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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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