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4 Substance-Related and Addictive Disorders Chapter Objectives After reading this chapter, you should be able to do the following:

• Explain why psychoactive substances are so popular.

• Analyze the potential dangers of using psychoactive substances.

• Explain how substance-related disorders are treated.

• Discuss ways that substance-related disorders can be prevented. Hemera/Thinkstock get81325_04_c04.indd 89 12/5/13 3:58 PM Section 4.1 Psychoactive Substances Are Ubiquitous 4.1 Psychoactive Substances Are Ubiquitous Chemicals that alter moods or behavior have been used for thousands of y\ ears by people from just about every culture and society. This chapter is concerned with why so many people use these psychoactive substances, the problems such substances can cause, how to help people who want to stop using substances, and how to prevent people from tak- ing them up in the first place. Psychoactive substances—chemicals that alter our moods or behavior—touch every aspect of modern life; they affect the way we live, work, relax, and die. In the United States, the total cost of substance abuse in 2008\ (the most recent year for which estimates are available) was $215 billion, including direct and indirect public costs related to crime, health, and productivity, with the majority of costs attribut - able to lost productivity (U.S. Department of Justice, 2011). This value represents both the use of resources to address health and crime consequences as well as the loss of potential productivity from disability, death, and withdrawal from the workforce. In addition, this money went toward preventing, treating, or remediating the effects of psychoactive substances (U.S. Department of Justice, 2011).

There is no precise boundary between social drinking and alcohol abuse. Like many psychological problems, substance-related disorders are often just exaggerations of common behaviors. How common? Recent data reported by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2011) reveal that 131.3 million Americans reported some amount of alcohol use. This number refers to general use of alcohol—a beer with some pizza, a glass of wine at dinner, for example. This is slightly more than half of Americans aged 12 or older and is similar to the 2009 estimate of 130.6 million people (51.9 percent). Nearly one-quarter (58.6 million) of people aged 12 or older participated in binge drinking at least once in the 30 days prior to the survey in 2010, a rate similar to that reported in 2009. For males, binge drinking is defined as the consumption of five or more alcoholic drinks in a row on at least one occasion during the preceding two-week period; for females, the consumption of four or more drinks (Wechsler, Lee, Kuo, & Lee, 2000). The rate in 2010 was similar to the rate in 2009 (23.7%). Finally, heavy drinking was reported by 6.7% percent of the population aged 12 or older, or 16.9 million people. This percentage was similar to the rate of heavy drink - ing in 2009 (6.8%).

More disturbingly, data provided by the National Survey on Drug Use and Health (NSDUH) showed that in 2010, “17.9 million persons aged 12 or older\ were classified with alcohol dependence or abuse. This represented 7.0 percent of the population” (NSDUH, 2011, p. 70).

Psychoactive substances form a spectrum. At one end are everyday substances, such as the caffeine found in coffee, soft drinks, and tea. At the other end of the spectrum are illicit and potentially dangerous substances, such as opiates (heroin, etc.). A variety of other substances lie between these two extremes.

Robert gives us an interesting example of an individual who may—or may not—have a drinking problem. Let’s meet him before we continue. get81325_04_c04.indd 90 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous Case Study: Robert Jones, Part 1 Robert (or Bob as he prefers to be called) is a 48-year-old African American male who has been mar- ried for 30 years to Paula. He has two children, aged 16 and 5. When Bob came to us, he was well dressed, presented pleasantly and appropriately, and had a friendly demeanor. He was not entirely sure why he was sent to the clinic, but he was sure that it was a mistake.

“I’ve got no idea what’s going on here. The cops stopped me one night after work. Both were African Americans, and they knew me. They’ve seen me in town, at church. They told me I was weaving all over the road, and they wanted to make sure I was okay. Of course I was okay! I’ve been driving for over 30 years and never had an accident, never had a ticket! They asked me twice if I’d been drink- ing. I don’t drink, well, not that much anyway. They thought I was drunk! Would I drive drunk? I’ve got two kids, one a teenager who’ll be driving soon herself. I told them no, and then they asked me to step out of the car as they wanted me to do some things for them . . . .” Bob continued his story for us during his initial intake interview. “This was so insane! I’ve got a gradu- ate degree. I’m an upstanding citizen. The cops asked me to walk a straight line, to touch the tip of my nose with the index finger of each of my hands. That wasn’t good enough! Then they asked me if I’d been drinking—again—and then they asked me to blow into a tube in this little machine. I wasn’t sure I needed to do this, but I’d heard if you refuse to do this you’re immediately arrested. Where’s the ‘innocent until guilty’ here?” Bob decided that he’d better go along with the officers’ request and he did, but he complained the whole time. The end result was shocking to him, to say the least, “They said I was drunk! My . . . BAR . . . or something like that [we corrected him and explained that this was his blood alcohol concentration (BAC)] was .20.” BAC refers to the percentage of alcohol that is in the body as compared to the total blood supply. A BAC of 0.08 is equivalent to about four drinks consumed per hour for an average-sized individual.

“That meant zip to me, so they told me it seemed like I’d had about 10 drinks. 10 drinks! That’d make me a rummy, a lush! I only drink beer anyway. 10 beers in one hour! That’d kill me much less anyone else!” We confirmed the BAC results on Bob’s paperwork, sent to us by his probation officer. She sent him to us as part of his plea bargain in order to avoid jail time. Bob believed that he had no reason to be in our office. “Why don’t you concentrate on the real problems out there—the murderers, lying politi- cians, and the drunks that kill people while driving—huh? I’m a hardworking family man; I don’t belong in here with the winos and the loony tunes.” We pointed out the conditions of his probation and gave him the option to leave. Bob thought about this for a while and then finally stood up to leave.

Please see your e-book for Parts 2 and 3 of this Case Study. Dependence on multiple substances is known as polysubstance dependence, a common pattern among many substance-dependent individuals (Rosenthal & Levouni\ s, 2005).

Because the DSM-5 contains many substance-related disorders, it is not possible to review each one here. Instead, this chapter emphasizes the common features of psychoactive get81325_04_c04.indd 91 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous substance use by focusing on the four substances most frequently used by American college stu- dents: caffeine, nicotine, alcohol, and marijuana.

Let’s start by surveying the physical and psycho- logical effects of each of these substances.

Caffeine If you need proof that practically everyone uses psychoactive substances at one time or another, just consider caffeine. It is practically everywhere.

The only way you can avoid it is to shun coffee, tea, Red Bull, many popular soft drinks, cocoa, and chocolate. Even then, you may not succeed because caffeine is also found in headache, diet, and cold medications. Today, coffee remains the world’s most popular source of caffeine.

Action Caffeine belongs to a class of chemicals called stimulants, whose main psychoactive effect is to make us more alert. Within 45 to 60 minutes after drinking a cup of coffee or munching a chocolate bar, caffeine is absorbed from the stomach and the intestines. Once in the bloodstream, it causes blood pressure, pulse rate, and stomach acid pro - duction to increase. In the nervous system, caffeine acts as an antagonist to the neuro- inhibitor adenosine (Greden & Walters, 1997). Antagonists are chemicals that reduce the potency of other chemicals. In contrast, agonists are chemicals that increase the potency of other chemicals. (For example, Prozac [fluoxetine] is a serotonin agonist). Caffeine is also a powerful diuretic because it increases the excretion of liquid from the body. iStockphoto/Thinkstock Caffeine can be found in products such as coffee, tea, soft drinks and chocolate.

Within 45 to 60 minutes of consuming substances with caffeine, its effects can be felt throughout the body. get81325_04_c04.indd 92 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous Figure 4.1: Some common sources of caffeine Data from Consumer Reports (1997), “What caffeine can do for you - \ and to you”, Consumer Reports on Health, vol. 9, no. 9, p. 97, 99–101, as appeared in Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 6.1, p. 238. Caffeine (mg) 025507 5 100 125 150 175 200 Espresso, 2 oz Regular coffee, brewed, 6 oz Instant coffee, 6 oz Coffee Jolt Cola, 12 oz Mountain De w, 12 oz Surge, 12 oz Coca-Cola Classic, 12 oz Pepsi, 12 oz Jav aW ater, 12 oz Water Joe, 12 oz Jav a Juice, 12 oz XTC Juice, 12 oz Soft Drinks Black tea, 6 oz Green Tea, 6 oz Te a Aspirin-Free Excedrin Anacin NoDoz Maximum Strength NoDoz Medications Source of Caffeine Health Effects Although it is widely used and generally regarded as safe, caffeine may still have adverse effects on health (Benowitz, 1990). For example, it increases the production of stomach acid, which may worsen digestive disorders and can cause acid reflux (“heartburn”).

Insomnia, poor sleep, and anxiety are also the potential results of overuse of caffeine (Judelson, Armstrong, Sokmen, Roti, Casa, & Kellogg, 2005; Ksir, Hart, & Oakley, 2008). get81325_04_c04.indd 93 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous Psychological Effects Because caffeine is a stimulant, many people consume drinks containing it to combat\ drowsiness, increase alertness, and boost energy. Paradoxically, many people also consume caffeine to relax. It is possible that the relaxing effect of caffeine is not the result of its chemi- cal action but of expectancies and social reinforcements. If we expect caffeine to be relaxing, it probably will be. See Figure 4.1 and Table 4.1 for some examples of other stimulants.

Nicotine Nicotine is the primary psychoactive ingredient in tobacco, a plant that has grown in the Americas for centuries. Let’s look at a few statistics to put tobacco\ use into perspective.

Despite the fact that the numbers for tobacco usage have decreased over the past few years, “in 2009 nearly 1 in 3 male high school students (30%) and more than 1 in 5 female high school students (22%) used some type of tobacco in the month before they were surveyed. About 1 in 5 students (20%) were consid- ered current cigarette smokers.

More than half of these students (51%) reported they had tried to quit smoking during the past year. Cigar smoking was also common among high school students (about 14%)” (Ameri - can Cancer Society, 2011).

Action Nicotine is a powerful stimulant, so toxic that it has been used as a na\ tural insecticide. A small amount instantly kills a variety of insects. In humans, nicotine i\ s one of the fastest- acting psychoactive substances. Within seconds of a smoker ’s puffing on a cigarette, nic - otine reaches the smoker ’s brain (Benowitz, 1996). It activates specific receptors in the midbrain that produce increased arousal. The end result is similar to the one produced by caffeine—smoking makes people more alert and less drowsy.

Health Effects Carbon monoxide, the poisonous gas found in automobile exhaust emissions, is also pres - ent in cigarette smoke. It reduces the smoker ’s oxygen supply, thereby affecting the heart and other circulatory organs. Tar (the organic chemicals suspended in smoke droplets) contains several known carcinogens (substances that can cause cancer). Many other dan- gerous substances, such as formaldehyde (a well-known carcinogen) and nitric oxide (a poisonous gas), are also found in tobacco smoke.

The effects of smoking on health have been known for decades. In 1948, researchers began a prospective study of more than 5,000 people living in Framingham, Massachusetts. Hemera/Thinkstock As with substances administered through a needle, our bodies physiologically react to nicotine within a matter of seconds. get81325_04_c04.indd 94 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous Their aim was to identify the factors that contribute to heart disease. \ The now-famous Framingham Heart Study revealed a number of risk factors (characteristics that seem to be associated with an increased risk of disease). Somewhat unexpectedly, at least at the time, high among those risk factors was smoking (Dawber, 1980). The Framingham study was the first evidence that tobacco smoking was related to heart disease. It was followed by a study of 8,000 men of Japanese descent, which found smoking also to\ be a risk factor for stroke (brain damage caused by the blocking or bursting of blood vessels i\ n the brain; Abbott et al., 1986). Smokers have three times as many strokes as people who have never smoked. A 34-year follow-up of the Framingham study shows a continuing associatio\ n between smoking and a range of diseases years after smoking ceases (Freund, Belanger, D’Agostino, & Kanne, 1993).

In addition to heart disease and stroke, smoking is a risk factor in respiratory diseases such as bronchitis and emphysema (Burchfield et al., 1995), in stomach ulcers, and in diseases of the mouth (Brannon & Feist, 1992). Exposure to the smoke of other people’s cigarettes, pipes, and cigars (passive smoking) is also a health risk, especially for young children (Ksir et al., 2008).

According to the World Health Organization (WHO), tobacco is the second leading cause of deaths all around the globe. The WHO estimates that 10% of all adult deaths are smok- ing related, which comes out to about 5 million people each year. This number is expected to grow to 8 million by 2030. Half of all smokers will die from their tobacco use (World Health Organization, 2010). In 2004, the World Health Organization estimated that 1.1 billion people are addicted to nicotine (Hasman & Holm, 2004).

Although smoking is directly related to strokes, heart disease, and high blood pressure as well as several types of cancer (George & Weinberger, 2008; Hymowitz, 2005), the best- known link is the relationship between smoking and lung cancer.

Psychological Effects Despite nicotine’s arousing effects, most smokers, like most coffee drinkers, claim that they smoke to relax. Some research suggests that smoking may actually increase stress lev - els (Parrott, 2000). On the contrary, some studies reveal that smoking is relaxing and that smoking increases under stressful circumstances (Hughes, 2005). As with coffee drinking, the relaxing effects of cigarette smoking may be, at least in part, the result of expectancies and social reinforcement.

Personality may play a role in nicotine use. Despite the well-known health risks, millions of people continue to smoke. Hans Eysenck (1991) suggested that this p\ henomenon may be partly explained as a behavioral expression of the personality trait of extroversion.

According to Eysenck, extroverts are born with low levels of arousal. The experience of low arousal is perceived as unpleasant, so extroverts continuously seek stimulation— and smoking is a source of stimulation. Not all extroverts smoke, of course. There are other ways to raise arousal; some may drink lots of coffee. However, once extroverts start smoking (because of peer pressure, rebelliousness, or for some other reason), they are likely to continue because smoking provides the stimulation they crave (Breslau, Kilbey, & Andreski, 1993). get81325_04_c04.indd 95 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous Nicotine, as a stimulant, belongs to the same class of substances as amp\ hetamines, cocaine, and MDMA, also known as “ecstasy,” which are described in Table 4.1.

Table 4.1: Examples of stimulants (other than caffeine and nicotine) NameDescription Amphetamine A synthetic (manufactured) compound that comes in legal prescription versions and illegal street versions, such as “speed.” Amphetamine powder can be inhaled (“snorted”) or injected. Amphetamines enhance neurotransmitter concentration, especially norepinephrine and dopamine.

This increased concentration produces alertness and arousal. Originally intended as an asthma medication, amphetamines still have several medical uses. For example, drugs such as Adderall (dextroamphetamine) and Ritalin (methylphenidate) may be prescribed for people with attention deficit/hyperactivity disorder (discussed in Chapter 11); and because they suppress appetite, they are sometimes used as diet aids. Large doses of amphetamines can also be fatal.

Cocaine Derived from the South American coca plant, cocaine, or coke, comes in several forms and was once an ingredient in Coca Cola (Musto, 1992).

Cocaine produces stimulatory effects similar to those produced by amphetamines. Also like amphetamines, cocaine can be injected, snorted, or smoked in forms known as free-base and crack. Cocaine acts to enhance the action of dopamine and other neurotransmitters, thereby increasing arousal while at the same time producing a variety of psychological effects including (after prolonged use) paranoia, anxiety, panic attacks, and even a psychotic disorder (Yudofsky, Silver, & Hales, 1993). Withdrawal does not seem to produce symptoms unless cocaine use extends over a considerable period (Gawin & Kleber, 1992). Similar to amphetamines, cocaine can be fatal in large doses (Harlow & Swint, 1989). In 2010 about 1 million people had cocaine dependence in the United States (NSDUH, 2011).

MDMA MDMA (3, 4-methylenedioxymethamphetamine), also known as “ecstasy” is technically a stimulant but is often considered to be a hallucinogen as it produces hallucinogenic effects. This drug is often used in clubs and at raves as it provides users with a boost in energy that allows them to go on dancing for extended time periods. MDMA has no medicinal effects and can lead to many physical problems, including increased blood pressure and heart rate, which can lead to cardiac arrest (Ksir et al., 2008).

Alcohol Alcohol (known more accurately as ethanol) is the second most commonly used psy- choactive substance in the United States and perhaps in the world. It is estimated that 2 billion people use alcohol (National Survey on Drug Use, 2008). It is found in wine, liquor, spirits, beer, cider, and many cold medications. Unlike smoking, alcohol use is positively correlated with educational attainment. College graduates drink more than those who ended their education after high school (although college stu\ dents with low marks drink more than high-performing students; Presley & Meilman, 1992). get81325_04_c04.indd 96 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous International comparisons suggest considerable cross-cultural variability in alcohol consumption depending on availability and cultural prohibi- tions (Helzer & Canino, 1992; Yamamoto, Silva, Sasao, et al., 1993).

In all ethnic groups, males are much more likely than females to be binge drinkers (Presley & Meilman, 1992). Women, however, appear to be closing the gap (Grucza, Bucholz, Rice, & Bierut, 2008). This also puts them at risk for other drug use, where they also seem to be catching up to men (Degenhardt et al., 2008). However, the gap between men and women still exists. Why might that be? First, blood levels of alcohol build up more quickly in women than in men of the same size because women have less of the enzyme— known as alcohol dehydrogenase, or ADH— that helps break down alcohol in the stomach before it enters the bloodstream (Brady & Back, 2008; Ksir et al., 2008). Second, many women do not drink when they are pregnant because of the now well-known fact that alcohol can cause birth defects (CDC, 2011).

Action Chemically, alcohol is a depressant. It lowers arousal and makes people drowsy (Yi, 1991).

Some of the other depressants included in the DSM-5 are described in Table 4.2.

Alcohol exerts a variety of effects on the central nervous system, but one of its most important is to reduce inhibition, which is controlled by the GABA neurotransmitter sys - tem (note that GABA stands for gamma-amino butyric acid; the “gamma” is typically abbre - viated with the Greek letter for gamma). The result is that drink - ers lose some degree of self- control. Alcohol dilates blood vessels, decreases blood pres - sure, lowers heart rate, and slows respiration. Although small amounts of alcohol are exhaled as vapor by the lungs, which can be measured by road - side breathalyzers, most of the ingested alcohol goes to the liver, where it is gradually bro- ken down (metabolized) and Sean Murphy/Lifesize/Thinkstock Males are more likely to be binge drinkers than females, partly due to the enzyme ADH (alcohol dehydrogenase) that builds up more quickly in women than men. MedicalRF.com/Getty Images GABA receptors on the cell surface. get81325_04_c04.indd 97 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous excreted. The average person can metabolize about one “standard drink”—the equivalent of one 12-ounce glass of beer, one 5-ounce glass of wine, or 1 ounce of 90-proof liquor—per hour. (We will discuss the BAC a bit later in this chapter.) Neither black coffee nor splashing cold water on one’s face makes any difference in the rate at which alcohol is metabolized; there is no quick way to sober up.

Health Effects Moderate amounts of alcohol, especially red wine, may reduce the likelihood of coronary heart disease (Kinsella, Frankel, German, & Kanner, 1993). On the other hand, chronic use of alcohol can damage the heart and just about every other organ in the body (Ksir et al., 2008). Alcohol irritates the digestive system, causing inflammation and bleedin\ g.

Prolonged and intensive use of alcohol can turn the liver into nonfunction\ ing, fibrous tissue. This syndrome is known as cirrhosis. A very high blood alcohol level can be fatal, although most people become unconscious before drinking enough to kill themselves.

Heavy drinking during pregnancy can put a fetus at risk of developing fetal alcohol syndrome (FAS), which is marked by intellectual disabilities, hyperactivity, facial defor - mities, heart defects, and organ malfunctions (Grilly, 2006; Finnegan & Kandall, 2008).

Even when they consume the same amount of alcohol, African American women and female members of certain Native American tribes are more likely to have children with fetal alcohol syndrome than are members of other groups (Gordis, 1991). Their increased vulnerability appears to be the result of genetic differences in alcohol metabolism (Gor - dis, 1991).

Psychological Effects Moderate amounts of alcohol make most people feel talkative and relaxed. Even though drinkers may relax, even modest amounts of alcohol can affect cognition (Ksir et al., 2008).

After a few drinks, we concentrate on only the immediate and the most obvious cues in our environment, ignoring complexities and long-term consequences. For example, y\ ou may feel like talking back to a professor or to your supervisor at work, but a sober consider - ation of the consequences will probably inhibit you from actually saying anything. Under the influence of alcohol, however, you may not consider the long-term consequences and just lash out. This narrowing of focus to the immediate is called alcoholic myopia (Steele & Josephs, 1990). This can lead to having unprotected sex and inappropriate, even danger - ous, acts of aggression (National Center on Addiction and Substance Abuse at Columbia University [NCASA], 2007), for example.

As the amount of alcohol in the bloodstream builds, vision becomes blurred, hearing grows less acute, and motor control begins to break down. It is these effects that make drinking and driving so dangerous. Indeed, alcohol was associated with around 31% of all automobile accident fatalities in 2007 (National Highway Traffic Safety Administration [NHTSA], 2007).

The level of cognitive and motor impairment produced by alcohol depends on its con - centration in the blood. Concentrations below 0.05% of blood by volume u\ sually produce feelings of relaxation, with minimal cognitive or motor effects. Higher concentrations affect judgment and motor coordination. Figure 4.2 shows the relationship between blood alcohol concentration (BAC) and body weight. get81325_04_c04.indd 98 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous Figure 4.2: Approximate blood alcohol concentration (BAC) and body weight The legal limit for BAC is 0.08% in most states. For people younger than 21 years of age, some states have set a BAC limit of 0.01%.

From Insel, P. M., & Roth, W. T., Core Concepts in Health 10th ed., Mayfield Publishing Company, 2000, p. 254. Reprinted by permission. 1 hour 2 hours 3 hours 4 hours 1 hour 2 hours 3 hours 4 hours 1 hour 2 hours 3 hours 4 hours 1 hour 2 hours 3 hours 4 hours 1 hour 2 hours 3 hours 4 hours 1 hour 2 hours 3 hours 4 hoursTotal Drinks 01 234567 8 1 hour 2 hours 3 hours 4 hours Time from first drink 90–109 lb(0.00%) Not impaired (0.01–0.04%) Sometimes impaired (0.05–0.07%) Usually impaired (0.06 and up) Al ways impaired 11 0–129 lb 130–149 lb 170–189 lb 210 lb & o ver 150–169 lb 190–209 lb BA C Zones:

N S U A N N N N N N N N N N N N S S S S S S S S S S S S S S SSS S S S S S S S S S U U U U U U U U U U U U U U U U U U U U U U U U U U U A A A A A A A A A A A A A A AA A AAA A A AA A AA A get81325_04_c04.indd 99 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous Not only is judgment affected by alcohol, but so are the attributional processes required to interpret and control emotions (Stritzke, Lang, & Patrick, 1996). For example, alcohol makes some people feel sexually aroused. Because their judgment is impaired, they may interpret innocent signs as indicating that another person feels the same way. Couple this with disinhibition, and it is not surprising that people influenced by a\ lcohol may do things they would never do while sober. It is primarily alcohol’s disinhibiting effect that makes people believe that it is “stimulating,” even though it is a depressant. Excessive disinhibi- tion can sometimes lead to aggression (Bye, 2007). Aggression, combined with impaired judgment, makes alcohol a factor in child abuse (Hall & Webster, 2002), as well as in many suicides, murders, and rapes, especially “date rapes” (Modestin, Berger, & Ammann, 1996; Painter, 1992). See Table 4.2 for a summation of depressants other than alcohol.

Table 4.2: Depressants other than alcohol Name Description Sedatives, hypnotics (sleep- inducing drugs), and anxiolytics (antianxiety drugs) Barbiturates (Seconal, Nembutal, and others), were first used in 19th-century Germany as sleeping aids. Benzodiazepines (e.g., Valium) are considered safer than barbiturates. The main effect of all sedative and anxiolytic drugs is to depress bodily functions. At low doses, these drugs are calming and promote sleep, but they can affect memory and interfere with psychosocial functioning (Warneke, 1991). The abrupt cessation of any of these drugs after prolonged use can cause neurological symptoms, including seizures. Because alcohol, sedatives, and anxiolytics all affect the GABA system (McKim, 1991), mixing alcohol and these drugs produces a strong and potentially deadly effect (Fils-Aime, 1993).

Opioids Opioid is the general term for substances derived from the opium poppy plant. Known as opiates or narcotics, these include opium, morphine, and heroin; synthetic variants, such as methadone; and naturally occurring brain substances, such as beta-endorphins (Jaffe, 1991). All opioids are habit-forming.

Although they may produce a brief feeling of elation, opioids are depressants (Barinaga, 1992). There is also evidence that opioids reduce the functioning of the immune system, thereby lowering resistance to disease.

Cannabis Cannabis is actually a short name for Cannabis sativa, a type of hemp plant that produces several psychoactive substances. Marijuana (also known as pot, weed, an\ d many other names) is a mixture of the dried shredded flowers and leaves of the plant. Hashish is a sticky resin obtained from cannabis flowers. Cannabis users usually roll the substance into a cigarette known as a joint or smoke it in a pipe. get81325_04_c04.indd 100 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous The psychoactive ingredient in marijuana is delta-9- tetrahydrocannabinol, usually called THC. Ordinary mari - juana contains about 3% THC, but some types can contain 20 times as much. At such high doses, THC can produce dis- torted sensations and percep - tions (hallucinations). Techni- cally, this makes cannabis a hallucinogen, but, as previ- ously noted, the DSM–5 clas- sifies it in a separate category because perceptual distortions do not always accompany can - nabis intoxication. Several hal - lucinogens are described in Table 4.3.

Table 4.3: Common hallucinogenic substances Name Description MDMA Widely known as “ecstasy,” MDMA has both hallucinogenic and amphetamine- like stimulating qualities. MDMA destroys neurons, especially those containing dopamine. It not only produces hallucinations but also a loss of motor control (Fischer, Lankford, & Galea, 1995).

Natural (plant-derived) substances Psilocybin (found in certain mushrooms), DMT (from the bark of the South American virola tree), mescaline (a cactus derivative), and other naturally occurring hallucinogens produce varying degrees of cognitive distortions depending on their concentration and on users’ expectations. (People who expect to see changing colors or bright lights are more likely to experience these sensations than those without such expectations.) LSD Lysergic acid diethylamide is one of the most powerful hallucinogens. The physical effects of LSD are similar to those of stimulants: increased heart rate and blood pressure, loss of appetite, sleeplessness, and dry mouth. LSD’s psychological effects depend on the amount ingested, individual differences, expectations, and the social context. Typical reactions include rapid mood swings, distortions in time, and hallucinations. Sensations become confused, and some people claim to “hear” colors and “see” sounds (a phenomenon known as “synesthesia”). People who find such sensory experiences frightening label their experience a “bad trip” (American Psychiatric Association [APA], 2000).

PCP Because its profile of psychological effects differs from those of LSD and MDMA, the DSM–5 puts phencyclidine (PCP) in a different category. Yet PCP is also a powerful hallucinogen. Widely known as angel dust, PCP was developed in the 1950s as a surgical anesthetic. However, many people given PCP had hallucinations. Hemera/Thinkstock Marijuana comes from the leaves of the Cannabis plant, as pictured here. Although cannabis is technically a hallucinogen, the DSM–5 places it in a separate category (Cannabis-related Disorders) because distorted perceptions do not always occur during cannabis intoxication. get81325_04_c04.indd 101 12/5/13 3:58 PM CHAPTER 4 Section 4.1 Psychoactive Substances Are Ubiquitous Cannabis is one of the oldest crops cultivated by human beings (see Grinspoon & Bakalar, 1993, for a history of marijuana). Ten-thousand-year-old clay pots unearthed in Taiwan were found to have strands of hemp fiber in their decorations. For centurie\ s, and until fairly recently, hemp fiber was a major source of cloth (the first Levi jeans were made of hemp), rope, canvas, and paper.

Action Within a few minutes of inhaling cannabis smoke, users experience dry mouth, rapid heartbeat, some loss of coordination, and slower reaction times. Blood vessels in the eyes expand, and blood pressure rises. Once in place, THC stimulates chemical reactions that produce the euphoria that users experience when they smoke cannabis.

Health Effects Many people use cannabis regularly with little obvious effect on their health. In fact, the most common physiological effects reported by cannabis users are feelings of thirst and hunger (“the munchies”). However, cannabis smoke contains many of the same ingre- dients as tobacco, so cannabis smoking can result in the same respiratory problems as cigarette smoking: cough, colds, and lung disease. In fact, because cannabis \ smokers try to keep the smoke in their lungs as long as possible, smoking a marijuana joint may actu - ally have a greater effect on respiratory health than smoking a cigarette. Cannabis also increases blood pressure and heart rate, so it may have particularly negative effects on people with heart or circulatory diseases (Hall, 2009; Brick 2004).

Many regular users of marijuana over the past few years have either demonstrat\ ed mari - juana abuse, or become physiologically dependent (meaning they develop a tolerance for it and demonstrate irritability and restlessness when they stop using [Chen et al., 2005]).

The 2011 National Survey on Drug Use and Health provides the following statistics:

“Marijuana was the illicit drug with the highest rate of past-year dependence or abuse in 2010, followed by pain relievers and cocaine. Of the 7.1 million persons aged 12 or older classified with illicit drug dependence or abuse in 2010, 4.5 million had marijuana or hashish dependence or abuse (representing 1.8 percent of the total population aged 12 or older, and 63.0 percent of all those classified with illicit drug dependence or abuse), 1.9 million persons had pain reliever dependence or abuse, and 1.0 million persons had cocaine dependence or abuse” (NSDUH, 2011, p. 70).

Psychological Effects The psychological effects of cannabis are highly variable. They depend on the amount of THC ingested, the expectations of the individual, and the social context\ . Some people feel nothing at all when they smoke marijuana. Most report feeling lazy, relaxed, and mildly elated (a state usually summarized as feeling “stoned”). Distort\ ed perceptions (sights, sounds, time, and touch) have also been reported (Mathew, Wilson, Humphreys, & Lowe, 1993). Occasionally, cannabis users suffer sudden feelings of anxiety and have paranoid thoughts (Ray & Ksir, 1993). A 2007 meta-analysis estimated that cannabis use is statisti - cally associated, in a dose-dependent manner, to an increased risk in the development of psychotic disorders, including schizophrenia (Moore et al., 2007). get81325_04_c04.indd 102 12/5/13 3:58 PM CHAPTER 4 Section 4.2 Why Are Psychoactive Substances So Popular? 4.2 Why Are Psychoactive Substances So Popular? Why do we use psychoactive substances? According to ethologists, scientists who observe natural behavior in humans and animals, substance use is a “displacem\ ent” activity, some - thing we do in place of another behavior. For example, psychoanalysts view smoking as a way of obtaining oral gratification, a displacement for the breast. Such simple explana - tions, however, hardly do justice to the complex web of factors controlling substance use.

Perhaps the most obvious reason for using a substance is to change our state of conscious - ness. If we need to get started in the morning or if we are having trouble concentrating on our work, a cup of coffee or a cigarette may help. Similarly, when we are tense, alcohol or cannabis may help us to relax. In other words, we use psychoactive substances to produce specific psychological effects.

Although they are important, the psychological effects of substances are only part of the story. Substance use is the complex result of several interacting factors: exposure and avail - ability, reinforcement, expectancies, social and cultural context, and biological variab\ les.

Modeling and Availability Before we can use a substance, we must first know that the substance exists a\ nd, second, have access to it. In the case of caffeine, modeling is almost universal. Parents, friends, practically everyone uses caffeine in one form or another. Alcohol use is also widely mod- eled. Children can identify the smell of alcohol (beer, wine, or whiskey) by the age of 6 (Noll, Zucker, & Greenberg, 1990).

Because we see so many people using caffeine, alcohol, and nicotine, often in happy sur - roundings, and because these substances are heavily promoted in the media and by peers, it is not surprising that most of us decide to give at least one of them a try. Contrast the familiarity and availability of caffeine, nicotine, and alcohol with our knowledge of and access to amphetamines.

Amphetamines are also stimu- lants, but they are not as widely used. Few of us see our parents or friends using them, and they can be legally obtained only with a doctor ’s prescription. In addition, marijuana is legal in some countries but not in oth - ers. Therefore those individuals who have been exposed to mari - juana will be more familiar with it and its usage than those peo - ple who live in other countries where marijuana is illegal. Med- ical marijuana usage remains part of the national debate in the United States. © Jonathan Blair/CORBIS The effects of modeling are prominent among caffeine, alcohol, and nicotine use. In this photograph, many of the quarry workers are taking a smoke break, thus showing how substances are promoted in the media and by one’s peers. get81325_04_c04.indd 103 12/5/13 3:58 PM CHAPTER 4 Section 4.2 Why Are Psychoactive Substances So Popular? Reinforcement Modeling and availability might determine which substances we are most likely to try, but other factors determine whether we will keep using those we do try. One of the most important is the positive reinforcement we get from changing our mental state through the use of a substance (Jaffe & Anthony, 2005; Volkow, 2005). These changes in mental state are perceived as pleasurable because they stimulate the brain’s “pleasure center,” the part of the brain that gives rise to subjectively pleasant feelings (Jaffe & Anthony, 2005; Olds, 1956). Although the exact location of the pleasure center is a matter of debate, it seems to be closely related to the dopamine system (Jaffe & Anthony, 2005). One of the reasons that people continue to use substances is to experience the reinforcing feelings produced when substances stimulate the brain’s pleasure center (see Figure 4.3).

Figure 4.3: The chemical process of dependence on nicotine Nicotine stimulates neurons to release dopamine, which is associated with pleasure. Receptor sitesDopamine Tr ansmitting ner ve cell Nerve signal Ner ve ending Receiver cell Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 6.4, p. 255. get81325_04_c04.indd 104 12/5/13 3:58 PM CHAPTER 4 Section 4.2 Why Are Psychoactive Substances So Popular? The reasons for using a substance may change over time. Consider cigarette smoking, for instance. Most of the time, people find their first experience unpleasant. The first few ciga- rettes may cause coughing, dizziness, nausea, even vomiting. It is amazin\ g that anyone would wish to repeat the experience, especially since most adolescents know the health risks before they light up their first cigarette (Ksir et al, 2008; Quadrel, Fischhoff, & Davis, 1993). Yet many go on to become smokers. One reason is peer group acceptance. Teenag - ers whose siblings or friends smoke are more likely to begin smoking than are those with no peers to emulate or impress (U.S. Department of Health and Human Services, 1990).

Because smoking is followed by peer approval, as well as by desired changes in mental state, it is reinforced. Exactly the same group dynamics reinforce the use of alcohol, canna - bis, and other substances. Social reinforcement is an important determinant of substance use because substances are an integral part of social activity.

In addition to positive reinforcement, negative reinforcement (escape from an aversive state) also plays an important role in substance use. Feeling tired or unable to concentrate is an unpleasant feeling. If a cigarette or a cup of coffee dissipates our fatigue and makes us more alert, we will be reinforced to try the same “cure” again the next time we feel tired or distracted. Similar negative reinforcement comes from substances that reduce feelings of anxiety and depression (National Survey on Drug Use, 2011).

Expectancies Expectancies, what people expect when they use a drug or substance, also influence usage (Leventhal & Schmitz, 2006). How can a substance like nicotine, which increases blood pressure, pulse rate, and arousal, help people relax and fall asleep? We have dis - cussed part of the answer; increases in arousal are reinforcing for low-arousal people, and stimulants affect the brain’s pleasure center, releasing pleasurable endorphins. But there is another factor operating as well—cognitive expectancies. If we bel\ ieve that a cup of tea will help us to sleep or that a cigarette will help us relax, then they probably will have these effects even though both tea and cigarettes contain stimulants. These expectancies about the effects of substances are the result of direct experience with a substance as well as exposure to parents, peers, and the media (Patrick, Wray-Lake, Finlay, & Maggs, 2010; Song, Ling, Neilans, & Glantz, 2007).

Social and Cultural Context As stated, the reinforcement produced by peer group acceptance is an important deter - minant of substance use, but economic factors are also related to substance use (Franklin & Makarian, 2005). For instance, people in lower socioeconomic classes \ have higher sub - stance abuse rates (Franklin & Makarian, 2005).

It is also important to note that substance use is a particularly seriou\ s problem for some ethnic groups (see Figure 4.4). Therefore, understanding substance use, and helping peo - ple with substance-related problems, requires sensitivity to the ways in which cultural norms affect substance-related behavior (Caputo, 1993; Ksir et al., 2008). get81325_04_c04.indd 105 12/5/13 3:58 PM CHAPTER 4 Section 4.2 Why Are Psychoactive Substances So Popular? Figure 4.4: Sociocultural landscape: Substance abuse statistics Race Percentage Who Exhibit Substance Abuse or Dependence 30 25 20 15 10 5 0 Native Americans 20.2% 9.8%9.6% 8.3% Hispanic Americans White Americans African Americans Asian Americans 4.7% How do races differ in substance abuse and dependence? In the United States, Native Americans (age 12 years and older) are much more likely than members of other ethnic cultural groups to abuse or be dependent on substances. Conversely, Asian Americans are considerably less likely than members of other groups to display substance abuse or dependence (NSDUH, 2005).

Adapted from Corner, R. J. 2007. Abnormal Psychology. 6e. NY: Worth Publishers, Fig. 12.1, p. 338. Reprinted by permission.

Biological Variables and Individual Differences Some people may be genetically vulnerable to suffer from drug abuse (Rutter, Moffitt, & Caspi, 2006). If they are exposed to certain substances, people with such predispositions are more likely than others to use again. For example, genetics certainly play \ a role in alcohol use (Walters, 2002). A possible mechanism for a predisposition to alcoholism is the Dopamine 2 (D2) gene found on chromosome 11 (Blum & Noble, 1993; Preuss, Zill, Koller, Bondy, & Soyka, 2007). About 66% of excessive alcohol users (people whose alcohol use has caused them problems) carry this gene, whereas it is present in only 20% of the rest of the population. The existence of the D2 gene does not mean that some people are born “alcoholics.” Other genes may be connected to substance-related disorders (see Kreek, 2008). In addition, an individual with a D2 gene might never drink beca\ use of religious reasons, choice, a pre-existing medical condition, or for some other reason. The same gene is also associated with other substances, including nicotine and opioids\ , and with compul - sive binge eating and gambling (Blum, Sheridan, Wood, et al., 1996).

Some people with the D2 gene may never develop substance-related problems because they have also inherited competing dispositions that counteract the effects of D2. For exam- ple, as many as half of all people of Asian descent lack one of the enzymes that helps break down alcohol in the liver. When they drink alcohol, they experience an “alcohol-flush get81325_04_c04.indd 106 12/5/13 3:58 PM CHAPTER 4 Section 4.3 Potential Problems of Sustained Substance Use syndrome” that includes a blushing red skin, dizziness, and nausea (Agarwal & Goedde, 1991). The alcohol-flush syndrome may be unpleasant enough to prevent affected people from drinking, even if they have inherited the D2 gene.

It is important to note that one-third of problem drinkers do not have the D2 gene. This suggests that there may be two different types of people who develop problems with alco- hol: (1) those with the D2 gene and a family history of excessive drin\ king, who develop alcohol-related problems early in life, and (2) those without the gene, whose drinking problems develop late in life and whose social and occupational functionin\ g is only mildly affected (Yoshino & Kato, 1996; Schuckit & Smith, 1996). Drinking in the second gr\ oup seems mainly affected by environmental factors (exposure, social reinforcement), whereas drinking in the first group may be influenced more by genetics.

4.3 Potential Problems of Sustained Substance Use The average American consumes 200 mg of caffeine per day, the equivalent of two strong cups of brewed coffee. Of course, many people consume much more. High caffeine con - sumption can induce caffeine intoxication, which is marked by restlessness, excitement, an inability to sleep, flushed face, muscle twitching, and in especially\ severe cases, ram - bling speech, heart rate abnormalities, and agitation (APA, 2013). Very large doses can even be fatal. Alcohol and cannabis also produce well-documented intoxication syn - dromes (APA, 2013).

You may know people who show no signs of intoxication even after consumin\ g signifi - cant amounts of alcohol and wonder why these people seem immune to its i\ ntoxicating effects. The answer is tolerance (the lessening of the body’s response to a drug after con- tinued use). As a result of tolerance, individuals using a drug will find that they begin to need greater and greater amounts in order to achieve the same effects as before, or even to achieve a lesser effect. Three beers may be enough to produce intoxication in a nonuser, whereas a much larger amount may have little or no effect on a habitual beer drinker.

People can develop tolerance to most (but not all) substances.

How much substance users consume, and how often, is partly determined by\ the amount of a substance in the user ’s body. For example, smokers adjust their habit to maintain a certain level of nicotine in their bodies. If nicotine levels fall below\ the desired level, they become irritable, restless, distractible, and hungry (Dodgen, 2005). These symptoms are known as nicotine withdrawal (APA, 2013). The DSM–5 also contains diagnostic crite- ria for alcohol withdrawal, which is marked by tremor, sweating, nausea, and anxiety.

In severe cases, people withdrawing from alcohol may experience disturbances in con - sciousness, including hallucinations (known as delirium tremens, or DTs). Withdrawal symptoms may be so severe that people continue using a substance just to avoid them. In such cases, substance use is being maintained by a form of negative reinforcement.

Substance Use Versus Substance Abuse Substance use, by itself, is not a psychological disorder. Substances present a psychologi - cal problem only when they produce adverse consequences. Consuming a glass of wine get81325_04_c04.indd 107 12/5/13 3:58 PM CHAPTER 4 Section 4.3 Potential Problems of Sustained Substance Use with dinner does not lead to adverse consequences for most people; thus, it is not a sign of a psychological disorder. In con- trast, drinking to the point of intoxication and missing classes several times a week for a num- ber of weeks could be a sign of what the DSM–5 refers to as a substance use disorder.

The DSM–IV–TR had separate categories for substance abuse and substance dependence. Substance dependence criteria included tolerance and with- drawal as well as loss of control (the feeling that once an indi - vidual began using a substance they were unable to stop, even if they intended to stop). The DSM-5 combined both categories into the new category Substance Use Disorder (APA, 2013). This new cat - egory codes the substance use disorder on a spectrum using the following specifiers:

Mild, moderate, and severe. In addition, the criterion that the individual had to have recurrent legal problems in order to qualify for the old substance abuse diagnosis has been eliminated from the DSM-5 (APA, 2013). It is now also somewhat more difficult to “qualify” for substance use disorder. In the DSM–IV–TR, to qualify for the old substance abuse diagnosis an individual had to satisfy minimally one criterion. I\ n the DSM-5 the individual must satisfy minimally two or more criteria. For the moderate subcategory an individual must satisfy minimally four or more criteria as opposed to satisfying three or more for the old substance dependence disorder.

Perhaps more importantly, a new criterion was added to the DSM-5 regarding substance use disorder: Craving, or a strong desire or urge to use a substance (APA, 2013). Craving implies physiological dependence which can lead to loss of control as well as intoxication.

Substance Dependence Chronic substance abuse may lead to a substance dependence. The DSM–5 uses the term dependence rather than addiction as addiction has pejorative con notations and, according to APA, has an uncertain definition (APA, 2013). (Substance dependence means much the same thing as addiction, an older term that has been seriously overused in recent years.) According to the DSM–5, all categories of substances except caffeine can produce dependence.

Once substance dependence forms, people begin to organize their lives around satisfying their craving. The chronic use of substances may also change body chemistry because Thomas Northcut/Lifesize/Thinkstock For most people, having a glass of wine with dinner does not lead to adverse consequences and therefore is not considered a psychological disorder. get81325_04_c04.indd 108 12/5/13 3:58 PM CHAPTER 4 Section 4.4 Overcoming Substance Dependence many substances actually replace the body’s nat- ural chemicals. When substances are discontin - ued, the body takes a while to restart its natural production. In the interim, the person experiences withdrawal symptoms.

Not all substances produce physical signs of tol - erance and withdrawal. The opposite is also true:

Tolerance and withdrawal can exist without the craving for a substance that marks dependence.

Scientists once thought that people who abuse alcohol enter an inevitable downward spiral in which they become increasingly dependent (Jell- inek, 1946), but we now know that alcohol abuse does not necessarily lead to dependence (DeWitt, Adlaf, Offord, & Ogborne, 2000; Schuckit, Smith, Anthenelli, & Irwin, 1993). What is still not entirely clear is why some alcohol abusers become depen - dent, whereas others do not (Sobell & Sobell, 1993; Vaillant & Hiller-Sturmhofel, 1997). It is impor - tant to emphasize that dependence is much the same disorder whatever the substance involved. 4.4 Overcoming Substance Dependence Substance use is often a difficult pattern to break. Even people who are highly motivated to quit may not necessarily succeed. This section illustrates the problems people face in overcoming substance depen- dence and maintaining recovery and offers some proposed solu - tions. Because the use of nico- tine and alcohol is so common, the main focus of this section is on these two substances, but the discussion also shows how lessons learned from helping people give up common sub - stances may be applied to less frequently used substances.

Practically all treatment pro - grams for substance depen- dence combine several differ - ent methods, a strategy known as multimodal treatment. The general idea is to wean people ©2013 Jeffrey Mayer/WireImage Glee actor Cory Moneith’s recent death resulting from substance abuse serves as yet another example of how difficult it is to overcome substance dependence. Hemera/Thinkstock Substance use or abuse is a difficult pattern to break, but there are a variety of treatment programs to wean people away from harmful substances. get81325_04_c04.indd 109 12/5/13 3:58 PM CHAPTER 4 Section 4.4 Overcoming Substance Dependence away from a substance; help them manage their craving; and give them the skills\ neces- sary to cope with social stress, anxiety, and other potential causes of substance abuse.

Stages in Overcoming Substance Dependence As summarized in Figure 4.5, people with substance dependence are thought to go through a series of stages in the process of recovery from substance dependence. This model was originally put forward by Lichtenstein and Glasgow (1992) to describe the process of quit- ting smoking, but it is applicable to practically any substance (see also Martin, Velicer, & Fava, 1996; Prochaska, 1996). From not even thinking about ceasing substance use and not thinking that they have a substance dependence (the precontemplation stage), people move through the contemplation stage, in which they are thinking about ceasing usage and are beginning to think that they have a substance dependence, to the actio\ n stage (in which they actually quit). In the final maintenance stage, they consoli\ date their treatment gains and attempt to avoid relapse. Most psychological treatment programs are aimed at the action stage, and the majority also addresses maintenance issues.

Figure 4.5: Lichtenstein and Glasgow’s stages of giving up a substance Precontemplation Contemplation Action Maintenance Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 6.6, p. 261. get81325_04_c04.indd 110 12/5/13 3:58 PM CHAPTER 4 Section 4.4 Overcoming Substance Dependence Detoxification Once the action stage is reached, the first step in many treatment programs is detoxifi- cation, removal of the substance from the body. Smokers must stop smoking; alcohol- dependent people must stop drinking; heroin users must stop injecting or snorting.

To minimize withdrawal symptoms and maximize the probability that an individual will continue treatment, detoxification is usually a gradual process (Wright & Thompson, 2002). Sometimes, people undergoing detoxification may be prescribed anxiolytics and antidepressants to help with the stress of the withdrawal process (Ksir et al., 2008). Care must be taken, however, to limit the use of these drugs to ensure that people do not give up one substance only to start using another. Residential facilities (hospitals, drug treat - ment centers) often provide the safest environment for people undergoing withdrawal.

However, inpatient treatment is more expensive than outpatient treatment (Bender, 2004), and there is little evidence that the extra expense necessarily produces better outcomes (Burdon, Dang, Prendergast, Messina, & Farabee, 2007; Smith, Kraemer, Miller, DeBusk, & Taylor, 1999). In addition, relapse rates are high for those patients who do not receive a treatment follow-up to detoxification (Polydorou & Kleber, 2008).

Detoxification does not, by itself, constitute a treatment. Many substance-dependent peo - ple go through cycles of detoxification followed by abuse and dependence followed \ by detoxification again (Vaillant, 1992). To break this cycle, clinicians may prescribe a medica - tion to block the action of the substance.

People who are dependent on alcohol may be prescribed a drug called Antabuse. If they take Antabuse and then consume alcohol, they will become quite ill—their h\ earts will race, they will vomit violently, and they may break out in soaking sweats. In theory at least, people who take Antabuse will stop drinking alcohol to avoid becoming ill (Grilly, 2006). Unfortunately, these aversive treatments rely on people’s actually taking the Anta- buse. A person who wants to drink without becoming sick needs only to stop taki\ ng the Antabuse—and that is just what many people do (Grilly, 2006; Børup, Kaiser, & Jensen, 1992; Jensen, Schmidt, Pedersen, & Dahl, 1991).

Substance Replacement and Maintenance Some forms of substance dependence may be so addictive that users settle\ for replacing a dangerous substance with a less dangerous one that they can stay on indefinitely. This is known as maintenance treatment. The most common drug maintenance program involves substituting the synthetic opioid methadone for the more dangerous opioid heroin (Dole & Nyswander, 1967; Warner, Kosten, & O’Connor, 1997). Methadone needs to be taken once a day, requiring either a daily trip to a clinic or take-home dosages. Although main- tenance treatment may help some people wean themselves off heroin, it is almost certain that participants in such programs will become dependent on methadone (McCance-Katz & Kosten, 2005). get81325_04_c04.indd 111 12/5/13 3:58 PM CHAPTER 4 Section 4.4 Overcoming Substance Dependence Self-Help Groups Self-help groups have a long history of treating people with substance dependence. Alcohol- ics Anonymous (AA), for exam- ple, has been offering a self-help program around the world since 1935 (Nathan, 1993). Al-Anon is a related organization that pro - vides support for the families of people dependent on alcohol (Galanter, 2008). There are simi- lar programs for people depen- dent on opioids and other sub - stances (Miller, Gold, & Pottash, 1989). The AA program usually progresses through a series of 12 steps. Alcohol-dependent people must first acknowledge their dependency, must then put their trust in a spiritual being (“a power greater than ourselves”), and must make amends to people whom they have harmed (Nace, 2008). Because people ar\ e not ran - domly assigned to AA or a control group, it is not possible to conduct controlled clinical trials on the effectiveness of AA.

Relapse Prevention Most substance abuse treatment programs have high relapse rates. For example, practi - cally all quit-smoking programs are successful at first, but after a time, 70% to 80% of participants begin smoking again. Some treatment programs attempt to improve on this by training people to deal with the potential causes of relapse before they occur. The main factor influencing relapse prevention and treatment efficacy seems to be treatment length.

Longer, repeated, and more intense treatments produce better results than brief treat - ments (Witkiewitz & Marlatt, 2007).

Treatment of Substance Dependence: State of the Art Despite the best efforts of generations of psychologists, substance dependence remains difficult to treat. A 25-year follow-up of men treated for heroin dependence found that 75% were either dead, in jail, or still abusing heroin; only 25% were substance-free (Hser, Anglin, & Powers, 1993). More recent data reveal that in the United States, the number of persons aged 12 or older needing treatment for an alcohol use problem (either abuse or dependence) was 18.5 million (7.3% of the population aged 12 or older; NSDUH, 2011, p. 70). Even though the NSDUH report does not discuss the difficulty of preventing alco- hol abuse or dependence relapse, practitioners and individuals with an alcohol abuse or dependence problem know the difficulty of maintaining recovery. In short, no single pro - gram seems to work for everyone. © John Van Hasselt/Corbis Many utilize self-help groups, like Alcoholics Anonymous, to overcome substance dependence. get81325_04_c04.indd 112 12/5/13 3:58 PM CHAPTER 4 Section 4.5 Prevention of Substance-Related Disorders Substance dependence is often associated with other psychological disorders (Higuchi, Suzuki, Yamada, et al., 1993; Kushner, Sher, & Beitman, 1990; McFall, Mackay, & Don- ovan, 1992). It is often difficult to determine whether substance abuse is the cause of another psychological disorder or its result, or both (Johnson, Freels, Parsons, & Vangeest, 1997). In most cases, however, it is necessary to treat any serious psychological disorders before people can moderate their use of substances. The problems of mentally ill chemi- cal abusers (MICAs) are especially severe (Kutcher, Kachur, Marton, et al., 1992). MICAs, who are most often young males, are generally poor, homeless, sickly, and likely to get into legal difficulties.

4.5 Prevention of Substance-Related Disorders Although they vary in their specifics, all clinical-based programs for substance depen - dence focus on the individual. The social forces maintaining substance abuse—peer pressure, lack of knowledge, advertising (in the cases of nicotine and alcohol\ ), and legal restrictions—are rarely addressed. Clinical programs are also expensive; they involve multiple sessions, and only limited numbers of people can be treated at one time. In contrast, prevention programs have the potential to save money because keeping dis - orders from developing is usually cheaper than treating disorders after they develop.

Prevention programs may benefit the most people who are unable to access or afford clinical treatment.

Legal Restrictions Perhaps the most straightforward approach to the primary prevention of substance abuse and dependence is to use the legal system. However, because legal restrictions on expo - sure to drugs have had limited success, public health authorities have argued that restrict - ing access might be a more effective means of preventing substance abuse (Jansen, 1996).

One approach to restrict access is to ban substance use in certain settings. Smoking, whi\ ch was once common in offices, restaurants, planes, and theaters, is now prohibited in most public areas. As the number of places where smoking is permitted decreases, smokers have fewer opportunities to pursue their habit. Thus, making smoking inc\ onvenient may reduce its prevalence (Levy, Chaloupka & Gitchell, 2004).

Health Education Programs Although people who use substances are usually aware of the health risks, they tend to believe that these risks apply more to other people than to themselves (Gibbons, McGovern, & Lando, 1991). This feeling of invulnerability, which applies to adults as well as adoles- cents (Quadrel et al., 1993), may explain why people continue to use dangerous substances even when they know that they are harmful (Gibbons et al., 1991). The main value of health warnings (such as the surgeon general’s warning on cigarette boxes or TV commercials get81325_04_c04.indd 113 12/5/13 3:58 PM CHAPTER 4 Chapter Summary that talk about the perils of drug use) is in moving those who use substances from the precontempla- tive to the contemplative stage of the substance- quitting process, at which point other, more pow - erful interventions take over.

Specific Educational Programs Global educational programs provide informa - tion about substances, but they do not address the factors that maintain substance use: peer pressure, mood changes, advertising, avoidance of withdrawal, and stress reduction. Specific edu - cational interventions designed to teach those at risk how to resist these influences and temp - tations, and how to deal with stress and with - drawal, may have a greater chance of succeeding (Ksir et al., 2008).

Worksite Programs As their name suggests, worksite programs are delivered to workers, and sometimes their fami- lies, at their places of employment. With the coop- eration of employers, workers are given time off to attend these programs and may even be rewarded for success. In an attempt at second - ary prevention, some employers also use chemical tests to screen employees for substance use. However, such programs raise certain ethical problems involving consent and disclo - sure of purpose (Forrest, 1997). Chapter Summary Psychoactive Substances Are Ubiquitous • Practically everyone has used a psychoactive substance at some time in t\ heir lives. These substances form a spectrum, from those that are commonly used, such as caffeine, to highly dangerous drugs such as crack cocaine. Caffeine, Alcohol, Nicotine, and Cannabis • Caffeine, nicotine, alcohol, and cannabis are the four psychoactive substances most commonly used by American college students. • Caffeine is found in many drinks, as well as in headache, diet, and cold me\ di - cations. Nicotine is the psychoactive ingredient in tobacco. Alcohol is found in wine, beer, spirits, and many medications. And cannabis is a type of hemp plant whose leaves may be ingested in a variety of ways. • Caffeine and nicotine are stimulants; they combat drowsiness, increase alertness, and help produce energy. © Bettmann/CORBIS Nancy Reagan’s famous “Just Say No” campaign brought health education and drug prevention programs to schools during the 1980s. get81325_04_c04.indd 114 12/5/13 3:58 PM CHAPTER 4 Chapter Summary • Alcohol is a depressant, which slows body processes and induces sleep. • Cannabis has a variety of stimulant and depressant effects. It also has the poten - tial to produce sensory and cognitive distortions. Health Effects of Common Substances • Although caffeine and nicotine may be dangerous to one’s health in large doses, they have not been linked to any specific illness. • At higher doses, alcohol can cause serious health problems, and cannabis smoke may be as dangerous as cigarette smoke. Psychological Effects of Common Substances • Although both caffeine and nicotine are stimulants, many people claim to find them relaxing. This may be a reflection of their ability to enhance the body’s natural opioids. • Relaxation may also be the result of cognitive expectancies and social reinforcement. • A third possibility is that some personality types (extroverts) are chronically underaroused, a state they find unpleasant. Because stimulants increase their arousal to “normal” levels, they find these substances produce pleasant feelings. Factors Influencing Substance Use • People begin to use substances such as nicotine, alcohol, and opioids pa\ rtially because of social conformity. • Certain personality traits—extroversion, for example—may also encourage people to use substances. Potential Problems of Sustained Substance Use • Using substantial amounts of many substances can result in intoxication. • Chronic use of substances may also produce tolerance, forcing users to continu - ally increase the amount they consume to achieve the same effect. • When one has a substance dependence, abruptly ceasing a habitually used sub - stance can produce the unpleasant symptoms characteristic of withdrawal. Overcoming Substance Dependence • First, the person must decide to change. Next comes an active attempt to\ change.

Finally, the new behavior must be maintained. • Most psychological interventions are aimed at the active stage; many also target the maintenance stage. • Practically all treatment programs aimed at substance abuse and dependence are multimodal (they combine several treatment methods). • Sometimes, replacing one substance with another, less dangerous one (replacing cigarettes with nicotine patches, for example) can assist the treatment process. • In addition to positive treatments, aversive conditioning has also been widely used to help people who are dependent on substances. Preventing Unhealthy Habits • Public health interventions have the potential to reach many more people at much less cost than psychological interventions. get81325_04_c04.indd 115 12/5/13 3:58 PM CHAPTER 4 Key Terms • Although they may be valuable in getting people to think about quitting,\ out - right prohibition and global educational programs have not proved successful in reducing substance dependence. • Worksite programs and self-help strategies have the potential to help many people give up substances. Critical Thinking Questions 1. Let’s assume that you are a regular coffee, tea, or cola drinker. How difficult would it be for you to quit drinking “cold turkey,” that is, to stop drinking these beverages completely, with no treatment interventions? 2. Some people believe that substance dependence is a moral flaw and is the fault of the dependent individual; they can stop whenever they like. What are your views on this perspective? 3. The chapter notes that some psychoactive substances cannot lead to physi\ ologi - cal dependence. Discuss your views on this. 4. Alcoholics Anonymous (AA) has been around for more than 70 years, and, in spite of no solid research support, the organization seems to be successful. How can a self-help group where no therapy is provided help someone stay sober and straighten out their lives? 5. Discuss your views on using psychoactive substances like methadone to tr\ eat opioid dependence. Key Terms agonist A chemical that increases the potency of other chemicals. alcohol (ethanol) The second most com- monly used psychoactive substance in the United States. alcohol dehydrogenase An enzyme that breaks down alcohol in the stomach and the liver. alcoholic myopia Narrowing of focus to the immediate. antagonist A chemical that reduces the potency of other chemicals. binge drinking Consumption, for a male, of five or more alcoholic drinks in a row on at least one occasion during a two-week period; for a female, it is four or more drinks. caffeine A stimulant; the most commonly used psychoactive substance in the United States. cannabis Marijuana or pot; a type of hemp plant that produces several psychoactive substances such as marijuana and hashish. delirium tremens (also known as the DTs) A symptom of alcohol withdrawal, which can include hallucinations, disorientation, insomnia, physical discomfort, shaking, and nausea. depressant A psychoactive substance that lowers arousal and makes people drowsy. detoxification Removal of the substance from the body, usually done in an inpatient setting. endorphins Body chemicals that inhibit pain and produce pleasure. get81325_04_c04.indd 116 12/5/13 3:58 PM CHAPTER 4 Key Terms ethologists Scientists who observe natural behavior in humans and animals. expectancies What people expect when they use a drug or substance. extroversion A personality trait com- monly found in people born with low levels of arousal. The experience of low arousal is perceived as unpleasant, so extroverts continuously seek stimulation. fetal alcohol syndrome (FAS) Disorder marked by intellectual disabilities, hyper - activity, facial deformities, heart defects, and organ malfunctions due to excessive alcohol consumption during pregnancy. hallucinogen A psychoactive substance that produces distorted sensations and perceptions (hallucinations). lysergic acid diethylamide (LSD) A very powerful hallucinogen. mentally ill chemical abusers (MICAs) Individuals, often young males, generally poor, homeless, sickly, and likely to get into legal difficulties, who misuse chemical substances. multimodal treatment Programs designed to cure substance dependence that com- bine several different methods. nicotine A psychoactive substance found in cigarettes; it acts quickly and is addictive. polysubstance dependence Dependence on multiple substances. psychoactive substance A chemical that alters our moods or behavior. stimulant A substance whose main psy- choactive effect is to make us more alert. substance use disorder A condition where the individual has a recurring pattern of substance-related difficulties. The more criteria the individual satisfies, the more likely the individual is physiologically dependent on that substance. substance dependence A medical condi- tion similar to addiction; the individual has problems living on a daily basis with- out using the substance. THC (delta-9- tetrahydrocannabinol) The psychoactive ingredient in marijuana. tolerance Body’s response to a drug wherein it takes more (sometimes less) of a psychoactive substance to achieve the same effect. withdrawal The physiological effects suf- fered by an individual once a psychoactive substance has been removed from the body. get81325_04_c04.indd 117 12/5/13 3:58 PM CHAPTER 4 get81325_04_c04.indd 118 12/5/13 3:58 PM