Chapter 17: Substance-Related Disorders
A substance is any natural or synthesized product that has psychoactive effects – it
changes perceptions, thoughts, emotions, and behaviours.
Tobacco, alcohol, and cannabis are common substances (US and CAN).
o Cocaine use = higher in US; LSD use = higher in CAN.
Men are more likely than women to use an illegal drug in their lifetime.
o Women, however, are more likely to become dependent on it.
A substance-related disorder occurs when the use of a substance leads to
significant problems in everyday functioning; i.e., shirking responsibilities, acting
impulsively, endanger their own lives, etc.
Definitions of Substance-Related Disorders…
There are four types of disorders recognized by the DSM: substance intoxication,
substance withdrawal, substance abuse, and substance dependence.
Drugs are classified into five categories:
o CNS Depressants (alcohol, barbiturates, benzodiazepines, and inhalants).
o CNS Stimulants (cocaine, amphetamines, nicotine, and caffeine).
o Opioids (heroin and morphine).
o Hallucinogens and phencyclidine (PCP).
There is a mixed group of drugs (club drugs), which includes:
o Ecstasy, GHB, ketamine, and Rohypnol.
o Substance intoxication is a set of behavioural and psychological changes
that occur as a direct result of the physiological effects of a drug.
o May suffer from hallucinations, attention is reduced, along with good
judgment. It’s harder to control their bodies; their reactions are slow or
o Either want to sleep a lot, or not at all.
o Their interpersonal relationships change: they may become gregarious,
o Intoxication declines when the amount of the substance in the body declines;
however, it may take hours or days for the substance to be completely out of
o Symptoms of intoxication depend on what was taken, how much was taken,
and the user’s tolerance.
E.g., initial high may be different from subsequent highs.
o Setting in which a substance is taken also affects symptoms experienced.
E.g., drinking at a party makes you loud; drinking at home makes you
E.g., may also be at a lower risk of harming oneself if drinking at home.
o A diagnosis of substance intoxication is usually only given when an individual
is experiencing significant disruptions in his or her life.
E.g., relationships, personal harm, etc. Withdrawal
o Substance withdrawal is a set of physiological and behavioural symptoms
that result when people who have been heavy substance users stop (or
o Symptoms are usually the opposite of substance intoxication of the same
o A diagnosis isn’t given unless it severely impacts the individual’s life.
E.g., side effects of caffeine withdrawal may be annoying (e.g.,
headache, etc.), they do not typically cause significant impairment.
o Caffeine withdrawal is not included in the DSM.
o Symptoms of withdrawal can begin a few hours after consumption stops.
End usually after a few days or weeks.
o Some withdrawal symptoms (e.g., seizures) may begin several weeks after
o Substance abuse is when a person’s recurrent use of a substance results in
significant harmful consequences.
o So, you can use a substance, but it isn’t abuse until you experience harmful
o Four categories of harmful consequences:
Fails to fulfill important obligations (work, school, home).
May fail to show up, unable to concentrate, etc.
Repeatedly uses the substance in situations in which it is hazardous to
Such as while driving.
Repeated legal problems.
Arrests for drunk driving, etc.
Continues to use the substance, despite having had legal or social
o Must show problems in at least one area within a 12-month period to qualify.
o Substance dependence (drug addict).
o Shows tolerance (a person experiences less and less effect rom the same
dose of a substance and needs greater and greater doses to achieve
intoxication) or withdrawal.
o E.g., a person who’s smoked for 20 years probably smokes so much that back
in the day it would have made them violently ill.
o A person who has a tolerance for a substance may have a higher blood-
concentration level, but show fewer symptoms (i.e., they’re unaware of it).
o Alcohol, opioids, stimulants, and nicotine have a high risk for tolerance.
PCP and marijuana have lower risks for tolerance.
o Those that are dependent often show severe withdrawal symptoms when
they stop taking it.
These people may take the substance to avoid the withdrawal
symptoms. o Most people who are dependent crave the substance and will do anything to
o Their lives may revolve around getting the substance.
How a person administers a substance can effect how quickly a person becomes
intoxicated, and likely it will produce withdrawal symptoms.
Routes of administration that get it right to the blood stream create dependency
o Injecting, smoking, and snorting.
o Also more likely to OD.
The quicker they act on the CNS, the more likely they are to become dependent.
Substances with short-lasting effects are more likely to become dependent.
Slow the activity of the CNS.
In moderate doses, they relax people, reduce concentration, and impair thinking and
In heavy doses, they induce a stupor.
o Effects on the brain occur in two stages.
o Low doses = promotes confidence, relaxation, perhaps euphoria.
o Increasing doses = may induce symptoms of depression: fatigue and lethargy;
decreased motivation, sleep disturbances, etc.
o Alcohol intoxication = slurred speech, unsteady gaits, trouble with attention
and memory, slow and awkward in reactions. May act inappropriately;
aggressive or rude.
o A blackout is amnesia (once you’re sober) about when you were drunk.
o More food in your stomach longer it takes to get drunk (because it takes
longer to pass from the stomach to the small intestine).
o Countries where alcohol is consumed more regularly (e.g., France) show a
lower rate of alcohol-related disorders.
o The legal definition of alcohol intoxication = blood-alcohol content above
o Drinking in large quantities can result in death;
1/3 is the result of respiratory paralysis.
o Alcohol can react fatally (e.g., with antidepressant drugs).
o Most alcohol-related deaths are due to accidents (car, private plane/boat),
Almost ½ of fatal car accidents are due to alcohol.
Almost 1/3 of all drownings are alcohol-related.
o Believed that most murderers are under the influence of alcohol.
o Abuse and Dependence
1. Use it in dangerous situations (e.g., when driving).
2. Fail to meet obligations (e.g., school, work).
3. Have recurrent legal or social problems as a result of alcohol. Alcohol dependency = problems of abuser + may show tolerance to
alcohol, spend a great deal of time intoxicated or withdrawing,
organize their lives around drinking, and continue drinking despite
social, medical, or legal problems.
Three distinct patterns of alcohol use:
Some drink a large amount every day and plan their days
Abstain from drinking for long periods than go on binges,
which last days or weeks.
Sober during the week; binge drink on the weekend.
Binge drinking = consuming five or more drinks within a couple of
Argued that for women it should be four or more.
23% of Americans reported binge drinking in the previous month.
19% of Ontario = binge drink in the previous month.
Study found that more Canadians drink, but Americans drink more.
Heavy alcohol consumption is associated with on-campus living, and
more Americans than Canadians live on-campus.
Binge drinking is increasing in school-age adolescents.
Nearly 50% of grade-12 students in Ontario reported binge
Easy to spot alcohol abuse/dependence. However, one confrontation
or a series of confrontations often do not motivate abusers to change
their behaviour or seek help.
Alcohol dependence is a heterogeneous disorder.
Antisocial (vs. non-antisocial) alcoholics:
Have more severe symptoms of alcoholism.
Remain alcoholics for longer.
Have poorer social functioning; have more marriage failures.
Heavier drug involvement.
More likely to come from a family of alcoholics.
Begin drinking at an earlier age.
Children are more likely to have behavioural problems.
Negative affect alcoholism = had depressive or anxious tendencies in
childhood, and only began heavy alcohol abuse in adulthood.
Seen more in women than men.
Divided into three stages:
Stage one usually begins within a couple of hours after
o Tremulousness (the shakes), weakness and
o Anxiety, headaches, nausea, abdominal cramps,
o Flushed, restless an easily startled. o Those with a moderate dependence may only
experience the first stage.
o Seizures may begin as early as 12 hours after cessation,
but more often occur 2-3 days later.
o Delirium tremens (DT). Hallucinations occur.
o Sleep very little and become agitated.
o Active and very disoriented.
o Fever, sweating, irregular heartbeat may develop.
o Fatal in 10% of cases.
o Death may occur from hyperthermia (raised body
temp), or collapse of the peripheral vascular system.
o DTs are more likely to occur in those who drank a large
amount who have additional medical illnesses.
Long-Term Effects of Alcohol Abuse
Toxic effects on the stomach, esophagus, pancreas, and liver.
Low-grade hypertension is the most common medical
condition associated with alcohol abuse.
o Combined with low triglycerides and bad cholesterol =
increased risk for heart disease.
Chronic alcohol consumption prevents the absorption of
nutrients (why they’re often malnourished; they also drink
more than they eat).
Some show a thiamine deficiency (problems with the CNS):
o Numbness and pain in extremities.
o Deterioration of the muscles.
o Loss of visual acuity (near and far).
Alcohol-induced persisting amnesic disorder = permanent
cognitive disorder caused by damage to the CNS.
o Wernicke’s encephalopathy = mental confusion and
disorientation. Severe states = coma.
o Korsakoff’s psychosis = loss of memory for recent
events and issues with recall.
Person may tell implausible stories to cover up
for the fact they can’t remember.
Alcohol-induced dementia = loss of intellectual abilities
(memory, abstract thinking, judgment, problem solving), and
changes in personality (e.g., paranoia).
o 9% of all people who abuse alcohol.
o Common cause of adult dementia.
Children may be born with fetal alcohol syndrome (FAS).
o Retarded growth, facial abnormalities, CNS damage,
mental retardation, motor abnormalities, tremors,
hyperactivity, heart defects, and skeletal abnormalities. o Est. 9 in every 1000 babies has FAS.
Even small amounts of alcohol are dangerous while pregnant.
o Growth, memory, and learning problems.
o Cultural Differences
Low alcohol consumption in places governed by Islamic law (e.g.,
Low alcohol consumption in Southeast Asians may be due to a lack of
an enzyme, acetaldehyde, which first breaks down alcohol.
If they do consume alcohol, it may be uncomfortable for them.
Finnish and Canadians drink about the same amount; Finnish men
drink more than Canadian men.
Alcohol use and dependence are some of the most common in Canada.
Ratio of treatment-nontreatment = 13:1.
Ages 10-19 (Canadian) = Europeans more likely to drink than Asians.
Aboriginal people appear to be at a higher risk for alcohol abuse and
o Gender Differences
62% of men said they’d consumed an alcoholic beverage in the last
month; 46% of women.
Men are more likely than women to binge drink, and have alcohol-
Difference is greater between those who adhere to gender roles.
Women are less likely than men to seek out treatment.
o Trends Across the Lifespan
Overtime, about half of those who’d abused alcohol stopped.
Alcohol dependency tends to be chronic.
Use of illegal substances tends to decline with age.
Liver metabolizes alcohol slower with age; older people
become drunker, faster.
Grew up in a time when there was a prohibition on
consumption; therefore, curtail their behaviours better.
Those who abuse alcohol may have died before they reach old
Benzodiazepines, Barbiturates, and Inhalants
o Initially, users may feel euphoric and become disinhibited. Later, may
experience depressed moods, lethargy, and perceptual distortions, etc.
o Benzodiazepines (Valium, etc.) and barbiturates (e.g., methaqualone) are
legally manufactured to treat anxiety and insomnia.
Most common pattern of abuse and dependency: begins being used at
parties, then chronic use, then addiction.
Especially likely among people who already abuse alcohol,
opioids, cocaine, amphetamines, etc. Another pattern: often in women and older people who get it from
their physicians; they photocopy prescriptions, obtain prescriptions
from different doctors, etc.
Cause drops in BP, heart and respiratory rates. May OD due to
respiratory failure or heart collapse.
OD more likely to occur when taken with alcohol (particularly
o Inhalants are volatile substances that produce chemical vapours.
Recent users may appear disoriented, drunk, etc.
May be nauseated, irritable, inattentive, etc.
Solvents = gas, paint thinners, glue, spray paint.
Medical anaesthetic gases = nitrous oxide (laughing gas).
Nitrates = dilate blood vessels and relax muscles; used as sexual
enhancers (AKA poppers or snappers).
According to OSDUS, use of inhalants = declines with age.
Use often accompanied by alcohol use.
Gasoline is the most common.
Chronic users have respiratory problems, and may develop rashes.
May lead to severe dementia. Can also cause hepatitis, liver, and
Death may occur because of depression of the respiratory or
Sudden sniffing death = acute irregularities in the heartbeat, or loss of
Users can also die because of delusions (e.g., I can fly!).
May suffocate themselves with bags over their mouths.
Activate the CNS; feelings of energy, happiness, power, lack of sleep, lack of appetite.
Cause dangerous changes in BP and heart rate, in the rhythm and electrical current;
and constriction of the blood vessels.
Toxic reactions to cocaine and amphetamines account for 40% of substance-related
disorders in the ER, and 50% of sudden substance-abuse deaths.
Side effects of caffeine and nicotine are not as severe as cocaine and amphetamines.
Prescriptions such as Ritalin are used to treat obesity, respiratory problems,
asthma, and a variety of other diseases.
o A white powder extracted from the coca plant.
o One of the most addictive substances.
o Snorting it = effects felt sooner.
o Can dissolve it in water and inject it.
o 1970 = freebase cocaine = separating the chemicals and heating it with ether.
o Crack = freebase cocaine that is boiled down into tiny chunks. Usually
smoked. o Cocaine activates the ventral tegmental area and the nucleus accumbens
(regulate reward and pleasure).
o Cocaine blocks the reuptake of dopamine into the transmitting neuron, thus
o Users often do not feel drugged.
o Taken chronically or at high doses, can create feelings of grandiosity,
impulsiveness, hypersensitivity, etc., to the point of paranoia and panic.
o After stopping use, users may feel tired, depressed, etc.
May also feel a craving for more.
o Many cocaine abusers and dependents started out taking marijuana and
o The strong affect on pleasure centers make it easier to become addicted to.
o Has a short half-life (leaves the body quickly); therefore, users must take a lot
of the drug to maintain their high.
Spend a lot of money on drugs, and therefore may take up prostitution
or do illegal things to make money.
o Many cocaine addicts develop HIV/AIDS.
o Medical problems:
Heart attacks, chest pain and respiratory failure, neurological effects:
strokes, seizures, headaches, gastrointestinal problems, physical
symptoms: chest pain, blurred vision, fever, muscle spasms,
o “Wealthy person’s substance” because it costs a lot.
o Most often in pill form, but can be injected intravenously, and
methamphetamine can be snorted to smoked.
o Initially introduced as antihistamines; now used to combat depression or
o A component in many diet drugs.
o Street names: speed, meth, and chalk.
o Produce their effects by causing the release of dopamine and norepinephrine,
and by blocking the reuptake of these neurotransmitters.
o Symptoms of intoxication (similar to those of cocaine):
Euphoria, confidence, alertness, agitation, and paranoia.
o However, causes neurotoxicity.
o Across studies, it is found that amphetamines reduce the availability of
dopamine D2 receptors (dopamine, serotonin, and vesicular monoamines.
o Produce hallucinations that are frightening.
o Paranoid, violent.
o Legal problems arise as the result of violent or aggressive acts when trying to
get the drugs.
o Tolerance develops quickly.
o Common medical problems are cardiovascular problems; increased BP, rapid
or irregular heartbeat, stroke-like damage to blood vessels.
o Elevated body temperature and convulsions occur during an OD.
o 12.2% of Canadian youths have tried amphetamines. o Sharing needles may lead to HIV.
o Overtime, those who use amphetamines become hostile and irritable.
o Meth mouth = poor oral hygiene caused by dry mouth, teeth grinding, and
o Crystal Meth use is especially prominent among gay and bisexual youths.
o An alkaloid found in tobacco.
o Cigarettes are the most common delivery method.
o Tobacco use has declined in industrialized countries, but is on the rise in
Greater decline in men than women.
o Female adolescents are more likely to initiate smoking; women are less likely
than men to quit.
o Operates on both the CNS and the PNS.
o Releases biochemical that affect the brain; dopamine, norepinephrine,
serotonin, and endogenous opioids.
o Nicotine resembles the fight-or-flight response; several body systems are
aroused in preparation of fight or flight.
Therefore, the “calming effect” of nicotine may be due to the release of
tension due to the addiction.
o Users need nicotine to feel normal because of the effects on the brain.
o Smoking is the number one preventable cause of death.
o Female deaths due to smoking are up.
o Babies of women who smoke are smaller at birth.
o In Canada, the top four causes of death are cancer, heart disease, stroke, and
chronic respiratory disease.
Cigarette smoking can contribute to all of them.
o Passive smoking = inhaling the smoke of others; the smoke is actually more
toxic than what the smoker inhales.
o The most potent predictor of youth smoking decisions is whether a
household member smokes regularly in the home.
o Best evidence for nicotine dependence is tolerance and withdrawal
Smokers show no aversion to the amount of cigarettes that would’ve
made them sick years ago.
Depressed, irritable, angry, anxious, frustrated, restless, hungry,
problems concentrating, etc.
o Nicotine is available and relatively cheap.
o More than 70% of people who smoke say they want to quit.
o Antidepressant bupropion can significantly reduce the craving for smoking.
o The most used stimulant drug.
o 75% is ingested through coffee.
o Stimulates the CNS; increasing levels of dopamine, norepinephrine, and
serotonin. o Causes metabolism, body temperature, and BP to increase.
o Caffeine intoxication = hand tremors, problems sleeping, frequent urination,
o Very large doses of caffeine can cause extreme agitation, seizures, respiratory
failure, and cardiac problems.
o It may be hard to give a diagnosis of caffeine dependence, according to the
DSM, because to this day, it doesn’t appear to produce social or occupational
o Still, tolerance can develop, as well as withdrawal symptoms.
Derived from the sap of the opium poppy to relieve pain.
Morphine, heroin, codeine, and methadone.
Bodies naturally produce opioids, called endorphins and enkaphalins.
o E.g., a sports injury causes the body to produce natural painkillers in order to
avoid going into shock. Doctors may prescribe hydrocodone (Vicodin), or
oxycodone (OxyCotin, Percocet, etc.).
Morphine is highly addictive.
Heroin was developed from morphine.
Explosion of heroin use = Vietnam War.
Mainlining = opioids are injected directly to the veins.
Initial symptom is often euphoria.
Severe intoxication can lead to unconsciousness, coma, and seizures.
Can suppress the part of the brain stem controlling the respiratory and
cardiovascular system to the point of death.
o i.e. people stop breathing and their hearts stop beating.
Dangerous when combined with depressants.
Withdrawal symptoms = dysphoria, anxiety, and agitation; an achy feeling;
increased sensitivity to pain, etc.
o May be sick, sweating, get goosebumps, etc.
o Usually come on within 8 to 16 hours, and peak at 36 to 72 hours.
Usually develop abuse or dependence began using other drugs first.
First use of heroin is typically in the teen years.
o Once dependent, heroin users need to shoot up every 4 – 6 hours to avoid
o This can become expensive, so many heroin users become prostitutes, steal,
o Heavy users often have a record by the time they’re 20.
o Most street heroin is cut with other drugs. As a result, they’re at an increased
risk for OD or death.
One of the greatest risks to opioid users is the potential of contracting HIV.
IV users also contract hepatitis, tuberculosis, serious skin abscesses, and deep
Pregnant women are at an increased risk of miscarriage and premature delivery.
Increased risk for SIDS. Most frequently abused drug is oxycodone.
Hallucinogens and PCP…
Clear withdrawal syndrome has not been found for hallucinogens or phenylcyclidine
Hallucinogens are a mixture of substances; lysergic acid diethylamide (LSD), and
LSD is the best-known hallucinogen.
One of the symptoms of intoxication is synesthesia; the overflow of one sensory
modality to another.
o E.g., “hear” colours.
Moods can shift very quickly.
o Some may be detached and show sensitivity to art, while others go from
elation to fear.
For some people, the anxiety and hallucinations created by hallucinogens caused
psychosis and they were hospitalized.
Phenylcyclidine (PCP) AKA angel dust.
Manufactured as a powder.
Not classified as a hallucinogen, but has many of the same side effects.
At low doses, it creates a euphoric feeling, a sense of intoxication, lack of concern,
talkativeness, and eye twitching.
At intermediate doses, causes disorganized thinking, body image distortions (e.g.,
feeling like one’s arms don’t belong to one’s body, etc.), depersonalization, etc.
A user may become belligerent, violent, etc.
At even higher doses, it can result in amnesia, coma, seizures, respiratory problems,
Symptoms of severe intoxication can last for days.
Hallucinogen or PCP abuse is diagnosed with the same criteria mentioned above:
o Fails to meets obligations
o Use in dangerous situations
o May have legal problems.
These drugs can cause paranoia or aggressive behaviour.
Use is higher among teenagers.
Also called ganja in Jamaica, kif in North Africa, dagga in South Africa, bhang in India
and the Middle East, and macohna in South America.
Most widely used illicit substance in the world.
Teenagers are especially heavy users.
Symptoms of intoxication may develop within minutes… and last for a couple hours.
Symptoms may present as euphoria, being in a dream-like stat