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Substance-Use Disorders

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

Substance-Use Disorders (cont’d.) Substance-Use Disorders (cont’d.)

• Illicit drug use occurs with greater frequency

in:
– Some ethnic groups
– Some age groups

Figure 11-1 Two Year Comparison of Past Month Illicit Drug Use Across Age Groups In comparing 2008 and
2009, increases in the use of illicit drugs (cannabis, cocaine, heroin, hallucinogens, inhalants, or nonmedical use
of prescription drugs) occurred in almost all age groups

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Substance-Use Disorders (cont’d.) Substance-Use Disorders (cont’d.)

• Arise when psychoactive substances are used

excessively
– Psychoactive substances: alter moods, thought
processes, or other psychological states
• Heavy substance use induces changes in brain
resulting in addiction
– Addiction: involves compulsive drug-seeking
behavior and loss of control over drug use

Figure 11-2 Ethnic Groups Comparison in Path Month Illicit Drug Use There are significant differences
between ethnic groups in the use of illicit drugs (cannabis, cocaine, heroin, hallucinogens, inhalants, or
nonmedical use of prescription drugs)

Substance-Use Disorders (cont’d.) Substance-Use Disorders (cont’d.)

• DSM-V: • DSM-V characteristics:

– Differentiates disorders according to specific – Inability to control substance use despite harmful
substance used effects
– Disorders involve maladaptive pattern of recurrent – Craving for and preoccupation with obtaining
use, extending over a period of at least 12 months substance
– Results in notable impairment or distress – Tolerance: decreases in effect of substance
– Continues despite social, occupational, occurring after chronic use
psychological, or physical problems – Withdrawal: adverse physical/psychological
symptoms that occur after reducing or ceasing
substance intake

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Substance-Use Disorders (cont’d.) Substance-Use Disorders (cont’d.)

• Physiological dependence: • Substance abuse is twice as prevalent in males

– State of adaptation that occurs after chronic than females
exposure to a substance • Drug use is much higher among adolescents
– Body begins to accept presence of substance as
• Heroin, crack cocaine, and methamphetamine
normal
present greatest danger
– Evidence of tolerance or withdrawal symptoms
indicate dependence • Alcohol is most dangerous when personal and
societal ramifications are considered

Substance-Use Disorders (cont’d.) Substances Associated with Abuse

• Prescription medications:
– Used to treat anxiety, insomnia or pain
• Legal substances:
– Alcohol, caffeine, tobacco, and household
chemicals, etc.
• Illegal substances:
– Methamphetamine, cocaine, and heroin, etc.

Figure 11-3 Age and Gender Differences in Substance-Use Disorder Diagnosis With the exception of
those aged 12 to 17, the incidence of last-year substance-use disorder diagnosis is about twice as high
for males compares to females

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Depressants Depressants (cont’d.)

• Cause generalized depression of central • Alcohol:

nervous system and a slowing down of – Moderate drinking:
responses • Lower-risk pattern of alcohol intake (one or two drinks
per day)
• Include:
– Binge drinking:
– Alcohol
• Episodic intake of five or more drinks for men or four or
– Opioids more drinks for women
– Sedatives – Heavy drinking:
• Chronic alcohol intake of more than two drinks per day
for men and more than one drink per day for women

Depressants (cont’d.) Depressants (cont’d.)

• Alcohol consumption in U.S.:

– One fourth of Americans aged 12 or older binge
drink
– Men are twice as likely to develop disorder, but in
women progresses more rapidly
– Ethnic differences in consumption
– Binge drinking and heavy drinking problematic
among 21-25 year olds
– 42% is consumed by 14% of young adults
Figure 11-4 Comparison in Alcohol Use Across Age Groups Almost half of those ages 18 to 20 years old
reported underage alcohol use in the past month, including 23% who reported binge drinking and 11%
who were heavy alcohol users. The Highest level of binge drinking and heavy alcohol use is seen in the
21 to 25 age group

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Depressants (cont’d.) Depressants (cont’d.)

• Alcohol consumption in U.S.:

– Heavy drinking in college
– Lifetime prevalence of abuse is 18%
– 5% of those who use alcohol are physiologically
dependent
• Withdrawal symptoms include headache, fatigue,
sweating, and body tremors
• Delirium tremens: life-threatening withdrawal
symptoms

Figure 11-5 Trends in Heavy Alcohol Use in 18-22 Year Olds There are significant differences in heavy alcohol
use between 18-22 year olds who attend college full time with those who attend part time or not al all, with
college-attendees consistently reporting more heavy drinking.

Depressants (cont’d.) Depressants (cont’d.)

• Effects of alcohol: • Effects of alcohol:

– Short-term effects – Long-term effects
• Affects mood and behavior • Tolerance
• Depresses CNS functioning • Neurological effect:
• Muscular coordination and judgment impaired – Impaired motor skills, reduced reasoning and judgment,
memory deficits, distractibility, reduced motivation
• Alcohol poisoning
– Declines in overall functioning
– Toxic effects resulting from rapidly-consuming alcohol or
ingesting large quantity of alcohol; can result in impaired • Effects on cardiovascular system
breathing, coma, and death • Cirrhosis of the liver
• Depends on body weight and consumption time period • Alcohol hepatitis
• Cancer of mouth and throat

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Depressants (cont’d.) Depressants (cont’d.)

• Course of alcoholism: • Opioids:

– “High functioning alcoholics” – Pain-killing agents that depress the central
– Study found 75% of individuals demonstrated nervous system
considerable recovery from dependence • Illegal substances
– Heroin and opium
• Recovery least likely for those who drank the most
• Recurrence rate higher among heavy drinkers • Prescription pain relievers
– Morphine, codeine, and oxycodone
• Individuals with psychiatric disorder, family history of
– Second leading form of drug use
alcoholism or more chronic, severe drinking most likely
– Increase in emergency room visits
to remain dependent
– Highly addictive

Depressants (cont’d.) Depressants (cont’d.)

• Opioids:
Long-term use of opioids linked with significant
social problems
• Many abusers began their habit with prescribed
medication, eventually buying prescription drugs
illegally or heroin (more lethal opioid)
– “Gateway” drug: substance that leads to use of even more
lethal substances
• Heroin and cheese (combination of heroin and over-
the-counter cold medications) increasingly being used
by adolescents
Figure 11-6 Emergency Department Contacts Related to Illicit Use of Prescription Opioids The number
of emergency room visits due to illicit use of prescription pain medications increased 111 percent
between 2004 and 2008; visits more than doubled in all age groups and for both males and females.

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Depressants (cont’d.) Depressants (cont’d.)

• Effects of opioids: • Sedatives:

– Produce feelings of euphoria and drowsiness – Have calming effects and are used in treating
– Tolerance builds rapidly resulting in dependency agitation, muscle tension, insomnia, and anxiety
and need for increased doses • Hypnotics: induce sleep
– Severe withdrawal symptoms • Anxiolytics: reduce anxiety

– Drug cravings can persist for years – Barbiturates and benzodiazepines have rapid
anxiolytic effects in moderate doses and hypnotic
– Medical problems associated with use
effect in higher doses
• Adulterants: substances used to increase bulk of illegal
drugs prior to sale

Depressants (cont’d.) Stimulants

• Effects of sedatives: • Central nervous system energizer, produce

– Drowsiness, impaired judgment, and diminished feelings of euphoria, improve mental and
motor skills physical performance, reduce appetite, and
– Excessive use can lead to accidental overdose and prevent sleep
death • Include:
– Combining alcohol with sedatives increases – Caffeine
danger
– Amphetamines
– Tolerance and physiological dependence
– Cocaine
– Withdrawal symptoms

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Stimulants (cont’d.) Stimulants (cont’d.)

• Caffeine: • Amphetamines (“uppers”):

– Stimulant found in coffee chocolate, tea, and soft – Speed up CNS activity
drinks – Produce feelings of euphoria and confidence but
– Most widely consumed psychoactive substance in also agitation, assaultive or suicidal behavior, and
the world delusions of persecution
– In North America, 90% of adults use daily – 2% of U.S. adults have experienced dependence
– Energy drink marketing has increased caffeine – More common in low SES and in men
consumption – Methamphetamine
– Tolerance and side effects

Stimulants (cont’d.) Stimulants (cont’d.)

• Cocaine: • Cocaine:
– Substance extracted from coca plant that induces – Crack:
feelings of energy and euphoria • Potent form of cocaine produced by heating cocaine
– Estimated 1.6 million users, with 1.1 million with other substances
demonstrating dependence • Produces immediate but short-lived effects

– High potential for addiction: 20% of users are

rapidly dependent on drug
– Withdrawal causes lethargy and depression
• Users often take multiple doses in rapid succession

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Stimulants (cont’d.) Hallucinogens

• Effects of cocaine: • Produces vivid sensory awareness, heightened

– Constant desire for cocaine can impair social and alertness, perceptions of increased insight,
occupational functioning and sometimes hallucinations
– Stimulates sympathetic nervous system • “Good trips” versus “bad trips”
• Irregular heartbeat, stroke, and death may occur
• Hallucinogen persisting perception disorder
– Acute psychiatric symptoms
• Psychosis, paranoia, and hallucinations • 1.3 million people involved in 2009
– Chronic difficulties:
• Anxiety, depression, sleep disturbances, and sexual
dysfunction

Hallucinogens (cont’d.) Dissociative Anesthetics

• Traditional hallucinogens are derived from • Produce dream-like detachment

natural sources – Phencyclidine (PCP) and ketamine (Special K)
– Lysergic acid diathylamide (LSD) and mescaline highly dangerous and potentially addictive
(both are uncommon) • Have dissociative, stimulant, depressant, amnesic and
hallucinogenic properties
• Effects of hallucinogens: • Cause disconnection, perceptual distortion, euphoria,
– Vary significantly and confusion
– Not addictive; dependence does not occur • Delusions, hostility, and violent psychotic behavior
– Development of tolerance • Delusions can persist after cessation of use
– Dectromethorphan (DXM)

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Substances with Mixed Chemical Substances with Mixed Chemical

Properties Properties (cont’d.)

• Substances that have varied effects on the • Nicotine:

brain and central nervous system – Widely-used ; highly addictive substance found in
• Include: tobacco
– Nicotine – Stimulant in low doses; relaxant in higher doses
– Cannabis – In 2009, almost 70 million adults and adolescents
– Inhalants (28% of population) used tobacco
– Ecstasy – 60% of current smokers are dependent
– Euphoric effects decrease; tolerance and withdrawal
increase

Substances with Mixed Chemical Substances with Mixed Chemical

Properties (cont’d.) Properties (cont’d.)

• Nicotine:
– Causes both the release of adrenaline (burst of
energy) and the release of dopamine (feelings of
pleasure)
– Adrenalin combined with insulin release results in
high blood sugar and loss of appetite
– One-half million deaths annually in U.S. and 5
million deaths per year worldwide

Figure 11-7 Past Month Cigarette Use Among Adolescents and Adults Across Age Groups Cigarette
smoking increases significantly during late adolescence and peaks between age 21 and 29.

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Substances with Mixed Chemical Substances with Mixed Chemical

Properties (cont’d.) Properties (cont’d.)

• Cannabis: • Marijuana is most commonly used illicit drug

– Contains chemical THC that can produce worldwide and in U.S.
stimulant, depressant, and hallucinogenic effects – 17 million adults and adolescents report use
– Marijuana is derived from leaves and flower of – Males are more likely to use
plant, while hashish comes from pressed resin – Represents 60% of illegal drug intakes
– Synthetic marijuana is increasingly popular and – Most frequently associated with diagnosis of
dangerous substance abuse
– Pervasive lack of concern over consequences
– “Gateway” drug

Substances with Mixed Chemical Substances with Mixed Chemical

Properties (cont’d.) Properties (cont’d.)

• Marijuana produces feelings of euphoria,

tranquility, and passivity combined with mild
perceptual and sensory distortions
• Effects of marijuana:
– Increase in anxiety and depression in females
– Can cause impaired memory, motor coordination,
and concentration
– Hallucinations and short-term psychotic reactions
(may become chronic)
Figure 11-8 Drugs Involved in First Time Illicit Drug Use in 2009 Among the 3.1 million adolescents and
adults who first used an illicit drug during 2009, over half reported their first drug was marijuana,
followed by prescription medications which accounted for over 25% of first drug experiences.
– Schizophrenia

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Substances with Mixed Chemical Substances with Mixed Chemical

Properties (cont’d.) Properties (cont’d.)

• DSM-V Cannabis withdrawal syndrome: • Inhalants:

– Clear patterns of withdrawal – Use of chemical vapors found in common
– Strong similarities with tobacco withdrawal household products (solvents, aerosol sprays, and
– Clean link between severity of withdrawal compressed air products)
symptoms and severity of cannabis dependence – Most common among 12 to 17 year olds
• Approximately 10% develop dependence – Chronic use common among white males
– Effects vary and are brief resulting in repeated
• Withdrawal symptoms
“huffing” to extend intoxication
• Legalization efforts

Substances with Mixed Chemical Substances with Mixed Chemical

Properties (cont’d.) Properties (cont’d.)

• Effects of inhalants: • Ecstasy:

– Impaired coordination and judgment, euphoria, – Has both stimulant and hallucinogenic properties
dizziness and slurred speech – In 2009, 1.1 million new users
– Hypoxia (oxygen deprivation) results in acute and – Produces euphoria, mild sensory and cognitive
persistent cognitive deficits distortion, feelings of intimacy and well-being,
– Any episode can result in stroke, acute respiratory followed by intense depression
distress or sudden heart failure – Drug dependence even among infrequent users
– Emotional and interpersonal difficulties – Withdrawal symptoms
• Paranoia, violent behavior, suicidal ideation, anxiety,
and depression

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Substances with Mixed Chemical

Properties (cont’d.) Polysubstance Use

• Effects of ecstasy: • Synergistic effect:

– Long-lasting damage in brain areas critical for – The result of chemicals (or substances) interacting
thought and memory to multiply one another’s effects
– Reduced ability to complete challenging cognitive • Dangerous combinations:
tasks – Tranquilizers and alcohol
– May lead to death – Alcohol and cocaine
– Stimulants and sleeping pills
– Multiple drug use involving ecstasy
– Alcohol and caffeine

Etiology of Substance-Use Disorders

Etiology of Substance-Use Disorders (cont’d.)

• Progression from substance use to abuse

– Individual decides to experiment with drugs
– Drug begins to serve important purpose;
consumption continues
– Brain chemistry becomes altered from chronic use
(physiological dependence, withdrawal symptoms,
and cravings)
– Lifestyle changes occur due to chronic abuse

Figure 11-9 Typical Progression Toward Drug Abuse or Dependence

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Etiology of Substance-Use Disorders Etiology of Substance-Use Disorders:

(cont’d.) Psychological

• Coping with psychological stress and

emotional symptoms is a major motive for
substance use
– Stress plays a role in development of alcoholism
and relapse
• 43% had concurrent psychiatric disorder
– Self-medication
– Post-traumatic stress disorder
– Major depression
Figure 11-10 Multipath Model for Substance Use Disorders The dimensions interact with one another
and combine in different ways to result in a substance-use disorder.
– Eating disorders

Etiology of Substance-Use Disorders:

Etiology: Psychological (cont’d.) Social

• Personality characteristics • Influence varies across lifespan:

– Behavioral undercontrol – Childhood:
– Impulsivity • Victimization and stressful events (neglect)
– Tension and anxiety reduction – Adolescents (particularly vulnerable period):
• Parental influences: attitudes and behaviors
• Environmental stressors
• Peer pressure and peer socialization
• Social expectations
• Desire to assert independence and rebel
• Desire to “have fun” or take risks

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Etiology of Substance-Use Disorders: Etiology of Substance-Use Disorders:

Social (cont’d.) Sociocultural

• Influence varies across lifespan: • Use varies according to:

– College: – Gender: males more than females
• First year is a vulnerable transitional period – Age: young adults more than older adults
– Less parental supervision; increased competition and pressure
to achieve; exposure to “wet environments,” and peer – SES: consumption increases with SES
influences – Ethnicity: Whites and Hispanics more than African
– Freshman overestimate quantity and social acceptability of
drinking
Americans
• Negative consequences associated with drinking can – Religion: Catholics more than Protestants or Jews
exacerbate college drinking and drug use – Country: “wet” versus “dry” cultures
• Eating disorders
– Parental incarceration

Etiology of Substance-Use Disorders: Etiology of Substance-Use Disorders:

Biological Biological (cont’d.)

• Gender differences in: • Genetic influences:

– Physiology, substance-induced changes in brain – Genes and epigenetic changes affect individual
functioning, and genetic mechanisms response to specific drugs
• Substance abuse changes brain chemistry and – Genetic and epigenetic variations influence
structure degree of pleasure experienced as well as
negative and positive effects of drug use
– Alteration of dopamine pathway
– Genetics influence personality traits that increase
– Changes in frontal cortex
risk as well as protective characteristics
• Genetic factors
– Heredity

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Methods and Effectiveness of Methods and Effectiveness of

Treatments Treatments (cont’d.)

• Disparity between 23.5 million needing

treatment and 2.6 million receiving it
• Over one million youth aged 12 to 17 need
drug treatment and 1.2 million need alcohol
treatment
• Many are unable to initiate treatment
• Treatment is most frequently sought for
alcohol abuse
Figure 11-11 Reasons Given for Not Receiving Substance-Use Treatment Among individuals with a substance
abuse problem indicated they would like to receive needed treatment, but they were unable to initiate
treatment for a variety of reasons, the most prevalent being they did not have health are coverage and could
not afford treatment.

Methods and Effectiveness of Methods and Effectiveness of

Treatments (cont’d.) Treatments (cont’d.)

• Variety of settings:
– Self-help groups
• Most common: almost 2.5 million individuals
participating in groups like AA and NA
• Provide a supportive approach
– Mental health clinics
– Inpatient or outpatient centers
• Problems with treatment programs:
– Not using evidence-based care
Figure 11-12 Substances for Which Treatment Was Received In 2009, Americans sought treatment – Access barriers
most frequently for alcohol abuse (2.9 million), followed by cannabis use (1.2 million)

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Methods and Effectiveness of Methods and Effectiveness of

Treatments (cont’d.) Treatments (cont’d.)

• Effective treatments: • Goals of treatment:

– Require strategies and pharmaceutical – Achieving sustained abstinence
interventions that are research-based – Maintaining a drug-free lifestyle
– Broad-spectrum interventions that include – Functioning productively in family, work, and
different treatment modalities (multimodal) other environments
• No single type of treatment is likely to be totally – Requires:
effective
• Changing habits
• Successful treatment outcome requires major life
changes • Minimizing thoughts of drugs and drug-related
activities
• Learning to cope with activities and stressors without
use of drugs

Methods and Effectiveness of

Treatments (cont’d.) Understanding and Preventing Relapse

• Most programs have two phases: • Relapse prevention takes into account
– Detoxification: physiological effects and neurological changes
• Body is purged of intoxicating substances, immediately – Neuroplasticity: the ability of the brain to change
or gradually prevented from using substance its structure and function in response to
• Focus on coping with withdrawal symptoms experience
– Preventing relapse (return to drug or alcohol use • Initial abstinence results in transient alterations in
after a period of abstention) neural functioning; sustained abstinence is necessary
• Relapse occurs when ongoing support for recovery is for neurological changes
not in place

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Understanding and Preventing Relapse Understanding and Preventing Relapse

(cont’d.) (cont’d.)

• Two types of relapse: • Factors associated with relapse:

– Regulated relapse: – Presence of another psychiatric disorder
• Process of weighing choices and making a conscious – Younger age at onset of drug use
decision to use a substance
– More extensive involvement with substances
• Seen before physiological dependency
– Antisocial behavior
– Compulsive relapse:
• Automatic resumption of drug-seeking behavior in
– Minimal connection with school or work
response to stressors or substance-related cues – Less support from drug-free family and peers
• Occurs later in addiction process – Negative emotional states, such as depression
• Driven by habit

Understanding and Preventing Relapse Understanding and Preventing Relapse

(cont’d.) (cont’d.)

• Pharmacological: • Contingency management procedures:

– Used to help minimize withdrawal symptoms – Participants receive either voucher or cash
– Goal is to disrupt physiological mechanism incentives for verified abstinence, adhering to
underlying substance abuse treatment goals, or taking prescribed medication
– Medications prescribed vary depending on significantly reduce relapse
substance use • Motivational enhancement therapy:
– Most produce only modest effects – Addresses ambivalence about giving up substance
– Medication alone is not sufficient to prevent use by considering advantages and disadvantages
relapse of making change

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Understanding and Preventing Relapse

(cont’d.) Treatment for Alcohol Dependence

• Effective treatment targets: • Alcoholics Anonymous (AA):

– Involuntary activation of reward circuits in – Regards alcoholism and disease and advocates for
response to drug-associated cues and the total abstinence
resultant drug-craving
• Pharmaceutical treatment:
– Psychological, social, and sociocultural factors that
led to initial substance use – Antabuse (disulfiram)
– Acamprosate
– Naltrexone
– Modest effect
• More research/access to treatment needed

Treatment for Opioid Dependence Treatment for Stimulant Dependence

• Early intervention is emphasized • No effective pharmacological interventions

– Length of use strongly influences treatment • Contingency management procedures
outcome
• Training cocaine users to cope with
• Pharmaceutical treatment: temptations and high-risk situation was
– Used to prevent relapse beneficial
– Methadone: effective but tolerance develops
– Buprenorphine
– Naltrexone
• Contingency management and counseling

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Treatment for Marijuana Dependence Treatment for Nicotine Dependence

• Research is focusing on brain systems uniquely • Relapse remains high despite cessation
affected by marijuana use – Need for long-term treatment strategies
• Psychological approaches show promise • Programs that provide emotional support and
– Brief therapy that enhance readiness to change
– Cognitive and behavioral therapy • Pharmaceutical treatments:
– Motivational enhancement – Nicotine replacement therapy (NRT)
– Extended treatment is important – Bupropion
• Contingency management procedures – Varenicline
• Outpatient treatment

Treatment for Nicotine Dependence

(cont’d.)

• Strategies to cope with negative emotions

• Virtual-reality therapy
– Helps smokers learn to effectively respond to
smoking-related cues
• Smoking quitlines and Internet interventions

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