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Chapter 11

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PSYC 3140
Kendra Thomson

1 SUBSTANCE RELATED DISORDERS AND IMPULSE DISORDERS - Substance related disorders: associated w/ abuse of drugs eg. alc, cocaine, heroin, other subs that alter way ppl think, feel behave - Impulse-control disorders: inability to resist acting on a drive/temptation o Eg. can’t resist aggressive impulses, impulses to steal, set fires, gample, pull out hair - Controversy – society sees both disorders as “lack of will” to stop = stigma Perspectives on Substance Related Disorders - 1992: Roman Catholic Church  durg abuse/drunk driving are sins - polysubstance abuse: using multiple substances o eg. Case of Danny: lifelong pattern of substance abuse  smoked cigs, always drank until drunk, experimented w/ cocaine, heroin, speed (amphetamines), downers (barbituates)  dropped out of school, variable moods - Substance  chemical compounds that are ingested to alter mood/behaviour o Includes commonplace legal drugs eg. alc, nicotine, caffeine (known as “safe drugs”)  Safe drugs  affect mood/behaviour, addictive, account for more health probs/mortality than all illegal drugs combined Levels of Involvement - Psychoactive substances: ingested, alter mood/behaviour, become intoxicated/high, lead to dependency Use - Substance Use: ingestion of psychoactive substances in moderate amts that don’t sig interfere w/ social, educational or occupational functioning o Eg. cup of coffee, illegal  marijuana, cocaine, amphetamines, barbiturates Intoxication - Substance Intoxication: physiological reaction to ingested substances eg. drunkenness or getting high o to become intoxicated, depends on which drug, how much ingested, ind biological reaction o intoxication = impaired judgment, mood changes, lowered motor ability (eg. probs walking/talking) Abuse - Substance abuse: DSM IV  how sig drug interferes w/ user’s life o If sub disrupts edu, job, relationships, puts you in physically dangerous situations (eg. while driving), related legal probs = drug abuser o High school drug use can predict later job outcomes 2  Study: researchers controlled for factors like education  found that repeated hard drug use (amphetamines, barbiturates, crack, cocaine, PCP, LSD, psychedelics, crystal meth, inhalants, heroin, narcotics) predicted poor job outcomes at age 29  Eg. inability to complete semester of college as direct result of drug abuse, driving home drunk, legal problems (DSM IV),  Drug dependency = severe form of disorder Substance Dependence - Substance Dependence/addiction: o 1. PHYSICAL REACTIONS: American Psychiatric Association  person is physiologically dependent on drug(s), requires inc more of drug to experience same effect (tolerance), will respond physically in neg way when substance is no longer ingested (withdrawal)  Tolerance/withdrawal are physiological reactions to chemicals being ingested (eg. headache when don’t have morning coffee)  Withdrawal from alcohol can cause alc withdrawal delirium (or delirium tremens – DTs)  person experiences hallucinations/body tremors  Withdrawal symptoms (from drugs in gen) : chills, fever, diarrhea, nausea, vomiting, aches/pains  Not all substances are physiological addicting  no severe physical withdrawal when stop taking LSD  Cocaine withdrawal = anxiety, lack of motivation, boredom  Marijuana withdrawal = nervousness, appetite change, sleep disturbance  Marijuana (cannibis) withdrawal is considered for inclusion in DSM V o 2. BEHAVIOURAL REACTIONS: Drug-seeking behavs as measure of dependence  repeated use of drug, need to ingest more of substance (stealing money to buy drugs, standing outside in cold to smoke), likelihood that use will resume after period of abstinence  behavioural reactions dif from physiological reactions to drugs = psychological dependence  DSM IV: def of subtsance dependence combines physio aspects w/ behavioural/psycho aspects  Applying DSM IV def of dependence to daily activities inc. substance use, chocolate, sex, shopping  “pathological gambling” – problematic forms of gambling behaviour in “Impulse Control Disorders” 3 section of DSM IV  has a ot in common w/ substance dependence, should be recategorized as “addiction w/o a drug” - Can you sue drugs and not abuse them? YES o Can drink wine/beer reg w/o drinking to excess o Some ppl use drugs eg. heroin, cocaine, crack (form of cocaine) on occasional basis w/o abusing them o ** we don’t know ahead of time who is likely to become dependent to the drug - Dependence can be present w/o abuse o Eg. cancer patients take morphine or pain can be dependent on drug  builds up tolerance and goes through withdrawal if stopped – w/o abusing drug - society punishes or prohibits drugs based on factors other than addictiveness o To rank drugs by their addictiveness  1. How easy is it to get hooked on these substances 2. How hard is it to stop using them? o Person’s vulnerability to drug depends on ind traits (physiology, psychology, social/economic pressures) o Figure 11.2 (pg 398)  rankings reflect only addictive potential inherent in drug  1. Nicotine 2. Ice, glass (methamphetamine smoked) 3. Crack 4. Crystal Meth (methamphetamine injected) 5. Valium (diazepam) Diagnostic Issues - early editions of DSM, alc and drug abuse not treated as disorders o categorized as sociopathic personality disturbances (which is now called antisocial personality disorder)  b/c substance abuse was seen as a symptom of other problems  considered sign of moral weakness, no influence of genetics/bio influence - DSM III 1980 – separate category created, since then it has acknowledged complex bio/psycho nature of substance abuse - DSM IV: substance-related disorders  subtypes of diagnoses for each substance = dependence, abuse, intoxication, withdrawal o Eg. Danny  received diagnosis of “cocaine dependece” b/c had high tolerance of drug, used larger amts than intended, unsuccessful attempts to stop using it, gave up activities in order to buy it - over 50% of ppl w/ alcohol disorders have an additional psychiatric disorder eg. major depression, antisocial personality disorder, bipolar disorder o Study: six countries (inc Canada) – alc disorders have high comorbidity w/ mood and anxiety disorders o Alc disorders are highly comorbid w/ pathological gambling - Substance abuse occurs concurrently w/ other disorders b/c: 4 o 1. Substance-related disorders + anxiety/mood disorders are highly prevalent in society, may occur together by chance o 2. Drug intoxication/witdrawal can cause symptoms of anxiety, depression, psychosis, can inc risk taking  eg Study:. Ppl drinking in past yr (especially heavy drinkers) are at inc risk for clinical depression  eg. Study (Ellery, Stewart, Loba): ingestion of alc led to inc risk- taking among reg gamblers when using video lottery terminal (VLT) compared to gamblers ingesting nonalc drink o 3. Mental health disorders cause substance use disorder  eg. ppl w/ anxiety disorders eg. post traumatic stress disorder / social phobia  may self-medicate w/ substances for anxiety symptoms - DSM IV – tries to define when a symptom ins a result of substance use / when it is not o Eg. if symptoms in schizophrenia or extreme states of anxiety appear during intoxication or w/in 6 weeks after withdrawal from drugs, they are not considered signs of separate psychiatric disorder o Eg. inds who shows signs of severe depression right after they stopped taking heavy doses of stmulants would not be diagnosed w/ major mood disorder  Severely depressed before use stimulants + symptoms persist for +6 wks after they stop  could have separate substance abuse disorder 5 Groups of Substances - 1. Depressants: result in behavioural sedation, can induce relaxation o eg. alcohol (ethyl alcohol), the sedative, hypnotic, anxiolytic drugs in barbituate family (eg. Seconal), and benzodiazepines (Valium, Halcion, Xanax) - 2. Stimulants: more active, alert, elevate mood o eg. amphetamines, cocaine, nicotine, caffeine - 3. Opiates: produce analgesia temporarily (reduce pain) and euphoria o eg. heroin, opium, codeine, morphine, oxycodone - 4. Hallucinogens: alter sensory perception, can produce delusions, paranoia, hallucinations o eg. Marijuana, LSD - 5. Other drugs of abuse: don’t fit into above categories: inhalants (eg. airplane glue), anabolic steroids, over the counter/prescription medication (eg. nitrous oxide) o psychoactive effects DEPRESSANTS - dec central nervous system activity - Principle effect: reduce physiological arousal, help us relax - Alcohol; sedative, hypnotic, anxiolytic drugs (eg. drugs prescribed for insomnia) 5 - Symptoms of physical dependence, tolerance, withdrawal Alcohol Use Disorders - Alcohol in history: o Wine/beer in pottery jars at Sumerian trading posts in western Iran, Soviet Georgia (dates back 7000 yrs) o Temperance Movement  morally condemned heavy drinking (in early NA) o Women’s Christian Temperance Union  alc edu courses in Can provinces  Temperance movements lead to American Prohibition (1919- 1933)  Reduced overall alc use  Side effects: inc in organized crime, bootlegging (led to repeal of Prohibition near the Depression) Clinical Description - Alc = depressent, but initial effect is a stimulant  red inhibitions, more outgoing o Inhibitory centres in brain are depressed cause initial stimulant effects - w/ continued drinking  alc depresses more parts of brain, impedes ability to function properly o impaired motor coordination (staggering, slurred speech), slowed reaction time, confusion, reduced ablity to make judgments, hearing/vision neg affected Effects - After alc is ingested: o 1. Passes through esophagus o 2. Into stomach (small amts absorbed) o 3. Most travels to small intestine (easily absorbed into bloodstream)  Circulatory system distrubtes alc throughout body  contacts all major organs o 4. including the heart (some alc goes into lungs, vaporizes and is exhaled  basis of breath analyzer test that measures levels of intoxication) o 5. As alc passes through liver, it’s broken down/metabolized by enzymes into carbon dioxide and water - Avg-size person can metabolize 7-10 g of alc/hr (aka 1 glass of beer, 1 ounce of 90-proof) - Complex effects of alc on brain  influences many neurorecepter systems (makes it difficult to study) o 1. Gamma Aminobutyric acid (GABA) system: sensitive to alc  GABA = inhibitory neurotransmitter 6  Major role = interfere w/ firitng of neuron it attaches to  When GABA attaches to its receptor, chloride ions enter cell, make it less sensitive to the effects of other neurotrans  Alc reinforces movement of choloride ions  neurons have diff firing  Although alc makes us more loose/sociable, it makes it more diff for neurons to comm. w/ each other  GABA systems acts on anxiety  alc’s anti-anxiety effects may result from its interaction w/ GABA system o 2. Glutamate System: interaction w/ alc and glutamate system results in blakcouts, loss of memory o 3. Serotonin system: sensitive to alc, affects mood, sleep, eating behav  responsible for alc cravings o 4. Dopamine reward system: pleasurable feelings ppl experience when drinking alc o Alc releases endogenous opioids (body’s natural occurring analgesics)  explains why alc has pain numbing effects - Long- term effects of heavy alc use are severe o Withdrawl from chronic alc = hand tremors (w/ sev hrs of stopping), nausea/vomiting, anxiety, transient hallucinations, agitation, insomnia, in extreme cases withdrawal delirium (/delirium tremens = DTs)  scary hallucinations/tremors  DTs can be red w/ med treatment - Alc will cause damage to organs depending on: o 1. vulnerability, o 2. frequency of use o 3. length of drinking binges o 4. blood alc levels during drinking o 5. whether body is given time to recover b/w binges - Conseq of long-term excessive drinking = liver disease, pancreatitis, cardiovascular disorders, brain damage o Alc perm kills brain cells (neurons)  may / may not be true – evidence for brain damage comes from ppl who are alc dependent, experience blackouts, seizures, hallucinations  Memory/ability to perform tasks = impaired  2 types of organic brain syndromes result from long-term heavy alc use: dementia and Wernicke-Korsakoff syndrome  Dementia: general loss of intellec abiilties, can be direc result of neurotoxicity aka “poisoning of brain”  Wernicke-Korsakoff syndrome: confusion, loss of muscle coordination, unintelligible speech - Fetal Alc Syndrome: combination of probs that occurs in child whose mom drank while preg o fetal growth retardation, cog deficits, behav probs, learning difficulties o facial features  skin folds at corners of eyes 7  low nasal bridge  short nose  groove b/w nose and upper lip  small head circumference  small eye openings  small midface  thin upper lip Statistics On Use - alc is legal in NA, we know more aboit it than other psychoaciv esubs - most adults in Canada drink in moderation - Canadian Addiction Survey (CAS)  23% of Canadans exceed low-risk guidelines for alc consumption, 17% classified as high-risk drinkers - Alc use in Canada ec b/w 1989-1994 o Decline in alc also in 25 other major industrialized countries (eg. USA) b/w 1979-1984 o Inc public awareness of health risks w/ alc use and abuse o Change in demographics  proportion of pop 60+ inc (alc use in this demographic is low) - Alc use now is higher than it was in 1989 - Men more likely than women to drink alc, more likely to drink heavily o Eg. 1998-1999 Canadian survey: 16% of adult men classifed as heavy drinkers, only 4% adult women - Drinking practices vary across societies o Eg. Comparison of 1998 Canadian Campus Survey w/ undergraduates at 16 unis across Canada and 1999 College Alc Study of 119 colleges and unis in USA  higher proportion of Canadian than American students drink alc, but higher proportion of American students are binge drinkers Statistics on Abuse and Dependence - 9% of Canadian drinkers have some prob w/ alc - 3% of adults = alc dependent in any yr o Canadian Addiction Survey:  5% of current drinkers admit to experiencing phys. health probs b/c of drinking  3% report financial probs b/c of alc use  3% report probs in social life/friendships b/c of alc - Young (18-29) single males = most likely to be heavy drinkers/ have alc use probs - Rates of alc use disorders vary widely outside Canada o Comparison of lifetime rates of alc dependence diagnoses  lowest reported rate = 1.2 % in rural villages in Taiwan, highest reported rate was in American National Comorbidity Survey at 14.1% o Low prev rates in Asian studies (Hong Kong, Taiwan) 8 o Cultural differences in alc b/c of dif attitudes towards drinking, availability of alc, physiological reactions, family norms Progression - ppl who abuse alc/dependent on it fluctuate b/w drinking heavily, drinking “socially” w/o neg effects, being abstinent (not drinking) - 20% of ppl w/ severe alc dependence have spontaneous remission, don’t re- experience probs w/ drinking - Sobell  prev thought that once probs arose w/ drinking, they just get worse o Thought that alcolism (like disease left untreated) would get progressively worse if not checked  Jellinek = father of this view (but based his findings off of faulty study) o Alcohol dependence is progressive for most ppl o Alcohol abuse is variable  Early use of alcohol may predict later abuse  Study: 6000 lifetime drinkers – found that drinking at early age (11-14) is predictive of later alcohol use disorders  Study: 636 male inpatients in alc rehab centre  Chronically alcohol-dependent men  General progression of alc-related life probs  ¾ of men reported moderate consequences of drinking in their 20s (eg. demotions at work)  30s  more serious probs eg. reg . blackouts, signs of alc withdrawal  late 30s/early 40s  long-term serious consequences of drinking eg. hallucinations, withdrawal convulsions, hepatits, pancreatitis  common pattern in ppl w/ chronic alc abuse and dependence  inc severe consequences  progressive pattern not inevitable for everyone who abuses alc, but we don’t understand what distinguishes ppl from those who are susceptible or not - Alc linked to violent behaviour o Many ppl who commit violent acts eg. murder, rape, assult are usually intoxicated @ time  JUST A CORRELATION  alc doesn’t necessarily make you violent  Lab studies  alc makes ppl more aggressive  But outside of lab  alc and aggressiveness are impacted by many interrelated factors eg. quality/timing of alc consumed, person’s history of violence, expectations of drinking, what happen sto ind while intoxicated o ALCOHOL DOES NOT CAUSE AGGRESSION 9  Reduces fear associated w/ being punished, impair ability to consider consequences of impulsive behav  Robert Phil  ppl w/ poorer executive cognitive functioning (planning, organizing abilities) are more likely to behave aggressively when intoxicated  Alc intoxication inc risk of being victim of violence Sedative, Hypnotic or Anxiolytic Substance Use Disorders - Depressants also include the following drugs : o Sedative (calming) o Hypnotic (slee-inducing) o Anxiolytic (anxiety-reducing) o Barbiturates (inc Amytal, Seconal, Nembutal)  fam of sedative drugs first synthesized in Germany in 1882 (prescribed to help ppl sleep, replaced alc/opium )  Widely prescribed during 30s/40s  50s – drug most abused by adults in NA o Benzodiazepines (Valium, Xanax, Rohypnol, Halcion)  used since 1960s (to red anxiety – initially called “miracle cure” for anxiety)  1980s – discovered that they aren’t godo to reduce tension/anxiety from everyday stresses  billions of doses ob benzos are consumed by NAs each yr  16 mil prescriptions of benzos made to Canadians in 2000  benzos = safer than barbiturates, less risk of abuse/dependence  still potential for dependence in treatment of anxiety/sleep disorders - discovered in 1970s - Benzodiazepine dependence o High tolerance can occur (escalate dose over time to achieve orig effect) o Severe withdrawal symptoms (b/c of high tolerance)  insomnia, trembling, agitation, emotional lability, photophobia (aversion to light), blurred vision, pain behind eyes, headaches, nausea, muscle/stomach cramps, paranoia, hostile, irritable, tearful, visual hallucinations (eg. seeing insects), illusions (eg. seeing sink faucet moving) - misuse of Rohypnol aka “roofies”  became more pop in 1990s b/c it has same effect as alc without odour o men giving drug to women w/o them knowing  date rape (led Rohypnol to be named the “date rape drug” Clinical Description - barbiturates o low doses - relax muscles/produce mild feeling of well-being o larger doses – sim results as heavy drinking = slurred speech, probs walking, concentrating, working 10 o extremely high doses - diaphragm muscles relax so much, can cause death by suffocation  overdosing on barbiturates is common means of suicide - benzodiazepines o used to calm, induce sleep o prescribed as muscle relaxants and anticonvulsants (antiseizure meds) o ppl who use them for nonmedical meds report first feeling pleasant higih, red of inhibition (sim to alc) o once dependency develops, withdrawal symptoms are sim to withdrawal from alc = anxiety, insomnia, tremors, delirium - DSM IV criteria for sedative, hypnotic, anxiolytic drug use disorders are sim to alc disorders o Both include maladaptive behav changes eg. inapprops sexual/aggressive behav, variable moods, impaired judgment, impaired social/occupational functioning, slurred speech, motor coordination probs, unsteady gait - sedative, hypnotic, anxiolytic drugs affect brain by acting on GABA neurotransmitter system (like alc) o when ppl combine alc w/ these drugs = very dangerous (eg. theory that Marilyn Monroe combined alc / too many barbiturates & killed hrself) Statistics - barbiturate use has dec - benzodiazepine use has inc - 4% of Canadians use benzodiazepines (higher rates among women, elderly, smokers) - Study (Ruiz): compared rates of benzo prescriptions in Canada (developed counry) and Chile (developing country) over 5 yrs o Total bnzo use was sim in 2 countries o Patterns of use of specific benzos differed  eg. Halcion rapidly eliminated in Canada, Valium slowly eliminated in Chile (slowly eliminated benzos are associated w/ grater risk of falls than rapidly elim. Benzos) STIMULANTS - most commonly consumed drugs in Canada o Include: caffeine, (in coffee, chocolate, soft drinks), nicotine (in tobacco products eg. cigs), amphetamines, cocaine - Stimulants make you more alert/energetic - Long history of use eg. Chinese physicians used amphetamine Ma-huang +5000 yrs ago  now marketed in NA as dietary supplement/weightloss aid o Linked to serioius health probs (eg. rise in blood pressure, deaths) o Natural drugs can be just as dangerous as manufactured ones 11 Amphetamine Use Disorders - low doses = elation, vigour, reduce fatigue, feel “up” o after elevation, experience “crash” = feeling depressed/tired o stimulants can lead to amphetamine use disorders (w/ sufficient use) - Amph made in labs o First synthesized in 1887, used as treatment for asthma as nasal decongestant o Amph reduce appetite – some ppl take them to lose weight o Over-night truck drivers, pilots, uni students pulling all nighters take amph to stay awake - prescribed for ppl w/ narcolepsy (sleep disorder of excessive sleepiness) - given to children (eg. Ritalin) w/ ADHD - can impair judgmenet - DSM IV diagnostic criteria for amphetamine intoxication o Sig beahv symptoms (eg. euphoria/affective blunting, changes in sociability, interpersonal sensitivity, anxiety, tension, anger, stereotyped behavs, impaired judgment, impaired social/occupational functioning) o Physiological symptoms: heart rate/blood pressure changes, perspiration/chills, nausea/vomiting, weight loss, muscular weakness, respiratory depression, chest pain, seizures, coma o Severe intoxication/overdose can cause hallucinations, panic, agitation, paranoid delusions o Amph tolerance builds quickly o Withdrawal: apathy, prolonged periods of sleep, irritability, depression - friendly fire incident in Afghanistan – caused by amphetamines (they don’t go into this at all… apparently 2 US soldiers shot 4 Canadian soldiers in Afghanistan in 2002 while on amphetaimines used to stay awake) - MDMA o Called methylene-dioxymethamphetamine o “designer drug” o First synthesized in 1912 in Germany, used as appetite suppressant o Now commonly called Ecstasy – recreational use rose in 1980s o Study – 1999 – past year useof Ecstasy was 7%, highest rate since 1991 o Rates higher in some subcultures  Eg. Study: drug use among ravers in Montreal  65% of rave- goers had used Ecstasy  Effects of drug “just like speed but w/o the comedown, you feel warm/trippy like acid, but w/o possibility of major freak out” - purified crystallized form of amphetamine called “ice” is ingested through smoking o stays in system longer than cocaine, causes aggressive behav 12 - potential to become dependent on amph = high, great risk for long term difficulties o may cause death – 1999 – 9 MDMA related deaths in Ontario - Amphetamines stimulate central nervous system o Enhances activity of norepinephrine and dopamine o Ampph help release these neurotransmitters, block their reuptake (making more of them available throughout body) o Too much amph (and therefore too much dopamine/ norepinephrine) = hallucinations/delusions  Theories for causes of schizophrenia Cocaine Use Disorders - replaced amph as popular stim drug in 1970s - comes from leaves of coca plant (bush in SA) - Latin Americans have chewed coca leaves for centuries to get relief from hunger/fatigue th - Cocaine introduced to NA in late 19 c, widely used until 1920s - 1885 – Parke, Davis & Co. manufactured coca and cocaine in 15 dif forms (inc. coca-leaf cigarettes/cigars, inhalants, crystals) o cheaper alternative was Coca-Cola  until 1903 contained 60 mgs of cocaine per 240 ml bottle Clinical Description - in small amts, cocaine inc alertness, produce euphoria, inc blood pressure/pulse, cuases insomnia, loss of appetite - drug makes one feel powerful/invincible (inc self-confident) - effects of cocaine are short-lived eg. less than 1 hr (snort repeadly to keep himself up) o cocaine binges  can inc paranoia, exaggerate fears (eg. that he would be caught doing cocaine, that someone would steal his drugs) - paranoia = common among cocaine abusers  occurs in over 2/3 of cocaine users - makes heart beat more quickly/irregularly o can have fatal consequences on person’s physical condition/amot of drug ingested - cocaine use (crack) by preg women may adversely affect babies o Study: cog effects of cocaine exposure on developing fetus  Found subtle deficits in auditory info processing in cocaine- exposed infants  explain why fetal cocaine exposure is associated w/ lang deficits in children exposed to drug as fetuses Statistics - cocaine use (across most ages) has dec in Canada - low levels of past yr cocaine use in gen pop 13 o eg. 1998-1999 Toronto Survey  1% of adults, 6% of students used cocaine in past yr - Cocaine usually snorted through nose, can also be injected o Vancouver – 80% of needle exchange clients inject cocaine (Montreal = 70%, Halifax = 52%) - Crack cocaine = crystallized form of cocaine, smoked - Use of crack cocaine is reported by less than 1% of adults, 2% of students in Toronto - Cocaine and amph in same group b/c have sim effects on brain o Feelings of “up” come from effect of cocaine on dopamine system o Cocaine enters bloodstream, carried to brain o In brain, cocaine molecules block reuptake of dopamine o Neurotransmitters released at synapse stimulate next neuron, then are recycled back to original neuron  Cocaine binds to places where dopamine neurotransmitters re- enter home neuron (blocking their reuptake by neuron)  Dopamine that can’t be taken in by the neuron remains in synapse, causing repeated stimulation of next neuron  stimulation of dopamine neurons in “pleasure pathway” = site in brain that is involved in experiences of please  Pleasure pathways causes high associated w/ cocaine - until 1980s – believed cocaine was “wonder drug” that produced euphoria but wasn’t addictive o Comprehensive Textbook of Psychiatry 1980  “taken no more than 2- 3 times/wk, cocaine creates no serious problems” - Few neg effects at first - But w/ continued use  disrupted sleep, inc tolerance causes need for higher doses, paranoia, gradually becomes socially isolated - Cocaine withdrawal  apathy, boredom (unlike alc withdrawal) - Vicious cycle: cocaine abused  withdrawal causes apathy - cocaine abuse resumes - Atypical withdrawal pattern misled ppl into believing that cocaine wasn’t addictive Nicotine Use Disorders - Nicotine Use Disorders: nicotine in tobacco is a psychoactive substance that produces patterns of dependence, tolerance, withdrawal - 1942 – Lennox Johnson (physician) “shot up” nicotine extract o found that after 80 injections, he liked it more than cigs, felt deprived w/o it - Tobacco plant is indigenous in NA, First Nations ppl smoked leaves centruies ago - ¼ of Canadian smoke (down from 49.5% who smoked in 1965) - DSM IV doesn’t describe intoxication pattern for nicotine 14 o Lists withdrawal symptoms eg. depressed mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, inc appetite, weight gaine - Nicotine in small doses: o stimulates CNS o Relieves stress, improves mood o Cause high blood pressure, inc risk of heart disease/cancer - Nicotine in high doses: o Blur vision o Cause confusion o Convulsions o Sometimes cause death - once smokers are dependent on nicotine, going w/o it causes these withdrawal symptoms - rate of relapse of nicotine use is equivalent among those using alc, heroin, cigs - Nicotine inhaled through lungs, enters bloodstream o After person inhales smoke, nicotine reaches brain in 7-19 s o Nicotine stimulates nicotinic acetylcholine receptors in midbrain reticular formation and limbic system (site of “pleasure pathway” - Nicotine may affect fetal brain (inc likelihood that children of mothers who smoke during preg will smoke later in life) - Smokers dose themselves throughout date to keep nicotine at steady level in bloodstream (10-50 nanograms per milliliter) - Cig smoking and alc drinking are commonly paired  nicotine adminstration (tobacco smoke( eads to inc alc consumpton o Smoking may make drinking alc more rewarding (in terms of effects on dopamine reward system) - Smoking linked w/ signs of neg affect o depression, anxiety, anger o eg. ppl who quit smoking but later resume, report that feelings of depression/anxiety were responsible for relapse o nicotine may help improve mood - Severe depression  occurs sig more often in ppl w/ nicotine dependence o Complex bi-directional relationship b/w cig smoking and neg affect (does smoking cause depression or depression cause smoking?) o Being depressed inc risk of becoming dependent on nicotine o At same time, being dependent on nicotine inc your risk of being depressed o *Genetic vulnerability combined w/ life stresses combine to mke one vulnerable to both nicotine dependence and depression Caffeine Use Disorders - most common psychoactive substance – used by 90% of NA - called “gentle stimulant” b/c thought to be least harmful of addictive drugs - found in tea, coffee, cola drinks, cocoa products 15 - high levels of caffeine are added to “energy drinks”  widely consumed in NA today, banned in some European countries (France, Denmark, Norway) b/c of health concerns - small doses  caffeine elevates mood, dec fatigue - larger doses  jittery, cause insomnia - caffeine takes long time to leave bodies (has blood half-life of approx 6 hrs)  disturbs sleep if caffeiene is ingested close to bedtime (and is worse in ppl w/ insomnia) - ppl react dif to caffeine (some sensitive, others rarely affected) - Moderate use of caffeine (1 cup of coffee per day) by pregnant women doesn’t harm fetus - Reg caffeine results in tolerance/dependence to drug o Withdrawal: headaches, drowsiness, unpleasant mood - Caffeine’s affect on brain: involve neuro-modulator adenosine and neurotransmitter dopamine o Blocks adenosine reuptake o We don’t know role of adenosine in brain function / whether interruption of adenosine system is responsible for elation/ inc energy of caffeiene use OPIOIDS - opiate = natural chemicals in opium poppy that have narcotic effect (relieve pain, induce sleep)  can cause opioid use disorders - opiods: family of substances that inc: natural opiates, synthetic variations (methadone, pethidine), comparable substances that occur naturally in brain (enkephalins, beta-endorphins, dynorphins) - Wizard of Oz – Wicked Witch puts Dorothy to sleep by making them walk through field of poppies o allusion to opium poppies used to produce morphine, codeine, heroin - Opiates induce euphoria, drowsiness, slowed breath - High doses  cause death if respiration is completely depressed - Opiates are analgesics  substances that relieve pain o Ppl given morphine before/after surgery - Oxycodone (OxyContin) : newer prescription opiate drug used to treat pain o Inc concern for potential for abuse/lethal overdose o Cape Breton, Nova Scotia  pop street drug (linked to death of 12 ppl in 2003-2004)  Nova Scota College of Physicians/Surgeons want to min inappropriate prescribing of oxycodone (min abuse potential)  Manufacturers of oxycodone fined $635 mil for misleading public re: addictive properties of drug - Withdrawal o So unpleasant that ppl cont to use drug even if want to stop o Perception that opioid withdrawal is life threatening  comes from heroin addicts in 1920s/30s 16  Users had aces sot cheaper/purer forms of drug, withdrawal had more serious side effects (than withdrawal from weaker versions used today) o ppl who stop opioid use experience withdrawal symptoms w/in 6-12 hrs  excessive yawning, nausea/vomiting, chills, muscle aches, diarrhea, insomnia  temp disrupting work, school realtionships  symptoms persist 1-3 days, process completed in approx 1 wk - # of ppl who use, abuse/ dependent on opiates is diff to know b/c most ppl who use opiates are secretive - women are at risk of abusing/becoming depending on prescription opioids (eg. codeine) - Emergency room admissions b/w 1995-2002  34.5% inc in heroin (most commonly abused opiate) - Risk beyond addiction/overdose o drugs usually injected intravenously  users at inc risk for HIV infection, AIDS o Survey in late 1990s – HIV incidence among injection drug users in Vancouver = highest ever documented among injection drug users in developed world o Injection drug users in Canada = 50,000-100,000 (high #s in Vancouver, Montreal, Toronto) o Epidemiological Study  prev of HIV infection among injection drug users in Van is b/w 17-31% o Fig 11.8 (Pg 412): HIV incidence rates among 2 groups of Vancouver injection drug users  HIV infection rates higher among injection drug users in unstable housing (homeless, single room occupancy hotel in downtown eastside) than those in stable housing (living in home/apt) o Buxton Study  Aboriginal injection drug users become HIV pos at 2X rate of non-Aboriginal injection drug users - Life of opiate addict is bleak o 24 year follow up Study: 500+ opiate addicts  follow up in 1985/86  27.7% of addicts had died, mean age at death was 40 yrs  Half of deaths result of homicide, suicide, accident, 1/3 from drug overdose  7-8% of group had stable pattern of daily narcotic use - high / “rush” from opiates comes from activation of body’s natural opioid system o brain already has its own opioids (called enkephalins and endorphins) – that provide narcotic effects o Heroin, opium, morphine activate this system (just like alc at certain doses) 17 HALLUCINOGENS - Change the way user perceived world  sigh, sound, feeling, taste, smell are distorted Marijuana - Marijuana: dried parts of cannabis / hemp plant (Scientific name = Cannabis sativa) - Cannabis grows wild in tropical areas of world (nickname “weed) - Drug of choice in 1960s/70s - Most routinely used illicit substance in Canada o 10% of Toronto adults report marijuana use in 1999 survey o 24% of Vancouver adults report use - Study: examined marijuana use in 15 yr olds in 31 dif countries o Canadian male adlesc had highest prev of frequent cannabis use - Smoke marijuana  altered perceptions of world o Reactions to marijuana include: mood swings, normal experiences seem funny, dreamlike state/dif to stand still o Heightened sensory experiences  vivid colours o Appreciate subtleties of music o Marijuana produces dif reactions for dif ppl  not uncommon to report no reaction for first time use  Ppl can “turn off” high if really motivated - Small doses  feelings of wellbeing - Larger doses  paranoia, hallucinations, dizziness o Common neg outcomes of long term use: impairment of memory, concentration, motvation, self-esteem, realtionships w/ others and employment  Atmotivational syndrome: impairment in motivation (apathy, unwillingness to carry out long-term plans) - Contradictory evidence for marijuana use o Chronic/heavy users report tolerance (especially to euphoric high  unable to reach levels of pleasure earlier experienced) o “Reverse Tolerance” – when reg users experience more pleasure from drug after repeated use - Major withdrawal signs usually don’t occur w/ marijuana o Chronic users who stop taking drug report: period of irritability, restlessness, appetite loss, nausea, diff sleeping o BUT – they don’t go through craving/psychological dependence characteristic of other drugs - Controversial use of marijuana for med purposes: o USA – ppl use marijuana illegally to help w/ nausea w/ chemo, or to help w/ other illnesses eg. glaucoma  Marijuana smoke may contain carcinogens eg. tobacco smoke  long-term use may contribute to diseases like lung cancer 18 o 1999 – Health Canada began giving exemptions on compassionate ground to patients to allow them to use marijuana for med  ppl w/ multiple sclerosis, spinal cord injuries, HIV/AIDS, cancer, arthritis, epilepsy are eligible - Controversy around decriminalization of use and possession of small amts of marijuana o 2004 – Parliament debating bill that mandated fining (rather than court sentences) ppl who had 15g or less of marijuana  Conservative party killed bill  Present – ppl gain criminal record if found guilty w/ possession of even small amt of marijuana - Marijuana first banned in Canada in 1923 under the Opium and Drug Act - Since 1997 marijuana under Controlled Drugs and Substances Act - 2000 – 30,000+ ppl charged w/ simple possession (most didin’t go to jail, just got crim record) - In favour of decriminalizing argue: o penalties are too harsh ppl w/ criminal record for possession of marijuana have diff getting jobs/traveling internationally o gov reserouces in law enforcement should be more usefully spent on public health campaigns to edu public re: marijuana use/addiction - Against decriminalization argue: o When drugs ar legalized, rates of use inc o Decriminalizing marijuana possession sends conflicting msgs to youth o Concern for marijuana as “gateway drug”  pave the way for harder drugs o Director of US drug policity in 2002 – “marijuana is most heavily abused drug in US, addiction rates have risen in recent yrs” o Since USA is not taking sim steps to decrminalize, this change in Canadian law can create diff for Canada-US border (if smuggling marijuana into Canada inc) - Marijuana contains 80+ varieties of chemicals called cannabinoids (believed to alter mood/behav) o Most common chemical = tetrahydrocannabinols (THC) o Marijuana users inhale drug by smoking dried leaves in marijuana cigs  Others use hashish  dried form of resin in leaves of the female plant LSD and Other Hallucinogens - Albert Hoffmann – 1943 – test synthedsized compound o 40 min ater, he felt dizzy, desire to laugh, hallucinated that the buildings outside were oving slowly - LSD (d-lysergic acid diethylamide): “acid”, most common hallucinogenic drug o Produced synthetically in labs, naturally occurring derivatives of grain fungus (ergot) 19 o Ergotism: disease that constricted flow of blood to arms/legs, resuled in gangrene/loss of limbs - LSD first produced iillegally in lab in 1960s for recreational use o Mind-altering effects of drug suited social effort to reject established society - LSD experimented in therapy o Spirituality theory of sobriety (eg. that spirituality can induce sobriety from alc for ppl w/ alc disorders)  Argued that therpsits can exploit spiritual aspect of LSD trip to assist in recovery from alcoholism  1950s – Dr. Humphrey Osmond did exp to test this theory of sample of 1000 patients w/ history of severe alcoholism  patients given single high dose of LSD  reported that 50% didn’t drink alc again  William Wilson (co-founder of AA) is has experiemented w/ LCD, advocates for use of LSD in therapy as treatment for alcoholism - Other hallucinogens (some occur naturally in plants) o Psilocybin – found in certain mushrooms o Lysergic acid amide – found in seeds of morning glory plant o Dimethyltryptamine (DMT) – found in bark of Virola tree in SA, CA o Mescaline – peyote cactus plant o Phenecyclidine (PCP) – processed synthetically - DSM IV Diagnostic Criteria for hallucinogen intoxication is sim for marijuana – not provided separately o Criteria include:  Perceptual changes eg. subjective intensification of perceptions, depersonalization, hallucinations  Physical symptoms: papillary dilation, rapid heartbeat, sweating, blurred vision - From experiences of ppl using hallucinogens  sensory distortions, eg. watching friend’s ear grow, beaiful spirals o Usually know that what they’re seeing isn’t real o Sometimes intense hallucinations w/ emotional content, religious meaning… - Tolerance develops quickly  LSD, psilocybin, mescaline o If taken repeatedly over sev days, drugs lose effectiveness o Sensitivity returns after 1 wk of abstinence - most hallucinogens – no withdrawal symptoms - Concerns about hallucinogen use: o Possibility of psychotic reactions  Eg. stories in press re: ppl jumping out windows b/c they believe they could fly  Little ev suggests that using hallucinogens produces greater risk than being drunk / under influence of other drugs 20 o ppl report having “bad trips”  frightening episodes eg. clouds turn into monsters, deep feelings of paraoia  usually someone on bad trip can be “talked down” by supportive ppl (reassure that exp is temporary) - unclear of LSD and other hallucinogens’ effects on brain o most of drugs resemble neurotransmitters  LSD, psilocybin, lysergic acid amide, DMT are chemically sim to serotonin  mescaline resemples norepinephrine  other hallucinogens sim to acetylcholine - Mechanisms responsible for hallucinations/perceptual changes are unknown OTHER DRUG ABUSE - inhalants, steroids, designer drugs o don’t fit into above categories, but can be physically damaging, alter sensory experiences - Inhalants: o Found in volatile solvents  make them easy to breathe into lungs directly o Eg. spray paint, hair spray, paint thinner, gasoline, amyl nitrate, nitrous oxide (“laughing gas”), nail polish remover, felt-tipped markeres, airplane glue, contact cement, dry-cealningfluit, spot remover o Most common in young males (13-15) w/ low SES o Rapidly absorbed into bloodstream through lungs by inhaling contaner/cloth held up to mouth/nose o The high is sim to alc intoxication  dizziness, slurred speech, incoordination, euphoria, lethargy o Build up tolerance to drug  Withdrawal  sleep disturbance, tremors, irritability, nausea (last 2-5 days) o Use can inc aggressive/antisocial behav o Long-term use = damage to bone marrow, kidneys, liver, brain - Anabolic-androgenic steroids (“roids”) o Derived form/synthesized form of testosterone o Legit med uses of steroids are for ppl w/ asthma, anemia, breast cancer, males w/ inadequate sexual development o Anabolic actions of drug (that can produce inc body mass) has led to illicit use  2% of males will use drug illegally during lives o administer drug on sched of sev weeks/months followed by break from use (called “cycling”)  or combine sev types of steroids (called “stacking”) o Steroid use doesn’t produce high, but used to enhance performance and body size 21  Eg. Ben Johnson  won 100-m dash at 1988 Seoul Olympic Games, strip
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