.

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A. PCP (PHENCYCLIDINE HYDROCHLORIDE) (p. 6.18) PCP was first used as a dissociative general anesthetic for humans, however, by the mid 60s the frequency and the severity of toxic and hallucinogenic effects limited the drug’s value to veterinary medicine. Today the only supplies are from illegal sources. PCP is often misrepresented as THC, mescaline, MDMA, or psilocybin. It can be smoked, snorted, swallowed, or injected. PCP blocks sensory messages to the central nervous system, dissolving inhibitions, deadening pain, and causing a mind/body separation. Hallucinations (tactile, visual, or auditory) were reported by about 40% of users. The most alarming effects of PCP—self-inflicted injuries and violent run-ins with authorities—occur because of PCP’s dissociative effects. A low dose of PCP lasts 1 to 2 hours, a moderate dose 4 to 6 hours, and a large dose, up to 48 hours. B. KETAMINE (p. 6.19) The effects of ketamine, a dissociative general anesthetic used in human and veterinary medical procedures, are very similar to those of PCP, its close chemical relative and predecessor, but do not last as long. Ketamine was the most common anesthetic used during the Vietnam War. Illegal use involves microwaving the liquid to create crystals that are then smoked in a crack pipe or snorted. A “K-land” dose of 100 to 200 mg results in a mild dreamlike intoxication, a sensation of a mind/body separation, dizziness, initial free-floating giddiness, slurred speech, and impaired muscular coordination. A 300 to 500 mg dose produces the full psychedelic experience known as “being in a K-hole,” described as an out-of-body near-death encounter with depersonalization, hallucinations, delirium, and occasionally bizarre or mystical experiences. Users are also anesthetized against pain. Costs range from $100 to $200 per vial, or $20 to $25 per dose. An overdose includes respiratory depression, increased heart rate and blood pressure, combative or belligerent behavior, convulsions, and in a few cases, coma. Several researchers have used ketamine to treat alcoholism in a technique known as ketamine-assisted psychotherapy. Rapid and dramatic development of tolerance, along with a profound psychic dependence, occurs with daily use of ketamine. Major effects last for about an hour, secondary effects include compromised coordination, judgment, and sensory perceptions lasting 18 to 24 hours. C. SALVIA DIVINORUM (Salvinorin A) (p. 6.20) Salvia’s unique psychic effects have been likened to a combination of various psychedelic drugs. Dried leaves and live cuttings are chewed and absorbed, causing dreamlike hallucinations, occasional delirium, and outof-body sensations. When it is smoked, the major effects last for a few minutes, taper off after 7 to 10 minutes, and disappear within 30 minutes. An ounce of Salvia divinorum can be extracted from 100 to 200 leaves, 13

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enough for 4 to 12 doses. Salvinorin A is thought to be the key psychoactive chemical. It takes 3 lbs. of leaves to make 1 oz. of salvinorin A extract. Some countries such as Germany and Australia regulate its use. As of 2010 it was legal in the United States but not for human consumption. Most users are high school or college students. D. AMANITA MUSHROOMS (pp. 6.20−6.21) The Amanita muscaria is a large mushroom with an orange, tan, red, or yellow cap with white spots. It can cause dreamy intoxication, hallucinations, delirious excitement, and can have a deadly physical toxic effect. The Amanita mushroom is one of the few psychedelics that can be sold legally in the United States but only for their historical and ethnobotanical interest; they are listed as a poison by the FDA making them illegal to sell for human consumption. A person can buy an ounce of minced Amanita mushrooms over the internet for about $15. E. DEXTROMETHORPHAN (Robitussin DM,® Romilar® & other cough syrups) (p. 6.21) Dextromethorphan, an opioid, is an ingredient in many nonprescription cough suppressants. High concentrations cause psychoactive and psychedelic effects. A 300 to 600 mg dose causes effects that will last for 6 to 8 hours. Intense mental effects include euphoria, mind/body separation, auditory and visual hallucinations, and a loss of coordination. Overdoses can occur. Naloxone has been used to treat overdoses. F. NUTMEG & MACE (p. 6.21) At the low end of the psychedelic drug spectrum are nutmeg and mace, both from the nutmeg tree (myristica fragrans). They can cause varied effects from a mild floating sensation to a full-blown delirium. Huge quantities must be consumed (about 20 g) to generate any effects leaving the user with a bad hangover and a severely upset stomach. Abuse is extremely rare outside of prison. G. BROMO-DRAGONFLY (p. 6.21) Sometimes referred to as FLY or B-FLY, this phenethylamine psychedelic is more potent and longer-lasting than other phenethylamines. It causes hallucinations, visual distortions, muscle tension, memory loss, confusion and acute anxiety. Effects last from six hours to four days. H. LEONOTIS LEONURUS ( Lion's Tail, Wild Dagga) (p. 6.22) This South African bush has effects similar to marijuana (e.g., lightheadedness, giddiness, mild euphoria, and mild hallucinogenic effects). As of 2011, dried leaves and seeds were legally available online.

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I. EFAVIRENZ (Sustiva®: HIV/AIDS medication) (p. 6.22) Used to treat AIDS and HIV, this protease inhibitor causes lightheadedness, dizziness, vivid dreams, hallucinations, depersonalization, relaxation and forgetfulness. The psychedelic effects occur in 25% of users. This drug is usually diverted from legitimate suppliers or stolen from AIDS/HIV patients.

VIII. MARIJUANA & OTHER CANNABINOIDS (PP. 6.22−6.40) A. HISTORY OF USE (pp. 6.22−6.25) From its probable origin in China or central Asia, hemp cultivation has spread to almost every country in the world. There are a variety of species; some Cannabis plants are better for fiber, some for food, some for medications, and some for inducing psychedelic effects. Over succeeding millennia, Cannabis continued to be used in all its forms. In third-century Rome, ropes and sails for ships’ riggings were made from hemp fiber. Cannabis was widely cultivated in America until the nineteenth century, when the end of slavery made it less profitable. Because it was not banned in the Qur'an by the Prophet Mohammed, Islamic cultures spread its use to Africa and Europe. After World War I, migrant laborers who worked in the United States introduced the habit of smoking marijuana for its psychoactive effects. As a result of newspaper articles written to scare the public, and a prohibitionist attitude, the use of Cannabis (except for sterilized birdseed) was banned by the Marijuana Tax Act of 1937. B. EPIDEMIOLOGY IN THE UNITED STATES (p. 6.25) In 1960, only 3 to 4 million people had tried any illegal drug. By 1979, 68 million people had tried marijuana. By 1992, the monthly rate of use dropped to one-third of its 1979 peak. By 2008, more than 15.2 million Americans were using marijuana on a monthly basis. According to the Drug Abuse Warning Network, more than 374,000 visits to emergency rooms listed marijuana as a contributing factor up from just 80,000 10 years earlier. In addition, 33% to 50% of adult male arrestees tested positive for marijuana. C. BOTANY (pp. 6.25−6.28) 1. Species Cannabis is the botanical genus of a number of species. Hemp is used to describe Cannabis plants that are high in fiber content. Marijuana is used to describe Cannabis plants that are high in psychoactive resins. Cannabis sativa, Cannabis indica, and Cannabis ruderalis are the three species referenced in this textbook . The most common species, Cannabis sativa is grown in tropical, subtropical, and temperate regions throughout the world. Variations of Cannabis sativa have sufficient quantities of active resins to cause 15

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psychedelic phenomena other variations have a high concentration of fiber and are used for hemp. The second species, Cannabis indica, sometimes called “Indian hemp,” is a shorter, bushier plant and is the source of most of the world’s hashish. Many illegal growers prefer Cannabis indica as the base plant for cultivating sinsemilla. The third species, Cannabis ruderalis (weedy hemp), a small thin plant, has a small amount of THC and is especially plentiful in Siberia and western Asia 2. Sinsemilla & Other Forms of Marijuana The sinsemilla growing technique increases the potency of the marijuana plant and is used in the cultivation of both Cannabis indica and Cannabis sativa. The sinsemilla technique involves separating female plants from male plants before pollination. Dried marijuana buds, leaves, and flowers are crushed and rolled into “joints” or smoked in pipes. In India, there are three preparations of marijuana: • Bhang - from the stem and the leaves, has the lowest potency. • Ganja - from the stronger leaves and the flowering tops. • Charas - the concentrated resin from the plant and is the most potent. This sticky resin is pressed into cakes and called “hashish.” The resin contains most of the psychoactive ingredients. Hash oil can be extracted from the plant (using solvents) and added to foods. The THC concentration of hash oil has been measured as high as 70%. 3. Growers The majority of the marijuana used in the United States comes from Mexico and Colombia. Mexican drug trafficking organizations (DTOs) have growing operations in the rich soils of remote U.S. forests. Plantings that have been discovered contained anywhere from 2,000 to 10,000 plants. In the United States, 10% to 50% of the available marijuana is homegrown. Heightened surveillance moved some outdoor operations indoors, 451,000 plants have been seized from indoor grows and 7,562,000 from outdoor grows. Some marijuana is grown hydroponically (in water). The advent of indoor growing led to a supply of very high-potency plants worldwide. The average potency of marijuana has risen to 10.14% in 2008 The common unit of sale is 1 oz. (a “lid”), the average street price in the United States ranges from $200 to $400 per “lid.” Street prices for smaller amounts average $10 a gram (28.3 g equals 1 oz.) one-eighth of an ounce – the most common measure (about 3 to 4 grams) goes for $50 to $60. The profits are enormous: 500 lbs. of marijuana bought in Mexico for $50,000 can bring $400,000 in St. Louis. Medical marijuana purchased at legitimate dispensaries costs about $40 to $60 for an eighth of an ounce. 16

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D. SYNTHETIC MARIJUANA (pp. 6.28−6.29) 1. Synthetic THC Synthetic THC, called dronabinol (Marinol®) or Cesamet,® is available to treat medical conditions such as glaucoma and multiple sclerosis. Patients prefer smoking it or eating it in food in order to control their intake. A third synthetic THC, Sativex, was developed to be used in a spray inhaler. 2. Designer Cannabinoids These are synthetic cannabinoid-like chemicals sold over the Internet and in head shops as incense or herbal smoking blends under a variety of trade names like K2,® Spice Gold,® and Yucatan Fire.® These compounds do not test positive for marijuana so they became popular in Europe and the United States, but increasing legal restrictions by more than a dozen states and a number of other countries are making them scarcer. E. PHARMACOLOGY (pp. 6.29−6.30) Researchers have discovered more than 420 chemicals in a single Cannabis plant. At least 30 of these chemicals, called cannabinoids, have been studied for their psychoactive effects. When smoked or ingested, these potent psychoactive chemicals are converted by the liver into more than 60 other metabolites. The most potent psychoactive chemical is ∆-9-tetrahydro-cannabinol, or THC. Cannabinol and cannabidiol are other prominent cannabinoids, but they are not thought to have psychoactive properties. 1. Marijuana Receptors & Neurotransmitters In 1988 and 1990, researchers detected receptor sites in the brain that were specifically reactive to THC, implying that the brain had its own natural neurotransmitters that fit into these receptor sites. Two years later the discovery of anandamide, an endocannabinoid that fits into the cannabinoid receptor sites, was discovered. A few years later, another endocannabinoid was discovered - 2AG which is more abundant but not as active as anandamide. The receptors for anandamide include CB1 and CB2 receptors. CB1 receptors are found mostly in areas of the brain that regulate the integration of sensory experiences with emotions as well as those controlling functions of learning, memory, a sense of novelty, motor coordination, and some automatic bodily functions. CB2 receptors seem to be limited to the immune system and a few other sites in the lower body. It is uncommon to physically overdose on marijuana because receptors are scarce in the part of the brain that controls respiration and blood pressure.

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F. SHORT-TERM EFFECTS (pp. 6.30−6.32) 1. Physical Effects Physical relaxation or sedation, some pain control, bloodshot eyes, lung irritation, an increase in appetite, and a small to moderate loss of muscular coordination are common. Other physical effects include increased heart rate, decreased blood pressure, and decreased eye pressure. Marijuana impairs tracking and causes a trailing phenomenon producing afterimages of a moving object. These effects impede the ability to perform tasks that require depth perception and hand/eye coordination. Marijuana can act as a stimulant as well as a depressant, depending on the variety and the amount of chemical that is absorbed in the brain, the setting in which it is used, and the personality of the user. Flooding CB1 receptors in the hypothalamus with THC increases the appetite. Smoking marijuana does not sharpen one’s sense of taste, but it does enhance the sensory appeal of foods, especially in a friendly environment 2. Mental Effects Within a few minutes of smoking marijuana, the user becomes confused and mentally separated from the environment. Additional effects include drowsiness, detachment, and difficulty concentrating. Very potent marijuana can produce giddiness, increased alertness, and major distortions of time, color, and sound, and excessively strong doses have been known to produce a sensation of movement under one’s feet, visual illusions, and sometimes hallucinations. Paranoia and depersonification can also occur. Marijuana is referred to as “the mirror that magnifies” because it exaggerates mood and personality and makes smokers more empathetic to others’ feelings. It also makes smokers more suggestible. The effects of THC on the amygdala, the emotional center of the brain, are key to understanding many of marijuana’s effects.

3. Novelty Part of the amygdala’s function is judging the emotional significance of objects and ideas encountered in a person’s environment. THC artificially stimulates the CB1 receptors in the amygdala, making even mundane objects interesting, - “virtual novelty.” When too much marijuana is used, receptors react by retracting into the cell membrane and becoming inactive (down regulation). The chronic user will perceive things that are truly novel as mundane and boring. To regain the perception of novelty, one has to continue to use

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4. Memory & Learning Normally, the hippocampus stores current sensory input for immediate use before it is shifted to long-term memory. The body’s own anandamide determines how much of the hippocampus is available. When an external cannabinoid like THC is taken into the body, it severely limits the available amount of hippocampal short-term memory. As use is discontinued, the short-term memory is usually restored Although marijuana slows learning and disrupts concentration because of its influence on short-term memory, it has a lesser effect on long-term memory. A recent study of 150 heavy marijuana users in treatment, found that memory, attention span, and cognitive functioning were impaired. However, smokers have the incorrect perception that they are learning and thinking at levels much higher than reality suggests. Marijuana affects the juvenile brain more severely than the adult brain. At the age of about 12, there is an explosion in the number of connections and synapses among the nerve cells in the brain. The ability to hone in on things that are important and ignore things that are not is reduced over time, impairing a person’s ability to judge danger. 5. Time The distortion of a sense of time (temporal disintegration) is responsible for several of the perceived effects of marijuana. Dull monotonous jobs seem less repetitive. On the other hand, a student who smokes marijuana while studying (a more complex activity) often becomes bored and abandons the task. Marijuana impairs a user’s ability to perform multiple and interactive tasks, like installing a computer program while under the influence. G. LONG-TERM EFFECTS (pp. 6.32−6.34) 1. Respiratory Problems Regularly smoking marijuana causes coughing and other symptoms of acute and chronic bronchitis. Dr. Donald Tashkin of UCLA determined through microscopic studies of these mucous membranes, that most damage occurs in the lungs of those who smoke both cigarettes and marijuana; approximately 75% of marijuana smokers also smoke cigarettes. Marijuana smoking damages lung tissue but whether it causes cancer is unclear. In 2006, Dr. Tashkin and other researchers found no link between exclusive marijuana smoking and lung cancer, even among heavy marijuana smokers. 2. Immune System Epidemiologic studies identify marijuana as a cofactor in the progression of HIV infection. Another animal study found that THC can lead to enhanced growth of tumors, including those associated with breast cancer, due to suppression of the anti-tumor immune response. It could 19

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be counterproductive for patients who are already immune depressed to smoke marijuana for therapeutic purposes. 3. Acute Mental Effects There is a debate over whether marijuana can cause a serious mental illness. A pre-existing mental problem complicates the precipitating influence of marijuana. Often the use of high THC marijuana will tip the mental balance of someone who is just holding on. Counselors reported treating people who experienced a bad trip and did not come all the way back. Even veteran smokers who commonly smoke low-grade “pot” may feel that somebody has slipped them a psychedelic like PCP or LSD when they smoke strong “BC bud” sinsemilla. They can experience extreme anxiety and paranoia. H. TOLERANCE, WITHDRAWAL & ADDICTION (p. 6.34−6.36)

1. Tolerance Tolerance to marijuana occurs rapidly, even though smokers are initially more sensitive, not less, to desired effects (inverse tolerance). High-dose chronic users can tolerate much higher levels without some of the more severe emotional and psychic effects experienced by first-time users. 2. Withdrawal Withdrawing from marijuana is a lengthy process because much of the THC is retained in the brain and only after a relatively long period of abstinence will the withdrawal effects appear. The discovery in 1994 of an antagonist that instantly blocks the effects of marijuana enabled researchers to search for true signs of tolerance, tissue dependence, and withdrawal symptoms in long-term users. Experiments indicate that marijuana dependence occurs more rapidly than previously suspected. Withdrawal effects of include: • anger, irritability, anxiety, and/or aggression; • aches, pains, chills; • depression; • inability to concentrate; • craving, etc. 3. Addiction More sophisticated sinsemilla cultivation techniques led to higher THC concentrations which increases the compulsive liability of marijuana use. Psychological addiction is more of a factor than physical addiction. Today many people smoke the drug in a chronic, compulsive way and have difficulty discontinuing their use. 20

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4. Is Marijuana a Gateway Drug? The exaggerations of use portrayed in early anti-drug films and collateral material resulted in ridicule and probably caused more drug abuse than it prevented. These misguided prevention efforts also obscured an important fact: the real role that marijuana use plays in future drug use and abuse. Marijuana is considered a gateway drug because people who smoke it commonly hang around others who smoke it or use other drugs, so the opportunities to experiment with other drugs are greater. A study of 311 young adult identical or fraternal twins in Australia found that those who smoked cannabis by age 17 had a 2.1 to 5.2 higher chance of other drug use, alcohol dependence, and drug abuse/dependence than those who didn’t smoke it. It could also be that those who are likely to smoke marijuana are 2.1 to 5.2 times more likely to experiment with other drugs. I. MARIJUANA (Cannabis) & the Law (p. 6.37−6.37) In the United States, the state and federal penalties for marijuana use vary. Federal law focuses more on heavy trafficking, although there are penalties for simple possession and personal use. Austria, Belgium, Germany, Greece, Ireland, Italy, and Spain don’t prosecute for possession of small amounts for personal use. In England the maximum sentence for Cannabis possession is a five-year prison term, though most sentences handed down are minimal. In the Netherlands, use is confined to the coffee shop system. Worldwide, the push for the medical use of marijuana has caused a reassessment of many of the legal penalties for sale (e.g., medical marijuana clubs) and use. 1. Marijuana, Driving & Drug Testing Repetitive tasks such as uneventful driving on familiar streets are do not present a problem while under the influence of marijuana, but when a complicated driving situation arises, requiring decision-making and swift reaction, the chances of error are significantly increased. Adverse effects of marijuana are magnified by polydrug use. 65% of heavy drinkers also use marijuana, which is the reason positive polydrug tests are the rule, not the exception, in drivers arrested for driving while under the influence. Tests showed lower levels of impairment in drivers who smoked a small amount of marijuana compared with those who drank a small amount of alcohol. However, drinking boosts overconfidence whereas marijuana makes drivers overly wary and sometimes paranoid. Testing machines can measure minute amounts of the THC metabolite but are generally calibrated to start registering at 50 nanograms per milliliter (ng/mL) in urine samples. It would take about 3 weeks before 21

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Long term smokers who quit would still register for 3 weeks on a test with a 50 ng/mL cutoff, it would take another 3 weeks to be completely negative. The Olympic Committee uses just 15 ng as its cutoff level. J. MEDICAL USE OF MARIJUANA (pp, 6.37−6.40) 1. Epidemiology & Dispensaries More than 16 states have legalized medical marijuana. As of 2010, Colorado had issued 66,000 medical marijuana cards while Oregon had issued 40,000. The states are considering ways to make money on this new trade, regardless of the attitude towards drugs. Fees, licensing, and excise taxes add millions and billions of dollars to state budgets. Once a person has been issued a card, they can purchase from dispensaries, individual growers, and/or buyer's clubs. In addition to smokable marijuana, "medibles" are also available - brownies, cookies, butter, and soft drinks are laced with marijuana and sold to the cardholders. Federal law conflicts with state law on this issue and the Supreme Court ruled that individuals could be prosecuted for breaking federal law. 2. Medical Effects Over the past 150 years, the medical profession has examined the use of Cannabis and its extracts for medicinal purposes. Historically, marijuana has been used as a muscle relaxant, painkiller, appetite stimulant, to control spasms and convulsions, to calm anxiety, to control glaucoma, etc. Passage of the Marijuana Tax Act of 1937 discouraged further research until the 1980s. By 1996, a number of states had passed laws permitting medicinal use of the drug. Research today has explored, and in some cases recommended, the use of Cannabis for some types of glaucoma, nausea, pain control, to subdue uncontrolled movements (e.g., multiple sclerosis), and to stimulate weight gain for wasting illnesses such as cancer and AIDS. The focus of recent research is on the other cannabinoids particularly cannabidiol or CBD. 3. Rationale For & Against Medical Marijuana The variation in the number of active ingredients complicates efficacy of smoking or ingesting marijuana for medical purposes. It is often the mental effects of calming, anxiety relief, or mild euphoria that make people feel good and think they are getting better. Marijuana is a psychoactive drug with dependency potential, which makes its use particularly risky for those who are recovering from abuse or addiction.

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Chapter 6 – ALL AROUNDERS Classroom or Small Group Discussion Topics 1. Ask students to list three reasons a person might use • MDMA “Ecstasy” • Marijuana • Ketamine 2. Discuss the pros and cons of legalizing LSD for ( a.) medical use,( b.) recreational use. Should it be available to psychologists and psychiatrists as a controlled substance limited to experimentation to determine its value as a therapeutic agent? 3. Should the use of psychedelics for religious purposes (e.g., the Native American Church's use of peyote) be legal? Must a church be well established with a minimum number of members to qualify? 4. Explore how the use of MDMA could be beneficial in teaching empathy to (a.) adolescents, or( b.) adults. 5. What makes marijuana “the mirror that magnifies”? 6. How would the effect of marijuana on the novelty center affect a student’s’ ability to pay attention in class even if they were not under the influence at the time. 7.

Discuss medical marijuana:

Are the criteria for qualifying for a medical marijuana card (where it is legal) fair? Could the process be abused? • Would taking medical marijuana in a spray form be as appealing to people as smoking it? • How much of the benefit of marijuana comes from its ability to induce a relaxed mental state? A relaxed physical state? Its ability to produce a disorienting high? 8. What are the students’ attitudes/positions on psychedelics, - do they differ from their thoughts regarding uppers, like cocaine, and downers, like alcohol? •

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Chapter 6 - ALL AROUNDERS Critical Thinking & Class Exercises 1. Have your students research the MK-ULTRA program conducted by the CIA to explore the use of psychedelic drugs as a weapon during the Cold War. •

Is it acceptable for governments’ to do this kind of research and to use it in warfare? Why or why not?

•

Is it acceptable to use a psychedelic like LSD to get a prisoner to talk? To get a “terrorist” to talk?

2. Examine the concept of synesthesia - provide students with colorful markers or crayons and blank paper. •

Play portions of a variety of music genres (classical, country, Indian etc.) while students visually interpret the music.

•

Replicate everyday sounds (e.g. creaking door, train, traffic, birds) and ask the students to draw what those sounds might look like.

•

Ask students what sounds reflect a particular color. (sweet sounds might be a pastel, violent sounds might be deep purple)

3. if a non-addictive, nontoxic, low-cost, short-term psychedelic is invented, should it be legalized? •

Process their discussion to see how it reflects currently available drugs that fit this category such as Salvia Divinorum.

•

What specific effects of psychedelic drugs make them illegal?

4. Break into groups of 2 to 4 and discuss what advice they would offer a younger relative who ask if it is OK to use marijuana. •

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Would the answer be different if the drug were LSD? Why or why not?

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Chapter 6 – All Arounders

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Uppers, Downers, All Arounders, 7th Edition – Instructor's Manual Chapter 7 – OTHER DRUGS, OTHER ADDICTIONS Overview Addicts rarely limit themselves to just one drug or a single compulsive behavior. An alcoholic can also abuse benzodiazepine downers and practice compulsive gambling. OTHER DRUGS The number of substances capable of altering a person’s physical and mental balance seems endless. Inhalants, sports drugs, smart drugs – are all part of the mix. Inhaling substances such as volatile solvents (e.g., aerosol sprays, metallic paints, butane lighter fluid), the nitrites (amyl, butyl, isobutyl), and anesthetics such as laughing gas (nitrous oxide), to change one’s consciousness, is popular among younger age groups in places where psychoactive drugs are not readily available. These substances are cheap, easy to find, quick acting, and intense. They cause a giddiness, elevated mood, and reduced inhibitions but can also cause impulsiveness, irritability, dizziness, slurred speech, unsteady gait, lack of muscular coordination, and loss of unconsciousness. Athletes use three class of drugs; therapeutic drugs, performance-enhancing drugs, and recreational/mood-altering drugs. • Non-psychoactive drugs that relieve pain are O-T-C analgesics, some muscle relaxants, antiinflammatories, and asthma medications. Psychoactive drugs that are used to relieve pain are primarily the opioids and skeletal muscle relaxants. • Drugs that are used for a competitive advantage are primarily anabolic-androgenic steroids, human growth hormone, and stimulants such as methamphetamine and sometimes caffeine. • Recreational drugs (e.g. alcohol, cocaine) are used by athletes for the same reasons they are used by the general public. Miscellaneous drugs include such diverse substances as kava, herbal medicines, embalming fluid, nootropic (“smart”) dugs, and even toad secretions. OTHER ADDICTIONS People become involved in compulsive nondrug behaviors for the same reasons people abuse drugs—to change their mood, forget their problems, get a rush, or to self-medicate. Heredity, environment and frequently practicing a compulsive behavior affect a person’s susceptibility to developing a behavioral addiction. These behaviors include: • Compulsive gambling; a new class of pathological compulsive gamblers in need of treatment has been created by the opportunities presented in gambling outlets, the acceptance of high stakes gambling presented as sport on television, and the widespread legality of gaming. • Eating disorders include anorexia, bulimia, and binge-eating disorder. Obesity is epidemic in our society and has created a huge financial liability because of the many health problems associated with excessive weight. • Other behavioral addictions include sexual addiction, compulsive shopping, hoarding, Internet compulsions, addiction to computer games, television, cell phone, tanning or body piercing, and exercise. Abstinence is not an option for some behavioral addictions, such as an eating disorder, so treatment goals must aim towards a return to a normal level of activity.

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Chapter 7 – OTHER DRUGS, OTHER ADDICTIONS Chapter Outline I. INTRODUCTION II. INHALANTS A. HISTORY (see chapter 1) B. EPIDEMIOLOGY 1. Worldwide 2. United States C. METHODS OF INHALATION D. VOLATILE SOLVENTS 1. Short-Term Effects 2. Long-Term Effects 3. Psychiatric Effects 4. Warning Signs of Solvent Abuse 5. Major Volatile Solvents a. Toluene (methyl benzene) b. Trichloroethylene (TCE) c. N-Hexane & Methyl Butyl Ketone d. Chlorofluorocarbon (freons) e. Alkanes f. Gasoline g. Alcohols E. VOLATILE NITRITES F. ANESTHETICS 1. Nitrous Oxide (N2O) 2. Halothane G. DEPENDENCE H. PREVENTION III. SPORTS & DRUGS A. INTRODUCTION B. HISTORY 1. International Politics 2. Commercialization of Sports 3. Extent of Abuse C. THERAPEUTIC DRUGS 1. Analgesics (painkillers) & Anesthetics 2. Muscle Relaxants 3. Anti-Inflammatory Drugs

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4. Asthma Medications (beta2 agonists) D. ANABOLIC STEROIDS & OTHER PERFORMANCE-ENHANCING (ergogenic) DRUGS 1. Anabolic-Androgenic Steroids (AASs or “roids”) E. HUMAN GROWTH HORMONE F. STIMULANTS 1. Amphetamines (amphetamine & methamphetamine) 2. Caffeine 3. Ephedra (ma huang) & Ephedrine 4. Tobacco G. OTHER PERFORMANCE-ENHANCING DRUGS & TECHNIQUES 1. Androstenedione & Dehydroepiandrosterone (DHEA) 2. Beta Blockers & atenolol 3. Erythropoietin (EPO) 4. Blood Doping 5. Herbal Medicines 7. Gamma-Hydroxybutyrate (GHB) 8. Soda Doping 9. Weight Loss 10. Miscellaneous Drugs H. RECREATIONAL/ MOOD-ALTERING USE OF DRUGS BY ATHLETES 1. Stimulants 2. Sedative-Hypnotics 3. Alcohol 4. Marijuana I. TESTING J. ETHICAL ISSUES IV. MISCELLANEOUS DRUGS A. UNUSUAL SUBSTANCES 1. Camel Dung 2. Embalming Fluid (formaldehyde) 3. Gasoline 4. Kava 5. Kratom 6. Raid,® Hairspray, & Lysol® 7. Sarpa Salpa 8. Strychnine 9. Toad Secretions (bufotenine)

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B. HERBAL PREPARATIONS & SMART DRUGS/DRINKS 1. Herbal Preparations 2. Smart Drugs/Drinks 3. Nootropics OTHER ADDICTIONS V. COMPULSIVE BEHAVIORS VI. HEREDITY, ENVIRONMENT, & COMPULSIVE BEHAVIORS A. HEREDITY B. ENVIRONMENT C. PRACTICING COMPULSIVE BEHAVIORS VII. COMPULSIVE GAMBLING A. SCOPE OF GAMBLING B. HISTORY 1. Gambling in Ancient Civilizations 2. Gambling in America C. POLITICS OF GAMBLING D. ONLINE GAMBLING E. PROBLEM & PATHOLOGICAL GAMBLING F. EPIDEMIOLOGY G. CHARACTERISTICS 1. Winning Phase 2. Losing Phase 3. Desperation Phase 4. Giving-Up Phase H. UNDERSTANDING THE COMPULSIVE GAMBLER I. MAGICAL THINKING & THE GAMBLER'S FALLACY 1. Recovery J. GAMBLER'S ANONYMOUS VIII. COMPULSIVE SHOPPING/BUYING & HOARDING A. HOARDING IX. EATING DISORDERS A. OVERVIEW B. GENETIC, ENVIRONMENTAL & NEURO-CHEMICAL FACTORS 1. Genetic Factors 2. Environmental Factors 3. Neurochemical Factors C. MEDICAL CONSEQUENCES OF OBESITY

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1. Diabetes D. PSYCHOLOGICAL PROBLEMS & CO-OCCURRING DISORDERS E. EPIDEMIOLOGY OF ANOREXIA, BULIMIA & BINGE-EATING DISORDERS F. ANOREXIA NERVOSA 1. Definition 2. Causes 3. Effects G. BULIMIA NERVOSA 1. Definition 2. Causes 3. Effects H. BINGE-EATING DISORDER (including compulsive overeating) 1. Definition 2. Causes 3. Effects 4. Treatment & Support Groups X. SEXUAL ADDICTION A. DEFINITION B. EFFECTS & SIDE EFFECTS XI. ELECTRONIC ADDICTIONS A. THE INTERNET B. CYBERSEXUAL ADDICTION C. CYBERRELATIONSHIP ADDICTIOND. D. INTERNET COMPULSIONS E. INFORMATION ADDICTION F. COMPUTER GAMES ADDICTION G. TELEVISION ADDICTION H. MOBILE PHONE ADDICTION XII. CONCLUSIONS

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Chapter 7 – OTHER DRUGS, OTHER ADDICTIONS Extended Outline I. INTRODUCTION (P. 7.2) Addictions aren’t limited to psychoactive drugs. Behavioral addictions like compulsive gambling, eating disorders and sexual addiction are also common among substance abusers. OTHER DRUGS (7.2−7.29) Inhalants are volatile liquids and sprays that produce many of the same psychoactive effects as street drugs. Sports drugs comprise a variety of substances used to heal injuries, increase performance, or alter the athlete’s state of consciousness. Hard-to-classify drugs include animal extracts, herbal preparations, smart drugs, and nootropics. II. INHALANTS (p. 7.2−7.11) Inhalants, sometimes classified as deliriants, comprise a wide variety of substances. They are used for their stupefying, intoxicating, and occasionally psychedelic effects. There are three main groups of inhalants. Volatile solvents (and aerosols) are hydrocarbons found in glues, gasoline, paint thinners, etc. Some aerosols are sprayed to produce a foggy mist and are inhaled for their gaseous propellants. Other volatile organic compounds are esters, ketones, alcohols, and glycols. Volatile nitrites include amyl and butyl nitrite; they are also used recreationally. Anesthetics. The most popular anesthetic is nitrous oxide (N2O), also known as “laughing gas.” A. HISTORY (pp. 7.4−7.5) Inhalant use dates as far back as 1400BC. The discovery of nitrous oxide (laughing gas) and chloroform in the late 1700s, and the rediscovery of ether in 1842, ushered in the modern era of inhalant abuse. At the beginning of the twentieth century, petroleum refining created a new group of products, solvents, thinners, and glues that were inhaled for their intoxicating or euphoric effects. After World War II, the abuse of glue and metallic paints rose dramatically. Inhalants cause 700 to 1,200 deaths yearly in the U.S. B. EPIDEMIOLOGY (p. 7.5)

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Inhalants are popular because they are quick acting (7 to 10 seconds), cheap, and readily available especially to adolescents. . 1. Worldwide Abuse is most prevalent among adolescents although there are adults who abuse inhalants. Use among transients is particularly high. Internationally, abuse is found among the young, the poor, street children, recent immigrants to cities, and indigenous peoples. Gasoline is the most common inhalant worldwide. Many adolescents are unintentionally exposed to inhalant chemicals. 2. United States Young people are more likely to abuse inhalants than are adults. Among 12- to 17-year-olds, in the U.S., females use slightly more than males. The number of abusers declines by two-thirds or more after the age of 25. Inhalant use in 8th, 10th, and 12th graders has gone down since 1995. Inhalant Lifetime Use 12–17 Yrs. Glue, shoe polish, or toluene 4.3% Gasoline or lighter fluid 3.6% Spray paints 3.0% Cleaning fluids 2.2% Amyl/butyl/cyclohexyl nitrites 1.6% Lighter gases (butane, propane) 1.2% Nitrous oxide 1.6%

18–25 Yrs. 2.0% 2.1% 1.2% 1.5% 2.3% 0.7% 9.2%

C. METHODS OF INHALATION (pp. 7.5-7.6) “Sniffing” breathing in the inhalant through the nose, directly from a container. “Huffing” placing a solvent-soaked rag over, or in, one’s mouth or nose and inhaling. “Bagging” placing the inhalant in a plastic bag and inhaling. “Spraying” the inhalant directly into the nose or mouth. “Balloons and crackers” inhaling from a balloon filled with nitrous oxide or another gas. “Crackers” refer to the pins or other “cracking” devices used to puncture the gas canisters. Directly breathing pressurized inhalants into the mouth or nose exposes fragile membranes to the caustic effects of these substances. There is also a danger of freezing lung tissue due to the amount of pressure. D. VOLATILE SOLVENTS (pp. 7.6-7.8) These are mostly carbon- and hydrocarbon-based compounds that are volatile (turn to gas) at room temperature. They include gasoline, paints, air dusters,

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paint thinners, lacquers, nail polish remover, spot removers, glues, lighter fluid, and a variety of aerosols. They are absorbed into the blood almost immediately after inhalation and quickly reach the heart, brain (within 7 to 10 seconds), liver, and other tissues. 1. Short-Term Effects Inhalation produces a temporary stimulation, an elevated mood, and reduced inhibitions. Impulsiveness, excitement, and irritability also occur. Soon the depressive effects begin including dizziness, slurred speech, unsteady gait, and drowsiness. High dose use can induce illusions, hallucinations, delusions, and a dreamy stupor that resembles alcohol intoxication. The intoxicated state may last minutes to an hour or more. After prolonged inhalation, delirium with confusion, psychomotor clumsiness, emotional instability, impaired thinking, and coma have been reported. •

Heart and vascular problems. Arrhythmias and myocarditis are common with volatile solvents and can induce cardiac arrest.

•

Lung problems. Solvents can cause pulmonary hypertension, respiratory distress, and lowered breathing capacity.

•

Liver problems. Chronic exposure will cause some liver toxicity, which is usually reversible.

•

Neonatal problems. Toluene can cause growth retardation, some odd facial features, and tremors.

2. Long-Term Effects Chronic abuse is characterized by lack of coordination, inability to concentrate, impaired memory, weakness, disorientation, and weight loss. Some effects are irreversible though not progressive after abuse ceases. Chronic abuse of toluene can result in dementia, spastic movements, and other CNS dysfunctions. Complications may result from the effect of the solvent or other toxic ingredients, such as lead which can lead to injuries of the brain, kidneys, bone marrow, and the lungs. 3. Psychiatric Effects In the United States, 70% of surveyed inhalant abusers met the criteria for one or more lifetime mood, anxiety, or personality disorders and about half that percentage experienced a mood or anxiety disorder in the past year. 4. Warning Signs of Solvent Abuse Though solvent abuse can be difficult to spot, there are various warning signs: headaches, chemical body odor, red, glassy or watery eyes, inflamed nose, nosebleeds, rashes, slurred speech, staggering gait, disorientation, etc.

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5. Major Volatile Solvents a. Toluene (methylbenzene) The most abused solvent is also the most common – toluene. It is found in: glues, drying agents, solvents, thinners, paints, inks, and cleaning agents. Several studies indicate that toluene has an extremely high abuse potential. Chronic abuse can affect balance, hearing, and eyesight and most often, cause problems with neurological functions and cognitive abilities. In one study 65% of chronic abusers of the toluene in spray paint had neurological damage b. Trichloroethylene (TCE) This common organic solvent is used in correction fluids, paints, metal degreasers, and spot removers. Occupationally, more than 3.5 million people are exposed to TCE. It causes overall depression effects and moderate hallucinations. The toxic effects are similar to those of toluene. c. N-Hexane & Methyl Butyl Ketone (MBK) Used as a solvent for glues and adhesives, there are reports of brain damage from occupational exposure as well as from deliberate recreational use. Recovery can take as long as three years in severe cases. d. N-Hexane & Methyl Butyl Ketone (MBK) This solvent for glues or adhesives can cause brain damage. e. Alkanes Alkanes are gases at room temperature, e.g., methane, ethane, butane, and propane. They are inhaled for their effects but can also cause cardiac arrhythmias and sudden death. f. Gasoline Gasoline sniffing is especially common among solvent abusers on American Indian reservations. Effects include insomnia, tremors, anorexia, and sometimes paralysis. When leaded gas is inhaled, symptoms can include hallucinations, convulsions, and the chronic irreversible effects of lead poisoning. g. Alcohols Ethanol, methanol, and isopropanol are the most commonly abused alcohol solvents. They can cause a mild high along with nausea, weakness, vomiting, headaches, and abdominal cramping.

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E. VOLATILE NITRITES (p. 7.9) Amyl nitrite was discovered in 1857 and was used to relieve angina (heart pains). Isoamyl, butyl, isobutyl, isopropyl, and most recently cyclohexyl nitrites followed. These inhalants dilate blood vessels, so the heart and the brain (as well as other tissues) receive more blood. Effects begin within 7 to 10 seconds and last for 30 to 60 seconds. Inhalation creates a feeling of fullness in the head, a rush, mild euphoria, dizziness, and giddiness. Excessive abuse can cause passing out, oxygen deprivation, and temporary asphyxiation. Nitrites, believed by some to enhance sexual activity, are sought by some gay males for their euphoric and physiological effects, which include relaxation of sphincter muscles. Two-thirds of nitrite abusers use other inhalants, one-third abuse alcohol, and one-third abuse other drugs. F. ANESTHETICS (pp. 7.9-7.11) Anesthetics include nitrous oxide, halothane, ether, ethylene, ethyl chloride, and cyclopropane; only nitrous oxide is widely used. 1. Nitrous Oxide (N2O) Nitrous oxide, discovered by Dr. Joseph Priestly in 1776, was popularized for both its anesthetic/analgesic and euphoric effects. The rave and party scene that began in the 1990s renewed interest in nitrous oxide (N2O or “laughing gas”) principally because of its rapid onset and equally rapid dissolution of desired effects. Most abusers purchase small pressurized metal or plastic canisters (e.g., WhipIt!® cartridges)of N20. The gas is under great pressure so the rapid vaporization can cause freezing to oral, nasal, or lung tissues if inhaled directly. Transferring the gas to a balloon and then inhaling it is a common method of use. Within 8 to 10 seconds of inhaling, the gas produces dizziness, giddiness, disorientation, silly laughter, a throbbing buzzing sound, and occasional visual hallucinations. It can also cause confusion, a headache, a sense that one is about to collapse or pass out, and impaired motor skills. These feelings dissipate when the gas leaves the body. The maximum effect lasts two or three minutes. Cognitive functioning returns to normal within five minutes. Because N20 replaces oxygen in the blood, long-term exposure can cause central and peripheral nerve cell and brain cell damage due to a lack of oxygen. When abused, there is a potential for seizures, cardiac arrhythmias, and asphyxia leading to central/peripheral nerve damage or death. N20 abuse can lead to physical dependence in some users and is an addiction among some dentists and anesthesiologists.

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2. Halothane Halothane, first synthesized in 1951, is a prescription surgical anesthetic gas. Its effects are extremely rapid and powerful enough to induce a coma for surgery. Because of its limited availability, it is most often abused by anesthesiologists and hospital personnel. G. DEPENDENCE (p. 7.11) The DSM-IV-TR classifies inhalant-use disorders as inhalant dependence and inhalant abuse. Inhalant-induced disorders include intoxication, intoxication delirium, persisting dementia, psychotic disorder, mood disorder, and anxiety disorder.” Though tolerance to volatile solvents will develop, the liability for physical and psychological dependence and addiction to these inhalants is less than that for other depressants. Treatment is difficult because most users are young and immature, and because continued use can cause cognitive impairments that hinder comprehension and recovery. H. PREVENTION (p. 7.11) Law enforcement officers, healthcare workers, teachers, and parents should be trained to recognize signs and symptoms of inhalant abuse. III. SPORTS & DRUGS (p. 7.11-7.29) A. INTRODUCTION (p. 7.11-7.13) The World Anti-Doping Agency (WADA) serves as the watchdog for sporting endeavors. Public awareness and more effective sanctions resulted in the asterisk notations appearing after sports stars' names indicating suspicion or conviction for use of performance-enhancing drugs. The three categories of sports drugs are: therapeutic drugs (analgesics, muscle relaxants, anti-inflammatories, and asthma meds); performance-enhancing drugs (ergogenic drugs), such as steroids, growth hormones, blood-doping drugs, and stimulants; and recreational and mood-altering drugs, both legal and illegal. Some athletes perceive drugs (often illicit ones) as a quick way to put on pounds and muscle, to increase stamina, to get up for a game, to relieve pain, to increase confidence, or to remain competitive with other athletes who use drugs. B. HISTORY (pp. 7.13-7.14)

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Greek Olympic athletes in the third century B.C. ate large amounts of mushrooms or meat to improve their performance. By the 1800s, cyclists, swimmers, and other athletes used opium, morphine, cocaine, caffeine, nitroglycerin, and even low doses of strychnine (marathoners). For half a century, athletes have used a variety of substances and techniques to increase their endurance and strength: nitroglycerin, caffeine, amphetamines, strychnine, cocaine, heroin, steroids, blood doping, and erythropoietin (EPO). 1. International Politics The Soviet weightlifting team used steroids in the 1952 Olympics and won medals. Steroid use was believed to be the way countries including the United States could maintain their competitive edge in international athletics and by 1958, steroids were available and abuse by athletes had become widespread In1999, the World Anti-Drug Agency (WADA) was formed to facilitate and implement a strong antidrug policy. 2. Commercialization of Sports The commercialization of sports through television, product endorsements, huge salaries, and endless publicity has led many athletes and coaches to adopt an attitude of winning at any cost. Over the past 30 years, the social and financial pressures to win have driven some athletes to try performanceenhancing drugs. 3. Extent of Abuse In the 1970s a large percentage of NFL players admitted to using amphetamines regularly. In 2009, it was estimated that at least 150,000 junior high and high school students used steroids. Young athletes bulk up during high school and then go clean in college. The actual extent of the problem is hard to determine because athletes are reluctant to admit use for fear of suspension or of becoming less desirable for product endorsements. C. THERAPEUTIC DRUGS (pp. 7.14-7.16) Drugs used in sports for specific medical problems are •

analgesics (painkillers) and anesthetics

•

muscle relaxants

•

anti-inflammatories

•

asthma medications

1. Analgesics (painkillers) & Anesthetics

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These drugs are normally used to deaden pain. They include topical anesthetics and systemic analgesic (e.g., aspirin or opioids). The most common opioids used in sports are hydrocodone, Demerol,® morphine, and Darvon®. The biggest danger associated with use results from their ability to block pain without repairing the damage; tissue dependence and compulsive use can also develop. 2. Muscle Relaxants Muscle relaxants depress neural activity within skeletal muscles, e.g., carisoprodol (Soma®), methocarbamol, as well as benzodiazepines. They are occasionally abused for their mental effects, particularly Soma.® They can be used to enhance the effects of other drugs and, when taken in large doses, can cause giddiness, drowsiness, and relaxation. There have been overdoses and deaths from overuse. Benzodiazepines and barbiturates, also used as muscle relaxants, have a higher dependence liability. 3. Anti-Inflammatory Drugs These drugs control inflammation and lessen pain and come in two classes. One class is nonsteroidal anti-inflammatory drugs (NSAIDs), e.g., aspirin. The other is corticosteroids, such as cortisone and Prednisone®. Side effects from corticosteroids are a significant consideration. Prolonged use can cause water retention, bone thinning, muscle and tendon weakness, etc. Psychoactive effects are minimal at low doses, but severe psychosis results from excessive high-dose use. 4. Asthma Medications (beta2 agonists) Asthma affects 10% of the general population and is aggravated by heavy exercise. A lesser condition, exercise-induced asthma (EIA), has been identified. The incidence of EIA is 11% to 23% in athletes. Asthma is widespread in athletics and certain asthma medications are permissible. Asthma medications like ephedrine are stimulants and are banned by most sporting organizations. These drugs can slightly increase oxygen intake by bronchodilation. D. ANABOLIC STEROIDS & OTHER PERFORMANCE-ENHANCING (ERGOGENIC) DRUGS (pp. 7.16-7.19) Most performance-enhancing drugs, substances, and techniques are banned by all sports-governing bodies. 1. Anabolic-Androgenic Steroids (AAS or “roids”) The most abused performance-enhancing drugs, anabolic-androgenic steroids (AASs), are derived from the male hormone testosterone or synthesized. The benefits include increased body weight, lean muscle mass, muscular strength, and, to a lesser extent, stamina. Psychologically, AASs increase aggressiveness

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and confidence. Some high school and college students use AASs strictly to enhance personal appearance. Patterns of Use. AAS users may take 20 to 200 times the clinically prescribed daily dosage. Some athletes practice steroid stacking by using three or more kinds of oral or injectable steroids and alternating cycles of use and nonuse. Cycling steroids involves taking them for a four- to 18-week period during intensive training, stopping for several weeks or months before beginning another cycle. Physical Side Effects. A bloated appearance, ruptured tendons and damaged ligaments due to increased muscle strength. Long-term use in males lowers testosterone production causing feminine characteristics (e.g., swelling breasts, smaller sex organs) to develop. Females show increased facial hair, decreased breast size, lowered voice, and clitoral enlargement as a result of long term use. Many of these effects are irreversible. In both men and women, severe cystic acne is common. Although AASs can be taken orally, by patch, as a topical gel, or via an implant, up to 99% of “roids” are injected, making users susceptible to infections. Cardiovascular problems include hypertension, thrombosis, and cardiomyopathy. Studies have linked AASs to cancer. Mental & Emotional Effects. AASs do make users feel more confident and aggressive, but as use continues emotional balance often swings from confidence to aggressiveness, to emotional instability, to rage, to hypomania, to depression, to psychotic symptoms, and to paranoia. This condition, referred to as “roid rage” abates when use is stopped. Compulsive Use & Addiction. Unlike most psychoactive drugs, AASs are not generally used for their immediate psychoactive effect but rather for longerterm gains. About one-third of users initially experience a sense of euphoria or well-being that contributes to their continued use and abuse of steroids. Distinct withdrawal symptoms indicative of dependence occur including craving, fatigue, depression, restlessness, insomnia, headaches, and a lack of sexual drive. Do Steroids Work? In 1984, the American College of Sports Medicine stated that steroids can increase muscle mass and strength when combined with diet and exercise. Supply & Cost. Athletes obtain steroids on the black market (through gyms, friends, Internet, or mail-order companies). Serious users spend $200 to $400 per week on anabolic steroids and other strength drugs - the cost of a single cycle can cost thousands of dollars. Some professional athletes spend $20,000 to $30,000 per year. Evaluation & Testing. Visible signs of AAS abuse include: overdeveloped muscles, bloating, severe acne, and unexplained aggression. Blood and urine testing and testing for changes in body chemistry are becoming increasingly more sophisticated as abusers try to outwit the testing agencies. After revelations by players such as Jose Canseco, Major League Baseball instituted

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comprehensive drug testing. The National Football League enforced penalties for use long before the Major League Baseball agreement. F. HUMAN GROWTH HORMONE (HGH) (pp. 2.19-2.20) Human growth hormone is a polypeptide hormone produced by the pituitary gland that stimulates growth in children. It also increases muscle mass, skin thickness, and connective tissues in muscles. Some studies have found that it has little effect on muscle development in those with normal HGH production. Until recently there were no conclusive tests for HGH use, there are now tests that can detect use for 10 to 14 days. Side effects include gigantism, abnormal bone growth, and metabolic or endocrine disorders. Abuse is also associated with cardiovascular disease, decreased sexual desire, and impotence. HGH can decrease life span by up to 20 years. E. STIMULANTS (pp. 7.20-7.21) In some sports such as football, the use of stimulants is more widespread than the use of steroids. Players begin using CNS stimulants as performance boosters but prolonged use becomes self-defeating. The IOC and every other sports organizations banned the use of any kind of amphetamine and most other strong stimulants. 1. Amphetamines (amphetamine & methamphetamine) Much of the increase in performance comes from the focusing effects of amphetamines and the increase in aggressiveness rather than specific muscular changes. Tolerance to amphetamines develops rapidly, and the beneficial effects of the drug diminish. Amphetamines can be detected up to four days after use. Heart and blood pressure problems, exhaustion, and malnutrition are common with prolonged use. 2. Caffeine Energy drinks containing caffeine have become popular with athletes and adolescents. Caffeine increases wakefulness and mental alertness. It also slightly increases endurance during extended exercise and increases muscle contraction. Side effects include increased digestive secretions, increased urination and dehydration. The IOC limits caffeine to 12 mg/mL—about three strong cups—just before competition. 3. Ephedra (ma huang) & Ephedrine Ephedra and ephedrine were formerly found in hundreds of legal OTC medications. They are used to increase strength and endurance and/or promote weight loss. When taken in excess, they can cause anxiety,

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headaches, high blood pressure, cardiac arrhythmia, poor digestion, and overheating. Ephedrine is banned by the NFL, the IOC, and the NCAA. 4. Tobacco The nicotine in cigarettes is a mild stimulant, but it does little for performance except perhaps to increase alertness. Smoking reduces lung capacity. Smokeless tobacco (spit tobacco) has many of the same effects as cigarettes but does not reduce lung capacity. Chewing tobacco, a mainstay of baseball players for years, fell from favor after a number of players spoke out and reveled the health problems caused by their habit. In 1994, the NCAA banned the use of all tobacco products during NCAA-sanctioned events. G. OTHER PERFORMANCE ENHANCING DRUGS & TECHNIQUES (p. 7.21-7.25) 1. Androstenedione & Dehydroepiandrosterone (DHEA) Androstenedione, a direct precursor in the biosynthesis of testosterone, is produced by all mammals. Athletes such as Mark McGuire have abused it to increase muscle mass. DHEA, a somewhat similar hormone, has been tried in an attempt to increase testosterone. OTC sales were banned in 1985. 2. Beta Blockers (propranolol [Inderol®] & atenolol [Tenormin®]) Beta blockers are normally prescribed to lower blood pressure, decrease heart rate, and prevent arrhythmias. Their ability to calm the brain and tremors makes them attractive to some athletes involved in riflery, archery, diving, ski jumping, biathlon, and pentathlon. Beta blockers are banned by the IOC and most athletic organizations. 3. Erythropoietin (EPO) EPO is a blood oxygen booster that stimulates bone marrow to produce more red blood cells to carry oxygen to muscles; it is used in endurance sports like cycling. There are tests for EPO analogues. The dangers associated with EPO use include thickening of the blood, which can lead to clots resulting in stroke and heart attacks. EPO is banned by the NCAA, the USOC, and most every other sport. 4. Blood Doping Blood doping increases endurance by transfusing extra blood into the body to boost the number of red blood cells available to carry oxygen. The athlete’s own blood is taken, stored and then reinfused five or six weeks later. Blood doping is used in endurance sports. Several expensive tests exist to detect blood doping. 5. Herbal Medicines Herbs, animal extracts, vitamins, minerals, proteins, etc., have been used by athletes to improve their competitive edge. Often, some of the ingredients not listed on a product trigger a positive test for banned substances.

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Creatine is an amino acid that is created naturally in the body and found in fish and meat. Creatine supplements are legal and sold over the counter to benefit sprint disciplines, such as running, cycling, and many power sports . 6. Gamma-hydroxybutyrate (GHB) This supplement was sold as a fat burner, an anabolic agent, a sleep aid, a muscle definer, and a psychedelic. It was used to reduce anabolic steroid water-weight gain and raised levels of HGH. Excess use can cause respiratory depression, amnesia, occasionally coma, and a dramatic slowing of the heart rate. 7. Soda Doping Some athletes believe that ingesting alkaline salts (sodium bicarbonate) 30 minutes prior to exercise delays fatigue by decreasing the development of acidosis. It is somewhat effective for events of short duration rather than for endurance activities. Its use can cause diarrhea, and excess water retention. 9. Weight Loss Despite the evidence that dehydration significantly diminishes performance, wrestlers, gymnasts, and jockeys will use diuretics, laxatives, exercise, fasting, self-induced vomiting, diet pills, amphetamines, tobacco, caffeine, and sweat off excess fluids in a sauna to make their competition weight. The NCAA recently changed training rules to counteract this unsafe practice. Diuretics are used to lose water weight rapidly, to limit the bloating caused by steroids, and to avoid detection of illegal drugs. Excessive use of diuretics causes serious dehydration. After a few months of continuous use, most diet pills and amphetamines lose their effectiveness and can be addicting. 9. Other Performance-Enhancing Drugs & Techniques Adrenaline and amyl or isobutyl nitrite is taken by weightlifters just prior to competing to increase strength. Bee pollen pellets are supposed to increase energy levels and performance. Most scientific studies, do not agree. Calcium pangamate. This nonvitamin, also called “vitamin B15,” supposedly keeps muscle tissue better oxygenated. It is reportedly a carcinogen. Cyproheptadine (Periactin®) is an antihistamine believed to cause weight gain and increase strength. Darbepoetin (Aranesp boosts the amount of oxygen in the blood. By 2002 a test was developed to detect it in urine. Gene doping involves the non-therapeutic use of genes, genetic elements, and/or cells that have the capacity to enhance athletic performance.

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Human chorionic gonadotropin (HCG) or tamoxifen is occasionally used after anabolic steroid treatment to try to restart the body’s own testosterone production. Modafinil (Provigil®) is a prescription drug that acts as a stimulant. It was thought to mask the use of THG in drug tests. Ornithine and arginine are amino acids taken to increase muscle mass through the release of HGH. High doses can lead to kidney damage. Primagen increases steroid production and is mainly used by European athletes. Vitamin B12 supposedly wards off illness and provides extra energy H. RECREATIONAL/MOOD-ALTERING USE OF DRUGS BY ATHLETES (pp. 7.25-7.27) 1. Stimulants The advantages and consequences associated with these drugs are the same for athletes as nonathletes. 2. Sedative-Hypnotics Benzodiazepines, barbiturates, and opioids are used as self-rewards for enduring the stress of performing. They also used as a tranquilizer to unwind after the excitement of competition or to counteract the effects of stimulants. 3. Alcohol Alcohol negatively affects reaction time, coordination, and balance. The NCAA specifically bans alcohol for rifle competition. The USOC does not ban it because it does not generally enhance performance. The problems with alcohol are connected to its excess use as a reward for performance. Alcohol is not tested for unless an athlete exhibits abuse problems. 4. Marijuana Marijuana hinders rather than helps performance because it lowers blood pressure, inhibits sweating, impairs the ability to follow a moving object, hinders the ability to do complex tasks, diminishes hand/eye coordination, and decreases oxygen because it is smoked. Marijuana is extremely fat-soluble and stays in the body for a long time, so impairment can persist for a day or two after casual use and longer after cessation of chronic use. Currently, the NCAA and the IOC ban all marijuana use for ethical and moral reasons rather than for performance reasons. I. TESTING (pp. 7.26-7.27) Drug-testing programs are in place in every sports organization as well as in individual colleges. The NCAA tests at all NCAA championships and at postseason football bowl games and conduct year-round anabolic steroid testing programs. In a survey of NCAA schools, only 56% of the respondents had an alcohol/drug education program for student-athletes.

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The World Antidoping Agency coordinates drug-testing programs, does research, creates educational programs, and publishes an annual list of banned substances. Each professional sports league (NFL, NHL, PGA, etc) has drug testing and drug use rules. A. ETHICAL ISSUES (p. 7.27) Drugs undermine the assumption of fair competition on which all sports rest, and they violate the very nature of sport. There is a real threat that the public will turn away from sports if they believe winning is based on access to the latest pharmacology to evade drug testing. IV. MISCELLANEOUS DRUGS (pp. 7.27-7.29) A. UNUSUAL SUBSTANCES (p. 328) 1. Camel Dung Some Arab countries produce hashish by force-feeding ripe marijuana plants to camels. Their four-chambered stomachs convert the marijuana into hashish camel dung. 2. Embalming Fluid (formaldehyde) Embalming fluid can be either inhaled for its depressant and psychedelic effects or used in the manufacture of other illicit drugs. Some abusers soak marijuana joints or cigarettes in the fluid before smoking. They are called “clickems” or “fry. 3. Gasoline There are records of people mixing gasoline with orange juice and drinking the concoction - in spite of the toxicity of leaded and unleaded gasoline. 4. Kava The roots of the Piper methysticin plant are chewed or crushed into a soapy liquid and swallowed. This milky exudate of the root (kava) produces a drunken state, similar to that of alcohol, when used in large quantities. Kava is used as a relaxant and an antianxiety drug. 5. Kratom At high doses, the leaves of this Southeast Asian tree are chewed to deliver opioid-like effects, inhibits smooth muscle contraction, and reduces pain. At low doses, it acts as a stimulant. 6. Raid,® Hairspray & Lysol® Abusers puncture the aerosol cans and swallow the liquid, mainly for its alcohol content. Recently, inner-city youths have been spraying Raid® onto marijuana and rolling it into a joint. 7. Sarpa Salpa

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This fish, a species of bream found off the coasts of South Africa, Cyprus, and Malta, becomes toxic after eating a certain algae, if it is eaten by something higher on the food chain – a human for example, hallucinations can occur. 8. Strychnine This poison is found in pesticides, lethal doses can cause muscular convulsions and death from asphyxia. It low doses, it causes stimulation, similar to methamphetamine. 9. Toad Secretions (bufotenine) The Bufo genus of toads (Colorado River, Sonoran Desert, Cane, and others) secretes a psychedelic substance called bufotenine from pores located on the back of the neck. B. HERBAL PREPARATIONS & SMART DRUGS/DRINKS (pp. 7.28-7.29) 1. Herbal Preparations For thousands of years, herbal preparations and other natural “cures” were the only medicines available. Their effectiveness was real and highly valued, but some of those curative effects came from the spiritual power given the substances by healers and medicine men and the power of faith. As the science of pharmacology advanced faith in traditional herbal medicines diminished. Today herbal medicine is making a comeback in the West. The healing properties of some products have not been rigorously tested to deliver the results claimed by the marketing materials. There are other concerns that some preparations contain prescription drugs, e.g., Valium® or substances that are banned in sports competitions or employment. 2. Smart Drugs/Drinks “Smart drugs” are drugs, nutrients, drinks, vitamins, extracts, and herbal potions (e.g., ginseng, gingko biloba, and caffeine) that manufacturers believe boost intelligence, improve memory, sharpen attention, increase concentration, detoxify the body, and energize the user. These are promoted as natural, healthy, and legal substitutes for club drugs or other illegal substances. Trade names include: Cloud 9,® Brain Tonix,® and Brain Booster®. 3. Nootropics Some smart drugs and drinks contain combinations of medications usually prescribed for Parkinsonism, Alzheimer’s disease, or dementia. It is believed that these drugs effectively rebalance the brain after abusing drugs. There are also claims that they slow or reverse the aging process. There is a proposal to classify these drugs as nootropics. Substances in this class would include those with low toxicity that improve learning, memory consolidation, and memory retrieval and are absent of any CNS effects. OTHER ADDICTIONS V. COMPULSIVE BEHAVIORS (PP. 7.29-7.31)

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Compulsive gambling, overeating, compulsive buying/shopping, obsessive sexual behavior, Internet use, and other electronic addictions and game playing, along with pathological lying, shoplifting, hair pulling/twisting, and fire setting—all offer opportunities for repetitive compulsive behaviors. The hallmark of impulse-control disorders, as listed in the DSM-IV-TR diagnostic manual, is a failure to resist an impulse that is harmful to the individual or others but often starts out as pleasurable. People engage in compulsive behaviors for the same reasons they engage in compulsive drug use. Compulsion, tolerance, withdrawal, abuse, denial, and relapse occur with compulsive behavioral addictions. Addictive behaviors alter brain chemistry in much the same ways as psychoactive drugs do. VI. HEREDITY, ENVIRONMENT & COMPULSIVE BEHAVIORS (PP. 7.31-7.32) Compulsive behaviors can be triggered by genetic predisposition, by environmental stressors, and by the repetitive behavior itself. Increased dopamine levels in compulsive gamblers, overeaters, and shoppers suggest a common biochemical thread. A. HEREDITY (p. 7.31-7.32) Twin and nuclear family studies show a connection between heredity and compulsive behaviors that do not involve psychoactive drugs. A much higherthan-normal percentage of twins born to obese parents, but subsequently raised in different households, ended up obese. The researchers also found that “shared environmental pressures were not significant” in affecting the twins’ weight gain. More than 90 different genes were identified as having an influence on an individual’s susceptibility to addictions. Researchers suggest a genetic basis (e.g., DRD2 A1 allele gene) not only for alcoholism, but also for drug dependence and behavioral addictions. They found that even though this marker gene appears in only 19% to 21% of nonalcoholic, nonaddicted, and noncompulsive subjects, it exists in: • • • • •

69% of severe alcoholics; 45% of compulsive overeaters; 48% of smokers; 52% of cocaine addicts; 51% of pathological gamblers.

Carriers of this A1 allele gene have a deficiency of dopamine receptors in the reward/control pathway making them more likely to seek out substances and activities that release excess dopamine. There is more than one marker gene for compulsive drug use and compulsive behaviors.

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B. ENVIRONMENT (p. 7.32) Environment affects behavioral addictions through: • • • •

Availability - state lotteries, slot and poker machines, and Indian gaming casinos; fast-food restaurants, lack of physical activity, an abundance of fats and sugars in processed food products; sex in the media and Internet pornography; shopping networks, a society focused on instant gratification

C. PRACTICING COMPULSIVE BEHAVIORS (p. 7.32) It is also easy to understand how engaging in the activity can lead to compulsive behavior. • • •

Having a big win while gambling imprints the brain with expectations of always winning. Excessive consumption of food resets brain chemistry so a person eats to change mood rather than sustain life. Compulsive use of pornography diminishes the importance or interest in normal sexual/emotional relationships.

VII. COMPULSIVE GAMBLING (P. 7.32-7.42) U.S. gambling revenues will top $135 billion by 2013; worldwide revenues will top $500 billion although the recent economic woes have slowed the growth. Gambling is defined by Gamblers Anonymous (GA) as, “Any betting or wagering, for self or others, whether for money or not, no matter how slight or insignificant, where the outcome is uncertain or depends upon chance or skill constitutes gambling.” Gambling includes: • poker, blackjack, craps, roulette, and pai gow; • slot machines and video poker machines; • horse and dog races; • bingo and raffles; • state-run lotteries and keno games; • sports betting, both legal and illegal; • stock speculation such as day trading; • Internet gambling; The numbers of gambling opportunities - mostly legal, are creating and/or enabling problem and pathological gamblers. A. HISTORY (pp. 7.33-7.35) 1. Gambling in Ancient Civilizations Evidence of gambling dates back to 40,000 B.C. with the discovery of astragali, four-sided rolling bones from the ankles of small animals. Roman soldiers cast lots for the robes worn at the Crucifixion; the knights of the Crusade gambled at dice. Along with the proliferation of gambling came restrictions against it.

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2. Gambling in America Three waves of gambling swept the United States. The first, from the 1600s until the mid-1800s, involved lotteries. The second began at the end of the Civil War in 1865 when riverboat gambling, saloon card games, roulette wheels, and dice games were introduced. After gambling was legalized in Nevada and 21 states opened pari mutuel racetracks other benchmarks followed: New Hampshire rediscovered the state lottery in 1964; Atlantic City opened to gambling; lotteries began in 38 states; off-track betting, riverboat casinos; and finally, the legalization of gambling casinos on American Indian lands completed this legitimization. Gambling has become a legal, respectable pastime. By 2009 more than 233 of the 562 American Indian tribes in the United States owned 423 gambling facilities in 28 states. State-supported lotteries were established through the 1980s and 1990s to supplement tax dollars and generate jobs. The growth in gambling has been as explosive worldwide. Macau, China is slated to overtake Las Vegas in gambling revenues. Other nations are following the U.S lead and increasing their stake in gambling. B. POLITICS OF GAMBLING (7.35) Those who favor gaming establishments argue that they attract tourists to the community, create jobs and generate tax revenues. However, each dollar spent gambling is a dollar that is only partly recycled into the local community. This money is referred to as “cannibalized dollars.” Most politicians support gambling because the revenue it generates increases state income without raising taxes. C. ONLINE GAMBLING (7.35) Online gambling exploded in the 1990s and continues to grow. In October 2006, Congress passed a law criminalizing the processing of funds by banks and credit card companies. (In 2011, a number of online gambling associations were prosecuted for laundering money. See Chapter 1) D. PROBLEM & PATHOLOGICAL GAMBLING (PP. 7.35-7.39) Problem gambling is defined as gambling behavior that causes problems in any part of one’s life. Pathological gambling adds the element of continual and significant disruption of most areas of one’s life. At-risk gambling applies to those who are susceptible to betting their way into problem or pathological gambling. Compulsive gamblers can be either problem or pathological gamblers.

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The only differences between problem and pathological gambling involve time and money. The average problem gambler spends $3,000 per year, the average pathological gambler loses at least $11,000 per year. In the early 2000s, most states had yet to establish prevention or treatment programs nor had they adequately studied the consequences of compulsive gambling. As the number of gambling opportunities/outlets increased, states began to fund gambling treatment. This is appropriate because the majority of state and casino gambling income is derived from problem, and pathological gamblers. E. EPIDEMIOLOGY (pp. 7.36-7.37) The proliferation of gambling outlets has a dramatic effect on the number of pathological and problem gamblers. An earlier meta-analysis study estimated that 125 million U.S. adults gamble and, of those, 2.2 million are pathological gamblers and 5.3 million are problem gamblers. Another study found that about 15 million were at risk for problem gambling. 1.1 million adolescents are pathological gamblers. Male compulsive gamblers outnumber female compulsive gamblers 2 or 3 to 1. The proliferation of slot machines may change that ratio because more women play slots. . Pathological gamblers (25% to 63% of gamblers) are likely to have other addictions or disorders; 50% have a mood disorder, 41% have an anxiety disorder, and 60% have a personality disorder. Over the past 25 years the 65 + demographic shows the greatest percentage of growth in gambling. College students have a higher rate of pathological/problem gambling than the general population. F. CHARACTERISTICS (pp. 7.37-7.39) There are several other types of gamblers. Recreational/social gamblers. These players are able to separate gambling from the rest of their lives. Professional gamblers. It’s a business for this group, losses are part of the game and some individuals are able to make a living gambling. Antisocial gamblers. These individuals have no conscience (loaded dice, marked cards) and will steal to gamble. There are two subtypes of pathological or problem gamblers: the actionseeker and the escape-seeker (although even action gamblers seek escape). Action-seeking gamblers are frenetic, excited, and always in action. Escape-seeking gamblers are often drawn to slot machines and poker machines (they are also called machine gamblers). They just want to be left alone. Like other addictions, pathological gambling is a progressive disorder requiring more gambling and larger bets.

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Symptoms of persistent recurrent pathological gambling are: •

preoccupation with gambling;

•

gambling with more and more money;

•

repeated unsuccessful efforts to control, cut back, or stop gambling;

• restlessness and irritability when attempting to control, cut back, or stop. A pathological gambler passes through four phases. 1. Winning Phase Initially gambling is recreational and pleasurable. For both action and escape gamblers, the goal is to stay in action and escape reality for as long as possible, winning is secondary. The winning phase can last one year or 10 years as skills improve. A winning phase doesn’t exist for machine gamblers. Early on, for 70% to 80% of both action and escape compulsive gamblers, a big win fueled the craving to gamble. A gambler with a susceptibility to compulsion begins to devote more time and wager more money. They remember their wins and minimize their losses. 2. Losing Phase A losing phase often starts with a losing streak that due simply to the laws of chance. Gamblers try to recoup their losses, and begin chasing their money and making bad decisions. Financial losses start to accelerate. 3. Desperation Phase In the end stages, gamblers often lose jobs, max out credit cards, borrow from friends and family, and some turn to illegal activities. Gamblers often bankrupt their families and suffer divorce or separation because of deteriorating family relationships. Embezzlement and theft become more common. 4. Giving-Up Phase At this stage pathological gamblers stop thinking they will win it all back, they just want to stay in action so they don’t have to think. Gamblers experience elated moods when they win and mania, depression, panic attacks, insomnia, health problems, and suicidal thoughts or actual attempts when they lose. G. UNDERSTANDING THE COMPULSIVE GAMBLER (p. 7.39) To a gambler, “It’s not about the money.” Compulsive gamblers want the rush or zoning out from a large win more than they want the money. The value of a win is that it allows the gambler to continue gambling. Gambling is a binge activity—gamblers will continue gambling until their access to money is gone, until the game ends, or until they are arrested. H. MAGICAL THINKING & THE GAMBLER'S FALLACY (pp. 7.40-7.41)

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Cognitive distortions are common to compulsive gamblers; researchers believe that about 70% of their gambling related thoughts are illogical. Magical thinking, the main cognitive distortion, is the belief that thinking equates with doing. It ignores cause and effect and denies the validity of the laws of chance. The "gambler's fallacy" is the belief that one can control random events such as a slot machine. Slot machines are designed and programmed to take advantage of this fallacy with “almost wins” encouraging the gambler to continue play. It takes an average of three and a half years of steady play to slide from social gambling into pathological gambling. 1. Recovery Recovery comes from correcting those cognitive distortions. It also comes from standard addiction treatment, recognizing that egotism and a sense of entitlement are much stronger in compulsive gamblers. I. GAMBLERS ANONYMOUS (pp. 341-342) Gamblers Anonymous, a 12-step recovery group has chapters in every state and in 45 countries worldwide. It was formed in 1957 on the model of Alcoholics Anonymous. Its basic tenet is to allow problem compulsive and pathological gamblers to help themselves by developing spirituality and ultimately changing the way they live. VIII. COMPULSIVE SHOPPING/BUYING & HOARDING (PP. 7.42-7.43) Handling money in an irresponsible manner is characteristic of almost any addict. Compulsive shoppers describe the relief from depression and the subsequent high when buying as similar to the high from cocaine. The highest level of excitement and pleasure for compulsive shoppers comes just before they say, “I’ll take it!” Studies put the number of compulsive shoppers somewhere between 2% and 10%. Often, compulsive shoppers enter a store without anything specific in mind and frequently purchase on impulse. Debt counseling is just a stopgap measure because the roots of the condition such as depression (very common) have not been addressed. Attending a self-help group for support is an alternative to shopping. There are more than 400 Debtors Anonymous groups in the United States. A. Hoarding Collecting, accumulating, and hoarding are offshoots of compulsive shopping. A hoarder’s worth and self-esteem come from objects and their ability to acquire them. Those that hoard relatively valueless objects: newspapers, plastic utensils, stuffed animals and in some cases, spoiled food and trash usually have deeply rooted psychological problems.

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IX. EATING DISORDERS (PP. 7.43-7.52) A. OVERVIEW (7.43-7.46) In World War II, 40% of the Army recruits were rejected because they were too small to go into combat with a heavy pack. At the end of the war the government launched the school lunch program to make children bigger and stronger, cheese, milk, bread and other heavy foods were provided through the program. It was too successful. Today approximately 27% of Army recruits are rejected because they exceed the weight requirements. In 2008, 33.8% of U.S. adults were considered obese compared with just 15% in 1980, when those who are overweight are included, that percentage climbs to 66%. Eating disorders include anorexia, bulimia, and binge eating. The World Health Organization estimates that 300 million people worldwide are obese and 750 million are overweight. The concept of beauty has changed over the centuries. A thin slight frame was once a sign of poverty and lower class status, plumpness was a sign of wealth and upper-class status. Today, the average fashion model is 5'11" and weighs 117 pounds. The average woman is 5'4 and weighs 140 to 164 pounds. Americans spend $40 to $100 billion per year on diet programs and products. The DSM-IV-TR classifies eating disorders as follows: Anorexia nervosa is an addiction to weight loss, fasting, and minimization of body size. Bulimia nervosa is an addiction to binge eating followed by self-induced vomiting, fasting, or excessive exercise. Binge-eating disorder is defined as “bulimia without vomiting,” Compulsive overeaters (the largest group) are overweight or obese. Eating disorders involve a sense of powerlessness over food, obsessive thoughts of food, use of food to escape undesirable feelings, secretive behavior, guilt, denial, and overeating or fasting regardless of the harm done. B. GENETIC, ENVIRONMENTAL & NEUROCHEMICAL FACTORS (pp. 246-247) Evidence suggests that eating disorders are a combination of genetic, neurochemical, psychodevelopmental, and sociocultural factors. 1. Genetic Factors Genes having the greatest impact are those that affect hunger, satiety, and food intake rather than metabolic rates. High-fat, high-sugar diets decrease the number of dopamine receptors (down-regulation) which increases craving, especially if there is a genetic anomaly. 2. Environmental Factors

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In a restrictive food environment where feast and famine are cyclical, the body’s homeostatic control system efficiently regulates body weight. In a society where rich food is readily available, the natural subconscious control of appetite and metabolism often becomes ineffective. It is necessary to take cognitive control of one’s eating habits. 3. Neurochemical Factors Compulsive overeating could be called "food addiction because certain high energy foods (fat, sugar) intensify craving and promote eating disorders. Consider how the concentration of drugs through refinement and synthesis increased their addictive liability over the centuries and then compare that with how the concentration of high-calorie foods (e.g., refined carbohydrates), increased compulsive overeating. Food manufacturers are aware of this distortion of normal mechanisms and often add sugar and other refined carbohydrates to satisfy this craving. C. MEDICAL CONSEQUENCES OF OBESITY (p. 3.47) Medical conditions associated with obesity include high blood pressure, high cholesterol, circulatory problems, heart disease, type II diabetes, sleep apnea, and a 15% to 60% greater risk of cancer. Being 80 or more pounds overweight shortens a person's life span by up to 12 years. 1. Diabetes. Diabetes has become epidemic in the United States and is spreading to other countries. About 8% of the population had diabetes in 2009, predictions indicate the number will double in 25 years. Adult onset type II diabetes is caused by overeating and consuming too many refined carbohydrates. D. PSYCHOLOGICAL PROBLEMS & CO-OCCURRING DISORDERS (pp. 7.47-7.48) Depression, anxiety, substance abuse, personality disorders, a negative body image, and poor self esteem are common among people with eating disorders. Abuse of tobacco, alcohol, amphetamines, prescription drugs, or over-the-counter substances is frequently found in 12% to 18% of those with anorexia, and 30% and 70% of those with bulimia. The brain does not differentiate between the euphoric feelings generated by bingeing and those generated by fasting. High levels of sugar have been found to reduce the levels of corticosteroids, the body’s stress hormones. E. EPIDEMIOLOGY OF ANOREXIA, BULIMIA & BINGE-EATING DISORDERS (p. 7.48) More than half of all eating disorders go undetected even though most eating disorders begin in adolescence, are chronic, and affect women disproportionately; 90% to 95% of anorectics and bulimics are women.

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Anorexia and bulimia are more common in developed nations with an abundance of food. Recent studies of schoolgirls in Cairo, Egypt, found rates for anorexia and bulimia about the same as those in England. In recent years, the age of onset of anorexia nervosa has dropped from as low as 13 years old to nine. Children starve themselves, use diuretics and laxatives, and throw up to stay thin. It is a growing obsession in modern society. In the United States, approximately 20% of college women have an eating disorder. F. ANOREXIA NERVOSA (pp. 7.48-7.49) Anorexia, an addiction to weight loss, fasting, and minimization was practiced as far back as the Middle Ages and known as the "holy anorexia." 1. Definition Anorexia could be considered “weight phobia.” •

Anorexia restrictors continue to lose weight by limiting their food intake through dieting, fasting, the use of amphetamines and other diet pills, and excessive exercise. • Binge-eating/purging types promote weight loss by purging using diuretics, laxatives, enemas, or self-induced vomiting. People afflicted with anorexia nervosa have a distorted perception of their body’s shape and size, avoid weight gain and eventually lose from 15% to 60% of their weight. 2. Causes Young female anorexics may have a tendency to perfectionism but they lack self-esteem and a sense of self. A refusal to eat gives them a measure of control over their lives. Additional characteristics of anorexia include anorexic delusions and compulsions. One theory suggests that what initially began as a strict diet, changes brain chemistry after three months and feeds the delusions and compulsion. 3. Effects Semistarvation strains all of the body’s systems, especially the heart, liver, and brain. Vomiting causes dehydration and depletes electrolytes which can lead to arrhythmias and cardiac arrest. Estrogen levels in females and testosterone levels in males decrease. Other symptoms are osteoporosis, sterility, miscarriage, and birth defects. Death rates among anorexic patients are estimated at 4% to 20%. Congestive heart failure and suicide are the most frequent causes of death. G. BULIMIA NERVOSA (pp. 7.49-7.50) 1. Definition Bulimia is characterized by eating large amounts of food in one sitting (bingeing) followed by inappropriate methods of ridding the body of the food. Methods include self-induced vomiting (used by 80% to 90% of bulimics), diuretics or laxatives, fasting, and excessive exercise.

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People with bulimia often are ashamed of their behavior, eat secretly, and consume food rapidly. Those with the disorder often are within a few pounds of normal weight. During binge episodes there may be a feeling of frenzy, of not being in control, and a sense of being disconnected from one’s surroundings. 2. Causes Causes include environmental/social pressures to be slim and the desire to be perfect. The biochemical changes involved with bulimia can make the disorder self-perpetuating. 3. Effects Frequent vomiting creates the risk of stomach acid burns to the esophagus, throat, and the tooth enamel (which can be permanently eaten away by acid). A Dental professionals is often the first to spot bulimic activity. Heart problems, such as arrhythmias, can develop as can electrolyte imbalances and irregular menstrual periods. Other problems include a greater liability for alcohol/drug abuse, a high rate of depression, and a greater risk of suicide. Psychological effects include loneliness and self-imposed isolation. H. BINGE-EATING DISORDER (including compulsive overeating) (pp. 7.50-7.51) For the first time in history, there are as many people overweight as underweight, about 1.1 billion of each in a worldwide population of almost 7 billion. 1. Definition Binge-eating disorder is marked by recurrent episodes of binge eating without vomiting, laxative use, or other compensatory activities. Extreme weight gain is often a consequence. A pattern of frequent eating and snacking over a period of several hours is a symptom of this condition. People eat in response to emotional states rather than to true hunger signals. They believe that they cannot control the amount eaten, the pace of eating, and the kind of food eaten. They will stop only when it becomes painfully uncomfortable. 2. Causes Research suggests that neurochemical changes to the stop switch elevates overeating to binge eating. Food is often used to modify emotions, especially depression. Weight gain may increase stress, guilt, and depression, perpetuating the overeating cycle. I. TREATMENT & SUPPORT GROUPS (pp. 7.51-7.52) 60% of overweight Americans turn to one or more of the hundreds of diet books, magazine articles, and more than a half dozen types of surgery (e.g., lap band gastric bypass). Support groups range from commercial ventures like TOPS® (Take Off Pounds Sensibly), Weight Watchers,® and Jenny Craig,® to self-

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help 12-step groups like Overeaters Anonymous, Food Addicts Anonymous, and GreySheeters Anonymous. Unless children learn good eating habits when they are young, maintaining a normal healthy weight become a lifetime process. X. SEXUAL ADDICTION (PP. 7.52-7.54) The porn/adult entertainment industry is estimated to generate more than $100 billion per year worldwide. 14 million the United States and 25 billion each in China and South Korea. As of 2011 there were more than 100,000 pornographic sites on the Internet, visited regularly by 72 million worldwide. A. DEFINITION (pp. 2.52-2.54) Sexual addiction is marked by sexual behavior over which the addict has little control. Sexual addiction can include masturbation and pornography (the most frequent behaviors) along with serial affairs, phone sex, fetishes, and frequent visits to topless bars and strip shows. The anonymity of the Internet feeds into traits found in many sex addicts. Many use chat rooms and message boards to find sex partners. Collateral addictions include love addictions (the compulsion to fall in love and be in love) and relationship addictions. The object of a sexual addiction can be pursuit of the pleasure and/or a desire to subdue pain or anxiety. There is a lack of control over the behavior, a continuation of the behavior despite adverse consequences, and an obsession with doing, planning to do, or simply thinking about the behavior. The incidence of sexual addiction in some studies is 3% to 6% of the population. 80% of sex addicts are male. B. EFFECTS & SIDE EFFECTS (p. 7.54) Whether it’s for the high or as a way to cope with depression, anxiety, stress, solitude, or low self-worth, compulsive sexual behavior conditions the body to seek the release of pleasure-giving neurotransmitters. Usually there is a culminating sexual event (e.g., exposure, rape, or molestation) and an orgasm, over which the addict has virtually no control. The event is often followed by remorse, guilt, fear of discovery, and resolutions to stop the behavior. XI. ELECTRONIC ADDICTIONS (PP. 7.54-7.58) All forms of electronic media have addicting qualities. . A. THE INTERNET (p. 7.55) The Internet was proposed in 1989 by a British-born computer scientist, Tim Berners-Lee. As of 2010 more than 2 billion people worldwide were connected. Besides ease of use and anonymity, the Internet is inexpensive, convenient, controllable, validating (it doesn’t criticize), rewarding, and escapist.

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Symptoms of Internet addiction include feeling irritable and anxious when not online, spending more time online; neglecting responsibilities because of online activities, etc. Some people experience a stimulant-like rush when online, others describe a feeling of tranquility by their quiet, isolated, online experience. Cybersexual addiction, computer relationship addiction, Internet compulsions, information addiction, and computer games addiction are the result of Internet use. B. CYBERSEXUAL ADDICTION (p. 7.55) See Sexual Addiction, earlier in this chapter. C. CYBER-RELATIONSHIP ADDICTION (p. 7.55) If connections made on the Internet are not created for sexual activity but becomes compulsive, they could be called “cyber-relationships.” Problems occur when an online relationship draws the participants away from his or her real-life relationships. Online friendships can lead to “cyber affairs,” often to the devastation of the neglected partner. D. INTERNET COMPULSIONS (p. 7.55-7.56) Accessibility creates and perpetuates Internet compulsions. There are hundreds of online casinos, stock-trading companies, and auction houses. The promise of large winnings and profits is a spur to activity. The notion that "I can do it whenever I want" makes abuse of this activity especially addicting. E. INFORMATION ADDICTION (p. 7.56) The ability to access thousands of Web sites that cover virtually every subject is attractive to a wide variety of Internet users. Young people may find that online activity is less threatening than actual human interaction and could be at risk for isolation. F. COMPUTER GAMES ADDICTION (p. 7.56) Adult males, teenagers, and children play computer games. The average game player spends 30 to 60 minutes a day playing games. Game addicts can play five, or more hours a day. Hundreds of role-playing games, particularly MMORPGs (massively multiplayer online role-playing games) were introduced in the 1990s.Two of the most popular are World of Warcraft® and Happy Farm.® G. TELEVISION ADDICTION (pp. 7.56-7.57) The average American watches 2.8 hours of TV a day. For compulsive TV watchers here and abroad, six to eight hours a day is standard. The benchmarks of addiction include compulsive use, using TV to change one’s mood, craving, loss of control, continued use despite adverse consequences, and development of tolerance.

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The distorted view of real life presented on many TV shows makes it harder for a compulsive viewer to make good decisions. The portrayal and promotion of dysfunctional families and relationships as the norm, rather than the exception, is confusing to adolescents and young adults. In one New Zealand study, kids 5 to 15 years of age who watched the most TV were the least likely to graduate from high school or college. H. MOBILE PHONE ADDICTION (pp. 7.57-7.58) The number of cell phones in the U.S. has gone from 385,000 in 1985 to an estimated 373 million in 2013. Worldwide it has gone from 2.7 billion cell phones in 2006 to an estimated 5.8 billion by 2013 with the biggest growth in Asia. Two of every five U.S. youths uses a cell phone and spend an average of an hour per day calling and/or texting. The jury is still out as to whether the communication advantages are overshadowed by the loss of privacy. The smart phone/Internet revolution is still in its infancy, and its impact on social and cultural behaviors is continuing to evolve. XII. CONCLUSIONS (P. 7.58) The disease is addiction, not inhalant abuse, steroid misuse, or compulsive gambling, eating, shopping, or sex. They are the manifestations of the disease. There are similarities between substance abuse and other all-consuming behaviors, but there are distinctive characteristics of a specific addiction that must be addressed in treatment. Psychotherapy, behavioral therapies, self-help groups, and psychiatric medications tailored to specific compulsive disorders offer hope for effective treatment and recovery.

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Chapter 7 - OTHER DRUGS, OTHER ADDICTIONS Classroom or Small Group Discussion Topics 1. Have students describe: A. The main attractions of inhalants as psychoactive substances B. Methods/techniques of inhalant use. C. The health risks of the inhalant substances D. The health risks of the techniques used for inhalants. 2. How would an ingenious seventh-grader use inhalants during school hours? What telltale signs might appear? 3. List common household products that warn against use without proper ventilation. Which of the products could be abused as inhalants? 4. Ask the class to debate the acceptability of steroid use in baseball. Have the students compare the statistics from the most recent baseball season to those from the seasons when Mark McGuire, Sammy Sosa, and Barry Bonds were breaking records with their power hitting. 5. Is it appropriate for state governments to sponsor gambling and lotteries activities where the majority of revenue comes from addicted players? 6. Should online gambling be permitted? If so should players be able to use their credit cards to pay for their gaming? 7. Discuss how the inclusion of corn syrup and other refined carbohydrates in many processed foods is similar to boosting the nicotine content of cigarettes. 8. What unusual substances are students aware of that have been or could be used as psychoactive drugs.

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Chapter 7 – OTHER DRUGS, OTHER ADDICTIONS Critical Thinking & Class Exercises 1. Have students take several deep breaths and describe the effects. How would those effects compare to the effects of “huffing” solvents described in the chapter? If any student had a personal experience accidentally smelling or inhaling a toxic substance (e.g., paint thinner) how did it affected them? 2. What would a student do if they discovered a younger brother or sister was inhaling dangerous chemicals. 3. Present the hypothetical: A varsity athlete who has never used steroids is elected co-captain of the team. It is widely suspected that most of the starting players on a rival team that won the league championship were on steroids. The co-captain’s team has dedicated itself to winning the league championship next year. Ask students to discuss what the co-captain should tell younger players who ask whether they should “start bulking up on “roids” for next season. 5. Have students go through the TV listings and through newspapers to find out how many references to gambling (including ads) there are. Have them scout their neighborhoods for stores or bars that have offer gambling. 6. How much time do your students spend watching TV, on the Internet, on their cell phones, or using other electronic devices? How much is too much? If they believed they had a problem – what would they do? 7. Ask students to design a support-group program for those with eating disorders. •

Should group therapy or 12-step groups be disorder specific (i.e., one for anorexics, another for overeaters)?

•

Should it be gender segregated, mandatory, or self-referred?

•

What kinds of issues should be discussed?

•

What role, if any, should family and friends play?

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Uppers, Downers, All Arounders, 7th Edition – Instructor's Manual Chapter 8 - DRUG USE AND PREVENTION: FROM CRADLE TO GRAVE Overview This chapter examines current drug use patterns among various age groups, surveys the relationship of drugs to sexual behavior, sexual violence, hepatitis, and AIDS, and explores drugs in the military, and in the workplace. Major elements of drug testing methods are also covered. Promising methods of drug-abuse prevention are studied including delaying the first use of addictive substances, increasing perceptions of the negative effects of abused drugs, normalizing perceptions of current drug use amongst peers, and enhanced parental involvement in prevention efforts. PREVENTION Drug use and abuse affects people throughout their lives, drug prevention and treatment should be available for every stage of life.  Substance abuse prevention ranges from total prohibition, to temperance, to harm reduction, to legalization. The main prevention strategies are supply reduction, demand reduction, and harm reduction. • Supply reduction aims to limit the amount of drugs available to the user through interdiction, legal penalties, and incarceration. • Demand reduction tries to reduce craving and drug demand through primary, secondary, and tertiary prevention strategies. Refinements of these strategies include universal, selective and indicated prevention. • Harm reduction limits the harm addicts do to themselves and to society. Primary, secondary, and tertiary prevention work best when appropriate education and participation occurs at every age level. A lack of adequate prevention funding makes this a difficult task. • Primary prevention is aimed at those who are drug naïve or who have merely experimented with drugs. It aims to keep them from ever using or to keep their use experimental and/or to occasional social use. • Secondary prevention is directed at casual and habitual users to prevent escalation of use to abuse and addiction. • Tertiary prevention is aimed at heavy users, abusers, and addicts to lead them to recovery and limit the harm they do to themselves. Treatment is the primary component of tertiary prevention.

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Chapter 8 - DRUG USE & PREVENTION: FROM CRADLE TO GRAVE Chapter Outline I. INTRODUCTION PREVENTION II. CONCEPTS OF PREVENTION A. Prevention Goals

B. Supply, Demand & Harm Reduction III. HISTORY A. Temperance Vs. Prohibition B. Did Prohibition Really Fail?

C. Amethyst Initiative D. Scare Tactics & Drug Information Programs E. Skill-Building & Resiliency Programs F. Changing the Environment G. Public Health Model H. Family Approach IV. PREVENTION METHODS A. Supply Reduction 1. Legislation & Legal Penalties 2. Outcomes of Supply Reduction

B. Demand Reduction 1. Primary Prevention 2. Secondary Prevention 3. Tertiary Prevention

C. Harm Reduction V. CHALLENGES TO PREVENTION A. Legal Drugs In Society B. Conclusions C. Funding FROM CRADLE TO GRAVE

VI. PATTERNS OF USE A. Use by Race & Class B. Use by Age VII. PREGNANCY & BIRTH A. Overview 1. Maternal Risks 2. Fetal & Neonatal Complications 3. Long-Term Effects

B. Specific Drug Effects 1. Alcohol

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2. Cocaine & Amphetamines 3. Opioids 4. Marijuana 5. Prescription & Over-The-Counter Drugs 6. Nicotine 7. Caffeine

C. Prevention

VIII. YOUTH & SCHOOL A. Adolescents & High School 1. How Serious Is The Problem? 2. Crime 3. The Effects of Drugs On Maturation 4. Risk-Focused & Resiliency-Focused Prevention For Adolescents 5. Primary, Secondary, & Tertiary Prevention For Grades K Through 12

B. College Students 1. Prevalence 2. Secondhand Drinking 3. Prevention in College

IX. LOVE, SEX, & DRUGS A. General Effects B. The Drugs 1. Alcohol 2. Cocaine & Amphetamines 3. Tobacco 4. Opioids 5. Sedative-Hypnotics 6. Marijuana 7. MDMA & MDA (ecstasy) 8. Mephedrone 9. PCP 10. LSD 11. Volatile Nitrites (amyl, butyl, etc.) 12. Nitrous Oxide (laughing gas) 13. Psychiatric Drugs 14. Aphrodisiacs

C. Substance Abuse & Sexual Assault D. Sexually Transmitted Diseases (Stds) 1. Epidemiology

E. Needle-Transmitted Diseases 1. Hepatitis A, B, & C 2. Abscesses, Cotton Fever, & Endocarditis 3. HIV & AIDS

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F. Prevention of Disease 1. Harm Reduction

X. DRUGS AT WORK A. Costs 1. Loss of Productivity 2. Medical Cost Increases 3. Legal Cost Increases B. Prevention & Employee Assistance Programs (Eaps) 1. Workplace Drug Testing 2. Employee Assistance Programs (Eaps) 3. Effectiveness of Eaps

XI. DRUGS IN THE MILITARY

XII. DRUG TESTING A. The Tests 1. Thin Layer Chromatography (TLC) 2. Enzyme-Multiplied Immunoassay Techniques, Radio Immunoassay, Enzyme Immunoassay 3. Gas Chromatography/Mass Spectrometry Combined (GC/MS) & Gas Liquid Chromatography (GLC) 4. Hair Analysis 5. Saliva, Sweat, & Breath

B. Detection Period 1. Latency 2. Detection Period Range 3. Redistribution, Recirculation, Sequestration,& Other Variables

C. Accuracy Of Drug Testing 1. Consequences of False Positives & Negatives

XIII. DRUGS & THE ELDERLY A. Scope Of The Problem 1. Overall Drug Use 2. Chemical Dependency

B. Physiological Changes 1. Factors Contributing To Elderly Drug Misuse & Abuse

C. Prevention Issues 1. Primary Prevention 2. Secondary Prevention 3. Tertiary Prevention

XIV. CONCLUSIONS A. Promising New Directions

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Chapter 8 - DRUG USE & PREVENTION: FROM CRADLE TO GRAVE Extended Outline I. INTRODUCTION (pp. 8.2−8.3) Because psychoactive drugs and addictive behaviors affect people’s lives from conception to death, prevention and treatment programs should be available at every stage of life. PREVENTION II. CONCEPTS OF PREVENTION (PP. 8.3−8.4) A. PREVENTION GOALS (p. 8.3) It is up to each society to decide what it wishes to prevent. Is the society trying to prevent use of any psychoactive drug, trying to ban only illicit drugs, or simply trying to limit the damage caused by use, abuse, and addiction? Prevention goals are achieved by •

preventing the disease of addiction from ever developing (primary prevention); • stopping inappropriate use as soon as it has begun in ‘non-dependent users” (secondary prevention); • reversing the progression of abuse and addiction in “dependent users” (tertiary prevention). Prevention efforts must also be targeted towards those who are in recovery (the “never to use again” community) to help them maintain continued abstinence from drugs, alcohol, nicotine or compulsive disorders. Traditionally, the three methods of achieving prevention goals are: • • •

reduce the supply (e.g. interdiction, legislation, legal sanctions), reduce the demand (e.g. education, intervention, treatment, individual and community development), reduce the harm that drugs do to users, friends and relatives of users, and society as a whole (e.g. medication replacement therapy, designated driver program, needle-exchanges, decriminalization).

III. HISTORY (PP. 8.4-8.8) A. TEMPERANCE VS. PROHIBITION (pp. 8.4−8.5) Attempts to regulate drugs, particularly alcohol, have wavered between moderation of use (temperance) and outright prohibition. The concept of

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complete prohibition, or today’s zero tolerance, runs on a 70-year cycle: 1780, 1850, 1920, and 1990.

B. DID PROHIBITION REALLY FAIL? (pp. 3.5−3.6) The popular belief that Prohibition, (enforced in 1920 and repealed in 1933), was ineffective, has endured for decades. The truth is that Prohibition did reduce health problems, domestic violence, crime, and consumption. The belief that Prohibition created organized crime is a myth. Criminal organizations existed long before Prohibition but organizational techniques were indeed refined during that era. Increased tax revenue and the public’s desire to drink caused Prohibition’s repeal. C. AMETHYST INITIATIVE (p. 8.6) In 2008 a petition movement known as the Amethyst Initiative garnered endorsements from the presidents of more than 100 of the nation’s leading independent liberal arts institutions. These academic leaders were interested in lowering the drinking age from 21 to 18, the age of consent and the age Americans are granted many other rights. It was also endorsed by the academic community with the hope that it would eliminate their campuses’ burden of policing and enforcing underage-drinking laws. Statistics and studies have clearly demonstrated the positive impact of the National Minimum Drinking Age Act of 1984 that established the nation’s minimum drinking age to 21. D. SCARE TACTICS & DRUG INFORMATION PROGRAMS (pp. 8.6− 8.7) Concerted attempts to lessen substance abuse didn’t begin until the 1960s. Knowledge-based programs were established to teach students about drugs and the associated problems caused by use. It was assumed that the use of scare tactics would reduce drug use. There is little evidence that drug information alone causes changes in behavior. Effective demand reduction prevention efforts decrease drug problems at a fraction of the cost of supply reduction efforts. E. SKILL-BUILDING & RESILIENCY PROGRAMS (p. 8.7) Prevention efforts expanded to address the psychological and developmental factors that might predispose individuals to drugs. The more risk factors an individual has the more likely they are to abuse drugs. Increasing skills that effectively address these risks are the aim of several programs.

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General competency building; training in self-esteem, in socially acceptable behavior, in decision-making, self-assertion, problem-solving, and vocational skills. Coping (resistance) skills; developing the self-reliance, confidence, and inner resources needed to resist drug use. Reinforcing protective factors and resiliency; ways to build on the natural strengths people already have. Support system development to provide easy access to sympathetic support resources. For more information and details on programs visit the SAMHSA National Registry of Evidence-based Programs and Practices (www.NREPP.samhsa.gov). F. CHANGING THE ENVIRONMENT (p. 8.8) Environmental change comes from community-based systems-oriented programs that get entire neighborhoods to take responsibility for preventing substance abuse. Typical community activities include: ◊ assessing the needs of the community and coordinating existing services; ◊ changing laws and public policy; ◊ increasing funding for family, school, and community prevention services; ◊ community-wide training and planning. G. PUBLIC HEALTH MODEL (p. 8.8) The public health model considers addiction as a disease in a • • •

genetically predisposed host (the actual user) who lives in a contributory environment (the actual location and the social network of the host) in which an agent (the drug or drugs) introduces the disease.

Prevention is designed to affect the relationships among these three factors. H. FAMILY APPROACH (p. 8.8) Family support, skills training, and therapy, along with parenting programs, aid in reducing the risk factors that lead to drug abuse and addiction. IV. PREVENTION METHODS (PP. 8.8−8.16) A. SUPPLY REDUCTION (p. 8. 8.10) Supply reduction seeks to decrease drug abuse by reducing the availability of drugs through regulation, restriction, interdiction, and law enforcement. Some of the activities include: •

interdicting drug smugglers and increasing law enforcement activities at border crossings;

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• • •

interdicting and limiting the supply of precursor chemicals; identifying, disrupting, and dismantling organized crime and gangs; enforcing and passing more severe laws; disrupting money laundering activities, etc. Despite these efforts, the overall availability of illicit drugs in the U.S. continues to increase.

1. Legislation & Legal Penalties (pp. 8.10−8.11) Since the Pure Food and Drug Act of 1906 and the Comprehensive Drug Abuse Prevention and Control Act of 1970, penalties for drug possession and sales have increased. To curtail drug availability, more severe penalties (longer prison terms, asset forfeiture, heavy fines) were levied against offenders. As a result, the prison population (federal, state, and local) has more than tripled between 1980 and 2006 to approximately 2.3 million. In 2005 nearly 55% of the inmates in federal prisons were there because of drug offenses. Half of all inmates reported drug use while committing the offense that put them in prison. Disparity in penalties for possession of crack cocaine and powder cocaine disproportionally impacted African American and other minority groups. This was addressed by the Fair Sentencing Clarification Act of 2010. Most states have mandatory minimum sentencing based upon possession of specific amounts of illicit drugs. Sentencing revision in the 2000s has enabled diversion of drug abusers into treatment rather than prisons. The epidemic of prescription drug abuse has resulted in states gaining more authority to monitor Schedule II, III, and IV prescribing practices. Medications like ephedrine and pseudoephedrine used as precursors in the illicit manufacture of methamphetamine are now controlled in many states. As of 2010, 16 states plus the District of Columbia permit medical marijuana. These laws conflict with federal laws which has resulted in confusion about how the state laws impact employment, housing, motor vehicle operations, and many other state/federal regulations 2. Outcomes of Supply Reduction (pp. 8.11−8.12) Advocates of supply reduction believe strict policies and strong penalties delay the impulse to use, force people into treatment, and keep them there. Some argue that this is a costly approach given the relatively minor impact on the supply. Drug courts are more frequently used today, avoiding backlogs in the justice system for thousands of arrests for minor drug offenses. First-time offenders are diverted to treatment, shifting a supply reduction technique to a demand reduction strategy. In 2010 synthetic marijuana chemicals began showing up in “head shops” as herbal incense under trade names like K2® and Spice®). This was followed by the introduction of new powerful synthetic stimulants like mephedrone (methylmethcathinone) and MDPV sold as bath salts (trade names: Vanilla Sky® 8                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

or Ivory Wave®). They were undetected in urine tests and by labeling these products as incense or bath salts, they circumvented drug regulations. States banned these substances allowing them to police supplies as new Schedule I drugs of abuse. B. DEMAND REDUCTION (pp. 8.12−8.15) Supply reduction has been only marginally successful so demand reduction has become a more viable option entailing primary, secondary, and tertiary prevention. Newer concepts of prevention (universal prevention) look at developing strategies targeting all members of a community. Those targeted towards specific higher risk populations are known as selective prevention and those strategies targeted for active drug abusers are known as indicated prevention. 1. Primary Prevention (pp. 8.12−8.13) Although primary prevention is the most important level of demand it receives the least federal, state, and local funding. Primary prevention efforts are designed to anticipate and prevent or delay initial drug use. Many studies have demonstrated that the age of first use is the strongest predictor of future drug or alcohol problems. Its goals are to promote nonuse or abstinence; help young people refuse drugs; delay the age of first use, and encourage healthy nondrug alternatives to achieving altered states of consciousness. This level of prevention attempts to instill resistance by teaching skills in coping, handling peer pressure, decision making, and other skills to help prevent young people from ever using psychoactive substances. Primary and universal prevention target nonusers of drugs or alcohol. 2. Secondary Prevention (p. 8.14) Secondary prevention seeks to halt drug use once it has begun and adds intervention strategies to education and skill building. Drug diversion programs (e.g., drug courts) for first-time drug offenders have proven to be useful and cost-effective. Selective prevention at this level targets non-dependent drug users who have high risk for developing drug dependence such as those who received their first DUII citation or children of addicts. The lag between first use of a drug and the development of physical and emotional problems makes drug experimenters less likely to believe that information about harmful effects applies to them. This is the biggest challenge to secondary prevention efforts.

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3. Tertiary Prevention (pp. 8.14−8.15) Tertiary prevention seeks to stop further damage from habituation, abuse, and addiction to drugs and to restore an abuser to health. Strategies include: • group intervention, • cue extinction therapy, • family therapy, • specific relapse prevention and life management skills, • psychopharmacological strategies, • promotion of a healthy lifestyle; and • development of support and aftercare systems. Indicated and tertiary prevention target dependent drug users. A major problem with this population is the “awareness gap”. Up to 76% of those who are dependent on drugs or alcohol do not recognize their own addiction. Screening, brief intervention and referral to treatment procedures for employment, health care enrollment or auto licensing may close this gap. Treatment results in abstinence or decreased drug use in 40% to 50% of cases, a steep reduction in crime (74%), and a savings of $4 to $20 for every $1 spent by a community. An estimated 20 million Americans desire treatment but only 1.4 million receive treatment (treatment gap). 20 to 30% of those on a waiting list for treatment follow through and enter treatment. C. HARM REDUCTION (pp. 8.15−8.16) Harm reduction focuses on techniques to minimize the personal and social problems associated with drug use rather than making abstinence the primary goal. Bleach distribution and needle-exchange efforts can reduce the spread of HIV without increasing illegal-drug use. Substituting a legal drug addiction for an illegal one as in methadone maintenance programs is another example. Programs that are more controversial include ◊ responsible use education which accepts some level of experimental or social ◊ decriminalization or legalization of all abused drugs; ◊ treatment that reduces an addict’s habit to manageable levels; ◊ permitting addicts to design and manage their intervention and treatment processes. These tactics conflict with federal drug policy and spread ambiguity about abuse of drugs. Surveys demonstrate that abuse of drugs increase when perception of drugs as being harmful decreases V. CHALLENGES TO PREVENTION (PP. 8.16−8.17) A. LEGAL DRUGS IN SOCIETY (pp. 8.16−8.17) The social and health problems attributed to alcohol, tobacco, and, to a lesser extent, prescription drug abuse are far greater than those caused by illicit drug

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use. These legal drugs are widely available and actively marketed by sophisticated advertising campaigns. Billions are also spent advertising over-the-counter (OTC) and prescription drugs. This two-tiered approach—acceptable and unacceptable drugs— breeds cynicism and disbelief of prevention messages. Alcohol and tobacco are successfully marketed to the general public using age and culturally targeted messages at specific populations. Similar methods promoting prevention could result in effective prevention outcomes. B. CONCLUSIONS (p. 8.17) One of the realities of prevention is that there is no quick fix. The success of the antismoking effort has taken almost half a century. •

First knowledge must change, then attitudes, and finally practices.

•

The job is never complete.

•

Over time, prevention efforts become more difficult to sustain.

•

No single approach works consistently.

C. FUNDING (p. 8.17) Prevention is vastly underfunded when compared with society’s cost of alcohol and drug abuse. Prevention is not perceived as exciting because the basic message is so simple, and public participation in local and national prevention activities is low. Exciting or not - prevention programs must available at every stage of life and they must be: • • • •

cultural and age specific, imaginative, accurate, and honest, non-judgmental, and generously funded and supported.

FROM CRADLE TO GRAVE V. PATTERNS OF USE (p. 8.17) A. USE BY RACE & CLASS (p. 8.18) In 2009, those least likely to have used an illicit drug were Asian Americans (3.7%) American Indians or Alaskan Natives were most likely (18.3%), Whites (9.6%), Blacks (9.6%), and Hispanics (8.8%), had fairly comparable rates of recent illicit drug abuse while persons reporting two or more ethnicities had a current illicit drug use rate of 14.3%. Alcoholics and addicts live in the inner city but a higher percent live in rural or suburban communities. Many of these individuals number among the most skilled, talented, intelligent, and sensitive individuals in our society. Intelligence is not a guaranteed protection against addiction.

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B. USE BY AGE (pp. 8.18, 8.19) Over the past 40 years there has been a gradual lowering of the age of drug users. In 2009 the average age of first use of alcohol and most illicit drugs lowered but the average age of first use for cigarettes, methamphetamine, heroin and sedatives increased. The number of Americans 12 and older who used illicit drugs in the past month (21.8 million in a population of 252 million) may seem small; however, they have an exaggerated effect on all levels of society VI. PREGNANCY & BIRTH (PP. 8.19−8.28) A. OVERVIEW (pp. 8.19−8.22) The health of both the mother and the child is compromised when drugs are used or abused during pregnancy. Most psychoactive substances can harm the developing fetus. In one survey, 18.6% of infants were exposed to alcohol at some time during gestation. As a result, fetal alcohol syndrome (FAS) is the third most common birth defect and the leading cause of mental retardation in the United States. Other results of the survey; 4.5% were exposed to cocaine, 17.4% to marijuana, and 17.6% to tobacco. Use of drugs in early pregnancy does the most damage to the developing fetus. The costs of caring for a drug exposed infant are three times higher than for an unexposed infant. 1. Maternal Risks (p. 8.20) Some conditions aggravated by drug use in pregnant women include anemia, sexually transmitted diseases, diabetes, high blood pressure, neurological damage, weakened immune system, and poor nutrition. Infections contracted from IV drug use include hepatitis C, endocarditis, and HIV/AIDS. Eighty percent of children with HIV in the United States were born to mothers who were IV drug abusers or sexual partners of IV drug abusers. A pregnant addict often has had no prenatal care or medical intervention prior to delivery and often lives a chaotic lifestyle. 2. Fetal &Neonatal Complications (pp. 8.21−8.22) When a pregnant woman uses psychoactive drugs, it is difficult to distinguish the effects of her toxic environment (domestic abuse, stress, poor nutrition) on the fetus from the direct effects of the drug. Psychoactive drugs easily cross the placental barrier, exposing a fetus to whatever chemicals the mother is using. After birth many drugs taken by the mother pass into the breast milk. The fetus is most vulnerable during the first 12 weeks but neurological damage can occur throughout a pregnancy if the mother uses drugs. The second trimester involves further maturation, the organs continue to be vulnerable. The third trimester includes maturation of the fetus and preparation for birth. Definite syndromes of neonatal withdrawal, intoxication, 12                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

and developmental or learning delays have been attributed to a variety of drugs, including alcohol. 3. Long-Term Effects (p. 8.22) Research indicates that the majority of drug-exposed babies who receive prenatal, perinatal, and postnatal care, along with continued services, manage to catch up developmentally to non-drug-exposed children after a slow start. Some studies have found persistence of learning disabilities at age seven and beyond. B. SPECIFIC DRUG EFFECTS (pp. 8.22−8.27) 1. Alcohol (pp. 8.22−8.23) A number of conditions are grouped under the acronym FASD, or fetal alcohol spectrum disorders. FAS, a birth defect syndrome, is characterized by a definite pattern of physical, mental, and behavioral abnormalities in children born to mothers who drank heavily during pregnancy. There are a number of other less severe yet more widespread conditions that involve cognitive abilities such as alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD), also known as “fetal alcohol effects” (FAE). Worldwide, from 0.33 to 2.9 cases per 1,000 live births have FAS. The U.S. rate is .50 to 2.0 per 1,000 live births. The incidence of ARND and ARBD is five to 10 times greater than FAS. Growth problems caused by prenatal alcohol use involve weight, height, and head circumference and can persists into adolescence. Parental use of alcohol and prenatal alcohol exposure increases the risk of sudden infant death syndrome (SIDS), places the child at a greater risk of being abused (2.7 times), and a 4.2 higher risk of being neglected. 2. Cocaine & Amphetamines (pp. 8.23−8.24) When cocaine use was at its highest levels, it was estimated that 4.5% of all U.S. infants were exposed in utero. Cocaine and amphetamines increase heart rate and constrict blood vessels, causing dramatic elevations in blood pressure in both mother and fetus. Thirdtrimester use of cocaine can induce sudden fetal activity, uterine contractions, and premature labor. Infants exposed to cocaine during pregnancy often go through a withdrawal syndrome characterized by extreme agitation, increased respiratory rates, hyperactivity, and occasional seizures. Many of the symptoms disappear after a few weeks if the mother’s breast milk is free of stimulants. A study of 406 children born to 153 meth-abusing women found a disability rate of 33%. This is a huge rate compared to children born to drug free women. Many abnormal neurobehavioral effects improve in the first three years of life.

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3. Opioids (pp. 8.24−8.25) Physical dependence on opioids leads to continuous use, so the effects on the fetus are greater than those associated with binge drugs such as cocaine. Women addicted to heroin, hydrocodone (Vicodin®), oxycodone (OxyContin®), buprenorphine (Subutex®), and other opioids have a greater risk for fetal growth retardation, miscarriage, stillbirth, and abruptio placentae as well as severe infections from intravenous use. Babies born to heroin-addicted mothers are often premature, smaller, and weaker than normal. A 600% increase in SIDS deaths was found in a study of 16,409 drug-exposed infants. A majority (60% to 80%) of opioid-exposed infants exhibit the neonatal abstinence syndrome (withdrawal) 48 to 72 hours after birth. Most cases of neonatal narcotic withdrawal can be treated with good nursing care. Opioid withdrawal in neonates can be fatal. Sufficient concentrations of opioids in breast milk expose newborns and have resulted in infant overdose deaths. 4. Marijuana (p. 8.25) Marijuana is used by 5% to 17% of pregnant women. Most marijuana exposure in newborns goes undetected or is masked by the use of other drugs. Marijuana-exposed children scored lower on verbal and memory performance tests, exhibited impulsive/hyperactive behavior, caused conduct problems, and were easily distracted. Anecdotal reports describe marijuana-exposed babies as showing withdrawal symptoms of abnormal responses to light and visual stimuli, increased tremulousness, “startles,” and a high-pitched cry. Marijuana use is contraindicated in breast feeding mothers. 5. Prescription & OTC Drugs (p. 8.25−8.26) OTC and prescribed medications are the most common drugs used by pregnant women. Benzodiazepines at dosages normally safe for the mother accumulate in fetal blood at more dangerous levels than in maternal blood. A withdrawal syndrome, similar to narcotic withdrawal, may also result. The use of benzodiazepines and barbiturate sedatives should be avoided during pregnancy. Many OTC medications contain stimulants, including caffeine or ephedrine, so their use should be carefully monitored. 6. Nicotine (p. 8.26−8.27) About 15.5% of pregnant women in 2009 smoked cigarettes. Nicotine and carbon monoxide can cross the placental barrier and reduce the fetal supply of oxygen. The risk of preterm delivery is increased if the mother smokes or is exposed to secondhand smoke. There is a 300% increase in the risk of SIDS in infants whose mothers are heavy smokers. Recent studies indicate that women smokers with a heavy habit are twice as likely to miscarry. Their babies weigh, on the average, 200 grams (7 oz.) less and have increased nervous 14                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

nursing (weaker sucking reflex). Long-lasting effects of smoking exposure before birth can include lower IQ and diminished cognitive ability. A study in India found that pregnant women who used smokeless tobacco had a threefold increased risk of stillbirth and were 2 to 3 times more likely to deliver a low-birth-weight baby. 7. Caffeine (p. 8.27) Studies of pregnant women found caffeine in 75% of infants at birth. Neonates, newborns, and infants have less tolerance for caffeine than adults. Physicians discourage caffeine use during pregnancy. C. PREVENTION (pp. 8.27−8.28) A pregnant woman must abstain from all unnecessary drug exposure. Screening instruments and programs are important in identifying AOD use. One effective screening tool is the 4Ps Plus (the woman’s Parental drug history, Partner’s drug history, her Past use history and any use during this Pregnancy). Once AOD use is identified, treatment, brief intervention, and prevention services can be implemented. Some experts fear that punitive measures for drug-using mothers keep them from prenatal clinics and doctors, and lead them to giving birth outside a hospital to avoid imprisonment or loss of custody. Professionals call for universal screening of pregnant women along with sufficient prenatal and drug treatment facilities. VII. YOUTH & SCHOOL (pp. 8.28−8.35) In spite of all the headlines about crack, LSD, and methamphetamine use among adolescents and college students, the most serious drug problem is alcohol. Tobacco is a close second and marijuana third. Recently, prescription drug use, especially opioids, has become more common. It has been found that the incidents of current or frequent use of illicit drugs in high schools and colleges are underreported. The true value of a youth survey is as a window to reveal trends in drug use, so it is possible to see changes from year to year and determine where our society is headed. An important observation is that when young people perceive drug use to be harmful, abuse of those drugs decrease and vice versa. A. ADOLESCENTS & HIGH SCHOOL (pp. 8.29−8.33) 1. How Serious Is the Problem? (pp. 8.29−8.30) Studies show a decrease in high school alcohol consumption over the past 30 years, a similar decrease in cigarette smoking, and a smaller drop in marijuana use. One study determined that •

Substance abuse adds 10% to the cost of elementary and secondary education

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•

•

Experimentation at an early age leads to more intensive use. By the 12 grade 85.7% of students who tried cigarettes, were still smoking, 83.3% of those who ever got drunk were still getting drunk, and 76.4% of those who tried marijuana were still using pot. If an individual reaches the age of 21 without smoking, using alcohol or other drugs, he or she probably never will.

Much of the alcohol and other drug use in high schools is experimental, social, or habitual with bouts of abuse. Most students have not used long enough for addiction to occur. Because they don’t have much experience managing their drinking and drug-taking habits, episodes of inappropriate use, including intoxication, drunk driving, and unsafe sex, are more likely. Adolescents believe they are invulnerable to the consequences of use, this results in a level of concern much lower than that of older users. Alcohol or drug use has catastrophic effects: 70% of teen suicides, 50% of date rapes and 40% of all teen drowning deaths involve alcohol or drug use. 2. Crime (p. 8.30) The most significant consequence of alcohol and/or drug use by adolescents is involvement with the justice system. More than half of juvenile male arrestees test positive for one or more illegal drugs. The drug found most frequently is marijuana. If authorities also tested for alcohol, the overall figures would be much higher. 3. The Effects of Drugs on Maturation (p. 8.30) Scientific research indicates that “To reach the emotional maturity of an average 18-year-old it takes 25 years.” Drugs delay maturity. When drugs or alcohol are habitually used in adolescence to avoid stress, to drown out emotions, or as a shortcut to feeling good, young people never fully learn how to deal with life’s conflicts without a psychoactive substance. 4. Risk-Focused & Resiliency-Focused Prevention for Adolescents (p. 8.31) Conditions that put an adolescent at risk for substance abuse and other behavioral addictions include physical, sexual, or emotional abuse, emotional and mental disturbances, lack of self-esteem, exposure to peer group pressure, etc. Researchers Steven Glenn, Ph.D. and Richard Jessor, Ph.D. believe the following must be in place to help children avoid drug use: • • • •

strong sense of family participation and involvement; an established personal position about drugs, alcohol, and sex; a strong spiritual sense and community involvement; attachment to a clean-and-sober adult role model.

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5. Primary, Secondary & Tertiary Prevention for Grades K through 12 (pp. 8.31−8.33) Prevention programs must be tailored to the specific age group, ethnicity, gender, and culture. Most successful programs are well structured and provide proven content. Prevention programs can be found through SAMHSA’s National Registry of Evidence-Based Programs and Practices. Model prevention programs include s Dare to Be You (DTBY), Family Matter, Lion’s Quest Skills for Adolescents, etc. Primary Prevention. Coordinated efforts among family members, teachers, and other school personnel are valuable. School-based programs teach life skills, resistance education, and/or normative education. LifeSkills Training, taught in grades 7 to 10, focuses on improving social skills and reducing peer pressure to drink. DARE (Drug Abuse Resistance Education), consists of 16 or 17 weekly onehour sessions presented to fifth or sixth graders conducted by uniformed police officers. AMPS (Alcohol Misuse Prevention Study) educates and develops peer resistance skills. Normative education is a strategy that aims to correct erroneous beliefs about the prevalence and the acceptability of alcohol and/or drug use among peers. Primary prevention must be on going rather than limited to a one-year attempt at inoculating students against drug and alcohol use. Because the roots of most addictions are related to family, family-focused primary prevention is a necessary and valuable adjunct to any school-based program. Secondary Prevention. School-based prevention programs should integrate secondary prevention programs and policies. Junior high and high schools should have clearly stated policies on substance use. Teachers and staff should be able to recognize drug use and be provided with information on how to deal with the consequences. Tertiary Prevention. This level uses student assistance programs (including counseling and social services), Alateen, other 12-step anonymous meetings, and peer intervention teams, to get drug abusers into early treatment. The honesty of peers is effective in reaching students who are in trouble. The Positive Behavioral Interventions and Supports (PBIS) provide support for schools that want to establish or strengthens their prevention programs. A large part of secondary and tertiary prevention is recognizing the signs of drug use in teenagers. Children of Alcoholics & Drug Abusers. It is estimated that one in four U.S. children under 18 years old are exposed to alcohol abuse or alcohol dependence in their family. Children in homes where alcohol and drug use are common take on certain roles: The hero (model child), a hardworking student also known as the “chief enabler,” who often takes over the duties of dysfunctional parents; 17                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

The problem child who experiences multiple personal problems, has a tendency to use drugs, and demands attention; The lost child who is extremely shy and deals with problems by avoiding family and social activities The mascot (or family clown) who tries to ease tension by being funny or cute and has trouble maturing. B. COLLEGE STUDENTS (pp. 8.33−8.35) Although illegal drugs, particularly marijuana, can be found on most college campuses, alcohol predominates. 1. Prevalence (pp. 8.33−8.34) The 2009 Monitoring the Future surveys found that  36.9% of full-time college students binge-drink  3.7% drink heavily on a daily basis   rates of daily smoking dropped from 15% in 1993 to 8% in 2009.  A CASA 2007 survey found  Fraternity and sorority members are more likely to drink than nonmembers  78% of college students who use illicit drugs have sex compared to 44% of those who do not use illicit drugs;  Consequences of drug and alcohol abuse on campuses include alcohol related injuries and deaths, alcohol-related rapes and sexual assaults, and assaults by binge drinking students. A change in federal law makes people ineligible for student financial aid if they have a drug conviction on their record. 2. Secondhand Drinking (p. 8.34) Many problems that occur on campuses are related to secondhand drinking— the effect binge drinkers and heavy drinkers have on other students. On drinking campuses, 86% of non-binge-drinking students reported being victims of assault and a dozen other provocations due to second-hand drinking. 3. Prevention in Colleges (pp. 8.34, 8.35) The belief that sowing one’s oats in college is a rite of passage to which students are entitled is one barrier to changing the view of a drinking (and drug-using) culture in college. Normative Assessment. One successful prevention approach is normative assessment. This program aims to change common misperceptions that drug and alcohol use among peers is higher than it really is. Instead of talking about drug and alcohol use, normative assessment emphasizes non-use.

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Other Programs. Some campus strategies directed at controlling alcohol use and abuse are: • •

regulate campus drinking; provide alcohol-, tobacco-, and drug-free dorms, and a social/entertainment/recreational activities;

• prohibit alcohol at campus events; • enforce campus alcohol/drug policies; • work with local communities • strengthen academic requirements, etc. As most college students mature, their alcohol and drug use decreases. IX. LOVE, SEX & DRUGS (PP. 8.35−8.48) Viagra® (sildenafil citrate) Cialis® (tadalafil), and Levitra® (vardenifil) have produced the most sweeping change in the use of drugs to enhance human sexuality even though they have no effect in the absence of sexual stimulation. Often psychoactive drugs substitute a simple physical sensation or the illusion of one, for more complex (and often more rewarding) emotions, such as desire for intimacy and comfort, love of children, or release from anxiety. Drugs are desirable to a wide range of ages and cultures, particularly if shyness, lack of confidence, aging, or physical changes have diminished one’s desire and abilities. Certain drugs can trigger sexual aggression, sexual harassment, rape, and child molestation. Drugs also encourage high-risk sexual behavior which can spread STDs. In the 1960s and 1970s, marijuana, amphetamines, and several other psychoactive drugs were readily available, frequently used, and had an effect on sexual activity. A less severe attitude toward sexual activity increased sexual contacts and drug experimentation. A. GENERAL EFFECTS (p. 8.36) The main effects psychoactive drugs have on sexual behavior are desire, /excitation, and orgasm. Many addiction counselors observe that clients combine sex and drugs to lower their inhibitions, improve their performance, and increase their fantasies. Sex and love are complicated processes and so tied to our mental state that people use drugs to shield themselves from their sexuality as well as from emotional involvement. B. THE DRUGS (pp. 8.37 – 8.42) Most of the effects on sexuality are from the drugs’ disruption of the neurotransmitters serotonin, dopamine, and norepinephrine. 1. Alcohol (pp. 8.37−8.38)

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Alcohol’s physical effects on sexual functioning are closely related to blood alcohol levels. Its mental effects, however, are less dose related and have more to do with the user’s psychological makeup and the setting in which it is used. Women & Alcohol. Because alcohol diminishes sexual arousal, women can suffer lowered self-esteem and feelings of inadequacy. Typically, alcoholic masks the connection between these feelings and her progressive alcohol use. In one study of chronic female alcoholics, 36% said they had orgasms less than 5% of the time. Men & Alcohol. Physically alcohol diminishes spinal reflexes, thus decreasing sensitivity and erectile ability. However, alcohol gives men more confidence because it acts on the area of the brain that regulates fight, fright, and fear, thereby promoting aggressiveness. As alcoholism progresses many men feel less sexual. In one early study, impotence was reported in 60% of heavy alcohol abusers. Adolescents & Alcohol. Risky and reckless behaviors are increased in teens that drink often resulting in unsafe sex. A British study found that 13 and 14 year old children who drank at least once a week were ten times more likely to engage in sex than their nondrinking peers. 2. Cocaine & Amphetamines (p. 8.38) Initial low-dose increases confidence, prolongs an erection, increases endurance, and intensifies an orgasm. Methamphetamine lasts hours longer than cocaine and thus prolongs the stimulation. Since initial feelings are so pleasurable, users come to depend on the drug to enjoy sex. Continued use sparks the cycle of dysfunction. Pre-existing sexual proclivities are directly related to the effect and the effectiveness of a drug on sex. In men, heavy or prolonged use often causes difficulty achieving an erection, delayed ejaculation, and a decrease in sexual desire. 3. Tobacco (pp. 8.38−8.39) Physically, nicotine can both stimulate and relax, depending on the set and the setting. Long-term tobacco use has occasionally been associated with lower testosterone and erectile dysfunction in men and reduced fertility in women. One study found that teens who smoke are more likely to participate in risky sexual behaviors than those who don’t. 4. Opioids (p. 8.39) Downers are often used to lower inhibitions, though the physiological depressive effects often decrease performance and eventually desire. Some users “nod off” during sex, long-term users report impaired performance and decreased sexual drive. The overall rate of impotence in one study of male addicts was 39%, jumping to 53% when they were high. 5. Sedative-Hypnotics (pp. 8.39−8.40) Physical depression trumps lowered inhibitions and relaxation and diminishes the ability to perform or respond sexually. Abuse results in sexual dysfunction and apathy toward sexual stimulation.

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Most of the short-acting sedative-hypnotics also cause amnesia (e.g., Rohypnol®). Sexual predators use them to seduce and rape, confident that their victims will have no memory of the event. Flunitrazepam (Rohypnol®). Flunitrazepam, causes profound amnesia and lowered inhibitions as well as a decreased ability to resist a sexual assault. This benzodiazepine is legal in approximately 60 countries, is illegal in the United States. GHB (gamma hydroxybutyrate). GHB lowers inhibitions and makes sex more pleasurable. Doubling the dose that induces a pleasant effect can disrupt coordination, induce sleep, and has the potential to induce coma within 10 to 20 minutes. GHB also causes amnesia and is used as a “date-rape drug”. Paradoxically, GHB is sold as a Schedule III medication to treat excessive daytime sleepiness under the trade name of Xyrem®. GBL (gamma-butyrolactone). Sold as a health supplement and found in some paint strippers, this chemical converts to GHB when ingested and thus has the same effects on sex. 6. Marijuana (p. 8.40) Marijuana, more than any psychoactive drug, illustrates the difficulty in separating the actual effects of use from the influence of the mind-set and setting where the drug is used. In one of the few studies on drugs and sexual function, marijuana was associated with inhibited orgasm but not inhibited desire. One risk of excessive marijuana smoking is that the user often forgets, or never learns, how to have sexual relations without being high, so the cycle of excess use is perpetuated. 7. MDMA & MDA (ecstasy, rave) (pp. 8.40−8.41) Users say that MDMA, unlike methamphetamines, calms them, produces warm feelings toward others, and induces a heightened sensual awareness. Although feelings of closeness and sensuality are enhanced, the ability to have an erection and an orgasm are more difficult. The neurological mechanism for some of the effects of MDMA is the manipulation of serotonin. Supposedly, sexual excitement occurs more often when coming down from the drug than while under the influence. 8. PCP (p. 8.41) PCP is generally not associated with sex, but because it is an anesthetic it has been used to deaden the pain of some unusual sexual practices. 9. LSD (p. 8.41) The effects of a psychedelic like LSD are so confusing to the senses that it is not considered a sexual enhancer so few controlled studies have been done. The same is true of psilocybin mushrooms and peyote.

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10. Volatile Nitrites (amyl, butyl, and others) (p. 8.41) Volatile nitrites are vasodilators and muscles relaxants. If inhaled prior to orgasm, they seemingly prolong and enhance the sensation. Abused as orgasm intensifiers by both gay and straight individuals in the 1960s, volatile nitrites were dubbed a “love drug.” They intensify orgasm by dilating blood vessels in the penis. They are also used because they relax anal sphincter muscles. 11. Nitrous Oxide (laughing gas) (p. 8.41) Nitrous oxide is not regarded as a sexually enhancing substance, although reports of sexual arousal, and orgasm have occurred in dentists’ offices while under the influence for a procedure. 12. Psychiatric Drugs (8.41) When used to treat a mental condition, psychotropic drugs can also affect the sexual functioning of the user. Studies involving tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), have linked them to decreased desire, erectile problems, and delayed orgasm. Antipsychotics, such as thioridazine (Mellaril®), also inhibit erectile function and ejaculation. There are some reports of lithium (used for bipolar disorder) decreasing desire and causing difficulty maintaining an erection. 13. Aphrodisiacs (pp. 8.41−8.42) Viagra, ® Cialis, ® and Levitra® facilitate the ability to have an erection by enhancing blood flow, but they are not actual aphrodisiacs. Some purported aphrodisiacs are • • • •

Spanish fly (a beetle toxin) or ground rhinoceros horn; pheromones, discovered in perspiration, have been shown to increase desire; Yohimbine, used in high doses as a treatment for impotence in men, increases blood pressure and heart rate thereby increasing penile blood flow; L-dopa, touted as an aphrodisiac during the 1970s.

C. SUBSTANCE ABUSE & SEXUAL ASSAULT (p. 8.42) One in three women in the United States will be the victim of sexual violence in her lifetime. In one study of sexual assaults, victims reported using drugs or alcohol in 51% of the cases; substance use by the assailants was found in about 44% of the cases. Another study found that approximately 60% of sexual offenders were drinking at the time of the offense. In most cases, the male user had tendencies toward improper or aggressive behavior, and the alcohol or other drug is the final trigger. • •

alcohol lowers inhibitions and muddles rational thought, cocaine and amphetamines increase confidence and aggression,

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• sedatives lower inhibitions, • Anabolic steroids increase aggression and irrational behavior, • marijuana makes users more suggestible to sexual activity. Date rape is often the result of a man, intending just to have sex, gets angry when he is refused or doesn’t get his way and takes what he feels is his right. Rape is motivated by a need to overpower, humiliate, and dominate a victim not a desire to have sex. Sexual abuse and domestic violence create emotional pain and trauma that intensifies a victim’s need to block feelings often leading to drug and alcohol abuse. D. SEXUALLY TRANSMITTED DISEASES [STDs] (pp. 8.43−8.44) The CDC estimates that 19 million new cases of sexually transmitted diseases occur each year in the United States, 340 million worldwide. 33.3 million people are living with HIV/AIDS. 1. Epidemiology (p. 8.43) The four most common sexually transmitted diseases include chlamydia, gonorrhea, syphilis, and trichamonas, others include genital herpes, genital warts, hepatitis B and C, and HIV/AIDS. About 85% of all STDs occur in people between the ages of 15 and 30. Almost half of all teenagers who are sexually active have had chlamydia, the fastest-spreading STD. The increased risk of STDs, including HIV disease, due to lowered inhibitions or trading sex for drugs is all too common among the drug-abusing population. The delayed incubation period before STD symptoms appear allows the disease to be unknowingly transmitted to others. E. NEEDLE-TRANSMITTED DISEASES (pp. 8.44–8.46) Needles can transmit many of the same illnesses that are transmitted sexually. They can inject substances, such as powered milk, procaine, or cleansing powder (Ajax) commonly used to cut drugs. Dangerous bacteria and viruses that contaminate the drug, or that remain in the syringe or on other contaminated elements of the needle kit can also be injected. 1. Hepatitis A, B & C (p. 8.44) Hepatitis A is often transmitted by fecal matter and is associated more with unsafe sex and poor hygiene than with drug use. Hepatitis B and C are more likely to be transmitted by needle. Hepatitis B is marked by inflammation of the liver and general debilitation, but it is more treatable than Hepatitis C. More than 75% of IV drug users test positive for hepatitis B. The blood-borne hepatitis C virus (HCV) is more dangerous and can cause liver disease, including cancer. Chronic flare-ups can cause inflammation and scarring of the liver.

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The positive rate of the hepatitis C virus in IV drug users is 50% to 90%. More than 2.7 to 3.9 million Americans are infected with HCV, and about 12,000 die each year from the disease. Worldwide 270 to 300 million people are infected. Sharing needles is responsible for almost two-thirds of the infections. Sexual transmission of HCV is about 20% of all infections. 2. Abscesses, Cotton Fever & Endocarditis (pp. 8.44−8.45) Needle use can also cause abscesses at an infected injection site. Needles can inject bits of foreign matter in the bloodstream that can cause an embolism or other conditions such as cotton fever. As veins become hardened or infected due to constant sticking, the user injects into the veins of the legs and then the neck. Another common complication is endocarditis, a sometimes-fatal condition caused by certain bacteria that lodge and grow in the valves of the heart. 3. HIV Disease & AIDS (pp. 8.45−8.46) AIDS is fatal because HIV destroys the immune system, making it impossible for the body to fight off serious illnesses. Introducing a drug intravenously bypasses all the body’s natural defenses, such as body hairs, mucous membranes, body acids, and enzymes; and the virus itself destroys the body’s last line of defense: the immune system. In 2009 there were an estimated 33.3 million people worldwide infected with HIV/AIDS, two-thirds live in sub-Saharan Africa. The rate of new infections is going down slowly but 2.6 million new cases were reported in 2009. 1.1 million Americans are infected with HIV or have AIDS, and 617,000 have died from the disease. More than one-third of all AIDS cases in the United States involved IV drug use. Men who have sex with other men are responsible for transmitting most AIDS cases in the United States. Among women, 75% of the cases are from heterosexual contact often with IV drug users. F. PREVENTION OF DISEASE (pp. 8.47−8.48) Communicable diseases start slowly then rage through the most susceptible groups. Continuing public education and public health prevention activities are crucial to stemming the spread of all STDs including AIDS. Some strategies include: • • • • • •

improved diagnosis and treatment treatment on demand for drug addiction; needle-exchange and condom distribution programs; outreach activities to get drug users into treatment; education and counseling programs; interdiction and law enforcement activities to limit the flow of drugs.

1. Harm Reduction (pp. 8.47–8.48) 24                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

In June 2003, the health ministry of Canada approved North America’s first legal and safe injection site for illegal-drug users in Vancouver, British Columbia. Addicts were able to shoot up under the supervision of a registered nurse. In San Francisco, several HIV prevention groups send outreach workers armed with AIDS educational materials, free bottles of bleach, and free condoms, to “shooting galleries,” crack houses, “dope pads,” and other areas to distribute these materials and provide treatment referrals if requested. Other groups distribute free needles. Greater tolerance towards relapse has also kept more IV drug users in treatment where they can be continually exposed to HIV prevention strategies. Studies show that people who test positive for HIV but stay clean-and-sober, maintain a healthy lifestyle with plenty of rest, good food, and exercise will avoid full-blown AIDS for years longer (10 to 20 years in many cases). Tragically, many countries with the highest HIV/AIDS rates cannot readily afford the very expensive treatment called for in the HIV and AIDS antiretroviral therapies. IX. DRUGS AT WORK (pp. 8.48−8.50) From a drug positivity rate of 13.6% in 1988, to a rate of 3.6% in 2009, drug use in companies that conduct drug testing has declined significantly. Drug users avoid applying at companies that have strict drug-free workplace policies and require drug testing. 8.4% of all workers employed full-time are current illicit-drug users while 8.8% report heavy alcohol use. 74.8% of illicit-drug users age 18 or older work full- or part-time, as do 80% of binge drinkers; 60.4% of those actually diagnosed with a substance-abuse disorder are employed. About 1.6 million workers use illicit drugs and are heavy drinkers. A. COSTS (pp. 8.48−8.49) It is estimated that substance abuse costs businesses about $200 billion per year. 1. Loss of Productivity (p. 8.48) Compared with a non-drug-abusing employee, a substance-abusing employee is: • •

late 3 to 14 times more often; absent 5 to 7 times more often.

2. Medical Cost Increases (p. 8.49) Drug-abusing employees: 25                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

• • •

have 3 to 4 times more on-the-job accidents; use 3 times more sick leave; file 5 times more workers’ comp claims;

3. Legal Cost Increases (p. 8.49) There are • •

direct and massive losses from embezzlement, pilferage, and property damaged during the commission of a crime; increased cost of security and more lawsuits.

B. PREVENTION & EMPLOYEE ASSISTANCE PROGRAMS (pp. 8.49, 8.50) Recommendations for a drug-free workforce include • • • • • • • •

written policies employee assistance programs employee awareness and education supervisor training drug and alcohol testing sanctions an appeals process evaluation

1. Workplace Drug Testing (p. 8.49) The percentage of positive drug tests among American workers dropped from 13.6% in 1988 to 3.6% in 2009. The most common drug found in those testing positive is marijuana. 26.8% of positive tests were in employees tested for cause, 5.4% for random testing, 5.3% for post-accident testing, 1.5% for periodic testing and only 3.4% for pre-employment testing. 2. Employee Assistance Programs (EAPs) (pp. 8.49−8.50) Successful EAPs balance the need of management to minimize the negative impact drug abuse has on a business with a sincere concern for the better health of employees. Today, 45% of full-time employees in large companies are covered by EAPs. Self-referral is encouraged but supervisors are trained to recognize problems and make referrals. An EAP has six basic components: • • • • • •

prevention/education/training; identification and confidential outreach; diagnosis and referral; treatment, counseling, and a good monitoring system (including drug testing); follow-up and focus toward aftercare; and a confidential record system and evaluation.

Primary Prevention. Education and training about the impact of substance abuse are provided at every level of a corporation. 26                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

Secondary Prevention. Both education and training focus on drug identification, major effects, and early intervention. Tertiary Prevention. The EAP formalizes its intervention approach, allowing for confidential self-referral, peer referral, and supervisor-initiated referral. 3. Effectiveness of EAPs (p. 8.50) For every $1 spent on an EAP, employers save anywhere from $5 to $16. The annual cost per employee of providing EAP services ranges from $22 for an outside program to $28 for and in-house program. There are a number of different types of EAPs. • • • • •

Internal/in-house programs Fixed-fee contracts Fee-for-service contracts Consortia Peer-based programs

X. DRUGS IN THE MILITARY (PP. 8.50−8.51) From 1980 to 1998, 30-day illicit-drug use dropped from 27.6% to just 2.7% of military personnel. By 2005 that rate had dropped to just 1.11%. The rate of heavy drinking showed a smaller decline, from 20.8% to 15.4%. The principal reason for the drop was an intensified program of urine testing. The message is zero tolerance. Formerly, drug users were treated and remained in the military, but zero tolerance excludes impaired people and discharge has become the preferred option. Heavy drinking still occurs at a higher rate: 15.4% in the military vs. 12% in society as a whole. In a recent U.S. Navy study, the prevalence of alcohol abuse was 28.2% of men and 15.1% of women. The military can discharge anyone whom it deems dangerous to other military personnel, and can conduct testing whenever and wherever it chooses. Each branch of the service has programs to help control drug and alcohol use. XI. DRUG TESTING (PP. 8.51−8.56) Researchers found that while drug testing showed a 66% decrease in positives, self-reported drug use increased by 30%. Drug testing is conducted for • • • • • •

pre-employment for-cause testing, random testing, periodic testing, post-accident testing, compliance in addicts who are in treatment, etc.

The federal government issued mandates in 1988 and 1998 for a drug-free workplace. At present the most widespread use of drug testing occurs in the military, the federal government, as a pre-employment requirement, in publicsafety positions (mostly transportation), and in drug treatment facilities. Most 27                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

medium and large businesses routinely use pre-employment testing to reject drug users. Random testing is conducted in jobs involving public safety.

A. THE TESTS (pp. 8.52−8.53) Many laboratory procedures test for drugs in the urine, blood, hair, saliva, sweat, and other body tissues. The drugs most often tested for are amphetamines, cannabinoids, cocaine, opioids, phencyclidine (PCP), and of course, alcohol. Other drugs commonly tested for are barbiturates, benzodiazepines, methadone.. 1. Thin Layer Chromatography (TLC) (p. 8.52) TLC searches for a wide variety of drugs and is sensitive to the presence of even minute amounts of chemicals. 2. Enzyme-Multiplied Immunoassay Techniques (EMIT), Radio Immunoassay (RIA), and Enzyme Immunoassay (EIA) (p. 8.52) All immunoassays use antibodies to seek out specific drugs. EMIT tests are extremely sensitive, quick and easy to conduct, but usually cannot determine the concentration of the drug present. 3. Gas Chromatography/Mass Spectrometry Combined (GC/MS) & Gas Liquid Chromatography (GLC) (p. 8.52) The GC/MS test is currently the most accurate, sensitive, and reliable method of testing. It uses gas chromatography separation and mass spectrometry fragmentation patterns to identify drugs. 4. Hair Analysis (pp. 8.52−8.53) Hair samples provide a picture of the degree of drug use over time. Positive immunoassay tests of hair fragments are confirmed by GC/MS. Several tests are done on a single strand of hair so the cost can be high, but hair analysis avoids many specimen manipulation problems associated with urine testing. 5. Saliva, Sweat & Breath (p. 8.53) Saliva and breath tests are used in spot testing of drivers involved in accidents or suspected of driving under the influence (DUI). Confirmation tests are usually mandatory because of the inaccuracy of the tests and probable court challenges. B. DETECTION PERIOD (pp. 8.53−8.54) Many factors influence the length of time that a drug can be detected in someone’s blood, urine, saliva, or other body tissues. A predictable drug detection period would be, at best, an educated guess. For urine testing the 28                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

three factors that determine drug use are latency, detection period range, and redistribution.

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1. Latency (p. 8.53) Drugs must be absorbed, circulated by the blood, and finally concentrated in the urine in sufficient quantity before they can be detected. This process, called latency, generally takes two to three hours for most drugs except alcohol, which takes about 30 minutes. Chronic daily user have drugs in their system and test positive with no latency. 2. Detection Period Range (p. 8.53) Once sufficient amounts of a drug reach the urinary tract, the drug can be detected for a certain length of time by urinalysis. DETECTION PERIOD RANGE CHART FOR URINE TESTING (p. 8.54) Alcohol ½ to 1 day Methamphetamines 2 to 4 days cocaine (coke, crack) 6 to 8 hours cocaine metabolite 2 to 3 days Marijuana single use 1 to 3 days casual use, 4 joints/wk 4 to 7 days daily use 10 to 15 days chronic, heavy use 1 to 2 months Heroin/oxycodone 2 to 4 days Ecstasy 30 to 48 hours 3. Redistribution, Recirculation, Sequestration & Other Variables (p. 8.54) Long-acting drugs like PCP can be distributed to certain body tissues or fluids, become concentrated and stored, and then be recirculated and reconcentrated in the urine weeks or months after stopping use. C. ACCURACY OF DRUG TESTING (pp. 8.54−8.56) There are high rates of false positive and negative test results. For this reason, many companies and agencies use a medical review officer (MRO) to review positive results and rule out any errors in procedure, environmental contamination, or alternative medical explanations. False-positive tests could result from the limitations of testing technology and/or from the mishandling of urine and other specimens. Negative results rather than false positives constitute the bulk of testing errors. Cheating occurs frequently in testing. Methods include concealing a container of clean urine, ingesting substances to mask detection of drug use, injecting clean urine into the bladder, and catheterization. The most reliable drug-testing programs include direct observation of the specimen and a rigid chain of custody of submitted samples. 30                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

1. Consequences of False Positives & Negatives (pp. 8.55−8.56)

Concerns about false-positive test results are well publicized, debated, and feared. People lose their jobs, are denied employment, are disqualified from the Olympics, or land in prison following an erroneous positive result. Less publicized or feared, but just as critical, are falsenegative results that prevent the discovery of drug abuse and feed the strong denial mechanism in the user. Treatment programs use testing early on to overcome denial and dishonesty in addicts. XII. DRUGS & THE ELDERLY (pp. 8.56−8.60)

A. SCOPE OF THE PROBLEM (pp. 8.56−8.57) 1. Overall Drug Use (p. 8.56) In 2011, 12% of the U.S. population is 65 years or older, that figure will increase to 21% by 2030. As the senior population grows, the problems

with drug overuse, abuse, and addiction will grow as well. Currently four out of five seniors suffer from some chronic disease, by age 65, 83% take at least one prescription drug per day; 30% take eight or more. 2. Chemical Dependency (pp. 8.56−8.57) Up to 17% of adults 60+ abuse alcohol and legal drugs. In addition to drinking or using socially, some abuse other psychoactive drugs to deal with problems. Physicians have a difficult time identifying alcoholism or drug abuse because many manifestations of drug abuse can be attributed to the other chronic illnesses often present in those over 55. Because addiction is a progressive illness regardless of age, continued use leads to progressive physiological, emotional, social, family, and spiritual consequences. B. PHYSIOLOGICAL CHANGES (pp. 8.57−8.59) The human body’s physiological functioning and chemistry become less efficient with age so drugs are more potent in older people. In addition to alcohol, the drugs most commonly abused by the elderly,

are hydrocodone (Vicodin®), narcotic cough syrups, Darvon® and other opioid analgesics, prescription sedatives, and OTC sedatives. There has also been a sharp increase in the use of psychiatric medications. Problems with medications occur when the patient misunderstands dosing directions, especially when several medications are involved. 1. Patterns of Senior Drug Misuse (p. 8.58) Overuse—taking more or many different types of drugs, than necessary; Underuse—failure to take a prescribed drug or not taking the correct dosage; Erratic use—failure to follow instructions; Contraindicated use—incorrect drug prescribed for the patient; Abuse and addiction—continued compulsive use of a drug for nonmedical purposes. 31                                                  Chapter 8 – Drug Use & Prevention: From Cradle to Grave                                        ©2011 CNS Productions, Inc.  

 

 

2. Common Drugs of Abuse Among Seniors (pp. 8.58−8.59) Alcohol, nicotine, and caffeine pose the greatest health problems for seniors. Nicotine. The unhealthy and deadly effects of smoking cannot be overemphasized. 16.5% of those over 50 smoke. About 94% of all 430,000 premature deaths from smoking are people over 50. Smokers have twice the mortality risk of cardiovascular disease than their nonsmoking peers. Caffeine. The majority of seniors use caffeine daily, with an average consumption of 200 mg per day. Current research indicates that caffeinerelated toxicity; anxiety, high blood pressure, heart arrhythmias, insomnia, and irritability in susceptible people occurs at doses as low as 100 mg per day. Alcohol. About 6% to 11% of seniors admitted to hospitals display symptoms of alcoholism. Age-related physiological changes significantly affect the way an older person responds to alcohol. Impaired co-ordination, fall injuries, confusion, memory problems, digestion problems, severe liver problems, and serious drug-medication interactions are consequences of alcohol abuse Over-the-Counter Medications. Seniors are the major consumers of OTC medications and dietary supplements. The OTC medications most misused and abused are sedatives, cold and cough aids, and stimulants. Prescription Drugs. Estimates of seniors abusing these drugs range from 5% to 33%. Abused medications include sedative-hypnotic medications and opioid analgesics (hydrocodone and oxycodone).

Illicit Drugs. Current and past data indicate a low prevalence of illicitdrug use (e.g., heroin, cocaine, meth, and marijuana) by this demographic. This may change as the surviving Baby Boomers reach 65. 3. Factors Contributing to Elderly Drug Misuse & Abuse (p. 8.59) Aging is associated with disease which disproportionately exposes the elderly to prescription and OTC medications. All too often health care professionals and family members regard symptoms merely as signs of aging, ignoring the potential for drug or alcohol abuse. Physicians often fail to do a thorough history of alcohol or substance abuse.

Current diagnostic criteria for substance abuse are based on younger populations and may not be applicable to seniors. Of total hospital admissions for the elderly, 20% are directly due to prescription or OTC drug reactions exclusive of alcohol and illicit-drug admissions.

C. PREVENTION ISSUES (pp. 8.59−8.60) 1. Primary Prevention (p. 8.59) Older people need to be reeducated about the dangers of excessive use of alcohol and other psychoactive drugs. Counseling about these issues should be readily available to the elderly.

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2. Secondary Prevention (pp. 8.59−8.60) Secondary prevention for the elderly must focus on recognizing early stages of alcoholism or drug abuse and employing age-appropriate assessment and intervention tactics. Frequently, there is strong denial by this age group. Alcoholism and addiction are primary diseases that must be treated. 3. Tertiary Prevention (p. 8.60) This age group is not responsive to abrupt, coercive, confrontational therapies. The pace of therapy has to be slow, patient, and reassuring. XIII. CONCLUSIONS (pp. 8.60−8.61)

The major challenge of prevention efforts for all ages is to provide accurate measurements of the long-term effectiveness of the strategies involved, not just short-term assessments of how much they learned; learning without action has little impact on the problem. Efforts must be measured in terms of long-term results rather than in terms of shortterm activities or process. A. PROMISING DIRECTIONS (pp. 8.60, 8.61) •

People are exposed to drugs from cradle to grave, prevention efforts must extend over a lifetime.

•

Early primary prevention can treat a pregnant woman who uses drugs so that her child is not born addicted.

•

The family is an effective prevention delivery system for children.

•

Elementary schools can integrate prevention into the curriculum.

•

Peer educator programs in middle schools can identify students who are natural leaders to serve as role models.

•

High school and college prevention must assume a higher level of sophistication to counter experimentation, social use, and habituation.

•

In the workplace, prevention must be continued through EAPs.

•

Programs should be developed that address and publicize the health risks of drug use.

•

For older people, preretirement and grief counseling can help prevent alcohol and other drug use.

•

Prevention must be adapted to the needs of specific audiences.

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Chapter 8 - DRUG USE & PREVENTION: FROM CRADLE TO GRAVE Classroom or Small Group Discussion Topics 1. List each of the six levels of use and ask students to put them in the correct order from low to high usage. (abstinence, experimentation, social use, habituation, abuse and addiction) 2. Suggest prevention education that would be appropriate for each level. What changes/modifications would be effective for different ethnic groups, age groups, or sexes. 3. List, analyze, and discuss various cultural connections between alcohol and a.) holidays, b.) family traditions, c.) sporting events, d.) media portrayal. 4. Assign each group of students one of the populations listed below and have them search online for examples of effective drug abuse prevention campaigns for that group and present their findings to the class. Have them identify any images, copy etc. that indicates the message is tailored for this group. •

Medical professionals

•

Elderly

•

People who are HIV positive,

•

Factory workers performing dull, repetitive jobs

•

College students

5. Should the elderly or terminally ill people be exempt from drug regulations because their life expectancy is short? Should they be given maximum pain relief and/or whatever pleasure they can gain directly from the drugs? Should controls and safeguards on psychoactive drugs for the aged and terminally be relaxed by staff in hospitals and care facilities? 6. Discuss the differences between the factors that encourage drug use among a.) children, b.) teenagers, c.) college-age students, d.) young adults, e.) middle age and f.) elderly. What factors might lead to drug abuse in these groups? 7. Recognizing that harm reduction or controlled use education is a controversial prevention strategy; discuss what college-level students can do to moderate the dangers to themselves and to others when they abuse alcohol by playing drinking games, chugging or drinking only to get drunk. 8. How do the students react to receiving an injection at the doctor's office (e.g. immunization, blood draw)? What would be necessary (state of mind) to use a needle as a method of drug use? 9. What are the physical and emotional consequences of using drugs to enhance sexuality—short-term and long-term? 10. Some people use drugs to overcome shyness or try to intensify sexual pleasure. What are some nondrug alternatives?

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Chapter 8 - DRUG USE & PREVENTION: FROM CRADLE TO GRAVE Critical Thinking And Class Exercises 1. Discuss the pros and cons of legal penalties and incarceration for a woman who uses drugs during pregnancy. 3. Evaluate the risk that substance abuse prevention education can actually encourage substance abuse. How did drug education affected the students’ behavior and attitudes? 4. Conduct a confidential survey about drug use among five friends. Average the results and discuss the findings. 5. Divide the class into three groups and have them discuss the advantages and disadvantages of mandatory drug testing in the work place from the point of view of employees, employers, and the public. What about drug testing or drug searches in schools? 6. Two tactics for secondary prevention of drug abuse among teenagers are peer counseling and alternative activities. Drawing on the experience of students, what kind of peer programs and alternative activity programs work; what kinds don't work? 7. Discuss the use of free needle-exchange programs as a means of preventing the spread of HIV. 8. Divide the class into male and female groups – have them note what they believe to be the differences and similarities in gender attitudes about love, lust and sex. 9. If you knew someone had a sexually transmitted disease and he/she had sex with a friend of yours, what would you do? What if the disease were HIV? 10. Discuss the hypothetical: If a true aphrodisiac were discovered, should it be readily available or controlled by prescriptions only.

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Uppers, Downers, All Arounders, 7th Edition - Instructors Manual Chapter 9 - TREATMENT Overview The most prevalent mind disorder is substance abuse. It causes more health and social problems than any other disease. Fortunately it is treatable and has as good or better treatment successes than those of other diseases like cancer, heart problems, diabetes, or arthritis. Current issues in treatment include: • the rapidly expanding use of medications for detoxification and withdrawal, and long-term abstinence; • the use of sophisticated brain-imaging techniques to study brain function; • the creation of more effective tools to diagnose addiction and match clients to the most effective treatment including tools to more accurately assess withdrawal symptoms; • an understanding of the neurophysiology involved with drug cravings and the recovery process; • an emphasis on evidence-based treatment practices; • drug courts and coerced treatment; • the lack of sufficient treatment resources • continued controversy over abstinence-based and harm reduction modes of treatment. Treatment leads to recovery in 50% to 80% of cases and saves at least $4 to $39 in actual costs for every $1 spent. Treatment results in crime reduction. Treatment can be customized for culture, gender, ethnic origin, and other specialized populations. This chapter examines the principles and goals of treatment, the different treatment options available, selection of a specific treatment approach, initiating treatment, the continuum of treatment (detoxification, initial abstinence, long-term abstinence, and recovery), individual/group therapy, the involvement of the family, adjunctive treatment services, drug specific treatments, target populations (culturally consistent treatment), and the recent developments in treatment medications. Preventing relapse after treatment include addressing the challenges of cognitive deficits, cravings (endogenous/intrapersonal and environmental/interpersonal triggers) and post acute withdrawal symptoms (PAWS). Behavioral addiction treatments are examined and require the same intensity and continuum of treatment as substance use disorders. This chapter also covers motivational interviewing, stages of change model, treatment in prisons, intervention strategies, and obstacles to effective treatment.

1                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

Chapter 9 - TREATMENT Chapter Outline I.

INTRODUCTION A. A Disease of the Brain B. Current Issues in Treatment

II. TREATMENT EFFECTIVENESS A. Treatment Studies 1. The California Drug and Alcohol Treatment Assessment 2. Drug Abuse Treatment Outcome Study 3. The Treatment Episode Data Sets 4. The National Survey of Substance Abuse Treatment Services 5. Treatment Research Institute B. Treatment & Prisons III. PRINCIPLES & GOALS OF TREATMENT A. Principles of Effective Treatment B. Principles of Drug-Abuse Treatment for Criminal Justice Systems (Cjs) Populations C. Goals Of Effective Treatment 1. Primary Goals 2. Supporting Goals IV. SELECTION OF A PROGRAM A. Diagnosis B. Treatment Options 1. Types of Facilities 2. Admissions V. BEGINNING TREATMENT A. Recognition & Acceptance 1. Hitting Bottom 2. Denial 3. Breaking Through Denial 4. Intervention VI. TREATMENT CONTINUUM A. Detoxification 1. Medication Therapy for Detoxification 2. Psychosocial Therapy B. Initial Abstinence C. Long-Term Abstinence D. Recovery E. Relapse Prevention

1. Cognitive Deficits 2. Post-Acute Withdrawal Symptoms (PAWS) 3. Cravings: Endogenous (internal) Triggers & Environmental (external) Triggers F. Relapse prevention Strategies 1. Cue Extinction 2. Psychosocial Support 3. Natural Highs E. Outcome & Follow-Up VII. INDIVIDUAL VS. GROUP THERAPY A. Individual Therapy 1. Motivational Interviewing & Motivational Enhancement Therapy B. Group Therapy 1. Facilitated Groups 2. Peer Groups 3. Self-Help Groups & Alcoholics Anonymous 4. Spirituality & Recovery 5. The 12 Steps of Alcoholics Anonymous 6. Educational Groups 7. Targeted Groups 8. Topic-Specific Groups 9. Ten Common Errors Made in Group Treatment by Beginning Counselors VIII. TREATMENT & THE FAMILY A. Goals of Family Treatment B. Different Family Approaches 1. Family Systems Approach 2. Family Behavioral Approach 3. Family Functioning Approach 4. Social Network Approach 5. Tough Love Approach C. Other Behaviors 1. Codependency 2. Enabling 3. Children/ Adult Children of Addicts IX. COMPLEMENTARY TREATMENT SERVICES X. DRUG-SPECIFIC TREATMENT A. Polydrug Abuse B. Stimulants (Cocaine & Amphetamines) 1. Detoxification & Initial Abstinence 2. Long-Term Abstinence C. Tobacco

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1. Nicotine Replacement 2. Treating the Behaviors D. Opioids 1. Detoxification 2. Initial & Long-Term Abstinence 3. Recovery 4. Other Opioid Treatment Modalities E. Sedative-Hypnotics (Barbiturates & benzodiazepines) 1. Detoxification 2. Initial Abstinence 3. Recovery F. Alcohol 1. Denial 2. Detoxification 3. Initial Abstinence 4. Long-Term Abstinence & Recovery G. Psychedelics 1. Bad Trips (acute anxiety reactions) H. Marijuana I. Inhalants J. Behavioral Addiction Treatment 1. Compulsive Gambling 2. Eating Disorders 3. Sexual Addiction 4. Electronic Addictions XI. TARGET POPULATIONS A. Men vs. Women B. Youth C. Older Americans 1. Factors 2. Treatment D. Ethnic Groups 1. African American 2. Hispanic 3. Asian & Pacific Islander (API) 4. American Indian & Alaskan Native E. Other Groups 1. Physically Disabled

2. Lesbian, Gay, Bisexual, & Transgender (LGBT) XII. TREATMENT OBSTACLES A. Developmental Arrest & Cognitive Impairments B. Follow-Through (Monitoring) C. Conflicting Goals D. Treatment Resources XIII. MEDICAL INTERVENTION DEVELOPMENTS A. Introduction B. Medications Approved To Treat Substance-Use Disorders Vs. Those Used Off-Label 1. For Alcohol Dependence 2. For Nicotine Addiction 3. For Opiate/Opioid Addiction 4. For Stimulant Drug Addiction 5. For Sedative-Hypnotic Dependence C. Medical Strategies in Development 1. Rapid Opioid Detoxification 2. Replacement of Agonist Effects 3. Antagonist (blocking) Medications or Vaccines 4. Mixed Agonist-Antagonist 5. Anticraving & Anticued Craving 6. Metabolism Modulation 7. Restoration of Homeostasis 8. Amino Acid Precursor Loading 9. Modulation of Drug Effects & Antipriming 10. Drugs with Unknown Strategies 11. Other Strategies D. The Drug Development Process 1. Step 1: Preclinical Research & Development 2. Step 2: Clinical Trials 3. Step 3: Permission to Market

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Chapter 9 - TREATMENT Extended Chapter Outline I. INTRODUCTION (P. 9.2−9.6) Treatment is effective. Scientifically based drug addiction treatments typically reduce drug abuse by 40% to 60%. A. A DISEASE OF THE BRAIN (pp. 9.2−9.3) Chemical dependency and addiction are more prevalent than other brain diseases. During the past year over 22 million Americans (8.7%) abused or were dependent on alcohol or an illicit drug, 29% were dependent on tobacco, and 2−6 percent had a gambling addiction. Chemical dependency is the #1 physical health problem in the U.S. B. CURRENT ISSUES IN TREATMENT (pp. 9.3−9.6) Eight aspects of chemical and behavioral dependency treatment dominate research, clinical practice, and discussion. 1. More medications are used to treat detoxification and withdrawal, lessen craving, substitute less damaging drugs, induce nutritional supplements, control depression, etc. 2. Brain imaging and other new diagnostic techniques, e.g., CAT, MRI, fMRI, PET, SPECT, and DTI, are now used to visualize the structural and physiological effects of addiction. 3. More-effective tools exist to diagnose addiction and better match clients to specific treatment interventions. 4. There is a deeper understanding of the neuroscience of relapse and recovery, e.g., new areas of the brain that correlate to the chances of relapsed (stay-stopped switch). 5. Evidence-based best practices are eclipsing practice-based treatments. 6. Research indicates coerced treatment (e.g., drug courts) is just as effective in promoting positive outcomes as voluntary treatment. 7. Treatment has been proven effective, but the decrease in treatment facilities shows a lack of treatment resources. For every $1 spent on treatment, up to $39 is saved, mostly in prison costs, lost time on the job, healthcare costs, and social services. The Mental Health Parity and Addiction Equity Act, of 2008 established substance use disorder as a medical condition and mandated funding for treatment, as of yet, the changes in the system are few. 8. Differing attitudes between abstinence-oriented recovery and harm reduction persist. Harm reduction includes, drug replacement therapy, needle exchange, decriminalization, and controlled drinking. Most treatment centers employ an abstinence-based philosophy that also incorporates many harm reduction techniques.

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II. TREATMENT EFFECTIVENESS (PP. 9.6−9.8) Treatment outcomes for drug and alcohol abuse result in long-term abstinence along with tremendous health, social, and spiritual benefits. A. TREATMENT STUDIES (pp. 9.7−9.8) 1. California Drug and Alcohol Treatment Assessment Study (CALDATA) California realized savings of $7 for every $1 spent on treatment. Treatment was most effective when patients were treated for at least six to eight months. Group therapy was more effective than individual therapy. 2. Drug Abuse Treatment Outcome Study (DATOS) The use of all drugs after treatment was reduced 50% to 70%. Short- and longterm residential programs seemed to have the greatest effect. 3. Treatment Episode Data Sets (TEDS) This survey describes admissions to substance-abuse treatment facilities. 4. National Survey of Substance Abuse Treatment Services (N-SSATS) An annual survey of all drug treatment facilities in the United States, public and private. 5. Treatment Research Institute, University of Pennsylvania Economic Benefits of Drug Treatment: A Critical Review of the Evidence for Policy Makers validates the cost-effectiveness of substance-abuse treatment. B. TREATMENT & PRISONS (p. 9.8) On December 31, 2005: • • • • • • •

2,284,913 Americans were in federal, state, and local prisons (11% were women); 93,000 were in juvenile detention facilities. 5 million were on parole or probation. 57% of federal and 20% of state inmates were serving a sentence for a drug offense; 11.5% were arrested for a drug-abuse violation; 40% to 65% of arrestees tested positive for alcohol or drugs; treatment slots are available for only about 10% of those who have serious drug habits, drug-abuse treatment reduces recidivism when treatment is linked to community services, fewer than 17% of incarcerated offenders with drug problems received treatment while in prison.

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III. PRINCIPLES & GOALS OF TREATMENT (PP. 9.8−9.11) A. PRINCIPLES OF EFFECTIVE TREATMENT (pp. 9.8−9.9) Principles of Drug Addiction Treatment lists 13 principles of effective treatment. • • • • • •

Addiction is a complex but treatable disease that affects brain function and behavior. No single treatment is appropriate for all individuals. Treatment must be readily available. Effective treatment attends to all needs of an individual, not just drug use. An individual’s treatment and services plan must be assessed continually Remaining in treatment for enough time is critical for positive outcomes Etc., etc, etc.

B. PRINCIPLES OF DRUG-ABUSE TREATMENT FOR CRIMINAL JUSTICE SYSTEM (CJS) POPULATIONS (pp. 9.9−9,10) • • • • • •

Drug addiction is a brain disease that affects behavior. Treatment must last long enough to produce stable behavioral changes. Assessment is the first step in treatment. Services must be tailored to fit needs. Drug use during treatment must be carefully monitored with drug testing. Etc., etc., etc.

C. GOALS OF EFFECTIVE TREATMENT (pp. 9.10−9.11)) Treatment is a lifelong process for the addict. 1. Primary Goals • •

Motivation toward abstinence. Creating a drug-free lifestyle.

2. Supporting Goals • • • •

Enriching job or career functioning. Optimizing medical functioning. Optimizing psychiatric & emotional functioning. Addressing relevant spiritual issues.

IV. SELECTION OF A PROGRAM (PP. 9.11−9.15) Most program selections are spontaneous, based on cost, familiarity, location, and convenience of access. Evidence-based assessment tools match addicts to an appropriate level of care

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COST OF TREATMENT • • • • • • • • •

Incarceration Probation Res. long-term treatment Res. short-term treatment Methadone maintenance Intensive outpatient Outpatient treatment Untreated addiction

$20,000–30,000 $15,000–20,000 $6,800–15,000 $4,400–8,000 $4,200 $2,500 $1,800 $30,000–150,000

A. DIAGNOSIS (pp. 9.11−9.12) Diagnostic tools are used to help verify, support, or clarify the potential diagnosis of chemical addiction. The most common are: • • • • • •

American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR); Selective Severity Assessment (SSA) evaluates 11 physiologic signs to confirm the severity of the addiction; National Council on Alcoholism Criteria for Diagnosis of Alcoholism (NCA CRIT) and its Modified Criteria (MODCRIT); Addiction Severity Index (ASI) (the most comprehensive and lengthy criteria) Michigan Alcoholism Screening Test (MAST); CAGE Questionnaire (the simplest assessment tool for problem drinking, consists of just four questions).

B. TREATMENT OPTIONS (pp. 9.12−9.15) No treatment is universally effective for everyone. A wide range of options exists. 1. Types of Facilities Medical model detoxification programs can be inpatient, residential, or outpatient. Residential/inpatient treatment short-term (1 to 28 days) Partial hospitalization and day treatment are outpatient medical model programs. Intensive outpatient programs: Methadone maintenance and other replacement therapies are considered outpatient medical model programs. Office-based medical detoxification and maintenance treatment for opiate abusers is provided by qualified private medical practitioners (O-BOAT). Social model detoxification programs are nonmedical (no or minimal medical staff presence) and are either residential or outpatient. 7                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

Social model recovery programs (also called outpatient drug-free programs); includes outpatient programs. Therapeutic communities (TCs) are long-term (1 to 3 years) self-contained residential programs that provide full rehabilitative and social services. Halfway houses permit addicts to keep their jobs and outside contacts while participating in a residential treatment program. Several religious movements and faith-based treatment initiatives also use halfway house or inpatient treatment programs. Sober-living and transitional-living programs are for clients who have completed a long-term residential program. Harm reduction programs, consist mainly of pharmacotherapy maintenance approaches. 2. Admissions In 2008, 1.849 million people were treated in various programs and facilities. It is estimated that another 17.4 million hardcore alcoholics and 6.4 million need illicit-drug treatment but did not receive needed care. 68% of all clients were male, 60% were white, 38% were referred to treatment through the criminal justice system. V. BEGINNING TREATMENT (PP. 9.15−9.19) Recovery is a lifelong process because the brain cells have been permanently changed. A. RECOGNITION & ACCEPTANCE (pp. 9.15−9.19) This self-diagnosis often requires the addict to hit bottom or be the subject of an intervention. Addicts and alcoholics rarely accept the diagnosis of their addiction from others. Coerced treatment via criminal justice sanctions can actually help an addict realize that they have hit bottom. 1. Hitting Bottom The earlier addiction is recognized, accepted, and treated, the more likely the individual will have good health and enjoy a rewarding life. Addicts need not hit bottom to accept that they have a chemical dependency problem and participate in treatment. 2. Denial Overcoming denial is the first step in all treatment. Denial is a refusal to acknowledge the negative impact that drug use is having on a person’s life. 3. Breaking Through Denial The addict is usually the last person to recognize and accept her or his addiction.

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There are several ways to break through denial. • • • • • •

Legal Intervention Workplace Intervention Physical Health Problems Pregnancy Mental Health Problems Financial Difficulties

Admissions By Source Of Referral In The U.S. In 2009 Total admissions Alcohol Only Alcohol W/Other Drug Heroin Crack Cocaine Marijuana Methamphetamine

1,849, 549 437, 204 347,058 267,335 152,819 321,648 121,485

4. Intervention Strategies have been developed to attack an addict’s denial. A formal intervention should be tried after informal interventions have failed. They should include; Love. An intervention should always start and end with an expression of love. Facilitation. An intervention specialist or a knowledgeable treatment professional should organize the intervention Intervention Statements. Each team member prepares a statement that they will personally present to the addicted person at the intervention. Anticipated Defenses & Outcomes. The facilitator prepares the team to deal with denial, rationalization, anger, and accusations. Intervention. Timing, location, and surprise are crucial components of the intervention. Contingency. Team members continue to meet after the intervention to process their experiences. VI. TREATMENT CONTINUUM (PP. 9.19−9.25) Recovery is gradual, and a client undergoes several changes regardless of which therapy is used: detoxification, initial abstinence, long-term abstinence (sobriety), and continuous recovery. A. DETOXIFICATION (pp. 9.19−9.21) It takes about a week to completely excrete a drug such as cocaine and perhaps another 4 weeks to 10 months until the body chemistry settles down. 9                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

Social or non–medically supervised programs require clients to go through a medical detoxification or be 72 hours clean and sober before admittance. The initial detoxification can be “white knuckle” or medically/chemically assisted detoxification, to minimize withdrawal symptoms. Assessment of the severity is a crucial first step to detoxification. Severe physical dependence on depressants can require hospitalization. 1. Medication Therapy for Detoxification A variety of medications are used during the detoxification phase to ease the symptoms of withdrawal and minimize the initial drug cravings; e.g., clonidine (Catapres®), phenobarbital, methadone, buprenorphine naltrexone, psychiatric medications, bromocriptine, acomprosate, nicotine patches, and disulfiram (Antabuse®). 2. Psychosocial Therapy Medical intervention alone is rarely effective during the detoxification phase. Intensive counseling and group work have proven to be effective in breaking down residual denial and engaging the client in the full recovery process. B. INITIAL ABSTINENCE (p. 9.21) Body chemistry must be allowed to regain balance. Depletion of neurotransmitters causes drug hunger, known as endogenous craving. Medical approaches include Antabuse® for alcoholism and naltrexone for opioids. C. LONG-TERM ABSTINENCE (p. 9.21) Continued participation in group, family, and 12-step programs is the key to maintaining long-term abstinence from all drugs. D. RECOVERY (pp. 9.21−9.22) Recovering addicts must restructure their lives and discover things that give them joy, pleasure and satisfaction resulting from natural highs instead of the artificial highs they came to seek through drugs. Continued participation in 12step or other groups is the path down which most recovering addicts have found success. E. RELAPSE PREVENTION (PP. 9.22−9.23) A relapse must be aggressively processed by the client and the counselor so that the causes can be identified and strategies developed to avoid future slips and relapses. 1. Cognitive Deficits About 30% to 80% of substance abusers suffer from mild to severe cognitive impairments. Patients often appear normal during the early phase of treatment but are actually experiencing an inability to fully understand and process the treatment curriculum. It may take weeks or months after 10                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

detoxification for reasoning to return to a point where the individual can begin to fully engage in treatment. 2. Post–Acute Withdrawal Symptoms (PAWS) & Cognitive Impairments PAWS are a group of emotional and physical symptoms that appear after major withdrawal symptoms have abated. The syndrome can persist for 6 to 18 months or longer. Symptoms include sleep disturbances, memory problems, inability to think clearly, anxiety, and physical coordination difficulties. 3. Cravings: Endogenous (INTERNAL) Triggers and Environmental (EXTERNAL) Triggers a. Endogenous Triggers (Internal or Intrapersonal Triggers) having the greatest impact are negative emotional and physical states or internally motivated attempts to regain control in order to use. Acronyms like HALT (hungry, angry, lonely, tired) remind addicts of these triggers. Abuse of an addictive drug disrupts brain chemistry resulting in an allostasis (imbalance) and a depletion of certain neurotransmitters which reinforces drug craving. Counseling, education, support from a sponsor, stress-reduction therapies, and participation in 12-step meetings are common treatment strategies. b. Environmental Triggers (External or Interpersonal) often precipitate drug cravings e.g., relationship conflicts, social pressures, lack of support systems, negative life events, sensory stimuli, and slippery people places, and things. Environmental triggers are manifested by true physiological responses to psychological triggers. F. RELAPSE PREVENTION STRATEGIES (p. 9.24) Relapse prevention has become the focus of almost every treatment program. Addicts must •

recognize their personal triggers

•

develop behaviors to avoid external triggers

•

have an automatic reflex strategy that will prevent them from responding to internal or external cues.

1. Cue Extinction Dr. Anna Rose Childress's Desensitization Program retrains brain cells to avoid reacting when confronted by environmental cues (cue extinction). 2. Psychosocial Support Initial abstinence is the phase during which addicts start to put their lives back in order. Building a support system is vital. 3. Natural Highs Humans can create virtually every sensation and feeling from natural life situations, (sports, art, dance, travel) that drugs create. 11                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

E. OUTCOME & FOLLOW-UP (pp. 9.24−9.25) Client outcomes and follow-up evaluations are a major element in treatment program activities. All types of addiction treatment have demonstrated positive client outcomes. VII. INDIVIDUAL VS. GROUP THERAPY (PP. 9.25−9.32) Medical treatments are only effective when integrated with psychosocial therapies. A. INDIVIDUAL THERAPY (p. 9.24−9.27) This therapy deals with clients on a one-on-one basis to explore the reasons for their continued drug abuse and to identify needs with the aim of changing behavior. Cognitive-behavioral therapy, reality therapy, aversion therapy, psychodynamic therapy, art therapy, motivational interviewing or enhancement, and social skills training are used. Individual treatment may continue over months, years. 1. Motivational Interviewing & Motivational Enhancement Therapy One of the most common counseling techniques is motivational interviewing coupled with a stages-of-change model. The technique uses a nonconfrontational style to involve clients in their own recovery process and help them change ambivalence about drug use into motivation to make the changes that lead to recovery. Motivational interviewing strives to express empathy, roll with resistance, develop and recognize discrepancies, and support self-efficacy by empowering clients to choose their own options. It guides clients through the stages of change: 1. precontemplation 2. contemplation 3. determination (preparation) 4. action 5. maintenance B. GROUP THERAPY (pp. 9.27−9.32) A major focus of group therapy is encouraging clients to help each other break the isolation of addiction. 1. Facilitated Groups Facilitated group therapy usually consists of six or more clients who meet with therapists or counselors on a daily, weekly, or monthly basis. 2. Peer Groups In peer group therapy, therapists play a less active role in the group’s dynamics. They observe interaction and are available to process any conflicts or areas of need but do not direct the process. 12                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

3. Self-Help Groups & Alcoholics Anonymous (AA) (12-step group) AA is the most widespread recovery movement in history. This peer group concept is based on 12 steps of recovery. Groups meet without a professional therapist or facilitator, problems are addressed and solved through personal/ spiritual change. 4. Spirituality & Recovery Spiritual and faith-based treatment interventions have a long and positive tradition in the recovery community. There is a 60% to 80% correlation between religion or spirituality and better health. 5. The 12 Steps of Alcoholics Anonymous The steps begin with “We admitted we were powerless over alcohol [cocaine, cigarettes, food, gambling] and that our lives had become unmanageable” and end with “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.” The 12 steps can work for any addictive behavior. 6. Educational Groups Trained counselors provide the education and often bring in other experts to promote individual lesson plans 7. Targeted Groups Focus on specific populations of users, such as men, ethnic groups, etc. 8. Topic-Specific Groups Participants focus on key issues that are a threat to their continued recovery, single moms, the death of a child, etc. 9. Ten Common Errors Made in Group Treatment by Beginning Counselors or Substance-Abuse Workers 1.Failure to have a realistic view of group treatment. 2. Self-disclosure issues, failure to drop the “mask” of professionalism. 3. Agency culture, personal style. 4. Failure to understand the stages of therapy. 5. Failure to recognize countertransference issues. 6-10. Etc., etc. VIII. TREATMENT & THE FAMILY (PP. 9.32−9.35) Addiction is considered a family disease because abuse of drugs and alcohol affect all members of an addict’s family. A. GOALS OF FAMILY TREATMENT (p. 9.32) •

Acceptance by family members that addiction is a treatable disease, not a moral weakness.

•

Establishing and maintaining a drug-free family system.

•

Developing a system for family communication and interaction.

•

Processing the family’s readjustment.

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B. DIFFERENT FAMILY APPROACHES (pp. 9.32−9.33) 1. Family Systems Approach The drug or drinking problem is seen as an integral part of the functioning of the whole family. 2. Family Behavioral Approach This approach provides specific interventions to support and reinforce those behaviors that promote a drug-free family system. 3. Family Functioning Approach •

Functional family systems

•

Neurotic or enmeshed family systems

•

Disintegrated family systems

•

Absent family systems

4. Social Network Approach The family breaks their isolation and develops skills that help them support the recovery effort. 5. TOUGHLOVE® Approach The family learns to establish limits for their interaction with the addict. C. OTHER BEHAVIORS (pp. 9.33−9.35) 1. Codependency Codependents are mutually dependent on the addicts to fulfill some need of their own. The chances of recovery are greatly reduced unless a codependent is willing to understand their role and submit to treatment. 2. Enabling There is a strong tendency to avoid confrontation about the addictive behavior and a subconscious effort to actively perpetuate the addiction. 3. Children of Addicts & Adult Children of Addicts (ACoA) Many children of addicts take on predictable maladaptive behavioral roles that often continue into their adult personalities. •

Model child

•

Problem child

•

Lost child

• Mascot child or family clown Although they may not abuse drugs, their behavior can be as dysfunctional as the addict’s. ACoAs also •

are isolated and afraid of people and authority figures;

•

are approval seekers;

•

are frightened by angry people and personal criticism;

•

become or marry alcoholics

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IX. ADJUNCTIVE & COMPLEMENTARY TREATMENT SERVICES (PP. 9.35−9.37) It is necessary to help identify these various needs and then case-manage addicts toward appropriate treatment or service providers. They include •

arts therapy

•

hypnosis

•

guided imagery

•

eye movement desensitization relaxation

•

virtual-reality graded exposure therapy

•

acupuncture

•

vitamin therapy

•

herbal therapy

•

homeopathy

•

nootropic or smart drugs

•

biofeedback

•

dance therapy

•

mindfulness meditation

•

hatha yoga

•

equine therapy

•

aroma therapy

•

sensory deprivation.

X. DRUG-SPECIFIC TREATMENT (PP. 9.37−9.54) A. POLYDRUG ABUSE (p. 9.37) Treatment programs must be aggressive in identifying the total drug profile of their clients. Many substance abusers also practice a behavioral addiction such as compulsive eating. Substance addiction must be addressed as chemical dependency rather than a drug-specific problem. B. STIMULANTS (cocaine & amphetamine) (PP. 9.37−9.39) Methamphetamine abusers are more likely to be male, white, gay or bisexual. A wide range of drug-induced psychiatric symptoms often accompanies stimulant abuse. 1. Detoxification & Initial Abstinence The vast majority of stimulant abusers respond positively to traditional drugcounseling approaches, e.g., cognitive-behavioral therapies (CBT) and behavioral therapies, like the Matrix Model, along with 12-step-oriented individual counseling. Many drugs are medically used to treat various symptoms of stimulant detoxification and initial abstinence: antidepressant agents, antipsychotic 15                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

medications, sedatives, nutritional approaches, naltrexone, and dopamine agonists to suppress withdrawal symptoms and initial craving. 2. Long-Term Abstinence To counter endogenous craving, many medications are used to stimulate dopamine release. Environmentally triggered craving is particularly intense in stimulant addiction. Continued abstinence weakens the craving response. C. TOBACCO (pp. 9.39−9.41) The only guarantee of success involving tobacco is never to begin use. The failure rate for most therapies is extremely high. Pharmacological treatments are preferred. 1. Nicotine Replacement Treatment Nicotine replacement systems include nicotine patches, nicotine gum, nicotine nasal spray, nicotine inhalers and nicotine lozenges. These systems slowly reduce the blood plasma nicotine levels to the point where cessation will not trigger severe withdrawal. If relapse prevention, counseling, and self-help groups are not used in conjunction with nicotine replacement therapy, the chances of relapse are high. 2. Treating the Symptoms It is necessary to reduce the anxiety, depression, and craving associated with nicotine withdrawal because those conditions trigger relapse. Only varenicline (Chantix®) and bupropion (Zyban®) are FDA approved to treat nicotine withdrawal and craving. 3. Treating the Behaviors CBT, motivational enhancement therapy, brief therapy, one-on-one counseling, group therapy, educational approaches, aversion therapy, hypnotism, and acupuncture are used. D. OPIOIDS (pp. 9.41−9.43) Opioid addiction has the highest rate of relapse. This is partially because physical withdrawal from opioids is more severe than withdrawal from stimulants. 1. Detoxification Methadone and buprenorphine are the FDA-approved medications for opioid detoxification. These drugs are substituted for heroin or the abused opioid and are gradually tapered to minimize withdrawal. 2. Initial Abstinence & Long-Term Abstinence A long-lasting opioid antagonist, such as naltrexone (ReVia®), is used after detoxification and supported by individual counseling sessions, group sessions, or self-help groups such as Narcotics Anonymous. Behavioral therapies like CBT, contingency management, and psychodynamic psychotherapy and family therapy are also used.

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3. Recovery The key to recovery from heroin or other opioid addiction is learning a new lifestyle. 4. Other Opioid Treatment Modalities Methadone. In 2005, 1,069 methadone maintenance clinics provided treatment for more than 200,000 heroin addicts. Methadone, a synthetic opiate, is less intense than heroin but is longer lasting so it delays heroin-like withdrawal symptoms for 36 to 48 hours. LAAM will remain active in the body for up to three days. Because use was connected to severe heart arrhythmias, it is no longer available in the United States and is only used in research settings. Buprenorphine, at low doses, is a powerful opioid, 50 times as powerful as heroin, but at doses above 8 to 16 mg, it blocks the opioid receptors. Subutex® is used during the early stage of detoxification; Suboxone® is used thereafter. Licensed physicians can treat patients with buprenorphine in their offices. E. SEDATIVE-HYPNOTICS (BARBITURATES & BENZODIAZEPINES) (pp. 9.43−9.44) The majority of tranquilizer and sedative abusers tend to be older, White (85% to 89%), and female (59% to 60%). Intensive medical assessment and medically managed treatment are necessary. 1. Detoxification Substitution therapy (using a drug that is cross- tolerant with another drug) is needed to detoxify dependency on these substances. The initial detoxification from sedative-hypnotics requires intensive daily medical management. 2. Initial Abstinence This requires participation in group, individual, and educational counseling. Switching addicts to nonbenzodiazepine alternatives, particularly SSRIs like Zoloft,® is preferable. BuSpar® (buspirone) can also be used. 3. Recovery Continued participation in self-help groups; Benzodiazepine Anonymous, Pills Anonymous, and Narcotics Anonymous has been the most effective means of promoting abstinence and recovery. F. ALCOHOL (pp. 9.44−9.46) Alcohol alone was the primary substance of abuse for almost 21.5% of all treatment admissions in the United States in 2005. 1. Denial Denial on the part of a compulsive drinker is the biggest hindrance to entering treatment. 2. Detoxification Up to 10% of untreated alcohol withdrawal and up to 3% of medically treated episodes include severe, potentially life-threatening symptoms such as seizure 17                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

activity which requires medical management. Withdrawal and detoxification should include emotional support and basic physical care. 3. Initial Abstinence Antabuse® (disulfiram) is initially used. In 1996, naltrexone (ReVia®) was approved for the treatment of alcohol addiction. Acamprosate (Campral®) has had modest treatment effects in lowering craving. After alcohol has been cleared from the client’s system, the clinician must evaluate the client for psychiatric problems. 4. Long-Term Abstinence & Recovery Clients must begin healing the confusion, immaturity, and emotional scars that kept them drinking for so many years. Relapse is always possible. Recovery is a lifetime process. G. PSYCHEDELICS (pp. 9.46−9.47) The overwhelming majority of users in treatment are male, White, and under the age of 24. The clinician or intake counselor can make only a tentative diagnosis until the drug has had time to clear. Treatment is most often focused on the intoxication or mental disorder, family dynamics, and social consequences. 1. Bad Trips (acute anxiety reactions) Psychedelics can lead to acute anxiety, paranoia, fear over loss of control, or feelings of grandeur leading to dangerous behaviors. The best treatment for someone on a bad trip is to talk him or her down. The condition known as hallucinogen persisting perception disorder (HPPD) is the recurrence of some of the symptoms after use has ceased. Addiction is treated with traditional counseling, education, and self-help groups. Treatment for Bad Trips ARRRT guidelines A Acceptance R Reduction of stimuli R Reassurance. R Rest T Talk-down H. MARIJUANA (pp. 9.47−9.48) There has been a steady increase in the number of people entering treatment for marijuana dependence. One reason is the wider availability at the street level of high THC marijuana. Marijuana can cause a true addiction syndrome encompassing both physical and emotional dependence. The physical withdrawal symptoms, though uncomfortable, rarely require medical treatment. Their onset is often delayed for several days or weeks after cessation of use. Motivational enhancement therapy and the development of coping skills, along with intensive relapse prevention therapy, are effective psychosocial interventions.

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I. INHALANTS (p. 9.48) First, immediately remove the patient from exposure to the substance. Monitor the patient for potential adverse psychiatric conditions. The symptoms must be evaluated and treated. About two-thirds of inhalant abusers admitted for treatment reported use of other drugs, primarily alcohol and marijuana. J. BEHAVIORAL ADDICTION TREATMENTS (pp. 9.48−9.52) Behavioral addictions require the same intensity of intervention and treatment as substance-abuse disorders. 1. Compulsive Gambling The proliferation of gambling facilities has contributed to the increase of problem and pathological gamblers and to the incidents of relapse. Most gamblers are reluctant to seek treatment. •

Withdrawal symptoms similar to those of alcoholism, e.g., restlessness, irritability, anger, headaches, diarrhea, etc. are common.

•

Gamblers Anonymous, the most common treatment modality, parallels the 12-step program used by Alcoholics Anonymous. One of the keys to treating compulsive gamblers is enabling them to overcome irrational thoughts (magical thinking) about their chances of winning. Gambling often coexists, replaces, or follows alcoholism, compulsive spending, and a few other disorders. Cognitive-behavioral approaches used to treat chemical dependencies and participation in GA are effective for gamblers. 2. Eating Disorders Early intervention is key to effective treatment of all three eating disorders— anorexia, bulimia, and binge eating. Diagnose and treatment of any medical complications, exercise, a balanced diet, a change of false perceptions about one’s body image, and enhancement of self-esteem are all necessary along with participation in Overeaters Anonymous or other 12-step group. Anorexia. Most severely ill anorexic patients must be hospitalized. It usually takes 10 to 12 weeks for full nutritional recovery. The complexities of anorexia require a team approach. Bulimia. Clients with bulimia usually have more long-term health problems than those with anorexia, often necessitating continuing medical care. The multidisciplinary treatment includes an internist, a nutritionist, a psychotherapist, and a psychopharmacologist. Family and group therapies are extremely useful. Binge-Eating Disorder (includes compulsive overeating) has both physiological and psychological causes. Therapy examines underlying traumas and uses behavioral therapy, pharmacological treatment with antidepressants, and occasionally, surgical intervention. Self-help groups, such as OA, OA-HOW, and GraySheeters Anonymous have been proven effective.

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a. Eating Disorders & Substance Abuse There is a link between those with an eating disorder and substance abuse problems. Common personality characteristics observed in both groups consist of secretiveness, ritualistic behaviors, obsession, social isolation, cravings, and a high tendency to relapse. b. Pharmaceutical Treatments for Obesity. Many stimulants used as diet aids have an addictive component, creating more problems than they solve. Many substances work initially, but lose their effectiveness through prolonged use. 3. Sexual Addiction Because many sexual aberrations stem from childhood sexual experiences, treatment must to deal with childhood development in addition to the mechanics of the addiction. The treatment often includes behavior modification (e.g., aversion therapy), cognitive-behavioral therapy, group, family or couple therapy, psychodynamic psychotherapy, motivational interviewing, and medications. Sexaholics Anonymous. The main issues addressed are the feelings of shame, guilt, anxiety, and depression that are associated with sexual addiction. 4. Electronic Addictions (Internet, gaming, cell phone) Because these addictions are so new, treatment personnel and treatment facilities are rare. Asian countries such as South Korea and China have tens of thousands of Internet addicts that should be in treatment. The traditional abstinence model is often impractical so a harm reduction model is usually necessary. Locating the computer in a different room, never going online without someone in the room/house, creating an Internet user log, telling people about your problem, etc. are all tactics that could help an addict. XI. TARGET POPULATIONS (p. 9.54−9.63) Treatment that is tailored to specific groups based on gender, sexual orientation, age, ethnicity, and economic status is more effect than a "one size fits all" approach. A. MEN VS. WOMEN (p. 9.54) Female substance abusers progress to addiction more rapidly than men, die at a younger age, and are less likely to ask for and/or receive help. Men are often external attributers, blaming negative life events outside their control for their addiction, women are more often internal attributers, blaming problems on themselves. Treatment approaches that are supportive rather than confrontational result in better outcomes for women. The greatest barriers to women seeking addiction are an inability to admit the problem, a lack of emotional support, and inadequate child care while in treatment.

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B. YOUTH (p. 9.55) Early onset drug use is the single best predictor of a future drug problem. The brain develops slowly from back to front cortices and is not fully mature until age 25, so an adolescent is less able to control impulsive and compulsive drug use. Teens overestimate the true risks of drug use but they sometimes take that risk because their perception of the potential benefits outweighs their exaggerated perception of the risks involved. Treatment should be molded around goals that are achievable within a short period and rewarded or reinforced immediately. Young people are less willing to accept guidance or intervention from adults and are more willing to listen to their peers. Normal adult programs do not work with young people. Specific youth-directed programs must be provided. C. OLDER AMERICANS (pp. 9.55−9.57) Thirty-seven million Americans are 65 years or older. Most problems in this group result from the abuse of alcohol and/or prescription and OTC drugs. 80% of seniors treated for drug problems identified alcohol as their main drug. It is difficult for healthcare professionals to spot drug or alcohol abuse in this group. 1. Factors That Contribute to Elderly Drug Misuse and Abuse •

Illness exposes the elderly to more prescription drugs.

•

Physical resiliency declines with age.

•

Health professionals are not adequately trained to spot drug abuse.

•

There are age-related physiological changes that exaggerate the effects and toxicity of alcohol and other drugs.

•

There is a lack of adequate social and support services for seniors

2. Treatment of the Elderly Alcohol or Drug Abuser At present, few treatment programs aimed specifically at older Americans with a substance-abuse problem exist. These individuals are most successful in therapy groups with people their own age although mixed groups will work. Withdrawal is more severe in the elderly, but detoxification can be managed safely. D. ETHNIC GROUPS (p. 9.57−9.61) One-third of the U.S. population is comprised of people of color. Treatment specifically targeted to ethnic and cultural groups promotes continued abstinence better than general treatment programs. 1. African American Non-Hispanic African Americans make up 20.9% of the admissions to publicly funded substance-abuse treatment facilities though they are only 12% of the population. Treatment intervention must address the following the facts: 21                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

•

African Americans have a higher pain threshold, which leads to a greater tolerance for suffering and delays a call for help. This results in moresevere addiction and the development of other life problems.

•

African-American women use crack at a greater rate than any other drug except alcohol. This leads to an alarming dissolution of supportive family structures;

•

drugs are seen initially as an economic resource, not an economic drain;

•

crime leads to chemical dependency rather than addiction leading to crime;

•

there is a very strong sense of boundaries;

•

it’s hard to determine if chemical dependency is a primary or secondary problem; drug users must understand that other issues can’t be tackled successfully without tackling recovery first;

•

the conspiracy theory is widely believed;

•

revelations are widespread in the African-American community; organized spirituality is fundamental to promoting recovery.

2. Hispanic In 2010, the U.S. Census Bureau estimated that 47.8 million (15.5%) of the U.S. population was of Hispanic origin. In 2008, 258,000 (13.7%) of all those in substance-abuse treatment in the United States were of Hispanic origin. There is cultural diversity and differences as well as the similarities. Programs must be flexible, have bilingual and bicultural staff, and be prepared to treat the whole family because family is so significant in Hispanic cultures. The core aspects of Hispanic cultures are dignidad, respeto, y carino—dignity, respect, and love. 3. Asian & Pacific Islander Asians and Pacific Islanders represent a variety of cultures with these characteristics: •

distinct and separate ethnic groups and languages (e.g., Japanese, Filipino, Cambodian, Indian, and Samoan);

•

a strong regard for family with enmeshed family systems;

•

a high respect for education;

•

slow to show emotion or be open about personal issues;

•

different key issues such as immigration, acculturation, and intergenerational conflicts;

•

greater responsiveness to credentialed professionals than to peer counselors and a preference for individual rather than group counseling;

•

a greater reliance on themselves to handle their addiction rather than a higher power or external control;

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•

a sense of family shame which keeps the family enabling and rescuing the addict repeatedly rather than insisting he/she get into treatment;

• a lack of available programs. The most commonly used drugs in API communities vary: •

Chinese—tobacco and alcohol;

•

Japanese—alcohol, marijuana, tobacco, crack cocaine, and methamphetamine;

•

Korean—alcohol (whiskey and rice wine) and crack cocaine.

4. American Indian Most American Indians live in 27 states, over half live in Arizona. Overall 63.8% of American Indian/Alaskan Native treatment admissions were for alcohol compared with 40.3% for the general population Bicultural and bilingual treatment personnel greatly increase the chances of successful treatment. Clinicians who are brought in to a reservation from the outside have trouble understanding the traditions, so they rely more on standard psychosocial therapy, which is not as effective and breeds distrust. E. OTHER GROUPS (pp. 9.61−9.63) Regardless of the group (homeless, gay, mentally or physically challenged) substance abusers must be involved in a treatment program that relies on peer groups 1. Physically Disabled Counselors can over-focus on a person’s physical disability and miss signs and symptoms of relapse or focus too strongly on the person’s addiction and not take into account the extra stress caused by the disability. Physical disabilities often involve pain creating a potential for abuse of prescription medications. 2. Lesbian, Gay, Bisexual & Transgender (LGBT) Various studies estimate that 20% to 35% of gay men and lesbians are heavy alcohol users (vs. 10% to 12% of heterosexuals). The social life of many in these groups takes place in bars or other places/events that promote drug and alcohol use. Of greater influence, and the roots of all addiction can be found in genetics tempered by childhood stresses such as social rejection or physical, emotional, or sexual abuse. Identifying the client’s “family” and involving them in treatment can be difficult. XII. TREATMENT OBSTACLES (PP. 9.63−9.65) Denial and lack of financial or treatment resources constitute the biggest obstacles to addiction treatment. A. DEVELOPMENTAL ARREST & COGNITIVE IMPAIRMENTS (pp. 9.63−9.64) The use of psychoactive drugs can delay users’ emotional development and keep them from learning how to deal with life’s problems. Damage to brain functioning often results in cognitive deficits, especially during the first several 23                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

months of abstinence and recovery. 30% to 80% of substance abusers’ have mild to severe cognitive impairments. It is often necessary to modify existing treatment protocols to the cognitive abilities of the client. Difficult and/or abstract concepts should be presented later in treatment when cognitive processing has improved. Three to six months of continuous abstinence is associated with the return of many, but not all, cognitive abilities. Goal setting, planning, sustained attention, response inhibition, problem solving and decision-making skills need to be learned. B. FOLLOW-THROUGH (MONITORING) (p. 9.64) Early program dropout or lack of compliance to the treatment protocol is clear indication of poor treatment outcomes. Client confidentiality, vital to the addiction treatment process has also contributed to the problem of poor treatment compliance. More and more professional boards (medical, nursing, legal) mandate the release of confidentiality as a condition of retaining a license. C. CONFLICTING GOALS (p. 9.64) An individual addict’s treatment goal may conflict with a program’s goal. Program goals may conflict with society’s goals. The problems of conflicting goals are best managed by the development of clear program objectives and goals, better assessment and matching of clients to programs. C. TREATMENT RESOURCES (p. 9.64) The biggest obstacle continues to be lack of treatment resources. For every 100 people put on waiting lists, 66% will never make it into treatment. Any delay in accessing treatment results in a loss of motivation. XIII. MEDICAL INTERVENTION DEVELOPMENTS (PP. 9.65−9.69) A. INTRODUCTION (p. 9.65) Advances in the understanding of the neuropharmacology of addiction during the 1990s, (The Decade of the Mind) led to a flood of medications targeted to treat chemical dependencies. B. MEDICATIONS APPROVED TO TREAT SUBSTANCE-USE DISORDERS vs. THOSE USED OFF-LABEL (p. 9.65−9.66) 1. For Alcohol Dependence Approved Disulfiram (Antabuse®) Aversive consequences (flushing, nausea, vomiting, dizziness, and rapid heartbeat) occur immediately, discouraging further use of alcohol in the recovering alcoholic. Naltrexone (ReVia®) disrupts activation of the reward/reinforcement pathway of the brain to curb craving. Acamprosate (Campral®) is thought to stabilize receptors to moderate the craving response. 24                                                                                Chapter 9 – Treatment                                                                               © 2011, CNS Productions, Inc. 

 

Naltrexone injectable suspension (Vivitrol®) received FDA approval for treatment of alcohol craving in 2005. Chlordiazepoxide (Librium) was approved for the treatment of acute alcoholism withdrawal symptoms. Off-label Clonidine (Catapres). 2. For Nicotine Addiction Approved Varenicline (Chantix®) blocks nicotine’s activation of the receptors, which slows the release of dopamine to decrease craving. Bupropion or amfebutamone (Zyban® or Wellbutrin®) the first oral pills to treat nicotine craving. Nicotine products, e.g., Nicorette® gum is available O-T-C for nicotine replacement therapy delivery systems, e.g., transdermal patches. Off-label Nortriptyline and clonidine 3. For Opiate/Opioid Addiction Approved Buprenorphine (Suboxone® and Subutex®) is used for opioid detoxification and replacement therapy. Physicians are granted DEA permission to administer this medication for opioid addiction in their office rather than having to be part of an approved treatment clinic (officebased opioid addiction treatment, or O-BOAT). Naltrexone (ReVia® and Trexan®) was approved by the FDA in 1984 to treat opioid dependence. It is an opioid receptor antagonist that blocks the actions of all opioids. Methadone is used for detoxification and replacement therapy of heroin addiction as a harm reduction strategy. Off Label Clonidine and lofexidine 4. For Stimulant Drug Addiction Off-Label Abuse of stimulant drugs disrupts the same brain neurotransmitters that are imbalanced in depression and thought disorders, so antidepressants (e.g., sertraline, trazodone, and imipramine) and neuroleptics (e.g. haloperidol, Risperdal,® and olanzapine) are frequently used to treat symptoms of stimulant withdrawal.

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5. For Sedative-Hypnotic Dependence Off-Label Though no medications have been FDA approved specifically to treat this condition, many drugs approved to treat seizure disorders (e.g., phenobarbital, various benzodiazepines, phenytoin, carbamazepine, and gabapentin) are currently used effectively to treat sedative-hypnotic drug dependence. C. MEDICAL STRATEGIES IN DEVELOPMENT TO TREAT SUBSTANCE USE DISORDERS (p. 9.66−9.67) Medications being developed to treat various SUDs can be classified either by the targeted stage of recovery or by their effects on the CNS and rest of the body. 1. Rapid Opioid Detoxification This sometimes-dangerous strategy uses various medications to manage opioid withdrawal symptoms in combination with naloxone or naltrexone, opioid antagonists that force the rapid onset of the abstinence syndrome. It is alleged to occur within six to eight hours. Opioid addicts are quickly able to return to their daily lives without prolonged withdrawal. 2. Replacement or Agonist Effects Positive results from methadone maintenance have stimulated the search for other replacement or agonist therapies. Methylphenidate and pemoline for cocaine and stimulant dependence and SSRI antidepressants and GHB for alcohol and sedative-hypnotic addiction are being tried. 3. Antagonist (blocking) Medications or Vaccines While taking these types of agents, addicts are unable to experience the effects of an abused drug should they have a slip. 4. Mixed Agonist-Antagonist The agonist part of this approach prevents withdrawal, while the antagonist effects prevent craving by blocking any further drug use, e.g., butorphanol and buprenorphine in opioid addiction. 5. Anticraving & Anticued Craving Medications that can curb endogenous or environmentally cued craving responses are dramatic developments in treatment, e.g., •

baclofen, a nonopioid muscle relaxant, also exhibits alcohol anticraving effects;

•

topiramate and other antiseizure medications appear to block craving for alcohol and other drugs;

•

mecamylamine appears to block environmentally cued craving of cocaine;

•

bupropion, approved for the treatment of nicotine craving.

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6. Metabolism Modulation Medications like disulfiram (Antabuse®) can alter the metabolism of an abused drug to render it ineffective or cause noxious reactions. 7. Restoration of Homeostasis Medications and nutrients that restore brain chemical balances are theorized to restore homeostasis, mitigating the need for drug use. 8. Amino Acid Precursor Loading This strategy administers protein supplements (e.g., tyrosine, taurine) to addicts in an effort to increase the brain’s production of its neurochemicals to restore homeostasis. 9. Modulation of Drug Effects & Antipriming A recent development is the use of medications that can modulate or blunt the pleasure-reinforcing effects of addictive drugs. Calcium channel-blocking medications prevent calcium ions from entering brain cells, blocking the release of dopamine Sodium ion channel blockers, e.g. riluzole, phenytoin, and lamotrigine interfere with neuron transmission by blocking the cells’ uptake of sodium and enhance the effects of GABA. 10. Drugs with Unknown Strategies Psychedelic drugs like ibogaine and ketamine are effective in treating cocaine and opioid addiction even though the early use of ibogaine to treat opioid addiction resulted in some fatalities. Other drugs that are being studied are dextromethorphan to treat opioid addiction, cycloserine, an antibiotic, to decrease opioid abuse, topiramate to limit alcohol abuse, and many others 11. Other Strategies Patented medical protocols. Prometa® employs FDA-approved medications (though not approved for addiction) in a rigid short-term protocol to abate drug hunger and promote recovery. Packaged clinical protocols to treat addiction are copyrighted and sold to treatment providers to help facilitate clinical interventions and promote better outcomes. An example of this is the Matrix Model for cocaine, methamphetamine, and other stimulant drug addictions. D. THE NEW DRUG DEVELOPMENT PROCESS (p. 9.69) Step 1: Preclinical Research & Development Step 2: Clinical Trials Step 3: Permission to Market

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Chapter 9 – TREATMENT Classroom or Small Group Discussion Topics 1. Research has documented that for every dollar spent on treating addictions the cost savings to society is between $4 and $20. Given these facts why isn’t there more federal and state money appropriated for treatment programs? 2. Break the class into small groups (3 to 5 students) and ask them to discuss “what they would say or do in the following scenarios?” After each member of the group has had an opportunity to provide input, have each group report the range of responses participants had to item 2.a. and 2.b. a. You were given prescription painkillers by your dentist after surgery. One day later, the pills are missing from your medicine cabinet. b. Your roommate regularly drinks a six-pack on Fridays and Saturdays. You notice that he or she begins drinking a six-pack during the week on Mondays and Wednesdays. c. Imagine that you are the parent of a 16 year old and you found a marijuana joint in your child’s room. How would respond? d. Imagine that you are the parent of a 16 year old and your child came home with alcohol on his breath and staggering. How would respond? 3. What are the implications of the claim that “addiction is not cured only arrested” in terms of a substance abuser’s ability to accept long-term recovery? 4. What are the advantages and disadvantages of allowing a person to “hit bottom” before initiating treatment? 5. What are the scientific reasons to support the use of replacement therapy or drug-substitution therapies (methadone for heroin)? There is a point of view among some that the use of this type of drug-substitution avoids the core addiction problem and just perpetuates drug-using behaviors. What are your views on the opposition to using drug-substitution therapy? 6. Which drug do your students believe poses the greatest challenge for recovery? Why?

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Chapter 9 - TREATMENT Critical Thinking & Class Exercises 1. Discuss the differences between the diseases of addiction, diabetes, and cancer. Have the students debate whether they think addiction is truly a disease. 2. Ask two students to improvise in front of the class using various words or actions for the following scenarios. (One student develops denial statements; the other student counters the denial statements.) a. Your high-school age brother is going out more often during the week, coming home smelling of alcohol, and is absent more often from school because of illness caused by the drinking. In addition, his grades are declining. b. Your father came home drunk again and hit your sister because she didn’t do her homework. You talk to your mother but she says not to interfere. c. Your roommate comes in late and drunk during the week, wakes you up to talk, and twice has vomited on the floor. 3. Have a group of five or six students dramatize an intervention. One student acts as the intervention leader, one acts as the addict and the others take on roles of friends, financial advisors, family members, and coworkers. Role plan a family intervention for a parent - designate one student for each of the following roles: the other parent, the model child, the problem child, the lost child, and the mascot child or family clown. 4. Ask students to place the 12 steps of AA in order (Write them in random order on a board, slips of paper etc.) Ask them to discuss specifically how the concept of powerlessness could keep many from seeking recovery. 5. What specific cultural factors and practices should be taken into account for each of the following groups: • • • • • • • •

African Americans Asian Americans Hispanics Native Americans Women Athletes Healthcare professionals Lesbian, bisexual, gay or transgendered

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Uppers, All Arounders, All Arounders, 7th Edition Chapter 10 - MENTAL HEALTH & DRUGS Overview MENTAL HEALTH & DRUGS Approximately one-third of adults with any mental disorder, such as depression, schizophrenia, bipolar disorder, anxiety disorders, and personality disorders, also have a co-occurring substance use disorder. Some 50% to 70% of substance abusers also have a co-occurring mental health disorder. One reason is that the same neurotransmitters affected by mental illness are also affected by psychoactive drugs. Addictions and related disorders consist of substance abuse and substance dependence. Substance induced disorders consist of intoxication, withdrawal and temporary (usually) or permanent symptoms of certain mental health disorders. Mental illness is determined by the combined influences of heredity, environment, and the use of psychoactive drugs. DUAL DIAGNOSIS (CO-OCCURRING DISORDERS) Co-occurring disorders are defined as the existence in one individual of a mental illness and an independent substance use disorder. A mental illness can be pre-existing or substance induced (temporary or permanent). Heavy methamphetamine use can induce a psychosis or a meth user could already have a pre-existing susceptibility to developing schizophrenia before they began using. Today there are fewer inpatient mental health treatment resources which has magnified the problem of cooccurring disorders. Those with mental/emotional problems often use drugs of abuse to self-medicate these problems. Drug use can aggravate, amplify or mask a mental illness making an accurate diagnosis difficult. Any assessment must be a “rule-out” diagnosis: effects of abused drugs must be given time to dissipate before making a diagnosis. The mental health community and the substance abuse community are cooperating and both acknowledge the need to treat both conditions simultaneously and both support the “every door is the right door” strategy. However, there are too few full-service facilities to treat this population. The potential use of Minkoff’s Four-Quadrant Model to help resolve conflicts between substance abuse and mental health professionals in determining treatment interventions is examined. Evolving problems of multiple diagnoses (poly drug abuse, chronic medical disorders, HIV/HCV-HCB) are also examined. This chapter reviews symptoms of the most common psychiatric disorders, the effects of the various mental illnesses and the connection between neurotransmitters, street drugs, and psychiatric drugs. Treatment approaches, in particular, the use of psychiatric medications, e.g., antidepressants, antipsychotics, lithium, and antianxiety drugs are discussed. Clinical treatments in group, individual and self-help groups are explored.

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Chapter 10 - MENTAL HEALTH & DRUGS Chapter Outline MENTAL HEALTH & DRUGS I. INTRODUCTION A. Brain Chemistry B. Classification of SubstanceRelated Disorders II. DETERMINING FACTORS A. Heredity & Mental Balance B. Environment & Mental Balance C. Psychoactive Drugs & Mental Balance DUAL DIAGNOSIS (Co-Occurring Disorders) III. DEFINITION IV. EPIDEMIOLOGY V. PATTERNS OF DUAL DIAGNOSIS A. Pre-Existing Mental Illness B. Substance-Induced Mental Illness VI. MAKING THE DIAGNOSIS A. Assessment 1. Reasons for Increased Diagnoses B. Understanding the Dually Diagnosed Patient VII. MENTAL HEALTH VS. SUBSTANCE ABUSE A. Recommendations B. Multiple Diagnoses VIII. PSYCHIATRIC DISORDERS A. Preexisting Mental Disorders 1. Thought Disorder (schizophrenia) 2. Major Depressive Disorder 3. Bipolar Affective Disorder B. Other Psychiatric Disorders 1. Anxiety Disorders 2. Dementias 3. Developmental Disorders 4. Somatoform Disorders 5. Personality Disorders 6. Eating Disorders

7. Gambling Disorder 8. Other Disorders C. Substance-Induced Mental Disorders 1. Alcohol-Induced Mental Illness 2. Stimulant-Induced Mental Illness 3. Cannabis Induced Mental Illness 4. Other Drug-Induced Mental Illnesses IX. TREATMENT A. Rebalancing Brain Chemistry 1. Heredity & Treatment 2. Environment & Treatment 3. Psychoactive Drugs & Treatment 4. Starting Treatment 5. Impaired Cognition 6. Developmental Arrest 7. Psychotherapy, Individual Counseling, & Group Therapy X. PSYCHOPHARMACOLOGY A. Psychiatric Medications vs. Street Drugs B. Drugs Used To Treat Depression 1. Selective Serotonin Reuptake Inhibitors (SSRIs) 2. Tricyclic Antidepressants 3. Monoamine Oxidase (MAO) Inhibitors 4. Stimulants C. Drugs Used To Treat Bipolar Disorder 1. Lithium D. Drugs Used To Treat Psychoses (antipsychotics or neuroleptics) E. Drugs Used To Treat Anxiety Disorders 1. Drugs for Obsessive-Compulsive Disorder 2. Drugs for Panic Disorder F. Compliance & Feedback

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Chapter 10 – MENTAL HEALTH & DRUGS Extended Outline I. INTRODUCTION (PP. 10.2) Of the 40 million Americans who experience any mental disorder such as schizophrenia, major depression, bipolar disorder, an anxiety disorder, or a personality disorder in the course of a year, 7 to 10 million also experience a substance-related disorder. A. BRAIN CHEMISTRY (pp. 10.2−10.3) Because the neurotransmitters affected by psychoactive drugs are also associated with mental illness, many people with mental problems are drawn to psychoactive drugs in an effort to rebalance their brain chemistry and control their agitation, depression, or other mental problems. The opposite is also true. Unbalanced chemistry due to drug abuse can aggravate a preexisting mental illness or mimic the symptoms of one. This connection between mental health and drug use can be seen in the similarity between the symptoms of psychiatric disorders and the direct effects of psychoactive drugs or their withdrawal symptoms. For example: •

cocaine or amphetamine intoxication mimics mania, anxiety, or psychosis;

•

cocaine or amphetamine withdrawal looks like major depressive disorder or generalized anxiety disorder.

B. CLASSIFICATION OF SUBSTANCE-RELATED DISORDERS (p. 10.3) Substance-related disorders are classified as mental disorders in the DSM-IVTR, the Diagnostic and Statistical Manual of Mental Disorders. They are divided into two general categories: 1. Substance use disorders (SUDs) involve patterns of drug use and are divided into substance dependence and substance abuse. •

Substance dependence is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress.

•

Substance abuse is defined as continued use despite adverse consequences.

2. Substance-induced disorders include conditions that are caused by the use of the specific substances. Disorders include intoxication, withdrawal, and certain mental disorders (e.g., delirium, dementia, psychotic disorder, etc.). The DSM-V, to be released in 2013 defines SUDs as Addiction and Related Disorders and classifies each substance or compulsive behavior as its own specific class.

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II. DETERMINING FACTORS (PP. 10.3-10.5) The main factors that affect the central nervous system’s balance and, therefore a person’s susceptibility to mental illness as well as addiction are heredity, environment, and the use of psychoactive drugs. A. HEREDITY & MENTAL BALANCE (p. 10.3−10.4) Research has already shown a close link between heredity and schizophrenia, bipolar disorder, depression, and anxiety. If a child has a close relative who has schizophrenia, the risk of that child developing the disorder jumps 15- to 30fold. The risk of developing depression or bipolar disorder is also greatly increased. If a person’s genetically susceptible brain chemistry is stressed by a hostile environment and/or psychoactive drug use, that person has an increased likelihood of developing mental illness. Genetic links for behavioral disorders, such as compulsive gambling, and attention-deficit disorder, have been found in twin surveys. A high genetic susceptibility does not mean that that mental illness or addiction will occur, only that there is a greater chance that it will occur. Excess dopamine is a key contributor to both real psychosis and drug-induced psychosis. B. ENVIRONMENT & MENTAL BALANCE (pp. 10.4−10.5) The same environmental factors that can induce a susceptibility to drug abuse can induce mental/emotional problems. The neurochemistry of people subject to extreme stress can be disrupted and unbalanced to a point where their reactions to normal situations are different from those of most other people. Abuse and sexual molestation can be major negative environmental factors. C. PSYCHOACTIVE DRUGS &MENTAL BALANCE (p. 10.5) If a nervous system is affected by enough psychoactive drugs, any individual could develop mental/emotional problems, but it is the predisposed brain that is more likely to have prolonged or permanent difficulties. The brain that is not predisposed is the one most likely to return to its normal functioning during abstinence. The type of drug has a great impact on symptoms of co-occurring disorders. A brain predisposed to major depression can aggravate that mental problem by heavy abuse of alcohol and sedative-hypnotics or withdrawal from stimulant drugs. A brain predisposed to schizophrenia can be activated and a psychotic episode triggered by psychedelic abuse.

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DUAL DIAGNOSIS (CO-OCCURRING DISORDERS) III. DEFINITION (PP. 10.5−10.7) A co-occurring disorder, is defined as the existence in an individual of at least one mental disorder along with an alcohol or drug use disorder. Examples of pre-existing mental disorders are: thought disorders (psychotic disorders), such as schizophrenia; mood disorders (affective disorders), such as major depression and bipolar disorder anxiety disorders, such as panic disorders, obsessive-compulsive disorders, post–traumatic stress disorder, and ADHD (*attentiondeficit/hyperactivity disorder). Examples of substance-induced mental disorders are: stimulant-induced psychotic disorders alcohol-induced mood disorders marijuana-induced delirium. There is a distinction between displaying the symptoms of mental illness and actually having a major psychiatric disorder. An evaluation of the severity and persistence of symptoms is necessary. It is common for people who are abusing substances to present with symptoms of a personality disorder. As a person achieves and maintains sobriety, however, most symptoms of the personality disorder will often dissipate. IV. EPIDEMIOLOGY (P. 10.7) In one study, 37% of alcohol abusers and 53% of other substance abusers admitted for treatment had at least one serious mental illness in addition to their drug problem. It is estimated that about 50% of individuals with severe mental disorders are affected by substance abuse. Of all people diagnosed with a mental illness 29% to 34% had a problem with either alcohol or other drugs. Of the 7 million to 13 million people with co-occurring disorders, under 25% received only mental health care, 9% received only substance-abuse treatment, 8% received both, 60% received no treatment. V. PATTERNS OF DUAL DIAGNOSIS (PP. 10.7−10.8) The particular substance and how it is used determine two patterns of dual diagnosis.

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A. PRE-EXISTING MENTAL ILLNESS (p. 10.7) One type of dual diagnosis involves a person who has a clearly defined mental illness and uses drugs, often to self-medicate symptoms of the mental illness. Some mentally ill people have a concurrent substance-abuse problem that does not involve self-medication. B. SUBSTANCE-INDUCED MENTAL ILLNESS (pp. 10.7−10.8) Because of substance abuse and/or withdrawal, the user develops psychiatric problems because the toxic effects of the drug disrupt the brain chemistry. The chemical imbalance associated with this type of diagnosis is usually temporary, and the mental illness disappears with abstinence within a few weeks to a year. A significant number of these problems do manifest as unresolved and chronic mental illnesses. VI. MAKING THE DIAGNOSIS (pp. 10.8−10.9) A. ASSESSMENT (PP. 10.8−10.9) The process for assessing mental illness in a substance abuser must be a “ruleout” diagnosis. This means that several possible diagnoses will be considered during the period of assessment. The prudent clinician addresses all symptoms but avoids making a specific psychiatric diagnosis until the drug abuser has had time to get clean/sober. 1. Reasons for Increased Diagnoses •

The reduction in the number of inpatient mental health facilities.

•

The proliferation of substances of abuse, particularly stimulants.

•

There are more licensed professionals with expertise

•

Mental health workers are more aware of substance abuse and its effects

•

Some clinicians are under pressure by managed care and diagnosis-related group payment structures to over diagnose mental illness in order to qualify for coverage. For these reasons, a great number of people with psychiatric disorders have been forced to deal with their problems on their own or as an outpatient. One quarter of the homeless population suffers from pre-existing mental illness and of that group, 70% also suffer from substance dependence. B. UNDERSTANDING THE DUAL-DIAGNOSIS PATIENT (p. 10.9) In the past, dual diagnosis patients were often shuffled aimlessly between the mental health care system and the substance-abuse treatment system without receiving adequate care from either. Substance-abuse treatment facilities do not pro-actively seek these patients because they perceive them to disorganized and disruptive. Psychiatric

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treatment centers also avoid these patients because they are perceived as substance abusers, disruptive, and manipulative. VII. MENTAL HEALTH VS. SUBSTANCE ABUSE (PP. 10.9−10.13) The following list comprises 12 differences between the mental health (MH) treatment community and the substance abuse (SA) treatment community. 1. MH treatment providers: “Control the underlying psychiatric problem, and the drug abuse will disappear.” SA treatment providers: “Get the patient clean-and-sober, and the mental health problems will resolve themselves.” 2. Partial recovery is more readily acceptable in MH than in SA programs. 3. Clients are more reluctant to seek help from the MH system than from SA treatment. 4. MH relies more on medication to treat the client, SA programs promote a drug-free philosophy or substitute a less-damaging drug such as methadone. 5. MH uses case management, shepherding clients from one service to another, SA programs emphasize self-reliance

6. MH uses a supportive psychotherapeutic approach; some SA programs continue to use confrontation techniques.

7. Both systems are hampered from sharing information due to confidentially laws. 8. MH treatment teams are composed of professionally trained individuals: In some SA programs, recovering substance abusers make up the bulk of the treatment staff. 9. MH relies on scientifically based treatment approaches. SA programs often rely on the philosophy “what works for me will work for you.” 10. MH aims to prevent the client from getting worse. In the past, SA programs would allow people to hit bottom to break through their denial. 11. MH treatment is individualized, many traditional SA programs lean towards “one size fits all.” 12. MH and SA education during treatment are structured and knowledge based, SA education also places importance on long-held traditions and peer experiences. Although the situation may be improving from the perspective of the MH treatment community, dual diagnosis represents a daunting challenge to the clinical expertise of the staff of SA programs. Patients are often misdiagnosed with mental illness early in the treatment or assessment processes, they are then incorrectly referred to MH programs that all too often reject them because of their concurrent abuse problems.

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A. RECOMMENDATIONS (pp. 10.11−10.12) The dual-diagnosis patient must be treated for both disorders simultaneously. They are best treated in a single program when appropriate resources are available. SA programs must establish links with MH service providers and vice versa to provide both short-term and long-range services to address the problems of dual diagnosis. Research has found that intensive case management was associated with the greatest improvement in dual-diagnosis clients. Dr. Kenneth Minkoff's Four-Quadrant Model of differing levels of mental health and substance abuse is useful when determining the most appropriate treatment placement and direction for a dual-diagnosis client. The four quadrants are Quadrant 1 - Less severe Mental Disorder (MD) and Less Severe SubstanceUse Disorder (SUD) Quadrant 2 - More severe (MD) and Less Severe (SUD) Quadrant 3 – Less Severe (MD) but a More Severe (SUD) Quadrant 4 – More Severe (MD) and More Severe (SUD) Q4

Q3

Q1

Q2

B. MULTIPLE DIAGNOSES (p. 10.12−10.13) Other combinations of diagnoses include: •

multiple drug (polydrug) abuse;

•

other medical disorders such as chronic pain hepatitis, diabetes, and sexual dysfunction;

• triple diagnosis (dual diagnosis plus HIV disease). When people are dually diagnosed, they must achieve sobriety from all drugs of abuse, and treatment must be linked to appropriate medical care. Dualdiagnosis patients are more likely to share needles, engage in prostitution, have sex with an IV drug user, and report being the victim of rape than those without a co-occurring disorder. Hepatitis C and other severe liver diseases are frequently seen in chemically dependent patients, requiring the development of drug programs that are holistic, use several modalities, and are multidisciplinary. VIII. PSYCHIATRIC DISORDERS (PP. 10.13−10.20) Overall, about 21% of the U.S. population is affected by one or more mental disorders during a given year. Anxiety disorders are the most prevalent.

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BRAIN DISORDERS IN AMERICANS (one-year prevalence) DIAGNOSIS Schizophrenia Mood disorders bipolar disorder major depression Anxiety disorders Any brain disorder

18-54 1.3% 7.1% (1.1%) (5.3%) 16.4% 21.0%

55 + 0.6% 4.4% (0.2%) (3.7%) 11.4% 19.8%

Adolescents 1.2% 6.2%

13.0% 20.9%

(a person might have multiple disorders)

A. PRE-EXISTING MENTAL DISORDERS (pp. 10.13−10.16) 1. Thought Disorder (schizophrenia) Schizophrenia is a chronic psychotic illness that affects 0.5 to 1.5% of the population. It is believed to be inherited and is characterized by: •

hallucinations, delusions, inappropriate affect (illogical emotional response),

•

difficulty connecting thoughts,

•

impaired ability to care for oneself,

• a pronounced detachment from reality, disorganized speech, etc. Schizophrenia usually strikes individuals in their late teens or early adulthood and can persist for life. It strikes men and women with equal frequency. Several abused drugs mimic schizophrenia and psychosis. Methamphetamine, steroids, MDMA, and sometimes marijuana can induce a toxic psychosis, paranoia, or dissociation from reality as can withdrawal from downers. 2. Major Depressive Disorder Almost 15% of Americans will experience a major depressive disorder in their lifetime, 6.7% in any one-year period. Major depression is characterized by depressed mood, diminished interest and pleasure in most activities, disturbances of sleep patterns and appetite, decreased ability to concentrate, feelings of worthlessness, and suicidal thoughts. These feelings must occur every day, for at least a week. Excessive alcohol use, stimulant withdrawal, and the comedown or resolution phase of a psychedelic (LSD or ecstasy) could result in tempo temporary druginduced depression. 3. Bipolar Affective Disorder Bipolar affective disorder is characterized by alternating periods of depression, normalcy, and mania. If untreated, many bipolar patients attempt suicide during their depression phase. The mania is characterized by a persistently elevated, expansive, and irritated mood; inflated self-esteem or grandiosity; decreased need for sleep; a pressure to keep talking; a flight of ideas; and an 9                                                                     Chapter 10 – Mental Health & Drugs                                                                 © 2011, CNS Productions, Inc. 

 

excessive involvement in pleasurable activities which have a high potential for painful consequences (e.g., drug abuse, gambling, or inappropriate sexual advances). Median age of onset for bipolar affective disorder is in the twenties and affects men and women equally. Toxic effects of stimulant or psychedelic abuse will often resemble a bipolar disorder. Users experience swings from mania to depression, depending on the phase of the drug’s action. B. OTHER PSYCHIATRIC DISORDERS (pp. 10.16−10.19) 1. Anxiety Disorders Anxiety disorders are the most common psychiatric disturbances seen in medical offices. Post–Traumatic Stress Disorder. PTSD is a persistent re-experiencing of a traumatic event. One study estimated that a quarter of those in treatment for substance abuse might have PTSD. Panic Disorder consists of recurrent unexpected panic attacks. A panic attack is a discreet period of intense fear or discomfort in the absence of real danger, accompanied by at least four of the following symptoms: palpitations, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, nausea or abdominal distress, etc. Others anxiety disorders include: agoraphobia, fear of open spaces; social phobia, fear of being seen by others acting in a humiliating or embarrassing way; simple phobia, an irrational fear of a specific thing (spider) or place; obsessive-compulsive disorder, uncontrollable intrusive thoughts that lead to irresistible and often distressing actions. Generalized Anxiety Disorder (GAD), unrealistic worry about several life situations that lasts for six months or longer. Often anxiety and depression overlap. Many anxiety disorders are simply an outgrowth of depression. Toxic effects of stimulant drugs and withdrawal from opioids, sedatives, and alcohol (downers) also cause symptoms similar to those described as anxiety disorders and can be easily misdiagnosed. 2. Dementias These are problems of brain dysfunction (e.g., Alzheimer’s disease) brought on by physical changes in the brain caused by aging, disease, injury to the brain, or psychoactive drugs. 3. Developmental Disorders These disorders include mental retardation, autism, communication disorders, and attention-deficit/hyperactivity disorders

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4. Somatoform Disorders These disorders have physical symptoms without a known or discoverable physical cause and are likely to be psychological. 5. Personality Disorders Disorders such as antisocial and borderline personality disorders are characterized by inflexible behavioral patterns that lead to substantial distress or functional impairment. Anger is intrinsic to personality disorders as are chronic feelings of unhappiness and alienation from others, conflicts with authority, and family discord. These disorders frequently coexist with substance abuse and are hard to treat. Borderline personality disorder (BPD), frequently seen as a co-occurring disorder in the treatment of addiction, is a pervasive pattern of instability of interpersonal relationships and self-image and marked impulsivity. Symptoms include frantic efforts to avoid real or imagined abandonment, identity disturbance, and other symptoms. 6. Eating Disorders Weak impulse control is often found in eating disorders and substance use disorders, a possible common etiology along with genetic factors for both conditions. Eating disorders often accompany major depression and PTSD. 7. Gambling Disorder Pathological gambling, an impulse-control disorder, is more common in clients who abuse, or are dependent on alcohol. Often, a recovering alcoholic or addict will switch addictions and become as pathological about gambling. 8. Other Disorders There are dozens of other mental disorders, including adjustment disorders, sleep disorders, sexual and gender identity disorders, etc. C. SUBSTANCE-INDUCED MENTAL DISORDERS (pp. 10.18−10.20) Among patients who suffer from these kinds of disorders, the majority of the mental health problems encountered are caused by the substance use rather than pre-existing conditions. 1. Alcohol-Induced Mental Illness Impulse-Control Problems include but are not limited to violence, unsafe sex, high-risk behaviors, and suicide. Sleep Disorders if induced by alcohol, can last for months after a person attains stable sobriety. Anxiety. Symptoms of alcohol withdrawal anxiety include increased pulse rate, body temperature, and blood pressure as well as a variety of anxiety-like symptoms. Depression. Studies indicate that up to 45% of alcoholics present with concurrent symptoms of major depressive disorder. After four weeks of sobriety only 6% of alcoholics report the persistence of depressive symptoms. The use of antidepressant medication is contraindicated in people who are heavy drinkers. 11                                                                     Chapter 10 – Mental Health & Drugs                                                                 © 2011, CNS Productions, Inc. 

 

Psychosis is marked by the development of psychotic symptoms after many decades of heavy drinking. Dementia. A patient with alcohol-induced dementia, even in its most severe form, can regain some cognitive functioning in sobriety, although the process may take up to a year Cognitive Impairment. Drug and alcohol abuse results in several regions of the brain becoming inactive. Decreased brain activity correlates to a high degree of cognitive impairments. 2. Stimulant-Induced Mental Illness Impulse-Control Problems. Stimulant abusers also demonstrate impulsecontrol problems. Stimulant-Induced Sexual Dysfunction. Initial use of cocaine or other strong stimulant often results in hyper sexuality accompanied by impulse-control problems. Stimulant–Induced Mood Disorders. Abuse of stimulants can produce the symptoms associated with the acute manic phase of a bipolar disorder. If stimulant-use is the cause, symptoms disappear upon cessation of intoxication. Mania. Manic-like symptoms caused by the use of stimulants will completely resolve upon cessation of intoxication. Depression. Depression is caused by an imbalance of neurotransmitters. This imbalance can last up to 10 weeks after a person stops using. If the symptoms of depression are caused by stimulant withdrawal, antidepressants may help, but only during the initial detoxification phase of treatment Panic Disorder. The use of stimulants can induce a panic attack. The panic focus in the brain increases in size with each stimulant-induced panic attack. At a certain point, which is unique to the individual, a person can develop a chronic panic disorder even if they never use stimulants again. Anxiety. Stimulant-induced anxiety disorders occur in the context of both acute intoxication and withdrawal. Psychosis. Individuals who have psychotic symptoms will usually reexperience them each time they use; and as abuse continues, the duration of the effects will lengthen. It is common for people to experience psychotic symptoms for many months. Stimulant-Induced Sleep Disorder. Stimulant addicts have been known to forgo sleep for several days and then crash when the drug runs out. Cognitive Impairment. Stimulant abuse causes both transient and permanent damage to the brain and cognitive impairment. 3. Cannabis (marijuana)-Induced Mental Illness The higher concentration of the active ingredient THC is thought to be responsible for the psychiatric syndromes noted in marijuana users.

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Cannabis Intoxication Delirium involves difficulty with memory, multitasking, and other simple cognitive processes. It may take three months or longer for this delirium to clear after a person stops using marijuana. Cannabis-Induced Psychotic Disorder involves paranoia along with auditory and visual hallucinations. These symptoms tend to be transient and occur only while the person is high. There are reports of hallucinogen persisting perceptual disorder (HPPD) with symptoms lasting several months. Cannabis-Induced Anxiety Disorder. A panic attack in the intoxicated user. Amotivational Syndrome. Does marijuana make a person amotivational, or do amotivational people tend to smoke marijuana? To date there are no good scientific studies. 4. Other Drug-Induced Mental Illnesses The incidence of substance-induced psychiatric symptoms is much greater than the incidence of pre-existing psychiatric problems (and symptoms). Because many psycho-stimulants release serotonin, symptoms of serotonin syndrome should be considered when treating psychoses related to their use. IX. TREATMENT (p. 10.21−10.23) Treatment of mental illness and/or addiction is moving toward rebalancing brain chemistry. A. REBALANCING BRAIN CHEMISTRY (p. 10.21−10.23) 1. Heredity & Treatment As of yet we cannot alter a person’s genetic code, but a person can be made aware of how their heredity could put them at risk for a certain mental illness, drug addiction, or other compulsive behavior. Researchers hope someday to be able to identify the medication (and the treatment) that is most compatible with a person’s genetic profile. 2. Environment & Treatment Even though heredity cannot be altered, environments can be changed and improved thereby altering brain chemistry to better handle both mental illness and drug abuse. 3. Psychoactive Drugs & Treatment All substance-abuse treatment providers must familiarize themselves with the basics of psychopharmacology, as it is the cornerstone of mental health treatment. The number of psychiatric medications (e.g., antidepressants, antipsychotics or neuroleptics, mood stabilizers, and antianxiety drugs) has increased. 4. Starting Treatment Best practice currently is to stabilize both substance and mental health problems in an attempt to make the most accurate assessment possible.

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5. Impaired Cognition A study of dual-diagnosis clients at a public hospital found the majority were mildly-to-severely cognitively impaired and had difficulty participating in treatment. It may take weeks or months after detoxification for reasoning, memory, and thinking to come back to a point where the dual-diagnosis individual can fully to engage in treatment. 6. Developmental Arrest Drug abuse and mental illness often result in the arresting of emotional development. Many dual-diagnosis clients have character traits that are normal in children but abnormal in adults, making traditional treatment difficult. Some of them are •

a low frustration tolerance;

•

an inability to work persistently for a goal;

•

lying to avoid punishment;

•

feeling hostile about dependency and testing limits constantly;

•

expressing feelings as behaviors;

•

shallowness of mood;

•

fear of being rejected;

•

having no hope or concept of the future;

•

exhibiting denial;

•

believing “Either you’re for me or against me.”

Treatment providers must appreciate where a person is in his or her developmental process and address treatment accordingly. These are problems of living, of living sober, and of living with the symptoms of mental illness. The best treatment will address all of the issues. 7. Psychotherapy, Individual Counseling & Group Therapy Psychotherapy can be applied in either an individual or a group manner. Group therapy has become the standard for both substance abuse and mental illness treatments. The therapist must be aware that the primary treatment of severe mental illness is psychopharmacology not psychotherapy, whereas the opposite may be true for treating substance use disorders. Current thinking regarding the proper use of psychotherapy in substance use disorders sequences the following phases: •

achieving abstinence.

•

maintaining abstinence after the patient has 6 to 24 months of sobriety.

•

Once abstinence has been maintained, psychotherapy for the substance abuser is indistinguishable from any other psychodynamically oriented treatment

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Cognitive-behavioral therapies (CBYs) are the most frequently used evidencebased psychotherapies for all three phases of co-occurring disorder treatment. X. PSYCHOPHARMACOLOGY (PP. 10.23−10.31) The dual-diagnosis patient often needs medication for psychiatric disorders, such as antidepressants and mood stabilizers for mood disorders, antipsychotic (neuroleptic) medications for thought disorders, and antianxiety medications (anxiolytics) for anxiety disorders. These medications should be prescribed only after a thorough assessment. Medications are used short-term, medium-term, or on a lifetime basis to rebalance the brain chemistry. Almost all medications affect the manner in which neurotransmitters work. They can •

increase the presynaptic release of neurotransmitters (methylphenidate);

•

block the neurotransmitter from connecting with a given receptor site (antipsychotics).

•

inhibit the reuptake of neurotransmitters (Selective serotonin reuptake inhibitors [SSRIs])

•

inhibit the metabolism of neurotransmitters (Nardil® and MAO inhibitors);

•

enhance the effect of existing neurotransmitters (benzodiazepines).

In addition to manipulating brain chemistry, some drugs act directly to control symptoms. It is imperative to constantly monitor each patient’s reactions to a drug and adjust the dose accordingly. A. PSYCHIATRIC MEDICATIONS VS. STREET DRUGS (pp. 10.24−10.25) One advantage physician-prescribed psychiatric medications have over street drugs is, except for the benzodiazepines and stimulants, that they are not addicting. Treating anxiety, depression, and other mental problems through psychiatric medications can relieve many of the reasons and the triggers for drug abuse. When a patient uses street drugs, he or she falsely believes they have control over which drugs they ingest, inject, or otherwise self-administer. The same patients, when receiving medication from a doctor, often express the belief that they are not in control of their lives. Thus, many rely on street drugs rather than on psychiatric medications. It is the physician’s role to work with the patient regarding all issues raised by the use of prescription medications. B. DRUGS USED TO TREAT DEPRESSION (pp. 10.25−10.27) Many in the psychiatric field believe that depression is caused by an abnormality in the production of the serotonin and norepinephrine. Antidepressants are usually meant to increase the amount of serotonin or norepinephrine available. 15                                                                     Chapter 10 – Mental Health & Drugs                                                                 © 2011, CNS Productions, Inc. 

 

1. Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine, sertraline (Zoloft®), citalopram (Celexa®), paroxetine (Paxil®), and fluvoxamine (Luvox®) are classified as SSRIs; they increase the amount of serotonin available to the nervous system. It generally takes two to four weeks for the full effects to be sensed. Most of the side effects are mild and dissipate in a few weeks. Using too many SSRIs, especially MDMA or other antidepressants, can induce serotonin syndrome. Caused by excess serotonin, the symptoms include elevated body temperature, shivering and tremors, mental changes, rigidity, autonomic nervous system instability, and occasionally death. Similar medications include serotonin-norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine [Effexor®] and duloxetine [Cymbalta®]), selective norepinephrine-dopamine reuptake inhibitors (NDRIs) include bupropion (Wellbutrin® and Zyban®); selective norepinephrine reuptake inhibitors (NRIs) include reboxetine (Edronax® and Vestra®). 2. Tricyclic Antidepressants Tricyclic antidepressants were once the primary medications used to treat depression but over the past 15 years the newer antidepressants have proved to have fewer toxic and side effects. Tricyclic antidepressants, such as imipramine and desipramine, block reabsorption of serotonin and norepinephrine by the sending neuron, thereby increasing the activity of those biochemicals. It usually takes two to six weeks for a patient to respond to drug therapy. 3. Monoamine Oxidase (MAO) Inhibitors These very strong drugs work by blocking an enzyme (monoamine oxidase) that metabolizes the neurotransmitters norepinephrine and serotonin. This, in essence, raises the level of these neurotransmitters. 4. Stimulants Amphetamine or amphetamine congeners (e.g., Dexedrine,® Ritalin,® and Cylert®) were once used to treat depression. However, tolerance developed rapidly and the mood lift proved to be too alluring so misuse and addiction developed quickly. Psychiatrists now prescribe nonstimulant medication. C. DRUGS USED TO TREAT BIPOLAR DISORDER (p. 10.27−10.28) Lithium is the primary drug used to treat bipolar disorder. Other medications include carbamazepine (Tegretol®), valproic acid (Depakene®), divalproex sodium (Depakote,® oxcarbazepine (Trileptal®), gabapentin (Neurontin®), and topiramate (Topamax®). All of these are used as mood stabilizers even though some were initially developed for other purposes. 1. Lithium Lithium is a naturally occurring mineral that helps stabilize both the highs and the lows of bipolar disorder. A patient can expect to see clinical improvement two weeks after initiation of the medication. The use of street drugs and alcohol is contraindicated in patients taking lithium.

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D. DRUGS USED TO TREAT PSYCHOSES (Antipsychotics or neuroleptics) (pp. 10.28−10.29) In the early 1950s, a new class of drugs, phenothiazines, was found to be effective in controlling the symptoms of schizophrenia, such as chlorpromazine (Thorazine®), thioridazine (Mellaril®), and prochlorperazine (Compazine®). Newer antipsychotics—nonphenothiazines like haloperidol (Haldol®), risperidone (Risperdal®), olanzapine (Zyprexa®), clozapine (Clozaril®), loxapine (Loxitane®), and molindone (Moban®)— block the effects of dopamine. New antipsychotics include aripiprazole (Abilify®), a dopamine system stabilizer and paliperidone (Invega®). Lurasidone (Latuda), iloperidone (Fanapt), and asenapine (Saphris) block dopamine and serotonin receptors. Researchers found that an excess of dopamine is one of the major causes of psychotic symptoms in schizophrenia. Most of the antipsychotic medications work by blocking the dopamine receptors in the brain, thereby inhibiting the effects of the excess dopamine. Blocking dopamine commonly creates symptoms such as involuntary movement and the inability to sit still. Another commonly encountered side effect of antipsychotic medications is sedation; patients may seem drugged. There is a trend toward using atypical antipsychotics such as risperidone (Risperdol®) for the acutely psychotic patient. Because the antipsychotic drugs do not have an immediate impact on the patient’s psychotic symptom, it may be several weeks before the patient experiences the full antipsychotic effect. Clozapine (Clozaril®) is usually effective in the 30% of patients who do not respond to standard antipsychotic drug therapy. More than 33.5 million prescriptions were written for antipsychotic medications in the United States in 2001, up 34% from the previous two years. Even more dramatic is the six-fold increase in the number of children taking antipsychotics. Patients with a pre-existing psychotic illness such as schizophrenia or schizoaffective disorder often self medicate with street drugs in an attempt to control their symptoms. E. DRUGS USED TO TREAT ANXIETY DISORDERS (p. 10.29) For generalized anxiety disorder and some of the other anxiety disorders, the benzodiazepines are widely used. They act very quickly, particularly Valium®. The calming effects are apparent within 30 minutes. Many physicians avoid prescribing any benzodiazepine on a chronic basis because they are habit forming, even at clinical doses, and have dangerous withdrawal symptoms. Other non-addicting drugs for anxiety include BuSpar® and the beta-blockers. SSRI antidepressants such as Paxil® have been approved for use in anxiety disorder. Buspirone (BuSpar®) is a serotonin modulator that blocks the transmission of excess serotonin. It has the advantage of minimal side effects and there is no evidence that the drug is habit forming. 17                                                                     Chapter 10 – Mental Health & Drugs                                                                 © 2011, CNS Productions, Inc. 

 

1. Drugs for Obsessive-Compulsive Disorder Obsessive-compulsive disorder (OCD) has been treated with almost every type of psychotropic medication, usually with poor results. 2. Drugs for Panic Disorder Several drugs are used to control panic attacks and panic disorder. SSRI antidepressant medications are recommended due to their favorable sideeffect profile. Other frequently used medications in the treatment of panic are the beta-blockers like propranolol. Some of these drugs can have serious cardiac side effects. F. COMPLIANCE & FEEDBACK (p. 10.31) The most challenging issue for any physician is improving patient compliance with the physician’s instructions for taking a prescribed medication psychiatric or otherwise. If patients do not experience the desired effects, they will often alter the dosage on their own, stop taking the medication, or combine it with other drugs, causing dangerous interactions. Feedback is important, the physician and the client must work in tandem for the greatest success.

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Chapter 10 - MENTAL HEALTH & DRUGS Classroom or Small Group Discussion Topics 1. List the thoughts and behaviors associated with anxiety and have students map the range of thoughts and behaviors associated anxiety ranging from pressure and anxieties of everyday life to conditions that require treatment. 2. Discuss nondrug ways (e.g. behaviors) people rebalance themselves when they are depressed or anxious (e.g. exercise, meditation). 3. Discuss the statement “A family is ruled by its sickest member.”, Have the class discuss the likely effects that someone with mental health problems or an addiction will have on a family. What can a family do to minimize the impact a family member with an addiction or mental health problem may have on a family so that life does not revolve around its sickest member. 4. Break students into groups of 4. Assign half the groups the task of generating a list of symptoms associated with mental illnesses covered in chapter 10. Have the other half generate a list of drug-induced or withdrawal-induced psychological and behavioral symptoms As a class - match symptoms that occur on both the list of mental illnesses and drug-induced or withdrawal-induced symptoms. 5. How should the mental health community and the chemical dependency community work together to treating a client with co-occurring disorders. 6. What are the advantages and disadvantages of individual counseling, of group counseling? 7. Ask students to comment on the stressors in their environment that have or could make them act irrationally. 8. Should the mental health communities’ reliance on medication therapy become the preferred treatment in chemical dependency? Why? Why not? 9. Discuss the scientific evidence that support the use of prescription drugs to treat and rebalance brain chemistry. What is the philosophical or moral opposition to the use of drugs to treat and rebalance chemistry?

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Chapter 10 - MENTAL HEALTH & DRUGS Critical Thinking & Class Exercises 1. 1. Ask students to discuss why males tend to be more reluctant to use mental health treatment and females more reluctant to use chemical dependency treatment. What personal and social factors might be involved? 2. 2. Ask students to debate the relative merits of mental health and substance abuse treatment procedures for dually diagnosed individuals. 3. 3. Break the students into groups of 4 and ask them to develop the type of treatment program they would ideally want to have for themselves if they were struggling with bipolar disorder in addition to a substance abuse disorder for alcohol and cocaine. 4. 4. Ask student to research the anti-anxiety drug Prozac and discuss the promises and potentially negative effects for dually diagnosed patients. 5. Have the students attend an open 12-step meeting of Alcoholics Anonymous or Overeaters Anonymous and then have them discuss their experiences always remembering the guiding principle of anonymity.

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