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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