Chapter 17: Substance-Related Disorders -substance: any natural or synthesized product that has psychoactive effects- it changes perceptions,

thoughts, emotions, and behaviour SOCIETY AND SUBSTANCE ABUSE Muslim countries following Islamic law strictly prohibit alcohol and enforce penalties against people caught using this or any other substance. Communists in China made it a major goal to eradicate the widespread use of opium Great Britain substance addiction is considered a medical disease, and people who abuse or are dependent on substances are treated by physicians. Traffickers in illegal substances are aggressively prosecuted by British government however users of illegal substances are more often referred for treatment than arrested Dutch made a distinction in their law enforcement between soft drugs (ex. cannabis) and hard drugs (ex. cocaine and heroin). Both are illegal but the possession, use and sale of cannabis are rarely prosecuted whereas hard substances are subject for heavy penalties which are enforced Dutch system based on belief that enforcing strict prohibition of softer drugs would drive users underground where they would come into contact with harder drugs Zurich, Switzerland famous for needle park sale and use of substances were carried out in the open and allowed by authorities while a doctor employed by the government stood by to handle any emergencies and to distribute clean needles. In 1992 the park closed because of evidence that addicts from around Europe had poured into the city and crime rates had soared Many substances come from plants and have been used for medicinal purposes for centuries Coca leaves can be manufactured into cocaine. Cocaine was used legally into the twentieth century to relieve fatigue and was an ingredient in the original Coca-Cola Opium, a milky juice produced from the poppy plant has been used to relieve pain. Leaves of a plant called khat have been chewed to produce a sense of well-being and relief from fatigue. Today modern derivatives of khat are used to make amphetamines a class of drugs used to treat attention deficit hyperactivity disorder and narcolepsy and included in OTC cold remedies and appetite suppressants for weight control Substances also been used for religious ceremonies to produce psychological changes important for the ceremonies Substances used by individuals to change their moods, thought, and perceptions, other members of society begin to get nervous because some individuals have great difficulty in using substances in moderation and begin to build their lives around using the substances. Their use of substances may lead to significant problems in their abilities to function in their daily lives. This person is said to have a substance-related disorder

DEFINITIONS OF SUBSTANCE-RELATED DISORDERS 1) 2) 3) 4) 5) Four substance-related conditions are recognized by DSM-IV-TR: substance intoxication, substance withdrawal, substance abuse, and substance dependence Substances can be grouped into 5 categories: Central nervous system depressants (alcohol, barbiturates, benzodiazepines, inhalants) Central nervous system stimulants (cocaine, amphetamines, nicotine, caffeine) Opioids (heroin, morphine) Hallucinogens and phencyclidine (PCP) Cannabis Many other substances are used for intoxicating effects that more rarely lead to substance-related disorders. Although most people exposed to certain substances (ex. antihistamines) experience no psychoactive effects or only mild and transients effects, some people experience significant problems when exposed, these people have other substance-related disorder

Intoxication Substance intoxication: set of behavioural and psychological changes that occur as a direct result of the physiological effects of a substance on the CNS.

People begin to be intoxicated soon after they begin ingesting a substance, and the more they ingest, the more intoxicated they become. Intoxication begins to decline as the amount of a substance in peoples blood or tissue declines, but the symptoms of intoxication may last for hours or days after the substance is no longer detectable in the body Short-term/acute intoxication can produce different symptoms from chronic intoxication (ex. first time people take cocaine may be outgoing, friendly and upbeat. With chronic use they may begin to withdraw socially and become less gregarious. Peoples expectations about a substances effects can also influence the types of symptoms shown Setting in which a substance is taken can influence the types of symptoms people develop. The environment in which people become intoxicated can also influence how maladaptive the intoxication is: people who drink alcohol only at home may be at less risk of causing harm to themselves or others Diagnosis of substance intoxication is given only when the behavioural and psychological changes the person experiences are significantly maladaptive in that they substantially disrupt the persons relationships, cause occupation/financial problems, or place the individual at significant risk for adverse effects

Withdrawal Substance withdrawal: set of physiological and behavioural symptoms that result when people who have been using substances heavily for prolonged periods of time stop using the substance or greatly reduce their use. Symptoms of withdrawal from a substance are typically the opposite of the symptoms of intoxication with the same substance. Diagnosis is not made unless withdrawal symptoms cause significant distress or impairment in a persons everyday functioning

Abuse 1) 2) 3) 4) Substance abuse: persons recurrent use of a substance results in significant harmful consequences. When their use causes chronic harmful consequences, they are considered to have a substance use disorder Person has to show repeated problem in at least one of these categories within a 12-month period to qualify for a diagnosis of substance abuse: Fails to fulfill important obligations Repeatedly uses the substance in situations in which it is physically hazardous to do so (ex. driving a car) Repeatedly has legal problems as a result of substance abuse (ex. arrests) Continues to use the substance even though they have repeatedly had social or legal problems as a result of the use For some the abuse of a particular group of substances evolves into dependence on those substances. Diagnosis of substance dependence pre-empts diagnosis of substance abuse since dependence is considered a more advanced condition than abuse

Dependence Substance dependence: closest to drug addiction, persons substance use leads to physiological dependence or impairment or distress, as manifested by an inability to use the substance in moderation; a decline in social, occupational, or recreational activities; or the spending of large amounts of time obtaining substances or recovering from their effects. A person is physiologically dependent on a substance when he or she shows either tolerance to or withdrawal from the substance (withdrawal symptoms may be so severe substances must be withdrawn gradually to prevent symptoms from becoming overwhelming or dangerous) Tolerance: present when a person experiences less and less effect from the same dose of a substance and needs greater and greater doses to achieve intoxication. Person who is highly tolerant to a substance may have a very high blood concentration of the substance without being aware of any effects of the substance. Alcohol, opioids, stimulants, and nicotine have high risks for tolerance Diagnosis can be given when a person compulsively uses a substance, despite experiencing significant social, occupational, psychological, or medical problems as a result of that use Routes of administration that produce rapid and efficient absorption of the substance into the bloodstream lead to more intense intoxication and a greater likelihood of dependence Some substances act more rapidly on the CNS thus lead to faster intoxication

Substances whose effects wear off quickly are more likely to lead to dependence or abuse than are substances with longer-lasting effects

DEPRESSANTS Alcohol Low doses people may be less inhibited. At increasing doses, it induces symptoms of depression, fatigue and lethargy, decreased motivation, sleep disturbances, depressed mood, and confusion. Alcohol can severely impair sexual functioning Extreme intoxication may fall into a stupor or coma. Once sober may have amnesia known as blackout, for the events that occurred while they were intoxicated Critical determinant of how quickly people become intoxicated with alcohol is whether their stomachs are full or empty. When stomachs empty alcohol is more quickly delivered from stomach to small intestine where its rapidly absorbed into the body. Person with a full stomach may drink significantly more drinks before reaching a dangerous blood-alcohol concentration or showing clear signs of intoxication Legal definition of alcohol intoxication is much narrower than criteria for a diagnosis of alcohol intoxication. Canada person is under influence of alcohol if blood-alcohol concentration is above 0.08 Drinking large quantities of alcohol can result in death from respiratory paralysis Alcohol abuse: use alcohol in dangerous situations, fail to meet important obligations, and have recurrent legal or social problems Alcohol dependence: typically have all the problems of an alcohol abuser, and they may show physiological tolerance to alcohol, spend a great deal of time intoxicated or withdrawing from alcohol, often organize their lives around drinking, or they continue to drink despite having significant problems that result from drinking. Characteristics of alcohol dependence match alcoholism Three distinct patterns of alcohol use seen in alcohol abusers and dependants: o Some drink large amounts of alcohol every day and plan their days around their drinking o Abstain from drinking for long periods and then go on binges. May stop drinking when faced with crises they must deal with. When they begin drinking again, they may be able to control their drinking for a while but it may soon escalate o Others are sober on weekdays but drink heavily during evenings or only on weekends Binge drinking: consuming five more drinks within a couple of hours. Women consuming four or more drinks within a short time More Canadian students drink Distinction between alcoholics who also have antisocial personalities and alcoholics who dont have antisocial personalities. Antisocial alcoholics have more severe symptoms of alcoholism, tend to remain alcoholic for longer, have poorer social functioning, have more marital failures, and have heavier drug involvement. Antisocial alcoholics more likely to come from families with alcoholism Another distinction between negative affect alcoholism and other alcoholism. Negative affect alcoholism people tend to have had depressive and anxiety symptoms in childhood. This pattern appears to be more common in women Alcohol withdrawal symptoms divided into 3 stages: o Few hours after drinking stops-tremulousness (the shakes), weakness, and profuse perspiration, anxiety (jitters), headaches, nausea, abdominal cramps, retch and vomit, flushed face, restless, easily startled but alert, mildly abnormal EEG pattern, see or hear things o Second stage begins as early as 12 hours after stopping- convulsive seizures o Third stage- delirium tremens (DTs): symptoms that result during severe alcohol withdrawal including hallucinations, delusions, agitation, and disorientation. Other symptoms from third stage may be fever, agitation, profuse perspiration, irregular heartbeat, death from hyperthermia (increased body temperature) or collapse of the peripheral vascular system Depressants slow the activity of the CNS. In moderate doses they make people relaxes, somewhat sleepy, reduce concentration, and impair thinking and motor skills. Heavy doses can induce stupor

People who make it through the entire withdrawal syndrome can show complete recovery from withdrawal symptoms Long-term Effects of Alcohol Abuse o Low-grade hypertension combined with increase in triglycerides and LDL cholesterol increase risk of heart disease o Malnourished because chronic alcohol ingestion decreases the absorption of critical nutrients from the GI system and in part because they tend to drink more than eat o Toxic effects on several systems o Chronic thiamine deficiencies which can lead to disorders of CNS (numbness and pain in extremities, deterioration of muscles, loss of visual acuity) o Alcohol-induced persisting amnesic disorder: permanent cognitive disorder caused by damage to the CNS, consists of 2 syndromes o Wernickes encephalopathy: mental confusion and disorientation and in severe states, coma o Korsakoffs psychosis: loss of memory for recent events and problems in recalling distant events. May confabulate, telling implausible stories in an attempt to hide their inability to remember o Alcohol-induced dementia: loss of intellectual abilities, including memory, abstract thinking, judgement, or problem solving, often accompanied by personality changes, such as increases in paranoia. Common cause of adult dementia o Children of mothers who ingest alcohol while pregnant may be born with fetal alcohol syndrome (FAS) which is characterized by retarded growth, facial abnormalities, CNS damage, mental retardation, motor abnormalities, tremors, hyperactivity, heart defects, and skeletal anomalies Cultural Differences in Alcohol Disorders o Low rates of alcohol consumption in Eastern Mediterranean and some African countries tied to Islam and its alcohol prohibitions. o Low rates of consumption in Southeast Asia may be due to absence in 50% of people of Asian descent of an enzyme that eliminates the first breakdown product of alcohol: acetaldehyde. They experience flushed face and heart palpitations, discomfort of this effect often least to avoiding alcohol altogether o Cross-cultural differences in binge-drinking behaviour o Vast majority of individuals with alcohol abuse and dependence dont seek treatment o Differences in alcohol use by ethnic group. Western Europeans have highest rates of alcohol use and Asians have lowest rates. o Aboriginals at high risk for alcohol abuse and dependence, frequent binge drinking noted as special problem. Tied to their excessive rates of poverty and unemployment, lack of education, greater sense of helplessness and hopelessness, and feelings of loss of cultural and community identity and sense of cultural shame o Protective factors from alcoholism are re-emergence of spiritual elements and return to cultural traditions Gender and Alcohol Use o Men more likely to binge drink, drink heavily, and have alcohol use disorders. Gender gap in alcohol use much greater among men and women who subscribe to traditional gender roles, which condone drinking for men but not women o Women less likely to seek out alcohol-specific treatment and receive care for their difficulties Trends Across the Lifespan o Young and middle-aged adults diagnosed with alcohol dependence tend to show chronic course at least over a 5-year period o Use of illegal substances in general declines as adults get older because: Liver metabolizes alcohol at slower rate and lower percentage of body water increases absorption of alcohol. As a result older people can become intoxicated faster and experience negative effects of alcohol more severely and quickly They get more mature in their choices, including the choice about drinking alcohol to excess Older people have grown up under stronger prohibitions against alcohol use and abuse and in a society in which there was more stigma associated with alcoholism

People who have used alcohol excessively may die from alcohol-related diseases before they reach old age

Benzodiazepines, Barbiturates, and Inhalants Depress the CNS. Intoxication and withdrawal from these substances similar to alcohol intoxication and withdrawal. Users initially feel euphoric and disinhibited but then experience depressed moods, lethargy, perceptual distortions, loss of coordination, and other signs of CNS depression Benzodiazepines and barbiturates legally manufactured and sold by prescription usually for the treatment of anxiety and insomnia Two common patterns arise in the development of benzodiazepine or barbiturate abuse and dependence: o Teenager or young adults begin using to produce a sense of well-being or euphoria. Then escalates to chronic use and physiological dependence. Likely among persons who have substance abuse problems with other substances o Initially use sedatives under physicians care for anxiety or insomnia then gradually increase their use as tolerance develops, without the knowledge of their physicians. Obtain prescriptions from several doctors or photocopy their prescriptions Barbiturates and benzodiazepines decrease blood pressure, respiratory rate, and heart rate. Death from respiratory arrest or cardiovascular collapse. Overdose especially likely when taking in combination with alcohol Inhalants are volatile substances that produce chemical vapours, which can be inhaled and which depress the CNS. May appear drunk or disoriented, slurred speech, nauseated, lack appetite, inattentive, irritable, or depressed. One group of inhalants is solvents (ex. gasoline, glue, spray paint). May inhale vapours directly from the cans or bottles containing the substances, soak rags with the substances and then hold the rags to their mouths and noses or inhale from bags. Chemicals reach lungs, bloodstream and brain very rapidly Others are medical anaesthetic gases (ex. nitrous oxide-laughing gas) Nitrites are a special class of inhalants that dilate blood vessels and relax muscles and are used as sexual enhancers. Illegally packaged nitrites are called poppers or snappers on the street Aboriginal youth prone to using inhalants Chronic users of inhalants may have a variety of respiratory irritations and rashes because of the inhalants. Inhalants can cause permanent brain damage to CNS and organ damage. Death can occur from depression of respiratory or cardiovascular systems. Sudden sniffing death by acute irregularities in heartbeat or loss of oxygen. Sometimes users suffocate themselves when using a bag. Can also cause dangerous delusional behaviour

STIMULANTS Drugs that activate the CNS causing feelings of energy, happiness, power, decreased desire for sleep, and diminished appetite Cocaine and amphetamines cause dangerous increases in blood pressure and heart rate, changes in rhythm and electrical activity of the heart, and constriction of blood vessels which can lead to heart attacks, respiratory arrest, and seizures Caffeine and nicotine are also stimulants Prescription stimulants are used to treat obesity, neurological disorders, asthma and other respiratory problems, and a variety of other diseases

Cocaine

Cocaine: white powder extracted from coca plant and one of the most highly addictive substances known. Snorting causes effects to be felt quickly, or dissolve powder in water and inject intravenously Crack is a form of freebase cocaine thats boiled down into tiny chunks which are usually smoked Cocaine activates the ventral tegmental area and the nuclear accumbens, areas of the brain that register reward and pleasure. Normally when pleasurable event occurs, dopamine is released into synapse of these areas of the brain and then bind to receptors on neighbouring synapses. Cocaine blocks reuptake of dopamine into transmitting neuron, causing dopamine to accumulate in the synapse, maintaining the pleasurable feeling

Initially sudden rush of intense euphoria, users often dont feel drugged. Taken at high doses or chronically leads to grandiosity, impulsiveness, hypersexuality, panic, and paranoia. After stopping users may feel exhausted and depressed and sleep a great deal and feel intense craving for both physiological and psychological effects Cocaine has short half-life (time needed for half of the drug to disappear from the body), its effects wear off quickly so person takes frequent doses to maintain a high Desperation to obtain cocaine can lead to engagement in extremely dangerous behaviours. Many contract HIV bu sharing needles or having sex in exchange for money for cocaine. Disturbances in heart rhythm and heart attacks, chest pain and respiratory failure, neurological effects, GI complications, blurred vision, fever, muscle spasms, convulsions, and coma Began as a wealthy persons substance but sharp reduction in cost lead to widespread use at all SES levels Crack is increasingly prevalent among street drug users in Canada

Amphetamines Amphetamines: most often swallowed can be injected through IV and methamphetamine can be snorted or smoked. These drugs initially introduced as antihistamines. Use them to combat depression or chronic fatigue from overwork or simply to boost their self-confidence and energy. Also component of diet drugs Street names: speed, meth, and chalk Amphetamines produce their effects by causing release of neurotransmitters dopamine and norepinephrine and blocking reuptake of these neurotransmitters Symptoms of intoxication: euphoria, self-confidence, alertness, agitation, and paranoia Cause neurotoxicity, human brain damage, reduce availability of dopamine D2 receptors and transporters for dopamine, serotonin, and vesicular monoamines. Can produce perceptual illusions that are frightening which can develop amphetamine-induced psychotic disorders Legal problems arise because of aggressive or inappropriate behaviour or buying drugs illegally Tolerance develops quickly Speed run- inject amphetamines frequently over several days without eating or sleeping. When a speed run ends they crash into a physical and emotional depression, may become suicidal Acute withdrawal symptoms typically subside within a few days but chronic users may experience mood instability, memory loss, confusion, paranoid thinking, and perceptual abnormalities Cardiovascular problems can rise, sharing needles can lead to HIV or hepatitis Increasingly used by people to keep up with rapid pace of todays work world. Employers may even provide amphetamines to employees to keep them working and increase their productivity Short-term problems of anxiety, depression, mental confusion, psychosis, fatigue, and headaches and the long-term problems of poor oral hygiene caused by dry mouth, teeth grinding, and jaw clenching collectively called meth mouth Use of crystal meth common among gay and bisexual Canadian youth

Nicotine

Nicotine: alkaloid found in tobacco. Cigarettes deliver nicotine to brain within seconds after person begins smoking Use of tobacco has declined in Canada and increasing in developing countries Decrease of smoking in North America greater for men than women and women less likely to quit once addicted to tobacco Youth who are recent immigrants less likely to be smokers than non-immigrant youth Nicotine operates on both central and peripheral nervous systems. Results in release of several biochemical that may have direct reinforcing effects on brain including dopamine, norepinephrine, serotonin, and endogenous opioids People often say they smoke to reduce stress but physiological effects of nicotine actually resemble the fight-or-flight response: several systems in the body are aroused in preparation to fight or flee a stressor including cardiovascular and respiratory systems. Subjective sense that smoking reduces stress may actually reflect release of tension and irritability that build in smokers between cigarettes because they are addicted to the nicotine. Nicotine addicts need nicotine to remain feeling normal because of nicotines effects on the body and brain

Caffeine

Smoking is number one preventable cause of death. in Canada top four causes of death are cancer, heart disease, stroke and chronic respiratory disease and smoking is a risk factor for all these causes Babies of women who smoke while pregnant are smaller at birth Second hand smoke contains more toxins than the smoke that the smoker actively inhales although the passive smoker doesnt inhale the smoke in concentrations as high as the smoker does Predictor of youth smoking decision is whether a household member smokes regularly in the home Nicotine causes most of the core symptoms of physiological and psychological dependence. When chronic heavy smokers try to stop smoking for an extended period they show severe withdrawal symptoms. They are depressed, irritable, angry, anxious, frustrated, restless, and hungry. Have trouble concentrating and desperately crave a cigarette Antidepressant bupropion can significantly reduce the craving for nicotine and help smokers stop smoking permanently

Caffeine: most heavily used stimulant drug. Caffeine stimulates the CNS, increasing levels of dopamine, norepinephrine, and serotonin. It causes metabolism, body temperature, and blood pressure to increase; appetite wanes and feel more alert; restlessness, nervousness, and hand tremors can ensue. Upset stomach, heart beating rapidly or irregularly, trouble sleeping, and urinate frequently. These are the symptoms of caffeine intoxication. Large doses can cause extreme agitation, seizures, respiratory failure, and cardiac problems. Diagnosis of caffeine intoxication should be given if an individual experiences significant distress or impairment in functioning as result of symptoms Cannot be diagnosed with caffeine dependence disorder because little evidence shows that dependence on the drug causes significant social and occupational problems Caffeine users can develop tolerance and undergo withdrawal symptoms if they stop

OPIOIDS Morphine, heroin, codeine, and methadone are all known as opioids. Derived from sap of opium poppy, which has been used for thousands of years to relieve pain. Bodies actually produce natural opioids which are called endorphins and enkaphalins to cope with pain. Doctors may also prescribe synthetic opioids such as hydrocodone or oxycodone Morphine was widely used as a pain reliever until it was discovered that its highly addictive. Heroin was developed from morphine, clear that heroin and all opioids have dangerous addictive properties Vietnam War young soldiers faced horrific circumstances found heroin cheap and easy to obtain Current use of heroin expands and contracts with the drugs price and availability on the street. When the drug is cheap and highly available, high levels of use occur Injected directly into veins (mainlining), snorted, or smoked. Initial symptoms often euphoria, sensation in abdomen like sexual orgasm (thrill, kick, flash), tingling sensation, sense of warmth, pupils dilate, drowsiness, lethargic, speech slurred, mind clouded, periods of light sleep, vivid dreams, reduced pain, person in this state referred to as being on the nod Severe intoxication lead to unconsciousness, coma and seizure. Can suppress part of brain stem controlling respiratory and cardiovascular systems to point of death (stop breathing and heart stops pumping). Especially dangerous when combined with depressants Withdrawal symptoms: dysphoria, anxiety, agitation, achy feeling in back and legs, increased sensitivity to pain, craving for more opioids, nauseated, vomit, profuse sweating, diarrhea, and fever First use of heroin is typically in late teens. May become psychologically dependent on effects of drugs at first then later become physiologically dependent. Iv users need to shoot up every 4-6 hours to avoid physical withdrawal IV users can contract hepatitis, TB, serious skin abscesses, deep infections and pregnant women who use heroin at risk for miscarriage and premature delivery, children are at increased risk for sudden infant death s. May become psychologically dependent on effects of drugs at first then later become physiologically dependent. Iv users need to shoot up every 4-6 hours to avoid physical withdrawal

IV users can contract hepatitis, TB, serious skin abscesses, deep infections and pregnant women who use heroin at risk for miscarriage and premature delivery, children are at increased risk for sudden infant death syndrome Frequently abused drug is oxycodone

HALLUCINOGENS AND PCP Hallucinogens and phencyclidine (PCP) produce perceptual changes even in small doses Hallucinogens: mixed group of substances including LSD and peyote. LSDs psychoactive effects discovered when Dr. Hoffman accidentally swallowed it and experienced visual hallucinations similar to those in schizophrenia. Symptoms of intoxication from LSD and other hallucinogens is synesthesia, the overflow from one sensory modality to another. People say they hear colours and see sounds. Hallucinogen known as ecstasy used by people who believe it enhances insight, relationships, and mood LSD was legal, reports of bad acid trips or bummers. s. Symptoms were severe anxiety, paranoia, and loss of control. Time passes slowly, boundaries between self and environment disappear, mood shifts, some become anxious and panicked, and detached. These experiences led to these drugs being labelled psychedelic. For some hallucinations and anxiety from hallucinogens so severe they became psychotic and required hospitalization Phenylcyclidine (PCP), also known as angel dust, is manufactured as a powder to be snorted or smoked. Not classified as hallucinogen but has many of same effects. Lower doses produce sense of euphoria, affective dulling, talkativeness, lack of concern, slowed reaction time, vertigo, eye twitching, mild hypertension, abnormal involuntary movements, and weakness Intermediate doses lead to disorganized thinking, distortions of body image, depersonalization, feelings of unreality, become hostile, and even violent Higher doses produce amnesia and coma, analgesia sufficient to allow surgery, seizures, severe respiratory problems, hypothermia and hyperthermia People with PCP intoxication often misdiagnosed as having psychotic disorders not related to substance abuse because intoxication can persist for several days

CANNABIS Cannabis (or hemp) plant leaves can be cut, dried, and rolled into cigarettes or inserted into food and beverages. Known as marijuana, weed, pot, grass, reefer, ganja and bhang. Most widely used illicit substance in the world and most commonly used illegal drug in North America. Teenagers especially heavy users of marijuana Symptoms of cannabis intoxication may develop within minutes if smoked but few hours if taken orally. Intoxication begins with high feeling, relaxation, dizzy, sleepy, and more aware of environments, everything may seem funny, grandiosity, lethargic. Cognitive symptoms of intoxication are negative because short-term memories and motor performances are impaired, slower reaction times, deficient concentration and judgement, and at risk for accidents. Effects greater for women than men but effects do appear to be reversible. Cannabis has hallucinogenic effects at moderate to large doses. Perceptual distortions, feelings of depersonalization, paranoid thinking, severe anxiety resembling panic attacks Physiological symptoms are increased heart rate, irregular heartbeat, increased appetite, and dry mouth. Cannabis smoke is irritating and thus increases risk for chronic cough, sinusitis, bronchitis, and emphysema and it contains even larger amounts of carcinogens than tobacco so high risk for cancer. Chronic use of cannabis lowers sperm count in men and may cause irregular ovulation in women Physical tolerance to cannabis can develop so users need greater amounts to avoid withdrawal symptoms. Symptoms of withdrawal include loss of appetite, hot flashes, runny nose, sweating, diarrhea, and hiccups THC, the active compound in cannabis, can help relieve nausea in people with cancer who are undergoing chemo and increase appetite in people with AIDS. Also helps in treatment of asthma and glaucoma. THC can be given as a pill but some argue that level of THC that enters body more controllable when taken in cigarette however people who ingest in pill form dont risk respiratory damage caused by smoke from cigarettes

CLUB DRUGS

Raves often sponsored by club owners or businesspeople, held in basements or other large spaces and participants often ingest drugs with stimulant and hallucinogen properties then spend the night listening and dancing to techno music. After drug effects disappear people are exhausted and spend hours sleeping. Greatest health concerns during raves is dehydration. Agitation and paranoia can set into the crowd Some common club drugs in addition to LSD are ecstasy, GHB, ketamine, and rohypnol Ecstasy has stimulant effects along with hallucinogen properties- heightened energy, restlessness, decreased social inhibitions. Short-term use of ecstasy can have long-term effects on cognition and health. People who use ecstasy have lower attention, memory, learning, and general intelligence than those that dont. Euphoric effects and some of the brain damage may be due to alterations in functioning of serotonin in the brain- serotonin levels in ecstasy users are half that of people who dont use it. Bizarre effects of ecstasy is teeth grinding Long-term users of ecstasy risk several cardiac problems and liver failure, increased rates of anxiety, depression, psychotic symptoms, and paranoia GHB is anabolic steroid and a CNS depressant. Low doses relieve anxiety and promote relaxation. Higher doses result in sleep, coma, or death. Was widely used by bodybuilders and athletes to lose fat and build muscle. It was banned except under supervision of physician because of reports of side effects- high blood pressure, mood swings, liver tumours, violent behaviour, sweating, headache, decreased heart rate, nausea, vomiting, impaired breathing, loss of reflexes, and tremors GHB considered one of the date rape drugs because associated with sexual assaults Ketamine is a rapid-acting anaesthetic that produces hallucinogenic effects in users ranging from rapture to paranoia to boredom. Can elicit out-of-body or near-death experiences and render user comatose. Numbness, loss of coordination, sense of invulnerability, muscle rigidity, aggressive behaviour, slurred speech, exaggerated sense of strength, and a blank stare. Because ketamine is an anaesthetic users feel no pain Large doses of ketamine- vomiting, convulsions, oxygen starvation of the brain and muscles. It is also a date rape drug used to anaesthetize victims Rohypnol (roofies) is a date rape drug. Has sedative and hypnotic effects. Experience a high, muscle relaxation, drowsiness, impaired judgement, blackouts, hallucinations, dizziness, and confusion. Comes in tablet which is easily crushed and slipped into drink- its odourless, colourless, and tasteless. Manufacturers changed how its made now it makes drinks blue or murky. Side effects include headaches, muscle pain, and seizures. Can be fatal with alcohol or other depressants.

GAMBLING AND SEX ADDICTION Problem gambling: pattern of gambling behaviour that causes harm to an individuals personal or family life, work, finances, or health Critics argue that provincial governments may be glossing over the societal and health costs of problem gambling because of the significant income gambling generates Sexual addiction, or hypersexual disorder, has been defined as a pattern of sexual behaviour that is initially pleasurable but that becomes unfulfilling and self-destructive; the person is unable to stop the behaviour however. Through repetitive sexual behaviour an individual may attempt to achieve a desired psychological state similar to that gained through a substance addiction Proposed that DSM-V include diagnosis of internet addiction when it includes specific consequences: o Excessive use o Withdrawal (including feelings of anger or tension when computer is inaccessible) o Tolerance (ex. more hours of use) o Negative repercussions (ex. social isolation) Hypersexual behaviour typically starts in adolescence and continues through adulthood

THEORIES OF SUBSTANCE USE, ABUSE, AND DEPENDENCE Substances affect several biochemical in the brain and these chemicals can have direct reinforcing effects on the brain. Brain appears to have its own pleasure pathway which affects our experience of reward. This pathway begins

in midbrain ventral tegmental area and then goes forward through nucleus accumbens and on to frontal cortex. Pathway is rich in neurons sensitive to the NT dopamine Some drugs (ex. amphetamines and cocaine) act directly to increase availability of dopamine in this pathway leading to strong sense of reward or high Other drugs increase availability of dopamine in more indirect ways. Ex. opiate drugs inhibit GABA which stops GABA neurons from inhibiting dopamine which makes dopamine available in the reward centre Chronic use may produce permanent changes in reward centres causing craving even after withdrawal symptoms pass. Repeated use of such substances causes dopamine neurons to become hyperactive or sensitized. This sensitization can be permanent so these neurons will be activated more highly by subsequent exposure to psychoactive substance or by stimuli that are associated with the substance (such as pipe which used to smoke crack). This sensitization creates a chronic, strong craving for the substance Substances that have especially rapid and powerful effects on the brain but also wear off very quickly (cocaine) create great risk for dependency Psychoactive drugs affect a number of other biochemical and brain systems Disease model of alcoholism and other drug addictions views these disorders as incurable physical diseases Social and psychological forces make some people more prone to these disorders than are others

Biological Theories Many of the biological theories focus on role of genetics and neurotransmitters. People who become substance dependent or abusive may react differently physiologically to substances than those who dont become dependent or abusive. Some theorists gave argued that alcoholism really represents an underlying biological depression Genetic Factors o Family studies show relatives of people with substance-related disorders more likely to also have substance disorder o Twin studies show family transmission of substance abuse and dependence is due to genetics o Some studies suggest genetics play stronger role in alcohol use disorders among men than women o Environmental circumstances such as sexual abuse are stronger predictors of alcoholism in women than men o First reports that genes play role in smoking by Fisher- concordance rate for smoking significantly higher in monozygotic twins than dizygotic twins o Hughes summarized data from twin studies of smoking and concluded 53% of variation in smoking behaviour attributable to genetic causes o Genes affect vulnerability to substance use disorders in part by influencing the functioning of neurotransmitter systems involved in metabolism and biosynthesis of substances o Variation in 2 genes that control enzymes that breakdown alcohol is related to low alcohol risk in Asians o Other genes involved in drug abuse related to CNS functioning o Much research focused on genes controlling dopamine system given its importance in reinforcing properties of substances. Genetic variation in dopamine receptor gene and transporter gene may influence dopamine concentrations at synapses and responses to dopamine thereby influencing how reinforcing a person finds such substances o Rewards of addictive drugs are habit forming because they act on brain circuits that naturally regulate biological rewards. People who have certain abnormalities in these genes that result in more dopamine at synapses appear less likely to become smokers than people without these abnormalities Alcohol Reactivity o Lower reactivity to moderate doses of alcohol among sons of alcoholics may lead them to drink substantially more before they begin to feel drunk, may also develop high physiological tolerance for alcohol o Men with low reactivity to moderate doses of alcohol significantly more likely to become alcoholics over time than men with greater reactivity o Women less prone than men to alcoholism because more sensitive than men to intoxicating effects of alcohol. 30% more of the alcohol enters womans bloodstream than a mans because women have less of an enzyme that neutralizes and breaks down alcohol. May experience more severe withdrawal symptoms if she

drinks too much. Women who abuse alcohol more at risk for negative health effects because their blood concentrations of alcohol are higher Alcoholism as a Form of Depression o Family history studies suggested that alcohol-related disorders and unipolar depression run together in families, with alcoholism more prevalent in male relatives and unipolar depression more prevalent in female relatives o Although many people with alcohol-related problems appear to use alcohol to cope with daily stresses, not wise to consider alcoholism simply another form of depression for several reasons: Children of alcoholics have higher rate of depression but these depressions might result more from stresses of having alcoholic parents than genetics Several studies failed to find higher rates of alcoholism among offspring of depressed people than offspring of non-depressed people Alcohol is CNS it can cause classic symptoms of depression Social consequences of alcohol abuse and dependency (ex. loss of job) can cause depression. When depression and alcohol dependency co-occur in individuals, depression is just as likely to be consequence as a cause of alcohol dependency. Odds of depression preceding alcoholism equal to odds that alcoholism will precede depression Studies show that adolescents who are depressed not more likely to become alcoholics than adolescents that arent depressed Simply prescribing antidepressant to alcohol abuser not enough to help overcome alcohol related problems in long run Depression among alcoholics usually disappears once they become abstinent Alcoholism and other drug addictions co-occur with many psychological disorders (schizophrenia, depression, etc.)

Psychological Theories Behavioural theories suggest that children and adolescents may learn substance use behaviours from modelling of their parents and important others in their culture, they learn these are acceptable behaviours and thus more likely to engage in them as well (monkey see, monkey do) Alcohol related problems more common among males so most adults modelling inappropriate use of alcohol are male Maladaptive alcohol use may be passed down through males in a family through modelling. Nicotine use appears to be especially sensitive to modelling effects by parents and peers Cognitive theories argue that people who develop alcohol-related problems have strong expectations that alcohol will help them feel better and cope better when they face stressful times Individual differences in personality produce different susceptibilities to reinforcing properties of drugs. A personality characteristic consistently related to increased risk for substance abuse and dependence is behavioural undercontrol, the tendency to be impulsive, sensation seeking, and prone to antisocial behaviour. Behavioural undercontrol runs strongly in families Sociocultural theorists note reinforcing effects of substances may be more attractive to people under great psychological stress, particularly those under chronic stress Chronic stress combined with an environment that supports and even promotes use of substances as an escape is a recipe for widespread substance abuse and dependence (ex. situation for soldiers fighting in Vietnam War) Substance use much more acceptable for men than women in many societies. Women appear less likely than men to have undesirable personality traits associated with substance use disorder, less motivated to drink to reduce distress, less likely to expect drug consumption to have positive outcomes, and carry protective factors such as being more nurturing toward others Women suffer alcohol related physical illnesses at lower levels of exposure to alcohol than men, heavy alcohol use associated with several reproductive problems, and more likely to suffer physical and sexual assault. Womens lower rates of alcohol-related disorders due to absence of risk factors and sensitivity to negative consequences. Lower consumption protects women from developing tolerance

Men tend to begin using substances in context of socializing with male friends, women most often initiated into use by family members or partners Alcohol advertising targeted to youth increases likelihood that adolescents will begin drinking or increase their level of drinking

TREATMENTS FOR SUBSTANCE-RELATED DISORDERS Historically treatment based on disease model which views disorders as medical disease and suggests biological treatments are most appropriate, people have no control over substance use because of their disease and thus must avoid all use of the substances Psychological interventions based on harm-reduction model which focus on psychological and sociocultural factors that lead people to use substances inappropriately and on helping people gain control over their use of substances thought behavioural and cognitive interventions. Does not presume people must avoid all use of substances Detoxification is first step in any treatment program. Individuals assisted in stopping use of the substance and then the substance is eliminated from the body. Detoxification especially important when substance can cause permanent organ or brain damage or is frequently lethal Once people stop using the substance and are through withdrawal process, a variety of biological and psychosocial therapies used to prevent relapse Must go through trans-theoretical stages of change before beginning treatment: o Pre-contemplation stage: person is not considering change o Contemplation: person actively evaluates pros and cons of changing o Preparation stage: planning and commitment to change consolidated o These early stages lead to the specific behavioural actions in which change is implemented o Final stage if successful: maintaining change for the long-term

Biological Treatments Medication can be used to help wean people off a substance, to reduce their desire for a substance, and to maintain use of substance at a controlled level Alcohol dependent people, a benzodiazepine, which has depressant effects similar to alcohol can be prescribed to reduce symptoms of tremor and anxiety, decrease pulse and respiration rates, and stabilize blood pressure. Dosage is decreased each day so patient withdraws from alcohol slowly but dont become dependent on benzodiazepine Antidepressants also used to help people weather withdrawal syndrome and continue abstaining from substance use. used to treat alcoholics or other drug addicts who are depressed but efficacy in treating substance problems or depression in absence of psychotherapy has not been consistently supported Selective serotonin reuptake inhibitors (SSRIs) can help reduce impulsive consumption of and craving for alcohol. Wide differences in response to SSRIs Antagonist drugs block or change the effects of the addictive drug, reducing desire of addict for the drug. Naltrexone and naloxone are opioid antagonists- block effects of opioids such as heroin. If a person takes heroin while on naltrexone and naloxone, he or she will not experience the positive effects of the heroin. This theoretically can reduce desire for the drug and therefore use of the drug. Naltrexone has also proven useful in blocking the high that can be caused by alcohol. Blocks the effects of the release of endorphins during drinking Drug acamprosate affects glutamate and GABA receptors in the brain, which in turn are involved in the craving for alcohol Disulfiram (commonly referred to as Antabuse) is a drug that can make alcohol punishing. Having one drink can make a person taking disulfiram feel sick and dizzy Pharmacological treatment of nicotine dependence, two general approaches: o Nicotine replacement therapy (nicotine patch/gum/spray/inhaler) to prevent withdrawal effects o Prescribe a medication that reduces craving for nicotine- bupropion which is an antidepressant Gradual withdrawal from heroin through methadone which is an opioid but has less potent and longer-lasting effects than heroin when taken orally. Methadone helps reduce extreme negative symptoms of withdrawal from heroin, it blocks receptors for heroin. Goal of treatment is eventually to withdraw individuals from methadone

Methadone maintenance programs are controversial, some believe they transfer dependency from heroin to a drug thats legal and provided by a physician however methadone patients are less likely to relapse into heroin use or become reinvolved in criminal activity

Behavioural and Cognitive Treatments Behavioural and cognitive techniques used in treatment of substance use disorders have certain goals in common: o Motivate individual to stop using the drug o Teach new coping skills to replace the use of substances to cope with stress and negative feelings o Change reinforcements a person has for using substances o Enhance individuals supports from non-using friends and family o Foster adherence to pharmacotherapies the person is using in conjunction with psychotherapy Behavioural Treatments: based on aversive classical conditioning sometimes used to treat alcohol dependency and abuse o Drugs such as disulfiram make ingestion of alcohol unpleasant or toxic. If they take drinks of alcohol the drug interacts with the alcohol to cause nausea and vomiting. Eventually through classical conditioning, they develop conditioned responses to the alcohol (nausea and vomiting). Learn to avoid alcohol through operant conditioning, to avoid the aversive response to it. this is effective in short-term o Covert sensitization therapy: use imagery to create associations between thoughts of alcohol use and thoughts of highly unpleasant consequences of alcohol use. seem effective in creating conditioned aversive responses to sight and smell of alcohol and in reducing alcohol consumption o Some people develop classically conditioned responses to the environmental cues often present when they drink. Cue exposure and response prevention used to extinguish conditioned response to cues associated with alcohol intake. Clients exposed to alcohol, encouraged to hold glasses to their lips and smell it but prohibited or strongly discouraged from drinking it. eventually this reduces desire to drink and increases ability to avoid drinking Cognitive Treatments: help identify situations in which clients most likely to drink and lose control over their drinking and their expectations that alcohol will help them cope better with those situations. Then work to challenge these expectations by reviewing the negative effects of alcohol on their behaviour. Help clients learn to anticipate and reduce stress, develop adaptive ways of coping, deal effectively with social pressure, and teach clients controlled drinking Controlled Drinking Controversy: notion that alcoholics can control drinking clashes with idea that alcoholism is a biological disease and if alcoholic takes one sip theyll lose control. Mark and Linda Sobell- first studies showing that cognitive behaviorally oriented controlled drinking program can work for alcoholics. Significantly less likely than alcoholics in abstinence program to relapse. These findings assailed by proponents of alcohol-as-a-disease model like Pendery, Maltzman, and West who did follow-up of Sobells controlled drinking group. The Sobells were publicly charged with fraud and multiple investigations. They were eventually cleared of any wrongdoing. Sobells detailed many flaws in Pendery article- lack of information on outcomes of alcoholics in abstinence program and better longterm income for controlled drinking. Controlled drinking programs can work for people with mild to moderate alcohol problems Abstinence violation effect is powerful contributor to relapse which has 2 components o Sense of conflict and guilt when alcoholic violates abstinence. May continue drinking to suppress guilt o Tendency to attribute violation of abstinence to lack of willpower and self-control rather than situational factors. Paves way to continued, uncontrolled drinking Relapse prevention programs teaches to view slips as temporary and situationally caused. Identify high-risk situations for relapse and how to avoid those situations or exercise effective coping strategies for the situations

Alcoholics Anonymous Organization created by and for people with alcohol-related problems. Based on disease model views alcoholism as a disease that causes alcoholics to lose all control over their drinking once they have the first drink. 12-step program o Admit theyre alcoholics and powerless against alcohol o Seek help from higher power

o Goal for all members is complete abstinence o Once they are able, group members devote themselves to helping others o Believe people are never completely cured, always recovering alcoholics AA doesnt appeal to everyone especially with emphases on ones powerlessness, need for higher power, and complete abstinence

Prevention Programs for University Students Young adults largest proportion of problem drinkers of any age group. Easy access to alcohol, social activities that focus on drinking, and peer pressure to drink. Alcohol-related accidents are leading cause of death in university students Programs to reduce drinking emphasize health-related consequences of drinking but long-term concerns and fear tactics have little effect on young people who are more likely to focus on short-term gains of alcohol use. must pay particular attention to students personal circumstances, with the employment of practical short-term cognitivebehavioural techniques Provide alternative recreational activities that dont focus on alcohol Alan Marlatt- recognize alcohol use as normative behaviour among young adults and focus education on immediate risks of excessive use of alcohol, payoffs of moderation, and skills training to prevent abuse of alcohol Based on harm-reduction model Alcohol Skills Training Program (ASTP) targets heavy-drinking university students. First taught to be aware of drinking habits by keeping daily records of alcohol consumption and situations in which they drink, taught to calculate own blood alcohol concentration, discuss negative effects of alcohol on social behaviours, ability to drive, weight gain, and hangovers. Set personal goals based on BAC and their desires to avoid negative effects of alcohol. Learn skills for limiting consumption, consider alternatives to alcohol, and taught skills for avoiding high-risk situations Prevention programs for university students aim to teach them the responsible use of alcohol

Gender-Sensitive Treatment Programs Differences in contexts for mens and womens substance abuse suggest need for different approaches to treating men and women Men- focus on challenging societal supports for their substance use and their view that substance use is an appropriate way to cope and on mens tendency to act aggressive or impulsive Women- treatment needs to focus more on issues of self-esteem and powerlessness and helping them remove themselves from abusive environments. Women substance abusers typically live with others who are substance abusers and may not have the support from their environment to stop

Some people may find changes from drugs rewarding because they are genetically or biochemically predisposed to do so. Rewards and punishments in the environment can clearly affect an individuals choice. People who find substances more rewarding will develop expectations that substances will be rewarding, which in turn will enhance how rewarding they actually are. Heavy substance users choose friends and environments that support substance use. Tend to find partners who are heavy users creating a biological and psychological environment for their children that promotes substance abuse and dependence. Cycle of familial transmission of substance abuse and dependence