One that hath wine as a chain about his wits,
such an one lives no life at all.
Alcaeus, 570 b.c.
Lecture 10
Substance Related Disorders (SRD)
Dale L. Johnson
In nearly every society in the world
people use mind-altering drugs of some kind. Some societies prohibit alcohol,
but allow hashish. In the United States alcohol and nicotine are legal and
widely available, but drugs such are marijuana, cocaine, heroin,
meta-amphetamines are illegal, and widely available. Also in nearly every
society drug use begins in adolescence, perhaps as a desire to experience
something new, to change the way one experiences. Adolescence is a time when
cognitive development consolidates, but the adolescent does not know yet what
can be known. Drugs provide avenues to new knowledge. The social context of
adolescence also has much to do with drug use initiation. Sexual drives make it
imperative that one be accepted by others of the same age. Acceptance is
sometimes dependent upon joining in chemical explorations. In the 1999 Swedish
film, Show me love, the two 16 year old girls finally find friendship in
each other. They are happy, and want to enhance their happiness by getting
high. They search through the family medicine cabinet for some chemical and
wonder if they can get high on alka-selzer. They try it and do get
high--expectation is powerful.
To get high is to be free of care,
the ordinary, hum-drum, worldly existence. In its beginnings, mardi gras was
celebrated to be free of care, and included much alcohol/drug use.
___________________________________________________________
DSM-IV CRITERIA FOR
SUBSTANCE DEPENDENCE
A maladaptive
pattern of substance use, leading to clinically significant impairment or
distress, as manifested by three or more of the following (one year):
1. Tolerance, as
defined by either of the following:
A. A need for markedly increased
amounts of the substance to achieve intoxication or desired effect.
B. Markedly diminished effect with
continued use of the same amount of the substance.
2. Withdrawal,
as manifested by either
A. Characteristic withdrawal
syndrome.
B. The same or similar substance
taken to relieve or avoid withdrawal symptoms.
3. Substance
taken in larger amounts or over a longer period than intended.
4. Persistent
desire or unsuccessful efforts to cut down or control substance abuse.
5. Great deal of
time spent in activities necessary to obtain the substance.
6. Important
social, occupational or recreational activities are given up or reduced because
of substance abuse.
7. Substance is
continued despite knowledge of having a persistent or recurrent physical or
psychological this is likely to have caused; e.g., recognition of
cocaine-related depression or drinking despite recognition than an ulcer was
made worse by alcohol consumption.
___________________________________________________________
Comments on the DSM-IV Criteria
Note that the criteria for
dependence are different from those for intoxication or abuse. See the textbook
for definitions. Note also that the dependence criteria include a mix of
biological and psychosocial criteria. Increased tolerance and withdrawal
symptoms are based on presumed biological processes. Time is spent making sure
a supply of the substance is always available, social and occupational obligations
suffer, and self-deception is present. Not all of these criteria need be
present for the diagnosis, and in fact, people vary tremendously in the range
of behaviors they show that are related to substance abuse or dependence.
Winston Churchill drank a quart of brandy every evening, and played a major
role in winning World War II. Ernest Hemingway and William Faulkner were drunk
every day and won Nobel prizes for literature. Freud was a cocaine addict.
Coleridge took opium on a regular basis. Would these men have functioned better
or worse without the substance of their choice?
We tend to think of the alcoholic as
the person sleeping on the sidewalk on Congress Avenue, or the drug-taker as
the out-of-control rock musician. Some of the people on Congress Avenue are
alcoholics and some rock superstars use drugs, but substance use (the general
term for alcohol and drugs) are in much more common use by people of all walks
of life. Faulkner drank much, but he could write. However, if he was like most
people with a substance use disorder he wrote better when he was sober. One of
the problems of understanding sustance abuse is that intoxication alternates
with sobriety for most people most of the time. People who are intoxicated
continually have short life spans. One of the challenges for the
substance-using person is to keep the sober periods long enough to make it
through the day without challenge. When I worked at St. Joseph hospital doing
group psychotherapy in the alcoholism program I met a man who had been sent by
his boss to the hospital. He admitted his drinking was out of control. He was a
machinist. For 20 years he went home for lunch at noon, and drank a pint of
whiskey. Then his wife died and the pint became a fifth and he could not get
back to work. He lost his sober time, and his job.
Public Health
Drug use is still a major problem,
but use has declined. This is also true of
alcohol use (See textbook Figure 11.6). To see where the changes began,
examine the figure below.
USA Use Compared with Use in
Other Countries
Annual Consumption per Adult
- France 24 liters of absolute alcohol
- Italy 21
+ Spain 19
West Germany 17
***
11 other countries
***
- USA 11
Ireland 9
+ Finland
8
Norway 5
Israel 2
France, Italy and Spain are wine
producing and drinking countries and wine was always a part of the social life.
Wine was drunk at every meal. German is a wine and beer country and alcohol was
a part of the social life. Ireland is relatively low despite the reputation the
Irish have for stout and whiskey because a large proportion of the population are
teetotalers. Finland and Norway are low because it is governmental policy to
curb alcoholism. Alcohol taxes are very high and access to alcohol is made
difficult. Israel is low because of religion-based discouragement of drinking
and drunkenness.
Italy, France and Spain rates have
decreased sharply as the people in these countries have responded to
governmental campaigns against excessive alcohol consumption. The rise in
consumption in Finland is difficult to understand.
There have been interesting changes
in alcohol consumption by Americans:
1940 30% Americans were drinkers, 2% problem
1978 78% “ “
“ 9% problem
1985 86% “ “
“ 12% problem
Since 1985 there has been a decline
in consumption and problems. This may be part of the concerns Americans have
adopted about being healthy. Many Americans now prefer to eat organic food,
avoid fats, get lots of fiber, and not drink too much or smoke at all.
In the 1930s, during prohibition, hardly
any Americans drank and very few had a drinking problem. Prohibition is said to
have been a social policy failure, but it was not. Alcohol consumption had been
high and was apparently rising. A national prohibition of alcohol use resulted
in an immediate decline in consumption. Unfortunately, it was accompanied by a
rise in organized crime and that was the failure of prohibition.
Alcoholism in America
ECA Lifetime prevalence men 20%
women
5%
Pregnancy and
Substance Abuse
There is consensus among public
health officials that women who are pregnant or planning a pregnancy cannot
drink alcohol, smoke cigarettes or take any other drug without out endangering
their baby. This is well-known, but nevertheless one baby in each one thousand
(1:1000) is born with fetal-alcohol syndrome. Alcohol affects two
neurotransmitters, glutamate and GABA, to kill neurons. The result is fetal
alcohol syndrome for which symptoms are a matter of degree depending on the
amount and timing of alcohol exposure.
Heavily exposed children have low intelligence, are behaviorally
difficult and have a limited future.
It has been known for many years
that smoking during pregnancy has adverse effects on the offspring. Now we know
that post-natal exposure to smoke also had bad effects. In our research at the
University of Texas at Galveston we found that women who did not smoke during
pregnancy, but who did after the baby was born had children who were 5 IQ points
lower than expected. 5 IQ points may
not seem like much, but it is roughly the same as what would be gained by being
in a very good preschool program.
Perspectives on Substance Related
Disorders (SRD)
An overview:
Substance
Use
Simple ingestion, no bad effects.
Intoxication
Physiological, psychological
reactions. Psychomotor impairments,
mood changes.
Abuse
The definition of substance abuse
includes frequent use, intoxication, social, vocational, and legal problems.
Dependence
Substance dependence includes all of
the above, but in addition includes:
Withdrawal: severe physiological
distress symptoms occur when the person is deprived of the substance.
Tolerance: the person is able to
take on more and more of the substance without apparent effect.
The symptoms of dependence are
both physiological and psychological.
Reactions vary widely. This is seen
even in animal studies. For example, cocaine withdrawal produces a lack of
motivation and the experience of boredom.
Drug seeking behaviors are typical.
The substance dependent person takes pains to make sure that the substance is
available when needed.
In rare situations dependence may be
present without abuse, and abuse without dependence.
Addiction
The relative addictiveness of
various drugs is shown in textbook Figure 11.2. These rankings are based on
estimates of how difficult it is to cease use of the substance. The most
addictive drug, nicotine, is also the most easily available, and in terms of
health risks associated with the drug, the one with the highest mortality.
Diagnostic Issues
It is rare for a person with a
substance abuse disorder seek help without prompting, or coercion, from someone
else. There are various self-diagnosis questionnaires such as the CAGE
questionnaire: Have you ever felt you ought to Cut down on your
drinking? Have people Annoyed you by criticizing your drinking? Have you
ever felt bad or Guilty about your drinking? Have you ever had a drink
first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)? Answering "yes" to any of these
questions suggest alcoholism. Furthermore, the response to one question is most
revealing: Do people who know you well say you are drinking too much? If the
answer is "yes" you can assume they are right.
Structured interviews are used to
make a diagnosis, but typically these are used only in research studies.
There are many questionnaires that
are also used in research. The Michigan Alcoholism Screening Test (MAST) is
typical of these. There are also several biological tests that can detect the
presence of alcohol. The famous breathalyzer test used by traffic police is one
of these.
Famous Drinkers
Authors Only
Hemingway Dorothy Parker
Faulkner Edna St. Vincent
Millay
O'Neill Edmund Wilson
T. Williams O'Henry
Dylan
Thomas Stephan Crane
John
Cleever Ambrose Bierce
Steinbeck Dashiell Hammett
T. Capote Raymond Chandler
Sinclair
Lewis Georges Simonon
Booth
Tarkington Ring Lardner
J. W. Riley James Agee
John O'Hara Randall Jarrell
James
Dickey Delmore Schwartz
Edgar Allen
Poe Malcolm Lowrey
Terry
Southern [List not complete]
Many authors have said that alcohol
releases creativity, encourages fluid thought. All agree, however, that they
write better when sober.
Scientists
None known
Scientists seem to depend less on
alcohol for creativity. Most say it clouds their thinking and interferes with
logical thought.
Types of Substances
You should read the textbook carefully on
this. I will only add a few comments for emphasis.
Depressants
Alcohol
Alcohol is a depressant, but its
initial effects are stimulating. In fact, one of the main reasons for drinking
and reasons for not being able to truly quit drinking, is that the early
stimulating effect is experienced as being so positive. It is not a big effect,
but it comes after the person has experienced a kind of let-down. The drink
provides a highly predictable pick-up. This predictability is an important part
of drinking. It is one of the reasons why drinkers tend to develop preferences
for what they drink. If they always have the same drink, they know exactly what
to expect, and they get it. Of course, for a serious drinker, any alcohol will
do, if the preferred drink is not available.
Early in a drinking episode there is
a sense of well-being, later there is a slowing of response and slurred speech,
together with psychomotor incoordination. These are signs of the depressant
effect.
Positive
Effects of Alcohol
Obviously, not all consumption of
alcohol is negative. It is a popular social lubricant, it gets the party going.
In addition, there are some possible health reasons for drinking. Research has
shown that moderate alcohol consumption (especially red wine) reduces heart
attack rates by as much as 50%. It raises high density lipoprotein levels
(HDL). It may be that the effects are not from alcohol but from phenolic
compounds found in wine. There was a Danish study of 13000 men found only wine
produced the positive effect. One drink per day was recommended in the US, but
the Danes recommended 3-5 glasses per day. Apparently, for reasons unknown,
only the Danes benefit from higher levels of consumption. Most experts regard 3
or more drinks a day as a lot of alcohol. Europeans, in general, disagree with
this American conclusion.
Negative
Effects
The negative effects of alcohol
consumption are many. One of the most insidious is hidden: it is that the
danger from alcohol mainly comes from the accumulation of alcohol intake over
time. This accumulation effect is chiefly responsible for the medical problems
listed below.
___________________________________________________________
MEDICAL
PROBLEMS ASSOCIATED WITH ALCOHOLISM
nervous system
dementia; Korsakov's psychosis;
peripheral neuritis
respiratory tract
tumors; carcinoma of the
bronchus
gastrointestinal tract
cancer of the
esophagus; pancreatitis;
liver
blood
anemia; hypoglycemia;
diabetes
cardiovascular
hypertension; coronary
heart disease
striated muscle
myopathy
endocrine
hypogonadism
chromosomal disorders
various diseases
reproductive
fetal alcohol syndrome
___________________________________________________________
I will not review the massive
economic, social, and occupational effects of alcohol. The textbook discussion
is adequate.
Other Depressants
Sedatives
These are prescription drugs used to
treat sleep disorders and anxiety.
Barbiturates
These include short-acting drugs,
such as methohexital (Bevital), which are active for 3-6 hours and are used as
anesthetic agents. Intermediate drugs are amobarbitol (Amytal), pentobarbital
(Numbutal), and secobarbital (Seconal) are used as sleeping pills. There
half-lives are 1-2 days. These drugs have a great addiction potential. The
Insitute of Medicine reviewed their use and recommended that they not be used
more than 2 weeks. After that the side effects tend to include insomnia.
Benzodiazapines
These include florazapam (Dalmane),
temazapam (Restoril), hazolam (Halcyon). These are effective sleeping pills,
but after usage for a few nights the half-life is such that they continue to
have depressant effects during the day. Driving is impaired. They are sometimes
used to cope with jet lag, but there are many associated problems. One is
severe memory loss.
Stimulants
Amphetamines
These are popular because they bring
about feelings of elation and vigor. But, "What goes up must come
down." The down is worse than the up is good. The person takes the drug
and has a remarkable high experience, but then plummets into despair, ennui, or
disinterest, and wants to climb back up. The person takes the drug again. There
are severe consequences from prolonged ingestion.
Designer drugs--MDMA:
methylene-dioxymethamphetamine was used as an appetite suppressant. Speed
without the comedown.
Ice-- this is smoked. It is aggression-promoting and the effects
are long-lasting.
All of these act on the central
nervous system by enhancing activity of the norepinephrine and dopamine
systems. The drugs release these neurotransmitters and block the reuptake. The
result of too much of each are delusions and hallucinations which give the
appearance of schizophrenia when the person appears for treatment.
Cocaine
Freud was fascinated by the effects
of cocaine on his own thinking. He did not realize he had become addicted and
that his behavior had changed markedly. He finally made that discovery, stopped taking cocaine and
his performance improved.
The drug increases alertness and
gives a sense of euphoria. The user feels powerful, invincible.
It has very short-lived effects. One
has to keep taking more and getting higher.
Prenatal effects: Effects on infants are still not clear.
Use has declined.
Neurological effects are similar to
those for amphetamines. Block reuptake of dopamine.
The psychiatrist, Grinspoon, in 1980
said that if taken no more than 2-3 times per week there were no addictive
effects. He was wrong and he made that assertion on the basis of too little
data. Grinspoon was also wrong in his view in the early 1970s about the benign
nature of marijuana.
Cocaine dependence develops slowly
(crack quickly).
One possible consequence of
continued use is schizophrenia. A New York study found that young men who were
cocaine users in adolescence were more likely to develop schizophrenia than a
matched group of non-cocaine users.
Cocaine causes blood to thicken by
increasing the number of red cells and by instigating a process that leads to
platelets sticking together. This phenomenon may be why cardiac problems are so
high for chronic cocaine users (A. Siegel, Archives of Internal Medicine,
Sept. 1999).
Cocaine also increases levels of the
protein FosB. When this is high a craving for more cocaine occurs. This may
explain why cocaine is so addictive (E. Nestler, Yale University).
Nicotine
This substance is highly addictive.
Nearly 25% of Americans smoke and nearly all began smoking in adolescence. That
the number should be so high is understandable given the addictiveness of this
substance and how difficult it is to stop smoking. The big question is why so
many adolescents begin smoking despite the widespread media information about
bad effects. The health risks for smoking are well-known, or certainly should
be. Nicotine causes high blood pressure, and increases the risk for stroke and
cardiac disease. Lung cancer is higher.
Stopping smoking is followed by extremely
persistent withdrawal symptoms--mainly, irritability and difficulty
concentrating. Once when I was department chairman, one of the faculty came
into my office, closed the door, and pacing back and forth said he thought he
was losing his mind. He could not work, was unable to sit still and was very
worried. After listening for awhile and watching him it occurred to me that he
was not smoking (most of the faculty smoked at that time. Now none do.) I asked
him if he had quit smoking and he said he had. He was going through nicotine
withdrawal.
Effects on nicotinic receptors are
in the midbrain reticular formation and the limbic system.
People who have stopped smoking
relapse for many reasons, including depression or anxiety. Stopping often means
that the person has been faced with a health ultimatum: stop smoking or die,
soon.
One of the side effects is that
depression is more common with smokers.
Caffeine
This drug has a half-life of 6
hours. This gives an indication of when the next cup of coffee is due. Caffeine
is a curious inclusion in a course on abnormal psychology because the
addictiveness of caffeine remains in question. There is no evidence of
increased usage over time and there are no, or minor, withdrawal symptoms. A.
Nehlig (1999) found no brain involvement such as is found in studies of the
addictiveness of cocaine. There are no known negative effects with moderate
consumption, meaning about 3 cups a day. However,
heavy use has some health risks. For example, drinking several cups of coffee a
day was found to be associated with a 30% reduced risk for colorectal cancer
(E. Giovanucci).
The neurotransmitter adendosine is
involved. Caffeine blocks its reuptake. It occupies a place on adenosine
receptors.
Opoids
These include a class of drugs and
naturally occurring chemicals in the brain--endorphin, beta-endorphins, and
enkephalins.
Opoids drugs include opium,
morphine, codeine and heroin.
The main effects of ingestion are a
sense of euphoria or peacefulness.
They are analgesics and have been
used to provide relief from pain..
The mortality of addicts is very
high. In one study, 28% died in the 24 year follow-up. The mean age of death is
about 40. One third die from a drug overdose, but many die from violence that
is part of the drug culture. As if this is not bad enough, many are also at
risk for HIV/AIDs, mainly through the use of infected needles.
Pain relief is underused for the
poor. The International Narcotics Control Board of the World Health
Organization reported on 2/23/00 that there is a severe shortage of morphine
and other medications for pain relief in most of the underdeveloped countries.
The people of the richer countries have wide access to painkillers, through
pharmacies, but because of the cost of morphine and other analgesiacs, they are
not available to those in need. Heroin is a highly effective painkiller, and
many doctors believe it should be available for people in painful, terminal
situations, but its use is banned in internationally and it is not available accept
through illegal means.
Hallucinogens
Drugs in this class lead to
distorted or altered perceptions.
Marijuana
This is a hugely popular drug. 5.5
million Americans smoke marijuana at least once a week.
It is the dried part of cannabis, or
hemp plant. Cannabis sativa.
The effects involve mood swings, but
the range of reactions is wide.
Continued use results in impaired
concentration and memory, and reduced motivation. Long-time users suffer
withdrawal symptoms when they stop smoking marijuana.
Negative features include the
presence of carcinogens that are like those associated with cigarette smoking.
There is a strong advocacy movement
to legalize marijuana for medical purpose. Actually, there is virtually no
evidence that the drug has beneficial effects on nausea or pain, but because
the drug is illegal there is little research. There are many anecdotal accounts
of the drugs benefits and there seems to be little reason why people who are in
cancer treatment and are suffering shouldn't have access to the drug if they
think it will help them (personal opinion).
LSD
and other
LSD was developed quite by accident
in 1943 by Albert Hoffman. He took the drug and 40 minutes later had visual
hallucinations. The active ingredient is d-lysergic acid diethylamide. It is
related to ergot, which is found in grain fungus.
Timothy Leary used LSD in 1961.
"Turn on, tune in, and drop out." Although I knew Leary before his
drug days and admired his work I can never forgive him for advocating the use
of drugs. His advocacy contributed to the spoiled lives of a great many young
people.
Other
Drugs of this Type
Psilocubin--mushrooms.
lysergic acid amide--morning glory seeds.
dymethyl tryptamine (DMT)-- bark of
the Virola tree.
mescaline--peyote plant.
phencyclidine (PCP)--synthetic.
The development of tolerance for
these drugs is rapid, but there are no withdrawal symptoms when the drug is not
taken.
Negative features include psychotic
reactions mainly in the form of flashbacks, but some of the symptoms are very
persistent and my lead to severe disorders such as schizophrenia or bipolar
disorder in vulnerable people.
These drugs are chemically similar
to the neurotransmitter serotonin. Mescaline resembles norepinephrine. Some
others are similar to acetylcholine.
Club Drugs
The National Institute of Drug Abuse
(NIDA) refers to some drugs as "club drugs" because they are used by
people in the trendy clubs. These include
Methylenedioxymethamphetamine
(MDMA)
It is also called ecstasy, XTC, X,
Adam, Clarity and Lover's Speed. It was patented in 1990 as an appetite
suppressant. It is similar to amphetamine and mescaline. It is extremely
dangerous in high doses and continued use results in brain damage. Memory
functions are especially affected. These memory problems persist after the
person stops using the drug (Bolla et al, Neurology, 1998, 51,
1532-1537). Recent research reveals that this drug has negative effects on
dopamine functioning. This disturbance could have disastrous effects on people
who have a predisposition for dopamine-related disorders such as schizophrenia.
Gamma-hydroxybutyrate
(GHB)
Also called Grievous Bodily Harm, G,
Liquid Ecstasy, and Georgia Home Boy.
It has often been involved in date
rapes and overdoses are common, and dangerous.
Ketamine
Called Special K, K, Vitamin K, and
Cat Valiums.
It was developed as an injectable
anesthetic and has been approved for use with humans and animals in medical
settings. It gives a dream-like reaction similar to PCP.
Rohypnol
It is sometimes called Roofies,
Rophies, Roche, and Forget-Me-Not pill.
It is related to the benzodiazapines
and is used in some countries as a treatment for insomnia. It has not been
approved for use in the USA.
It has remarkably long-lasting
effects, and a side effect of retrograde amnesia (person cannot recall
experiences while under the drug).
Methamphetamine
Other names: Speed, Ice, Chalk,
Meth, Crystal, Fire and Glass.
This is a toxic, highly addictive
stimulant that is used by truck drivers and other required to work alertly for
long periods of time. It has become a major illicit drug in rural America.
Continued use of this drug is likely to result in brain damage, as revealed by
MRI brain studies.
Causes of Substance Abuse
Disorders
Why do people abuse substances? This
question may be answered at several levels. In alcoholism treatment programs
the question is raised nearly everyday. People respond, "I drink to feel
better," or "I drink to stop feeling so guilty, anxious, worried,
etc." Perhaps the best response
for people with severe alcoholism is "I drink to feel normal."
An often-asked question is why
do some people become alcoholic and not others. To find answers we search in
the usual places.
Biological
Certainly there are brain changes that
are associated with substance abuse. The textbook reviews some of these. There
is a belief in the scientific community that once these biological changes are
understood it will be possible to design medications that will have an effect
on substance abuse. Think for a moment about what these pills might do. Would
they enable the person to be a non-alcoholic social drinker? No one thinks so.
In any case, that would hardly apply to other substances. Some people do smoke
so little that there is little risk for adverse effects. My father-in-law was
example. For many years he smoked one cigarette a day, just after dinner in the
evening. He died at age 94 of illnesses not related to smoking.
One promising area for the pills is
to reduce craving associated with addiction. If this kind of medication is
developed it could have a major impact as a factor for relapse prevention.
Genetic.
Twin and adoption studies indicate a genetic predisposition. There
is a major difficulty with genetic research on addictions. One has to use the
substance to be at risk for developing the disorder. One might be genetically
at risk and never use the substance. Obviously, the person will not develop the
disorder. I once had a neighbor who was a highly successful businessman. He
said his father and grandfather were serious, abusive alcoholics. He and his
brother grew up hating alcohol and never drank. Although genetically
predisposed, they did not develop alcoholism.
Part of what is inherited is the
body’s ability to metabolize alcohol.
Asians have difficulty with this
metabolism. When they drink they have an alcohol flush reaction. Some 30-50% of
Asians show this. Why not American Indians since they are genetically related
to Asians? Actually, they do.
Sons of alcoholics show a rapid
positive response to alcohol and a slower onset of down feeling. This means
they have a better appreciation of the highs and are less sensitive to the lows
associated with drinking.
Psychological
Positive reinforcement for use
because of associated pleasurable feelings. This is true for humans and
animals.
There is also commonly an immediate
reduction of negative feelings that may exist.
Adolescents with negative feelings
(lonely, sad, tense) drank more. Drugs were apparently used to escape these
feelings.
The psychologist, Solomon, proposed
an opponent process theory. Alcohol consumption leads to high feelings and then
to a low feeling. The lows are more unpleasant than the highs are pleasant. To
get rid of the low feeling, one seeks the high with more alcohol.
There is also the self-medication
hypothesis. This is mostly related to mental disorders involving unpleasant
feelings such as depression, anxiety, bipolar disorder and schizophrenia. It is
believed that people with these disorders may use substance to get rid of
negative feeliings.
In my work with alcoholics at St
Joseph Hospital I heard one theme about the cause of drinking repeatedly. Many
said they drank to feel normal. The addicted person often feels empty or
incomplete until the substance is taken and then the person feels complete.
This feeling is powerful and contributes to the high relapse rates.
Cognitive factors
When people use substances the
expectancy effects are powerful. They expect a certain emotional outcome from
the substances and they tend to get it. This is true in any substance use.
Research has shown that people who expect to drink alcohol, but who have been
given fruit juice with no alcohol act as if they have ingested alcohol.
Expecting drugs would improve
quality of life led to higher use among adolescents.
Urges, cravings are in part
expectancy effects.
Social Dimensions
Cultural
Dimensions
There are widespread cultural
variations in drug use. These include the types, amount, when, under what
circumstances and with whom.
There are also great differences in
expectations of use under certain circumstances. I found great pressure by the
people around me to drink vodka when at social events in Russia and to drink
wine in France. On the other hand alcohol was used with moderation in
Scandinavia with no pressure to drink more, and there were many warnings about
drinking and driving. Officially, there is no alcohol in muslim countries, but
use of other drugs is common.
Treatment
Biological
Agonist
Substitution
Methadone is used in the treatment
of heroin abuse. The effect is similar to heroin, but, I have been told, not
quite as good. As it is legal, there is less criminal activity. It seems to be
the most effective means for treating heroin addiction. Addicts can take methadone
and go to work without negative effects.
Nicotine patches used to reduce
craving for cigarettes. Typically these are used with psychological methods.
Antagonist treatment
Naltrexone is an opiate antagonist.
Some positive effects in reducing craving.
Aversive
Treatments
Disulfiram or antabuse has been used
for many years. This drug prevents the breakdown of acetaldehyde. When antabuse
and alcohol are taken together the person feels very ill. To stay sober all the
person would have to do is take the antabuse pills regularly. However,
noncompliance is so high that it is essentially ineffective.
When nicotine is taken with silver
nitrate a bad taste results. Some
researchers have hoped that this would discourage tobacco use. All that has
happened is that silver nitrate use has been discouraged.
Clonidine has been used with opiates
to cut the craving for the drug.
Desipramine and other antidepressants have been used in the same way. A
new drug developed for epilespsy may have some promise. The drug is gamma
vinyl-GABA (GVG) and it acts on reward centers to counter the craving for
cocaine. It is also believed to be effective with nicotine. GVG is still
untested.
Psychological Treatments
On any one day
in the United States 700,000 people are in alcoholism treatment either as
in-patients or out-patients. For many, detoxification is the first step in
treatment. The major treatment approaches used are cognitive behavioral
therapy, behavior therapy, motivational enhancement therapy, and Alcoholics Anonymous.
Inpatient
There is little evidence that
hospitalization produces better results than outpatient treatment and, of
course, is a great deal more expensive. However, one reason for using hospitals
for treatment is that many addicts also have other medical problems and these
can be recognized and treated better in the hospital.
Walsh (1991) compared 227 people
randomly assigned to inpatient treatment, AA, or a choice between the two. At
the end of the program all were improved. There was no difference between
groups. At follow-up, the inpatient group did best.
Alcoholics
Anonymous (AA)
One of the earliest of the self-help
organizations was Alcoholics Anonymous which was formed in 1935 by two American
men, Bob Smith and Bill Wilson. Its main features are that one attend AA
meetings every day and at each meeting confess that one is an alcoholic. It is
also important to follow the 12 steps.
Twelve Steps
1. We admitted we were powerless over
alcohol--that our lives had become unmanageable.
2. Came to believe that a power greater
than ourselves could restore us to sanity.
3. Made a decision to turn our will and
our lives over to the care of God as we understood him.
4. Made a searching and fearless moral
inventory of ourselves.
5. Admitted to God, to ourselves, and to
another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove
all these defects of character.
7. Humbly asked him to remove our
shortcomings.
8. Made a list of persons we had harmed,
and became willing to make amends to them all.
9. Made direct amends to such people
whenever possible, except when to do so would injure them or others.
10. Continued to take personal inventory
and when we were wrong promptly admitted it.
11. Sought through prayer and meditation
to improve our conscious contact with God as we understood him, praying only
for knowledge of his will for us and the power to carry that out.
12. Having had a spiritual awakening as a
result of these steps, we tried to carry this message to alcoholics and to
practice these principles in all our affairs.
Although widely regarded as
effective it may not be as effective as people would like it to be. For
example, one major problem is that 50% of participants drop out after 4 months
and 75% drop after 12 months.
Controlled
Use
See the textbook on this. It may be
best for young men with first time driving while intoxicated (DWI). It seems to
be of no value with long-time alcoholics.
Components of Psychological Treatments
Psychotherapy
It is likely that all
psychotherapies have been used in the treatment of substance abuse and all have
similar outcomes. During and just after psychotherapy there is a reduction in
substance abuse. I have run a check on this using PubMed and PsycInfo and have
found very few recent controlled clinical trials.
Behavior therapy seems to better in
the short term than dynamic therapy. Relapse prevention training shows some
additional improvement.
Aversion
therapy
In this, the person is given a
favorite alcoholic drink and then whirled in a chair until the person gets very
sick. This is repeated to form an association between alcohol and sick feeling.
It works, and aversion therapy clinics were once very popular in Houston.
However, alcoholics know their psychology, too. They discovered that if they
drank and got sick, the thing to do was to drink some more. They could unlearn
the association and drink comfortably.
Covert desensitization--imagine
unpleasant effects of substance.
contingency management. Rewards for
goals.
Community reinforcement. Improve
relationships.
Relapse
Prevention
See textbook.
Treatment Effectiveness
I will go out on a limb and make a
few generalizations.
No one knows how well AA works
because AA does not welcome researchers. There are a few studies and it looks
as though AA is effective for people who stay with the program, but drop-out
rates are high.
All treatments seem to be effective
in the short-term.
There are no effective treatments in
the long-term. Most people relapse.
Thus, if you read that so-and-so has
been driving while intoxicated and has been referred for "counseling"
don't expect much. Of course, some people may benefit from psychotherapy or
counseling, but we do know who will or how much
The research challenge is to develop
relapse prevention programs.
The figure below shows the research of
Polich et al. on treatment effectiveness. The treatments were in-patient, AA
enhancement, group therapy. This is very likely the most commonly used type of
therapy in the country. Note the high death rate, low abstinence rate and the
high rate of problem drinking. These results could be for other substances, but
they would probably have higher mortality rates.
POLICH, ARMOR &
BREIKER
ALCOHOLISM
TREATMENT EFFECTIVENESS
922 MEN
!
8 TREATMENT
PROGRAMS
4 YEAR FOLLOW-UP
14.5% DEAD
85.5% ALIVE
/ ! \
/ ! \
54% SERIOUS PROBLEMS 18% DRINKING 28%
ABSTINENT
NO ILL EFFECTS
/ \
50% DRINKING 50% DRINKING
MODERATELY MORE THAN 4 DRINKS
A DAY: "MUCH"
________________________________________________________________________
Cross, et al. (Alcohol Clinical
Experimental Research, 1990, 14, 169-173) did a 10-year follow-up of
treated alcoholics with 200 patients with results that were quite different
from those of Polich et al. Their
patients did better. However, there was a difference; all of their patients were active members of the US Army and
thus, were under constant observation with severe penalties for resuming
drinking. A German study (Fuerlein
& Kufner, European Archives of Psychiatry and Neurological Science,
1989, 239, 144-157) at 48 months post treatment found 46% were abstinent which
is much higher than Polich and associates found. Vailland and associates (American
Journal of Medicine, 1983, 75, 455-463) did an 8-year follow-up and found
25% were abstinent, about like Polich et al. Variations in follow-up results
are certain to occur owing to differences in patient groups, treatments and so
forth. The important thing is that treatment methods have far to go. None show
good long-term results.
Socioeconomic
Intervention
Can alcoholism be reduced? The
answer is "yes." We know this because where ever the cost of alcohol
is increased, consumption drops. If alcohol is less available, consumption
drops. We also know it is possible from the work of the Scandinavians. They had
high rates of alcoholism and made changes in laws. They did most of the things
below.
1. Limit access to alcohol by
restricting sales to state-run package stores and controlling the number of
cafes, etc. with liquor licenses. Limit sales hours as in Norway. There are no
sales before 10:00 am or after 9:00 pm.
2. Increase taxes on alcohol to make
it too expensive for casual purchase. Most spirits such as gin cost three times
as much in Scandinavia as in the USA.
3. Prohibit all advertising of
alcohol on billboards, magazines, newspapers, TV, radio.
4. Increase the legal drinking age
to 21.
5. Increase punishments for alcohol
abuse.
Driving while
intoxicated (DWI). First offense, 3 weeks in jail, drivers license
suspended for 6 months and a $500 fine. Repeat offenses get really harsh. There
are almost no DWIs in Norway. It just isn't worth it.
Violent crimes
associated with alcohol are punished at a higher level. Spouse or child abuse
done with alcohol is punished with mandatory jail sentences.
6. Educate public on the dangers of
alcohol use.
7. Provide free treatment clinics.
These steps were taken by the
national governments and have been reaffirmed by successive governments.
Scandinavian countries have many political parties, but none advocates changes
in these laws. They are popular with the majority of the people.
Abuse of nicotine can be controlled
in a similar way.
1. Raise taxes
2. Ban cigarette vending
machines to reduce under age smoking
3. Reduce public smoking
areas
4. Eliminate farm
supports for tobacco growers
5. Educate the populace
6. Install effective
smoking prevention programs nation-wide. Note that the most popular prevention
program, DARE, is not effective. Some other programs are effective.
Prevention
Since treatment lacks
long-term effectiveness for substance-use disorders it may be more humane and
cost-effective to put more money and effort into prevention. For example, if
one does not begin to smoke by late adolescence it is highly unlikely that the
person will ever become addicted to nicotine. The same is true for other
disorders although the risk period tends to be later. The textbook mentioned
one prevention program, DARE, Drug Abuse Resistance Education, and states that
research has found it to be very popular, but ineffective. This does not mean
that all prevention programs are ineffective.
In developing prevention
programs the first step is to understand the risk factors for substance abuse
and today much is known about these factors. For example, alcohol and tobacco
use in the 10th and 11th grades predicts later use of marijuana. One often
hears people say that they have been smoking marijuana since they were 15 and
have not gone on to other drugs. So, they say, smoking cigarettes, then
marijuana does not mean that one inevitably moves to hard drugs. Of course not.
That is not what a risk factor means. To be at risk is that chances are greater
that one will have some disorder related to the risk factor. It has to do with
chances for groups of people and has little to do with the prediction for any
individual.
Individuals over the age
of 20 are less likely to initiate use of marijuana than are those under the age
of 20. Friends use of marijuana has the strongest influence on marijuana use
(also tobacco, alcohol, etc.). The typical pattern of use is alcohol to tobacco
to marijuana to other drugs. Substance use is associated with several personal
characteristics of users such as sense of efficacy, hyperactivity, and
depression. The person who feels in control of her or his situation, can
concentrate and learn, and is not depressed, is less likely to initiate
substance use.
Ellickson and Bell
(1993) (Preventive Medicine, 22, 463-483; Science, 1990, 247,
1299-1305) found a school-based program reduced beginning substance use for
non-users and reduced the amount of use by experimenters. In a similar way, Pentz and associates
(1989) also demonstrated that a school-based program could reduce tobacco use (JAMA
Journal of the American Medical Association, 261, 3259-3266.). To learn
more about prevention research see www.health.org or www.nida.nih.gov and go to
the Division of Epidemiology and Prevention Research. Or go to
www.niaa.nih.gov.
Some Books on Substance Abuse
Hamill, Pete
(1994). A drinking life. Boston: Little Brown.
Gold, Ivan
(1990). Sams in a dry season.
New York: Houghton Mifflin.
Greene,
Graham The honorary consul.
Berryman,
John. Recovery.
Gordon,
Barbara I’m dancing as fast as I
can.
Styron,
William Holiday in darkness. Halcyon.
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