HSC ch.9 drug use and addiction

addiction

ADDICTION The most serious drug-related risks are addiction and impairment of daily activities. The drugs most often associated with addiction and impairment are psychoactive drugs—those that alter a person's experiences or consciousness. In the short term, psychoactive drugs can cause intoxication, a state in which, sometimes, unpredictable physical and emotional changes occur. A person who is intoxicated may experience Page 215potentially serious changes in physical functioning. His or her emotions and judgment may be affected in ways that lead to uncharacteristic and unsafe behavior. Recurrent drug use can have profound physical, emotional, and social effects. Although addiction is most often associated with drug use, many experts now extend the concept of addiction to other behaviors. Addictive behaviors are habits that have gotten out of control, with resulting negative effects on a person's health. The most characteristic feature of addiction is a loss of control caused by a disruption in the brain's system that regulates motivation and reward. It manifests as an unrelenting pursuit of a physical or psychological reward and/or relief through substance use or behaviors, such as gambling, despite unwanted consequences. Addiction involves craving and the inability to recognize significant risk or other problems with behaviors, interpersonal relationships, and emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment, addiction is progressive and can result in disabling or deadly health consequences. Looking at the nature of addiction and a range of addictive behaviors can help us understand similar behaviors when they involve drugs. What Is Addiction? Today scientists view addiction as a chronic disease that involves disruption of the brain's systems related to reward, motivation, and memory. Dysfunction in these systems leads to biological, psychological, and social effects associated with pathologically pursuing pleasure or relief by substance use and other behaviors. The American Psychiatric Association (APA) defines addiction as a "complex condition, a chronic brain disease that causes compulsive substance use despite harmful consequences." In addition to disorders related to drugs, the APA also includes a new category of behavioral addictions such as gambling disorder and Internet gaming disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the standard classification system used by mental health professionals.Page 216 Although experts now agree that addiction is more fully defined by behavioral characteristics, they also agree that changes in the brain underlie addiction. One such change is tolerance, in which the body adapts to a drug so that the initial dose no longer produces the original emotional or psychological effects. This process means the user has to take larger and larger doses of a drug to achieve the same high. The concept of addiction as a disease process, one based in identifiable changes to brain cells and brain chemistry rather than a moral failing, has led to many advances in the understanding and treatment of drug addiction. As noted, many researchers now view activities like gambling, eating, exercising, and sex as potential behavioral addictions, and some scientists assert that these activities release brain chemicals that cause a pleasurable rush in much the same way that psychoactive drugs do. The brain's own chemicals thus become the "drug" that can cause addiction. These theorists suggest that all addictions—whether to drugs or to pleasurable activities—have a common mechanism in the brain. In this view, addiction is partly the result of our own natural wiring. The view that addiction is based in our brain chemistry does not imply that people are not responsible for their addictive behavior. Many experts believe it is inaccurate and counterproductive to think of all bad habits and excessive behaviors as diseases. All addictions involve an initial voluntary step, and other factors such as lifestyle, personality traits, and environmental factors play key roles in the development of addiction. Diagnosing Substance Misuse and Addiction In general terms, substance misuse is use of a substance that is not consistent with medical or legal guidelines. Misuse is a broad concept and can include use of illegal drugs, prescription drugs in greater-than-prescribed amounts, another person's prescription drug, or a legal substance like alcohol in an unsafe manner. Some researchers distinguish between misuse and abuse on the basis of an individual's intent. For example, taking double a prescribed dose of sleeping medication because the first dose didn't seem to help would be an example of drug misuse. The situation in which a person takes multiple painkillers in an effort to get high would be considered drug abuse. However, either scenario could be dangerous, and any drug misuse carries the risk of negative effects. You do not have to be addicted to a drug or even misuse it more than once to suffer serious consequences. In the DSM-5, the APA provides criteria for diagnosing problems associated with regular drug use. Classifying a person as having a substance use disorder is not as simple as applying a label; instead, an individual is classified based on symptoms ranging from mild (an average college binge drinker) to severe (a person who is out of control). The latest version of the DSM dropped the past distinction between dependence and abuse in diagnosing drug-related disorders; however, both terms are still used in other contexts. Note that physical dependence, in a narrow sense, can be a normal bodily response to use of a substance. For example, regular coffee drinkers may experience caffeine withdrawal symptoms if they reduce their intake; however, that does not mean they have a substance use disorder. In the context of addiction and substance use disorders, the National Institute on Drug Abuse specifies that dependence may involve this type of physical dependence but must also meet other criteria, such as compulsive use. Addiction is a psychological or physical dependence on a substance or behavior that has undesirable, negative consequences. According to the APA, people with addiction are focused on a particular drug or behavior to the point that it takes over their lives; they use the substance or engage in the behavior compulsively despite knowing it will cause problems. We refer to the DSM-5 definition of substance use disorders in this chapter but also recognize the terms dependence, abuse, and addiction, which are commonly used in mental health literature. The term abuse, however, is slowly falling out of favor and being replaced with such terms as misuse, disorder, and dependence. The 11 DSM-5 criteria for a substance use disorder are listed below; they are grouped in four categories. The severity of the disorder is determined by the number of criteria a person meets: 2-3 criteria indicate a mild disorder. 4-5 criteria point to a moderate disorder. 6 or more criteria are evidence of a severe disorder. Impaired Control Taking the substance in larger amounts or over a longer period than was originally intended. Expressing a persistent desire to cut down on or regulate substance use, but being unable to do so. Spending a great deal of time getting the substance, using the substance, or recovering from its effects. Page 217 Craving or experiencing an intense desire or urge to use the substance. Social Problems Failing to fulfill major obligations at work, school, or home. Continuing to use the substance despite having persistent or recurrent social or interpersonal problems caused or worsened by the effects of its use. Giving up or reducing important social, school, work, or recreational activities because of substance use. Risky Use Using the substance in situations in which it is physically hazardous to do so. Continuing to use the substance despite the knowledge of having persistent or recurrent physical or psychological problems caused or worsened by substance use. Drug Effects Developing tolerance to the substance. When a person requires increased amounts of a substance to achieve the desired effect or notices a markedly diminished effect with continued use of the same amount, he or she has developed tolerance to the substance. Experiencing withdrawal. In someone who has maintained prolonged, heavy use of a substance, a drop in its concentration within the body can result in unpleasant physical and cognitive withdrawal symptoms. Withdrawal symptoms are different for different drugs. For example, nausea, vomiting, and tremors are common withdrawal symptoms in people dependent on alcohol, opioids, or sedatives. QUICK STATS 48 states and the District of Columbia allow some form of legalized gambling. (No form of gambling is legal in Hawaii or Utah.) —National Council on Problem Gambling, 2016 The Development of Addiction We all engage in activities that are potentially addictive. Some of these activities can be beneficial if they are done appropriately and in moderation. But if a behavior starts to be excessive, it may become an addiction. An addiction often starts when a person does something to bring pleasure or avoid pain. The activity may be drinking a beer, using the Internet, playing the lottery, or shopping. If it works, the person is likely to repeat it. Reinforcement leads to an increasing dependence on the behavior. Tolerance—caused by physical changes to brain cells and reward pathways in the brain—develops, and the person needs more of the substance or behavior to feel the expected effect. Eventually the behavior becomes a central focus of the person's life, and other areas such as school performance or relationships deteriorate. The behavior no longer brings pleasure, but repeating it is necessary to avoid withdrawal, which is the physical and mental pain that results from going without it. Something that started as a seemingly innocent way of feeling good has triggered physiological changes in the brain that create a behavioral prison. Although many common behaviors are potentially addictive, most people who engage in them do not develop problems. The reason lies in the combination of factors involved in the development of addiction, including personality, lifestyle, heredity, the social and physical environment, and the nature of the substance or behavior in question. For addiction to develop, these diverse factors must come together in a certain way. For example, nicotine (the psychoactive drug in tobacco) has a high potential for physical addiction. Genetic factors make some individuals much more likely to develop dependence and addiction if they start smoking. Other factors—family, social, or cultural—play a role in determining if someone takes a first puff and, if so, whether he or she continues smoking long enough to become addicted. Like other addictions, addiction to nicotine begins with a voluntary and seemingly inconsequential "yes or no" choice that spirals out of control. Examples of Addictive Behaviors As noted, behaviors that are not related to drugs can become addictive for some people. Such behaviors can include eating, gambling, and playing Internet games. Any substance or activity that becomes the focus of a person's life at the expense of other needs and interests can be damaging to health. Like addiction to drugs, behavioral or nondrug addiction involves symptoms such as craving, loss of control over the behavior, tolerance, withdrawal, and a repeating pattern of recovery and relapse. These symptoms support the theory that nondrug addictions promote changes in the brain regions and systems associated with misuse of and addiction to alcohol, nicotine, or other drugs. Compulsive Gambling Compulsive gamblers cannot control the urge to gamble, even in the face of ruin. The consequences of compulsive gambling are not just financial; the suicide rate of compulsive gamblers is 20 times higher than that of the general population. About 1% of adult Americans are compulsive (pathological) gamblers, and another 2% are "problem gamblers." Some 42% of college students gamble at least once in a year, and Page 218about 3% gamble at least once a week. Sixty-five percent of pathological gamblers commit crimes to support their gambling habit. When taken to an extreme, even healthy activities such as exercise can become addictive. © Dirima/Getty Images The APA recognizes gambling disorder as a behavioral addiction associated with at least four of 10 characteristic behaviors, including preoccupation with gambling, unsuccessful efforts to quit, using gambling to escape problems, and lying to family members to conceal the extent of gambling. These characteristics have much in common with the behavioral dysfunctions used to describe addiction. Many compulsive gamblers also have drug and alcohol misuse problems. Internet Gaming Disorder Recognized as a potentially addictive behavior by the APA but indicated for further study is Internet gaming. Similar to other addictions, Internet gaming disorder can be classified as mild, moderate, or severe based on the impact on a person's life. Characteristic behaviors include preoccupation with Internet games, loss of interest in other activities, using gaming to relieve anxiety or guilt, and risking opportunities or relationships due to time spent gaming. The disorder is separate from gambling disorder and different from general use of social media or the Internet. Compulsive Exercising When taken to a compulsive level, even healthy activity can turn into harmful addictions. For example, compulsive exercising is now recognized as a serious departure from normal behavior. Compulsive exercising is often accompanied by more severe psychiatric disorders such as anorexia nervosa and bulimia (see Chapter 14). Traits often associated with compulsive exercising include an excessive preoccupation and dissatisfaction with body image, use of laxatives or vomiting to lose weight, and development of other obsessive-compulsive symptoms. Work Addiction People who are excessively preoccupied with work are often called workaholics. Work addiction, however, is based on a set of specific symptoms: An intense work schedule The inability to limit your own work schedule The inability to relax, even when away from work Failed attempts at curtailing the intensity of work (in some cases) A person with a work addiction is likely to neglect other aspects of life. For example, she or he may exercise less, spend less time with family and friends, and avoid social activities. Work addiction typically coincides with a well-known risk factor for cardiovascular disease—the Type A personality (see Chapter 15). Traits associated with Type A personality include competitiveness, ambition, drive, time urgency, restlessness, hyper-alertness, and hostility. Sex Addiction More controversial is the notion of addiction to sex. Behaviors associated with sex addiction include an extreme preoccupation with sex, a compulsion to have sex repeatedly in a given period of time, a great deal of time and energy spent looking for partners or having sex, sex used as a means of relieving painful feelings, and the experience of negative emotional, personal, and professional consequences as a result of sexual activities. Some experts are reluctant to call compulsive sexual activity a true addiction. However, even therapists who challenge the concept of sex addiction recognize that some people become overly preoccupied with sex, cannot seem to control their sex drive, and act in potentially harmful ways in order to stay satisfied. This pattern of sexual behavior seems to meet the criteria for addictive behaviors discussed earlier. Compulsive Buying or Shopping A compulsive buyer repeatedly gives in to the impulse to buy more than he or she needs or can afford. Compulsive spenders usually buy luxury items rather than daily necessities, even though they are usually distressed by their behavior and its social, personal, and financial consequences. Some experts link compulsive shopping with neglect or abuse during childhood; it also seems to be associated with eating disorders, depression, and bipolar disorder. Internet Addiction In the years since the Internet became widely available, millions of Americans have become compulsive Internet users—as many as one out of eight people; among college students, approximately one out of seven fit this description. To spend more time online, Internet addicts skip other important activities. Compulsive Page 219Internet users often spend their work time online, a fact that has led many employers to adopt strict Internet usage policies. Despite negative financial, social, or academic consequences, compulsive Internet users don't feel able to stop. As with other addictive behaviors, Internet addiction may result when people use their behavior to alleviate stress or avoid painful emotions (see the box "Is Internet Use a Problem for You?"). ASSESS YOURSELF: Is Internet Use a Problem for You? To assess the extent to which your Internet use is creating problems in your life, answer the following questions using this point scale: Not Applicable 0 Rarely 1 point Occasionally 2 points Frequently 3 points Often 4 points Always 5 points ______ 1. How often do you find that you stay online longer than you intended? ______ 2. How often do you neglect household chores to spend more time online? ______ 3. How often do you prefer the excitement of the Internet to intimacy with your partner? ______ 4. How often do you form new relationships with fellow online users? ______ 5. How often do others in your life complain about the amount of time you spend online? ______ 6. How often do your grades or schoolwork suffer because of the amount of time you spend online? ______ 7. How often do you check your e-mail before something else that you need to do? ______ 8. How often does your job performance or productivity suffer because of the Internet? ______ 9. How often do you become defensive or secretive when someone asks you what you do online? ______ 10. How often do you block out disturbing thoughts about your life with soothing thoughts about the Internet? ______ 11. How often do you find yourself anticipating when you will go online again? ______ 12. How often do you fear that life without the Internet would be boring, empty, and joyless? ______ 13. How often do you snap, yell, or act annoyed if someone bothers you while you are online? ______ 14. How often do you lose sleep due to late-night log-ins? ______ 15. How often do you feel preoccupied with the Internet when offline or fantasize about being online? ______ 16. How often do you find yourself saying "just a few more minutes" when online? ______ 17. How often do you try to cut down on the amount of time you spend online and fail? ______ 18. How often do you try to hide how long you've been online? ______ 19. How often do you choose to spend more time online over going out with others? ______ 20. How often do you feel depressed, moody, or nervous when you are offline, which goes away once you are back online? Add the points associated with your responses to get your final score. The higher your score, the more problems your Internet usage is causing you. Here's a general scale to help you evaluate your score: 0-30 points: No problematic Internet usage. 31-49 points: You are an average online user. If your score exceeds 40 points, you may surf the web a bit too long at times, but you have control over your usage. 50-79 points: You are experiencing occasional or frequent problems because of the Internet. You should consider their full impact on your life. 80-100 points: Your Internet usage is causing significant problems in your life. You should evaluate the impact of the Internet on your life and start thinking about how to address the problems. source: Adapted from Netaddiction.com. Internet Addiction Test (http://netaddiction.com/internet-addiction-test/). Retrieved February 20, 2016. Reprinted by permission of Dr. Kimberly S. Young.

how drugs affect the body

HOW DRUGS AFFECT THE BODY The drugs discussed in this chapter have complex and variable effects, many of which can be traced to changes in brain chemistry. However, the same drug may affect different people differently or the same person in different ways under different circumstances. Beyond a fairly predictable general change in brain chemistry, the effects of a drug may vary depending on drug factors, user factors, and social factors.Page 224 Changes in Brain Chemistry Psychoactive drugs produce most of their key effects by acting on brain chemistry in a characteristic fashion. Before any changes in brain chemistry can occur, however, molecules of the drug have to be carried to the brain through the bloodstream via a particular route of administration. A drug that is taken by mouth has to dissolve in the stomach, be absorbed into the bloodstream through the lining of the small intestine, and then pass through the liver, heart, and lungs before returning to the heart to be carried via arteries to the brain. A drug that is already dissolved and is injected directly into the bloodstream will reach the brain in much less time, and drugs that are inhaled and absorbed by the lungs travel to the brain even more rapidly. The more quickly a drug reaches the brain, the more likely the user is to become dependent on it. Once a psychoactive drug reaches the brain, it acts on one or more neurotransmitters, either increasing or decreasing their concentration and actions. Cocaine, for example, affects dopamine, a neurotransmitter thought to play a key role in the process of reinforcement—the brain's way of telling itself, "That's good; do the same thing again." When a neurotransmitter is released by one neuron, it travels across a gap, called a synapse, to signal another neuron. The signaling is controlled in part by removing the neurotransmitter molecules from the synapse by a process called reuptake. Some drugs, such as cocaine, inhibit the resorption of dopamine, thereby extending or intensifying their action (Figure 9.1). The euphoria cocaine produces is thought to be a result of its effect on dopamine. Heroin, nicotine, alcohol, and amphetamines also affect dopamine levels. FIGURE 9.1 Effect of cocaine on brain chemistry. Under normal circumstances, the transmitting neuron controls the reuptake of dopamine at a synapse. Cocaine blocks the removal of dopamine from a synapse; the resulting buildup of dopamine causes continuous stimulation of the receiving neurons. The duration of a drug's effect depends on many factors and may range from 5 minutes (crack cocaine) to 12 or more hours (LSD). As drugs circulate through the body, they are metabolized by the liver and eventually excreted by the kidneys in urine. Small amounts may also be eliminated in other ways, including in sweat, in breast milk, and via the lungs. Drug-Related Factors When different drugs or dosages produce different effects, the differences are usually caused by one or more of five different drug factors: The pharmacological properties of a drug are its effects on a person's body chemistry, behavior, and psychology. Pharmacological properties also include the amount of a drug required to exert various effects, the time course of the effects, and other characteristics such as a drug's chemical composition. The dose-response function is the relationship between the amount of drug taken and the type and intensity of its effects. Many psychological effects of drugs reach a plateau in the dose-response function, so that increasing the dose does not increase the effect any further. With LSD, for example, the maximum changes in perception occur at a certain dose, and no further changes in perception take place if higher doses are taken. However, all drugs have more than one effect, and the dose-response functions usually are different for different effects. This means that increasing the dose of any drug may begin to result in additional effects, which are likely to be more unpleasant or dangerous at high doses. The time-action function is the relationship between the time elapsed since a drug was taken and the intensity of its effect. A drug's effects are greatest when its concentrations in body tissues are changing fastest, especially if they are increasing. The person's drug use history may influence the effects of a drug. A given amount of alcohol, for example, will affect a habitual drinker less than an occasional drinker. Tolerance to some drugs builds rapidly. To experience the same effect, a user has to abstain from the drug for a period of time before that dosage will again exert its original effects. The method of drug use directly affects the strength of the response. Methods of use include ingestion, inhalation, injection, and absorption through the skin or tissue linings. Drugs are usually injected in one of three ways: intravenously (IV, or mainlining), intramuscularly (IM), or subcutaneously (SC, or skin popping). Page 225 Physical Factors Certain physical characteristics help determine how a person will respond to a drug. Body mass is one variable: The effects of a certain dose of a drug on a 150-pound person will be greater than its effect on a 200-pound person. Other variables include general health and genetic factors. For example, some people have an inherited ability to rapidly metabolize a cough suppressant called dextromethorphan, which also has psychoactive properties. These people must take a higher-than-normal dose to get a given cough suppressant effect. If a person's biochemical state is already altered by another drug, this too can make a difference. Some drugs intensify the effects of other drugs, as is the case with alcohol and sedatives. Some drugs block the effects of other drugs, such as when a tranquilizer is used to relieve anxiety caused by cocaine. Interactions between drugs, including many prescription and over-the-counter (OTC) medications, can be unpredictable and dangerous. One physical condition that requires special precautions is pregnancy. It can be risky for a woman to use any drugs at all during pregnancy, including alcohol and common OTC products like cough medicine. The risks are greatest during the first trimester, when the fetus's body is forming rapidly and even small biochemical alterations in the mother can have a devastating effect on fetal development (see Chapter 8). Even later, the fetus is more susceptible than the mother to the adverse effects of any drugs she takes. The fetus may even become physically dependent on a drug being taken by the mother and suffer withdrawal symptoms after birth. QUICK STATS In 2014, prescription pain medications and heroin were involved in 28,647 deaths, or 61% of all drug overdose deaths. —Centers for Disease Control and Prevention 2016 Psychological Factors Sometimes a person's response to a drug is strongly influenced by the user's expectations about how he or she will react (the psychological set). With large doses, the drug's chemical properties seem to have the strongest effect on the user's response. But with small doses, psychological (and social) factors are often more important. When people want to believe that a given drug will affect them a certain way, they are likely to experience those effects regardless of the drug's pharmacological properties. In one study, regular users of marijuana reported a moderate level of intoxication (high) after using a cigarette that smelled and tasted like marijuana but contained no THC, the active ingredient in marijuana. This is an example of the placebo effect—when a person receives an inert substance yet responds as if it were an active drug. In other studies, subjects who smoked low doses of real marijuana that they believed to be a placebo experienced no effects from the drug. Clearly the user's expectations had a greater effect than the drug itself. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Has an OTC medication (such as a decongestant) ever made you feel strange, drowsy, or even high? Did you expect to react to the medication that way? Do such reactions influence the way you use OTC drugs? Social Factors The setting is the physical and social environment surrounding the drug use. If a person uses marijuana at home with trusted friends and pleasant music, the effects are likely to be different from the effects if the same dose is taken in an austere experimental laboratory with an impassive research technician. Similarly, a dose of alcohol that produces mild euphoria and stimulation at a noisy, active cocktail party might induce sleepiness and slight depression when taken at home while alone.

preventing drug related problems

PREVENTING DRUG-RELATED PROBLEMS Drug research will undoubtedly provide new information, new treatments, and new chemical combinations in the decades ahead. New psychoactive drugs may present unexpected possibilities for therapy, social use, and misuse. Making honest and unbiased information about drugs available to everyone, however, may cut down on their misuse. Although the use of some drugs, both legal and illegal, has declined dramatically since the 1970s, the use of others has held steady or increased. Mounting public concern has led to great debate and a wide range of opinions about what should be done. Efforts to address the problem include workplace drug testing, tougher law enforcement and prosecution, and treatment and education. With drugs entering the country on a massive scale from South America, Southeast Asia, and elsewhere, and being distributed through tightly controlled drug-smuggling organizations and street gangs, the success of any program is uncertain. Drugs, Society, and Families The economic cost of drug misuse is staggering. According to the U.S. Department of Justice, the National Drug Intelligence Center, and the National Institute on Drug Abuse, the cost to society of illicit drug use alone is $193 billion annually. That figure is higher than the cost of many major health problems, including diabetes, obesity, and smoking. But the costs are more than just financial—they are also paid in human pain and suffering. The relationship between drugs and crime is complex: Drug possession itself is a crime, some crimes are committed in order to obtain drugs, and some crimes are committed because of the loss of control associated with drug use. The criminal justice system is inundated with people accused of crimes related to drug possession, sale, or use. The FBI reports that roughly 1.5 million arrests are made annually for drug violations. In 2013, the most recent year for which data are available, about 16% of state prison inmates (208,000) were serving time for drug offenses. In 2015, almost half of federal inmates (86,080) were in prison because of drug offenses. The Bureau of Justice Statistics reports that about half of all state and federal prisoners—roughly 850,000 men and women—meet diagnostic criteria for drug abuse or addiction. Many assaults and murders are committed when people try to acquire or protect drug territories, settle disputes about drugs, or steal from dealers. Violence and gun use are common in neighborhoods where drug trafficking is prevalent. Addicts commit more robberies and burglaries than criminals not on drugs. People under the influence of drugs, especially alcohol, are more likely to commit violent crimes like rape and murder than are people who do not use drugs. To what extent is drug misuse also a health care issue for society? In the United States, illegal drug use leads to more Page 236than 800,000 emergency department admissions and nearly 20,000 deaths annually. It is in the best interest of society to treat drug addiction in those who want help, but there is not nearly enough space in treatment facilities to help the millions of Americans who need immediate treatment. Drug addicts who want to quit, especially among the urban poor, often have to wait months for acceptance into a residential care or other treatment program. Drug use takes a toll on individuals and families. Children born to women who use drugs such as alcohol, tobacco, or cocaine may have long-term health problems. Drug misuse in families can become a vicious cycle. Children who observe the adults around them using drugs assume it is acceptable. Abuse, neglect, lack of opportunity, and unemployment become contributing factors to drug use, perpetuating the cycle (see the box "Drug Use and Race/Ethnicity"). DIVERSITY MATTERS: Drug Use and Race/Ethnicity Surveys of the U.S. population find a variety of trends in drug use and misuse among racial and ethnic groups (see the accompanying table). In addition to these general trends, there are also trends relating to specific drugs. According to the Monitoring the Future survey, African American high school students have for many years had significantly lower rates of illicit drug use compared to white students. The gap has narrowed in recent years, however, due to increased rates of marijuana use among black students and a leveling off of marijuana use among whites. African American high school students at all grade levels report higher usage of bath salts and lower usage of hallucinogens than other groups. Among twelfth graders in 2015, heroin use was higher among black students (1.0%) than among whites (0.4%) and Hispanics (0.5%). A similar rise in marijuana use has been seen among Hispanic students in recent years, with Hispanics reporting the highest levels of past-year marijuana use among students at grades 8, 10, and 12. Among twelfth graders, Hispanic students report the highest past-year use of synthetic marijuana, cocaine, and inhalants. Overall, Hispanic students report the highest levels of illicit drug use in eighth grade, with the gap among groups narrowing by twelfth grade; the higher dropout rates among Hispanic students compared to whites and African Americans may contribute to this pattern. Past-Month Illicit Drug Use among People Age 12 and Over by Race/Ethnicity, 2015 Race/Ethnicity Percentage Not Hispanic or Latino White 10.2 Black or African American 12.5 American Indian or Alaska Native 14.2 Native Hawaiian or Other Pacific Islander 9.8 Asian 4.0 Two or more races 17.2 Hispanic or Latino 9.2 White twelfth graders report the highest nonmedical use of several prescription drugs, including Oxycontin and Vicodin. In 2015, nonmedical use of Adderall among twelfth graders was reported by 8.4% of white students, 5.9% of black students, and 4.4% of Hispanic students. Alcohol use was also highest among white students: the 30-day prevalence of alcohol use reported in 2015 among twelfth graders was 24.0% among blacks, 36.3% among Hispanics, and 40.9% among whites. sources: Johnston, L. D., et al. 2016. Monitoring the Future National Survey Results on Drug Use, 1975-2015: Overview, Key Findings on Adolescent Drug Use. Ann Arbor: Institute for Social Research, The University of Michigan; SAMHSA Center for Behavioral Health Statistics and Quality. 2016. Results from the 2015 National Survey on Drug Use and Health (http://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.htm). Legalizing Drugs Pointing out that many of the social problems associated with drugs are related to prohibition (which failed for alcohol from 1920-1933) rather than to the effects of the drugs themselves, some people have argued for various forms of drug legalization or decriminalization. Proposals range from making drugs such as marijuana and heroin available by prescription to allowing licensed dealers to sell some of these drugs to adults. Proponents argue that legalizing some currently illicit drugs—but putting controls on them similar to those used for alcohol, tobacco, and prescription drugs—could eliminate many problems. Some states have adopted policies that decriminalize possession of small amounts of marijuana—that is, possession for recreational use either is legal or is treated as a misdemeanor crime without significant penalty. Opponents of drug legalization argue that allowing easier access to drugs would expose many more people to possible addiction. Drugs would be cheaper and easier to obtain, and drug use would be more socially acceptable. Legalizing drugs could cause an increase in drug use among children and teenagers. Opponents point out that alcohol and tobacco—drugs that already are legal—are major causes of disease and death in our society. QUICK STATS In 2015, 3.7 million people age 12 and over (1.4% of the population) received treatment for a problem related to the use of alcohol or illicit drugs. —Substance Abuse and Mental Health Services Administration, 2016 Drug Testing The workplace is another segment of our society where drug use is common. According to data from recent surveys, the majority of substance users hold full-time jobs. Drug use in the workplace not only creates health problems for individual users but also has a negative effect on productivity and on safety of coworkers. Statistics from the federal government show that 8.4% of full-time workers were illicit drug users in 2007, the most recent year for which data are available. In absolute numbers, approximately 13.1 million illicit drug users and 13.0 million heavy alcohol users were full-time workers in 2007. Illicit drug use is highest among workers in the food industry and construction sectors, while heavy alcohol use is greatest among construction, mining, and repair workers. Many companies test current and prospective employees for drug use. © Ron Wurzer/Getty Images The economic burden of lost productivity resulting from premature death, illness, and disability is estimated to run as high as $114 billion for drug misuse and $179 billion for heavy alcohol use. The extent of the drug problem has given rise to the development of workplace policies to help workers regain their health and well-being. Workplace policies developed to address the problem often include drug testing and referral services. Despite controversial aspects of drug testing in the workplace, a growing number of U.S. workers recognize the need for such screening. According to the Quest Diagnostics Drug Testing Index, overall drug use among U.S. workers has declined by 74% since the Drug-Free Workplace Act of 1988, Page 237although positive urine tests for marijuana, stimulants, and opioids continue to rise. Most drug testing involves a urine test. Testing for alcohol may involve a blood or breath test. The accuracy of these tests has improved in recent years, so there are fewer opportunities for people to cheat or for the tests to yield inaccurate results. If a person tests positive for drugs, the employer may provide drug counseling or treatment, suspend the employee until he or she tests negative, or fire the individual. The FDA has approved several OTC home drug testing kits designed to allow parents to check their children for drug use. Urine samples are collected at home, and preliminary results may be available immediately, but final results require that the sample be sent to a laboratory for analysis. Many experts, including the American Academy of Pediatrics, advise against the use of home tests in cases of suspected drug use. Instead they recommend a comprehensive evaluation by a qualified health care professional. Treating Drug Addiction Under the Affordable Care Act, all insurance sold on health insurance exchanges or provided by Medicaid to certain newly eligible adults must include services for treatment of substance use disorders such as alcohol or drug addiction. Treatment for addiction often is characterized by discrete and repeated episodes of short-term abstinence and relapse. Regardless of the therapeutic approach, many individuals undergoing treatment often return to drug or alcohol use. Relapse, which commonly occurs within one year after treatment, can result in worsening of the original substance use problem. Preventing relapse and maintaining long-term cessation of drug use is an exceedingly complex medical goal. Medical interventions based on pharmaceutical aids to enhance the individual's long-term commitment to change and stay drug-free remain challenging. Relapse prevention research Page 238includes expanding the repertoire of behavioral skills individuals need to decrease the risk of recidivism. Medication-Assisted Treatment Medications are increasingly being used in addiction treatment to reduce the craving for the abused drug or to block or oppose its effects. Perhaps the best-known medication for drug use is methadone, a synthetic drug used as a substitute for heroin. Methadone prevents withdrawal reactions and reduces the craving for heroin. Its use enables heroin-addicted people to function normally in social and vocational activities, although they remain dependent on methadone. The drug buprenorphine in combination with naloxone, approved for treatment of opioid addiction, reduces cravings and relapse. Many other medications are under study; drugs used specifically in the treatment of alcohol and nicotine dependence are discussed in Chapters 10 and 11. Medication therapy can appear more efficacious and efficient and is therefore popular among patients and health care providers. However, the relapse rate remains high. Combining drug therapy with psychological and social services improves success rates, underscoring the importance of psychological factors in drug dependence. Treatment Centers Treatment centers offer a variety of short-term and long-term services, including hospitalization, detoxification, counseling, and other mental health services. The therapeutic community is a specific type of center, a residential program run in a completely drug-free atmosphere. Administered by ex-addicts, these programs use confrontation, strict discipline, and unrelenting peer pressure to attempt to resocialize the addicted individual with a different set of values. Halfway houses, which are transitional settings between a 24-hour-a-day program and independent living, are an important phase of treatment for some people. Strategies for evaluating programs are given in the box "Choosing a Drug Treatment Program." CRITICAL CONSUMER: Choosing a Drug Treatment Program When evaluating different facilities or programs for drug treatment, consider the following issues: What type of treatment or facility is most appropriate? Intensive outpatient treatment is available through many community mental health centers, as well as through specialized drug treatment facilities. Such programs typically require several sessions per week, combining individual therapy, group counseling, and attendance at 12-step meetings. Residential, or inpatient, facilities may be associated with a medical facility such as a hospital, or they may be freestanding programs that focus solely on substance use treatment. Some residential treatment programs last longer or cost more per week than many health insurance plans will cover. How will treatment be paid for? Many health insurance plans limit residential treatment to a maximum number of weeks. They may also require that the insured first attempt an intensive outpatient treatment before they will approve coverage for a residential facility. Is there likely to be a need for medical support? Chronic abusers of alcohol or other CNS depressants may experience life-threatening seizures or other withdrawal symptoms during the first few days of detoxification. Malnutrition is common among substance abusers, and injection drug users may suffer from local infections and blood-borne diseases such as hepatitis or HIV infection. Medical problems such as these are best handled in an inpatient program with good medical support. Is the treatment center or program certified and licensed? What type of oversight is in place? What is the level of professional training of the staff? Is there a medical doctor on-site or making frequent visits? Are there trained nurses? Licensed psychologists or social workers? Many successful programs are staffed primarily by recovering alcohol or drug users. Those staff members should have training and certification as addiction specialists. Finally, is the facility listed under SAMHSA's National Review of State Alcohol and Drug Treatment Programs and Certification Standards for Substance Abuse Counselors and Prevention Professionals? Does the program provide related services, such as family and job counseling and posttreatment follow-up? These types of services are extremely important for the long-term success of drug use treatment. Can a prospective client visit the facility and speak with the staff and clients? A prospective client and his or her family should be allowed to visit any treatment center or program. Groups and Peer Counseling Groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have helped many people. People receiving treatment in drug substitution programs or substance use treatment centers are often urged or required to join a mutual-help group as part of their recovery. Many of these groups follow a 12-step program. Group members' first step is to acknowledge that they have a problem over which they have no control. Peer support is a critical ingredient of these programs, and members usually meet at least once a week. As part of a 12-step program, each member is paired with a sponsor to call on for advice and guidance in working through the 12 steps and getting support if the temptation to relapse becomes overwhelming. With such support, thousands of substance-dependent people have been able to recover, remain abstinent, and reclaim their lives. Chapters of AA and NA meet on some college campuses; community-based chapters are listed in the phone book, in local newspapers, and online. Other organizations provide an alternative to the 12 steps such as LifeRing Secular Recovery, Rational Recovery, SMART Recovery, Women for Sobriety, and Refuge Recovery. Many colleges also have peer counseling programs, in which students are trained to help other students who have drug problems. A peer counselor's role may be as limited as referring a student to a professional with expertise in substance dependence for an evaluation or as involved as helping arrange a leave of absence from school for participation in a drug treatment program. Most peer counseling programs are founded on principles of strict confidentiality. Peer counselors may also be able to help students who are concerned about a classmate or loved one with an apparent drug problem (see the box "If Someone You Know Has a Drug Problem..."). Information about peer counseling programs is usually available from the student health center. TAKE CHARGE: If Someone You Know Has a Drug Problem... Changes in behavior and mood in someone you know may signal a growing dependence on drugs. Signs that a person's life is beginning to focus on drugs include the following: Sudden withdrawal or emotional distance Rebellious or unusually irritable behavior A loss of interest in usual activities or hobbies A decline in school performance A sudden change in the chosen group of friends Changes in sleeping or eating habits Frequent borrowing of money or stealing Secretive behavior about personal possessions, such as a backpack or the contents of a drawer Deterioration of physical appearance If you believe a family member or friend has a drug problem, locate information about drug treatment resources available on campus or in your community. Communicate your concern, provide him or her with information about treatment options, and offer your support during treatment. If the person continues to deny having a problem, talk with an experienced counselor about setting up an intervention—a formal, structured confrontation designed to end denial by having family, friends, and other caring people present their concerns to the drug user. Participants in an intervention would indicate the ways in which the individual is hurting others as well as himself or herself. If your friend or family member agrees to treatment, encourage him or her to attend a support group such as Narcotics Anonymous or Alcoholics Anonymous. And finally, examine your relationship with the abuser for signs of codependency. If necessary, get help for yourself; friends and family of drug users can often benefit from counseling. A naloxone kit is an example of a harm reduction strategy for people at risk of an opioid overdose. © Portland Press Herald/Joe Phelan/Getty Images Harm Reduction Strategies Because many attempts at treatment are at first unsuccessful, some experts advocate the use of harm reduction strategies. The goal of harm reduction is to minimize the negative effects of drug use and misuse: A common example is the use of designated drivers to reduce Page 239alcohol-related motor vehicle crashes. Drug substitution programs such as methadone maintenance are another well-known form of harm reduction; although participants remain drug dependent, the negative consequences of their drug use are reduced. Additional examples of harm reduction strategies include the following: Syringe exchange programs, designed to reduce transmission of HIV and hepatitis C Safe injection facilities or sites where heroin users can go to inject heroin under medical supervision Provision of easy-to-use forms of naloxone, a drug that rapidly reverses opioid overdose, to family members and caregivers of heroin users; in 2014, the FDA approved a hand-held naloxone autoinjector Free testing of street drugs for purity and potency to help users avoid unintentional toxicity or overdose Codependency Many treatment programs also offer counseling for those who are close to drug abusers. Drug misuse takes a toll on friends and family members, and counseling can help people work through painful feelings of guilt and powerlessness. Codependency, in which a person close to the drug abuser is controlled by the abuser's behavior, sometimes develops. Codependent people may come to believe that love, approval, and security are contingent on their taking care of the abuser. People can become codependent naturally because they want to help when someone they love becomes dependent on a drug. They may assume that their good intentions will persuade the drug user to stop. Codependent people often engage in behaviors that remove or soften the effects of drug use on the user—so-called enabling behaviors. The habit of enabling can inhibit a drug abuser's recovery because the person never has to experience the consequences of his or her behavior. Often the enabler is dependent, too—on the patterns of interaction in the relationship. People who need to take care of others often marry people who need to be taken care of. Children in these families often develop the same behavior pattern as one of their parents—either becoming helpless or becoming a caregiver. For this reason, many treatment programs involve the whole family.Page 240 Have you ever been an enabler in a relationship? You may have if you've ever done any of the following: Given someone countless chances to stop abusing drugs Made excuses or lied for someone to his or her friends, teachers, or employer Joined someone in drug use and blamed others for your behavior Lent money to someone to continue drug use Stayed up late waiting for or gone out searching for someone who uses drugs Felt embarrassed or angry about the actions of someone who uses drugs Ignored the drug use because the person got defensive when you brought it up Avoided confronting a friend or relative who was obviously intoxicated or high on a drug If you come from a codependent family or see yourself developing codependency relationships or engaging in enabling behaviors, consider acting now to make changes in your patterns of interaction. Remember, you cannot cause or cure drug addiction in another person. Preventing Drug Misuse Obviously the best solution to drug misuse is prevention. Government attempts at controlling the drug problem have historically focused on stopping the production, importation, and distribution of illegal drugs. A national drug policy announced in 2010, however, redirects federal funding and efforts into stopping the demand for drugs. Developing persuasive antidrug educational programs may offer the best hope for solving the drug problem in the future. Indirect approaches to prevention involve building young people's self-esteem, improving their academic skills, and increasing their recreational opportunities. Direct approaches involve providing information about the adverse effects of drugs and teaching tactics that help students resist peer pressure to use drugs in various situations. Developing strategies for resisting peer pressure is one of the more effective techniques. Prevention efforts need to focus on the different motivations individuals have for using and misusing specific drugs at different ages. For example, grade-school children seem receptive to programs that involve their parents or well-known adults such as professional athletes. Adolescents in junior or senior high school are often more responsive to peer counselors. Many young adults tend to be influenced by efforts that focus on health education. For all ages, it is important to provide nondrug alternatives—such as recreational facilities, counseling, greater opportunities for leisure activities, and places to socialize—that speak to the individual's or group's specific reasons for using drugs. Reminding young people that most people, no matter what age, are not users of illegal drugs, do not smoke cigarettes, and do not get drunk frequently is a critical part of preventing substance misuse.Page 241 Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Do you know someone who may have a drug problem? What steps, if any, have you taken to help that person? If you were using drugs and felt that things had gone out of control, what would you want your friends to do for you?

why people use and misuse drugs

Page 220 WHY PEOPLE USE AND MISUSE DRUGS Using drugs to alter consciousness is an ancient and universal pursuit. People have used alcohol for celebration and intoxication for thousands of years. People in all parts of the world have exploited the psychoactive properties of plants, such as the coca plant in South America and the opium poppy in the Far East. In the 19th century, chemists began extracting the active chemicals from medicinal plants, such as morphine from the opium poppy and cocaine from the coca leaf. This activity was the beginning of modern pharmacy, the art of compounding drugs, and of pharmacology, the science and study of drugs. It was also the start of the era of human-made psychoactive drugs, from codeine to methamphetamine, which continues to the present. Drug misuse and addiction among Americans was more common by 1900 than at any time before or since. In the early 1900s, concerns about drug addiction and the need to regulate drug sales and manufacture led to new federal drug laws in the United States. Middle-class use of regulated drugs dropped, and addiction became restricted to, and increasingly identified with, criminal subcultures. Drug misuse expanded in America during the 1960s and 1970s, reaching a peak in 1979. Rates then declined until the early to mid-1990s, when drug misuse rates began to rise in certain age groups. Between 2007 and 2015, the percentage of people age 12 and over who used marijuana in the past month increased from 5.8% to 8.3%. Heroin use has also been increased: The number of people reporting past-month heroin use in 2015 was 329,000, compared to 195,000 in 2009. The Allure of Drugs Young people may be drawn to drugs by the allure of the exciting and illegal. They may be curious, rebellious, or vulnerable to peer pressure. Young people may want to imitate adult models in their lives or in the movies. Most people who take illicit drugs do so experimentally, typically trying a drug one or more times but not continuing. The main factors in the initial choice of a drug are whether it is available and whether peers are using it. Although some people use drugs because they have a desire to alter their mood or are seeking a spiritual experience, others are motivated by a desire to escape boredom, anxiety, depression, feelings of worthlessness, or other distressing symptoms. They use drugs to cope with the difficulties they experience in life. For people living in poverty, many of these reasons for using drugs are magnified. They may be dealing with dangerous environments, unstable family situations, severe financial stress, and lack of access to mental health services. Further, the buying and selling of drugs provide access to an unofficial alternative economy that may seem like an opportunity for success. How do some people use psychoactive drugs without becoming addicted? The answer seems to be a combination of physical, psychological, and social factors. Research indicates that some people may be born with a brain chemistry or metabolism that makes them more vulnerable to addiction. Other research suggests that people who were exposed to drugs in the womb may have an increased risk of abusing drugs themselves later in life. Research shows that about one-third of people with psychological disorders also have a substance use disorder; about one-third of those have a second mental disorder. People with two or more coexisting mental disorders are referred to as having dual (co-occurring) disorders. Diagnosing psychological problems among people with substance use disorders can be difficult because drug intoxication and withdrawal can mimic the symptoms of a mental illness. Social factors can influence drug dependence. These include factors discussed earlier—growing up with a family member who uses drugs, belonging to a peer group that emphasizes or encourages drug use, and living in poverty. Page 221Because they have easy access to drugs, health care professionals are also at a higher risk. For people who are unemployed or otherwise deprived of traditional sources of livelihood, drug sales provide access to an income in an alternative economy. © Marie-Reine Mattera/Getty Images Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever repeatedly or compulsively engaged in a behavior that had negative consequences? What was the behavior, and why did you continue? Did you ever worry that you were losing control? Were you able to bring the behavior under control? Risk Factors for Drug Misuse and Addiction The causes and course of an addiction are varied, but people with addictions (commonly referred to as addicts) share some characteristics. As mentioned, many use a substance or activity as a substitute for healthier coping strategies. People vary in their ability to manage their lives, and those who have trouble dealing with stress and painful emotions may be susceptible to addiction. Some people may have a genetic predisposition to addiction to a particular substance based on a variation in brain chemistry. People with addictive disorders usually have a distinct preference for a particular addictive behavior. They also often have problems with impulse control and self-regulation and tend to be risk takers. Nevertheless, drug misuse and addiction occur at all income and education levels, among all ethnic groups, and across all age groups (see the box "Drug Use among College Students"). Society is concerned with the casual or recreational use of illegal drugs because it is not possible to know when it will lead to addiction. Some casual users develop substance-related problems; others do not. Some drugs are more likely than others to lead to addiction (Table 9.2), but even some heroin or cocaine users do not meet the APA's criteria for substance use disorder. WELLNESS ON CAMPUS: Drug Use among College Students Drug use in college has long been recognized as a significant health problem that affects many students. According to the most recent survey data from the NSDUH, 22.3% of young adults aged 18-25 reported using an illicit drug in the past 30 days, with marijuana the most commonly used drug (refer to Table 9.1). Other surveys show that recreational drug use is fairly common among college students. According to the 2015 American College Health Association-National College Health Assessment, 15.0% of college students reported using marijuana at least once in the past 30 days. Nearly 6% of student reported nonmedical use of prescription stimulants within the past year. Drug use on college campuses has been examined extensively, and many experts believe that no single factor can explain the widespread impact of this phenomenon. Family history, peer pressure, depression, anxiety, low self-esteem, and the dynamics of college life (for example, the drive to compete and a distorted perception of drug use among peers) have been suggested as potential explanations for college-age drug use. Excessive alcohol use often accompanies illicit drug use and the risk of combining drugs and alcohol increases with the number of drinks a young adult consumes during a single session. In 2015, among the 17.3 million heavy drinkers age 12 and over, 32.5 percent were also current illicit drug users. Persons who were not current alcohol users were less likely to have used illicit drugs in the past month. The term AOD (alcohol and other drug) has been coined to refer to this type of substance use among college students. Further, AOD use and depression and/or anxiety are generally recognized as coexisting conditions that require a comprehensive approach to prevention and treatment. Despite the growing awareness among college counselors and other health professionals who work with college students, it is not entirely clear whether anxiety and depression precede the onset of alcohol and drug use or whether early precollege exposure to alcohol and drug use exacerbates more serious psychiatric disorders by the time a student enters college. A third line of research suggests that AOD use, depression, and anxiety share common causes such as genetic predisposition and family history. However, one aspect of drug use among college students remains clear: AOD use has dramatic consequences for the educational, family, and community lives of students. Poor academic performance has been linked with AOD use. Further, driving while intoxicated remains one of the most dangerous outcomes associated with AOD use affecting families and communities. Several AOD prevention programs are now under way at college campuses. Several federal laws have been enacted to provide resources and a legislative framework for addressing AOD use at schools. The 1989 Drug-Free Schools and Communities Act and the 1998 Higher Education Amendments are examples of concerted federal legislative efforts to encourage the development of educational policies for preventing alcohol and other drug use and providing assistance to college students at risk for these harmful behaviors. Table 9.2 Psychoactive Drugs and Their Potential for Substance Use Disorder and Addiction Very high Heroin High Nicotine, morphine Moderate/high Cocaine, pentobarbital Moderate Alcohol, ephedra, Rohypnol Moderate/low Caffeine, marijuana, MDMA (methylenedioxymethamphetamine), nitrous oxide Low/very low Ketamine, LSD (lysergic acid diethylamide), mescaline, psilocybin source: Adapted from Gable, R. S. 2006. Acute toxicity of drugs versus regulatory status. In J. M. Fish (Ed.), Drugs and Society: U.S. Public Policy, pp. 149-162. Lanham, MD: Rowman & Littlefield. Factors Associated with Trying Drugs It isn't possible to accurately predict who will misuse drugs or become addicted, but young people at a high risk of trying drugs—the first step toward misuse—tend to share the following characteristics: Male. Males are more likely than females to use almost all types of illicit drugs. In 2013, according to the National Survey on Drug Use and Health (NSDUH), the rate of illicit drug use among people age 12 and over was higher for males (11.5%) than for females (7.3%). Males are more likely than females to be current users of marijuana (9.7% versus 5.6%), cocaine (0.8% versus 0.4%), and hallucinogens (0.7% versus 0.3%). National overdose deaths from prescription drugs, cocaine, and heroin are consistently higher in males than females. However, females are just as likely as males to eventually become addicted. Troubled childhood. Teens are more likely to try drugs if they have had behavioral issues in childhood, have suffered sexual or physical abuse, used tobacco at a young age, or suffer from certain mental or emotional problems. Thrill-seeker. Impulsivity and a sense of invincibility is a factor in drug experimentation. Dysfunctional family. A chaotic home life with poor supervision, constant tension or arguments, or parental abuse increases the risk of teen drug use. Having parents who misuse drugs or alcohol increases the risk for teen drug and alcohol use. Peer group that accepts drug use. Young people who are uninterested in school, have problems at school, have difficulty fitting in, or view illicit substances with an accepting attitude are more likely to try drugs. Poor. Young people who live in disadvantaged areas are more likely to be around drugs at a young age. Girl dating an older boy. Adolescent girls who date boys two or more years older than themselves are more likely to use drugs. Factors Associated with Not Using Drugs As a group, nonusers also share some characteristics. Not surprisingly, people who perceive drug use as risky and who disapprove of it are less likely to use drugs than those who believe otherwise. Drug use is also less common among people who have positive self-esteem and self-concept and who are assertive, independent thinkers who are not controlled by peer pressure. Self-control, social competence, optimism, academic achievement, and religiosity (religious beliefs and attendance of religious services) are also linked to lower rates of drug use. Home environments are also influential: Coming from a strong family, one that has a clear policy on drug use, is another characteristic of people who don't use drugs. Young people who communicate openly with and feel supported by their parents are also less likely to use drugs.

risks associated with drug misuse

Page 222 RISKS ASSOCIATED WITH DRUG MISUSE Addiction is not the only serious potential consequence of drug misuse. In 2011 nearly 2.5 million emergency department visits were related to drug misuse or abuse (Table 9.3). The following are serious concerns as well: Intoxication. People who are under the influence of drugs—intoxicated—may act in uncharacteristic and unsafe ways because their physical and mental functioning are impaired. They are more likely to be injured from a variety of causes, to have unsafe sex, and to be involved in incidents of aggression and violence. Unexpected side effects. Psychoactive drugs have many physical and psychological effects beyond the alteration of consciousness. These effects range from nausea and constipation to paranoia, depression, and heart failure. Some drugs also carry the risk of fatal overdose. Unknown drug constituents. There is no quality control in the illegal drug market, so the composition, dosage, and toxicity of street drugs are highly variable. Studies indicate that half of all street drugs don't contain their promised primary ingredient. In some cases, a drug may be present in unsafe dosages or mixed with other drugs to boost its effects. Makers of street drugs aren't held to any safety standards, so illicit drugs can be contaminated or even poisonous. Infection and injection drug use. Heroin is the most commonly injected drug, but users can also inject cocaine, amphetamines, and other drugs. Many injection drug users (IDUs) share or reuse needles, syringes, and other injection supplies, which can easily become contaminated with the user's blood. Small amounts of blood can carry enough human immunodeficiency virus (HIV) and hepatitis C virus (HCV) to be infectious. In 2014, 5% of new diagnoses of HIV infection in men were due to injection drug use and another 3% to male-to-male sexual contact and injection drug use. Injection drug use also accounts for nearly half of new HCV infections. Page 223The most recent surveys of active IDUs indicate that approximately one-third of young (aged 18-30 years) IDUs are HCV-infected. The prevalence of HCV infection in older and former IDUs is typically much higher (approximately 70%-90%), reflecting the increased risk of continued injection drug use. The high prevalence of HCV among former IDUs is largely attributable to needle sharing during the 1970s and 1980s—before the risks of blood-borne viruses were widely known and before educational initiatives were implemented. Table 9.3 Emergency Department (ED) Visits Involving Drug Misuse or Abuse, by Drug Combination: 2011* REASON FOR ED VISIT NUMBER OF ED VISITS PERCENTAGE OF ED VISITS Pharmaceuticals only 835,275 33.9 Illicit drugs only 656,025 25.4 Illicit drugs with alcohol 261,125 10.6 Alcohol with pharmaceutical(s) 257,520 10.4 Illicit drugs with pharmaceutical(s) 247,342 10.0 Alcohol only in patients younger than 21 117,653 4.8 Illicit drugs with alcohol and pharmaceuticals 88,008 3.6 Total ED visits, drug misuse or abuse 2,462,948 100 *From 2004 to 2011 (latest available data), ED visits related to drug misuse or abuse have risen steadily each year for a total increase of 52%. ED visits related to the use of pharmaceuticals with no other drug involvement rose substantially (148%) as did the use of pharmaceuticals with illicit drugs (137%), and pharmaceuticals with alcohol (84%). The increases reflect nearly 500,000 more ED visits related to pharmaceuticals alone in 2011 compared with 2004, over 142,000 more ED visits related to pharmaceuticals and illicit drugs, and more than 42,000 more ED visits related to pharmaceuticals and alcohol. source: Substance Abuse and Mental Health Services Administration. 2013. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits (HHS Publication No. SMA 13-4760, DAWN Series D-39). Rockville, MD: Substance Abuse and Mental Health Services Administration. Unsterile injection practices can cause skin and soft tissue infections, which can progress to gangrene (tissue death) and be fatal if untreated. Other risks include endocarditis (infection of the heart valves), tuberculosis, and tetanus. The surest way to prevent diseases related to injection drug use is to never inject drugs. IDUs should use a new needle and syringe with each injection and should use sterile water and supplies to prepare drugs. Bleach or boiling water may kill some viruses and bacteria but are not foolproof sterilization methods. Many viruses can survive in a syringe for a month or more. Syringe exchange programs (SEPs)—where IDUs can trade a used syringe for a new one—have been advocated to help slow the spread of HIV and reduce the rates and cost of other health problems associated with injection drug use. Opponents of SEPs argue that supplying syringes to addicts gives them the message that illegal drug use is acceptable and worsens the nation's drug problem. However, studies have shown that well-implemented SEPs do not increase the use of drugs, and most offer AIDS counseling and provide referrals to drug treatment programs. Getting people off drugs is clearly the best solution, but there are far more IDUs than treatment facilities can currently handle. Legal consequences. Many psychoactive drugs are illegal, so possessing them can result in large fines and imprisonment. According to the Federal Bureau of Investigation (FBI), the highest arrest counts for all types of crimes were for drug use violations (estimated at 1.6 million out of 11.2 million total arrests in 2014). QUICK STATS 68.2% of new HCV infections in 2014 occurred among people who used injection drugs two weeks to six months before they noticed symptoms. —Centers for Disease Control and Prevention, 2016 Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever tried a psychoactive drug for fun? What were your reasons for trying it? Whom were you with, and what were the circumstances? What was your experience? What would you tell someone who was thinking about trying a drug?

groups of psychoactive

GROUPS OF PSYCHOACTIVE DRUGS The following sections and Figure 9.2 introduce six representative groups of psychoactive drugs: opioids, central nervous system (CNS) depressants, central nervous system stimulants, marijuana and other cannabis products, hallucinogens, and inhalants. Some of these drugs are classified according to how they affect the body. Others—the opioids and the cannabis products—are classified according to their chemical makeup. Chart lists the street names, appearance, methods of use, and short-term effects of commonly misused drugs. [D] FIGURE 9.2 Commonly misused drugs and their effects. sources: The Partnership for a Drug-Free America. 2016. Drug Guide (http://www.drugfree.org/drug-guide/); National Institute on Drug Abuse. 2016. Commonly Abused Drugs Chart (https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts) Opioids Opioids are natural or synthetic (laboratory-made) drugs that relieve pain, cause drowsiness, and induce euphoria. Natural opioid-like hormones released by the brain, called endorphins, can inhibit pain and induce euphoria. Opium, morphine, heroin, methadone, codeine, hydrocodone, oxycodone, meperidine, and Page 227fentanyl are opioids. When taken at prescribed doses, opioids have beneficial medical uses, including pain relief and cough suppression. Opioids tend to reduce anxiety and produce lethargy, apathy, and an inability to concentrate. Prescription painkillers such as oxycodone and hydrocodone are opioids that can have serious consequences such as fatal respiratory depression. The recreational use of these drugs is reported in about 2% of the population aged 12 and over. © Education Images/Universal Images Group/Getty Images Although the euphoria associated with opioids is an important factor in their misuse, many people experience a feeling of uneasiness when they first use these drugs. Even so, the misuse of opioids often results in addiction. Tolerance can develop rapidly and be pronounced. Withdrawal symptoms include cramps, chills, sweating, nausea, tremors, irritability, and feelings of panic. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), heroin use has been rising since 2007, increasing from 373,000 yearly users to 828,000 users in 2015. Heroin overdose deaths have also spiked alarmingly, increasing from 3,036 deaths in 2010 to 10,574 deaths in 2014. The potentially high but variable purity of street heroin poses a risk of unintentional overdose (see Figure 9.3). Symptoms of overdose include respiratory depression, coma, and constriction of the pupils; death can result. Heroin-related overdose deaths increased by 286% since 2002. Rates of heroin addiction doubled. FIGURE 9.3 Heroin addictions and deaths, 2002-2013. source: Centers for Disease Control and Prevention. 2015. Today's Heroin Epidemic Infographics (http://www.cdc.gov/vitalsigns/heroin/infographic.html). When taken as prescribed in tablet form, these drugs treat moderate to severe chronic pain and do not typically lead to misuse. However, as is the case with other opioids, use of prescription painkillers can lead to misuse and addiction. When taken in large doses or combined with other drugs, oxycodone and hydrocodone can cause fatal respiratory depression. Some people who become addicted to prescription opioid painkillers may eventually turn to heroin because heroin is far cheaper than prescription opioids. Recent surveys have found that people who are addicted to opioid painkillers are 40 times more likely to also be addicted to heroin; 45% of heroin users are also addicted to prescription painkillers. In 2014, pharmacies in the United States dispensed 245 million prescriptions for opioid painkillers, enough for every American adult to have a bottle of pills. In 2016, the Centers for Disease Control and Prevention announced a new effort to reduce the number of inappropriate prescriptions written for opioid painkillers.Page 228 QUICK STATS Emergency room visits associated with Xanax misuse more than doubled from 57,419 in 2005 to 124,902 in 2010. —Substance Abuse and Mental Health Services Administration, 2014 Central Nervous System Depressants Central nervous system depressants, also known as sedative-hypnotics, depress the central nervous system (CNS). The result can range from mild sedation to death. Types The various types of barbiturates are similar in chemical composition and action, but they differ in how quickly and how long they act. Antianxiety agents, also called sedatives or tranquilizers, include the benzodiazepines such as Xanax, Valium, Librium, clonazepam (Klonopin), and flunitrazepam (Rohypnol, also called roofies). Other CNS depressants include methaqualone (Quaalude), ethchlorvynol (Placidyl), chloral hydrate, and gamma hydroxybutyrate (GHB). Effects CNS depressants reduce anxiety and cause mood changes, impaired muscular coordination, slurring of speech, and drowsiness or sleep. Mental functioning is also affected, but the degree varies from person to person and also depends on the kind of task the person is trying to do. Most people become drowsy with small doses, although a few become more active. Medical Uses Barbiturates, antianxiety agents, and other sedative-hypnotics are widely used to treat insomnia and anxiety disorders and to control seizures. Some CNS depressants are used for their calming properties in combination with anesthetics before operations and other medical or dental procedures. From Use to Misuse People are usually introduced to CNS depressants either through a medical prescription or through drug-using peers. The use of Rohypnol and GHB (discussed in greater detail later in this chapter) is often associated with dance clubs and raves. The misuse of CNS depressants by a medical patient may begin with repeated use for insomnia and progress to dependence through increasingly larger doses at night, coupled with doses during stressful times of the day. Most CNS depressants, including alcohol, can lead to addiction. Tolerance, sometimes for up to 15 times the usual dose, can develop with repeated use. Tranquilizers can produce physical dependence even at ordinary prescribed doses. Withdrawal symptoms can be more severe than those accompanying opioid addiction and are similar to the DTs of alcoholism (see Chapter 10). They may begin as anxiety, shaking, and weakness but may turn into convulsions and possibly cardiovascular collapse and death. While intoxicated, people on depressants cannot function well. They are often confused and may be obstinate, irritable, or abusive. Long-term use of depressants like alcohol can lead to serious physical effects, including brain damage, with impaired ability to reason and make judgments. Overdosing with CNS Depressants Too much depression of the central nervous system slows respiration and may stop it entirely. CNS depressants are particularly dangerous in combination with another depressant, such as alcohol. People who combine depressants with alcohol account for thousands of emergency department visits and hundreds of overdose deaths each year. Club Drugs Some people refer to club drugs as soft drugs because they see them as recreational—for the casual weekend user—rather than as addictive. But club drugs have many potential negative effects and are particularly potent and unpredictable when mixed with alcohol. Substitute drugs are often sold in place of club drugs, putting users at risk for taking dangerous combinations of unknown drugs. Rohypnol (flunitrazepam) is a sedative that is 10 times more potent than Valium. Its effects, which are magnified by alcohol, include reduced blood pressure, dizziness, confusion, gastrointestinal disturbances, and loss of consciousness. Users of Rohypnol may develop physical and psychological dependence on the drug. Rohypnol has never been approved for medical use by the U.S. Food and Drug Administration (FDA); along with some other club drugs, it is used as a "date rape drug." Because they can be added to beverages surreptitiously, these drugs may be unknowingly consumed by intended rape victims. In addition to depressant effects, some drugs also cause anterograde amnesia—the loss of memory of things occurring while under the influence of the drug. Rohypnol can be fatal if combined with alcohol. GHB (gamma hydroxybutyrate) can be produced in clear liquid, white powder, tablet, and capsule form. GHB is a CNS depressant that in large doses or when taken in combination Page 229with alcohol or other depressants can cause sedation, loss of consciousness, respiratory arrest, and death. GHB may cause prolonged and potentially life-threatening withdrawal symptoms. GHB is often produced clandestinely, resulting in widely varying degrees of purity; it has been responsible for many poisonings and deaths. Club drugs such as Rohypnol are referred to as "date rape drugs" because they can be added surreptitiously to drinks. © Rubberball/Getty Images QUICK STATS In 2014, deaths from opioid overdose surpassed car crashes as the leading cause of injury-related death in the United States. —Centers for Disease Control and Prevention, 2016 Central Nervous System Stimulants Central nervous system stimulants speed up the activity of the nervous or muscular system. Under their influence, the heart rate accelerates, blood pressure rises, blood vessels constrict, the pupils and bronchial tubes dilate, and gastric and adrenal secretions increase. There is greater muscular tension and sometimes an increase in motor activity. Small doses usually make people feel more awake and alert, and less fatigued and bored. The most common CNS stimulants are cocaine, amphetamines, nicotine (see Chapter 11), ephedrine, and caffeine. Cocaine Usually derived from the leaves of coca shrubs that grow high in the Andes in South America, cocaine is a potent CNS stimulant. For centuries, natives of the Andes have chewed coca leaves both for pleasure and to increase their endurance. For a short time during the 19th century, some physicians were enthusiastic about the use of cocaine to cure alcoholism and addiction to the painkiller morphine. Enthusiasm waned after the drug's adverse side effects became apparent. Cocaine quickly produces a feeling of euphoria, which makes it a popular recreational drug. Cocaine use surged in popularity during the early 1980s, when the drug's high price made it somewhat of a status drug. The introduction of crack cocaine during the 1980s made the drug available in smaller quantities and at lower prices to more people, a shift affecting poor inner-city users of crack cocaine. Cocaine use peaked in 1985 with an estimated 3% of adult Americans reporting use. Methods of Use Cocaine is usually snorted and absorbed through the nasal mucosa or injected intravenously, providing rapid increases of the drug's concentration in the blood and therefore fast, intense effects. Another method of use involves processing cocaine with baking soda and water, yielding the ready-to-smoke form of cocaine known as crack. Crack is typically available as small beads or pellets smokable in glass pipes. The tiny but potent beads can be handled more easily than cocaine powder and marketed in smaller, less expensive doses. Effects The effects of cocaine are usually intense but short-lived. The euphoria lasts from 5 to 20 minutes and ends abruptly, to be replaced by irritability, anxiety, or slight depression. When cocaine is absorbed via the lungs by either smoking or inhalation, it reaches the brain in about 10 seconds, and the effects are particularly intense. This is part of the appeal of smoking crack. The effects from IV injections occur almost as quickly—in about 20 seconds. Since the mucous membranes in the nose briefly slow absorption, the onset of effects from snorting takes 2-3 minutes. Heavy users may inject cocaine intravenously every 10-20 minutes to maintain the effects. The larger the cocaine dose and the more rapidly it is absorbed into the bloodstream, the greater the immediate—and sometimes lethal—effects. Sudden death from cocaine is most commonly the result of excessive CNS stimulation that causes convulsions and respiratory collapse, irregular heartbeat, extremely high blood pressure, blood clots, and possibly heart attack or stroke. Although rare, fatalities can occur in healthy young people; among people aged 18-59, cocaine users are seven times more likely than nonusers to have a heart attack. Chronic cocaine use produces inflammation of the nasal mucosa, which can lead to persistent bleeding and ulceration of the septum between the nostrils. The use of cocaine may also cause paranoia and aggressiveness. When steady cocaine users stop taking the drug, they experience a sudden "crash" characterized by depression, agitation, and fatigue, followed by a period of withdrawal. Their depression can be relieved temporarily by taking more cocaine, reinforcing its continued use. A binge cocaine user may go for weeks or months without using any cocaine and then take large amounts repeatedly. Although he or she may not be physically dependent, a binge cocaine user who misses work or school and risks serious health consequences is clearly abusing the drug.Page 230 Although the use of cocaine decreased in the general U.S. population after 1985, cocaine is responsible for more deaths and emergency department visits than any other illicit drug. This presumably reflects the fact that smoking crack is more toxic than snorting powdered cocaine. Most deaths result from people using cocaine in combination with other substances, such as alcohol or heroin. Cocaine Use During Pregnancy Cocaine rapidly passes from the mother's bloodstream into the placenta and can have serious effects on the fetus. A woman who uses cocaine during pregnancy is at higher risk for miscarriage, premature labor, and stillbirth. She is more likely to deliver a low-birth-weight baby who has a small head circumference. Her infant may be at increased risk for defects of the genitourinary tract, cardiovascular system, central nervous system, and extremities. It is difficult to pinpoint the effects of cocaine because many women who use cocaine also use tobacco and alcohol. Infants whose mothers use cocaine may also be born intoxicated. They are typically irritable and jittery and do not eat or sleep normally. These characteristics may affect their early social and emotional development because it may be more difficult for adults to interact with them. Cocaine also passes into breast milk and can intoxicate a breastfeeding infant. Amphetamines Amphetamines (uppers) are a group of synthetic chemicals that are potent CNS stimulants. Some common drugs in this family are amphetamine (Benzedrine), dextroamphetamine (Dexedrine), and methamphetamine (Methedrine). Crystal methamphetamine (also called ice) is a smokable, high-potency form of methamphetamine, or meth. Crystal meth is easy to manufacture and cheaper than crack cocaine, and it produces a similar but longer-lasting euphoria. The use of crystal meth can quickly lead to addiction. Effects Small doses of amphetamines usually make people feel more alert. Amphetamines generally increase motor activity but do not measurably alter a normal, rested person's ability to perform tasks calling for challenging motor skills or complex thinking. When amphetamines improve performance, it is primarily by counteracting fatigue and boredom. In small doses, amphetamines increase heart rate and blood pressure and change sleep patterns. Amphetamines are sometimes used to curb appetite, but after a few weeks the user develops tolerance and higher doses are necessary. When people stop taking the drug, their appetite usually returns, and they gain back the weight they lost unless they have made permanent changes in eating behavior. Misuse and Addiction Much amphetamine misuse begins as an attempt to cope with a temporary situation. A student cramming for an exam or an exhausted long-haul truck driver can go a little longer by taking amphetamines, but the results can be disastrous. The likelihood of making bad judgments increases significantly. The stimulating effects may also wear off suddenly, and the user may precipitously feel exhausted or fall asleep ("crash"). Crystal meth is often manufactured in small, home "laboratories," like the one featured in the RV in the popular television series Breaking Bad. © A.F. Archive/Alamy Another problem is state dependence, the phenomenon whereby information learned in a certain drug-induced state is difficult to recall when the drug wears off. Performance may deteriorate when students use drugs to study and then take tests in their normal, nondrug state. (Users of antihistamines may also experience state dependence.) Repeated use of amphetamines, even in moderate doses, often leads to tolerance and the need for increasingly larger doses. The result can be severe disturbances in behavior, including a temporary state of paranoid psychosis, with delusions of persecution and episodes of unprovoked violence. If injected in large doses, amphetamines produce a feeling of intense pleasure, followed by sensations of vigor and euphoria that last for several hours. As these feelings wear off, they are replaced by feelings of irritability and vague uneasiness. Long-term use of amphetamines at high doses can cause paranoia, hallucinations, delusions, and incoherence. Methamphetamine is more addictive than other forms of amphetamine. It also is more dangerous because it is more toxic and its effects last longer. In the short term, meth can cause rapid breathing, increased body temperature, insomnia, tremors, anxiety, and convulsions. Meth use has been linked to high-risk sexual behavior and increased rates of sexually transmitted infections, including HIV infection. In the long term, the effects of meth can include weight loss, severe acne, hallucinations, paranoia, violence, and psychosis. Meth use may cause extensive tooth decay and tooth Page 231loss, a condition referred to as "meth mouth," but this may be due to poor hygiene associated with chronic meth use and severe drug dependence in general. Meth takes a toll on the user's heart and can cause heart attack and stroke. Methamphetamine users have signs of brain damage similar to those seen in Parkinson's disease patients. These symptoms can persist even after drug use ceases, causing impaired memory and motor coordination problems. Withdrawal from meth causes symptoms that may include muscle aches and tremors, profound fatigue, deep depression, despair, and apathy. Addiction to methamphetamine is associated with pronounced psychological cravings and obsessive drug-seeking behavior. Women who use amphetamines during pregnancy risk premature birth, stillbirth, low birth weight, and early infant death. Babies born to amphetamine-using mothers have a higher incidence of cleft palate, cleft lip, and deformed limbs. They may also experience symptoms of withdrawal. Ritalin A stimulant with amphetamine-like effects, Ritalin (methylphenidate) is used to treat attention-deficit/hyperactivity disorder (ADHD). When methylphenidate is injected or snorted, dependence and tolerance can result rapidly. Ephedrine Although somewhat less potent than amphetamine, ephedrine produces stimulant effects. Ephedrine has been linked to heart arrhythmia, stroke, psychotic reactions, seizures, and some deaths, and it may be particularly dangerous at high doses or when combined with another stimulant such as caffeine. The FDA has banned the sale of ephedrine. Caffeine Caffeine is a very popular psychoactive drug and also one of the most ancient. It is found in coffee, tea, cocoa, soft drinks, headache remedies, and OTC preparations like NoDoz. (Table 9.4 lists typical levels of caffeine in several popular beverages.) In ordinary doses, caffeine produces greater alertness and a sense of well-being. It also decreases feelings of fatigue or boredom, so using caffeine may enable a person to keep at physically tiring or repetitive tasks longer. Such use is usually followed, however, by a sudden letdown. Caffeine does not noticeably influence a person's ability to perform complex mental tasks unless fatigue, boredom, or other factors have already affected normal performance. Table 9.4 Caffeine Content of Popular Beverages COFFEE SERVING SIZE (OZ.) TYPICAL CAFFEINE LEVEL (MG)* Regular coffee, brewed 8 95 Regular coffee, instant 8 93 Espresso 1 64 Decaffeinated coffee, brewed 8 5 Decaffeinated coffee, instant 8 2 TEA Regular tea, brewed 8 47 Decaffeinated tea, brewed 8 2 Green tea, brewed 8 Varies SODA Code Red Mountain Dew 12 54 Mello Yello 12 53 Diet Coke 12 47 Dr. Pepper, Diet Dr. Pepper 12 41 Sunkist Orange Soda 12 41 Pepsi 12 38 Coca-Cola Classic, Diet Pepsi 12 35 ENERGY DRINKS No Name 8.4 280 SoBe No Fear 16 174 Monster Energy, Rockstar 16 160 SoBe Adrenaline Rush 16 152 Full Throttle, Full Throttle Fury 16 144 AMP Energy Drink 16 143 Red Bull 8.3 76 Vault 8 47 *Caffeine levels vary greatly by brand of product, manner of preparation, and amount consumed. The amounts shown here are averages based on tests conducted by a variety of organizations. The FDA limits the amount of caffeine in cola and pepper soft drinks to 71 milligrams per 12-ounce serving. To find the exact amount of caffeine in any product, check that product's label. sources: Center for Science in the Public Interest. 2007. Caffeine Content of Food & Drugs (http://www.cspinet.org/new/cafchart.htm); Mayo Clinic. 2008. Caffeine Content in Tea, Soda, and More (http://www.mayoclinic.com/health/caffeine/AN01211); U.S. Department of Agriculture, Agricultural Research Service. 2009. USDA National Nutrient Database for Standard Reference, Release 22 (http://www.ars.usda.gov/ba/bhnrc/ndl). Caffeine mildly stimulates the heart and respiratory system, increases muscular tremor, and enhances gastric secretion. Higher doses may cause nervousness, anxiety, irritability, headache, disturbed sleep, and gastric irritation or peptic ulcers. In people with high blood pressure, caffeine can cause blood pressure to rise even further above normal; in people with type 2 diabetes, caffeine may cause glucose and insulin levels to rise after meals. Drinks containing caffeine are rarely harmful for most people, but some tolerance develops, and withdrawal symptoms of irritability, headaches, and even mild depression occur. Thus although we don't usually think of caffeine as a dependence-producing drug, for some people it is. The DSM-5 does not include caffeine in the substance use disorder category, but it does suggest further research on the impact of caffeine use. People can usually avoid problems by simply decreasing their daily intake of caffeine. If intake is decreased gradually, withdrawal symptoms can be reduced or avoided. About 80-90% of American adults consume caffeine regularly. The average daily intake is about 280 mg.Page 232 Energy "Shots" The popularity of small (1.5- to 3-ounce) energy drinks has increased dramatically in recent years. Because these products are sold as dietary supplements rather than food, their caffeine content is not regulated by the FDA. Each two-ounce "shot" typically contains the same amount of caffeine (roughly 100 mg) as a regular-size cup of coffee. Marijuana and Other Cannabis Products With approximately 22.2 million current users, marijuana is the most widely used illegal drug in the United States. This status may be changing as more states—25 and the District of Columbia (DC) at the time of writing—legalize medical marijuana as well as regulate recreational usage. THC (tetrahydrocannabinol) is the main active ingredient in marijuana. Marijuana plants that grow wild often have less than 1% THC in their leaves. When selected strains are cultivated by separation of male and female plants (sinsemilla), the bud leaves from the flowering tops may contain 7-8% THC. Hashish, a potent preparation made from the thick resin that exudes from the marijuana leaves, may contain up to 14% THC. These various preparations have all been known and used for centuries, so the frequently heard claim that today's marijuana is more potent than the marijuana of the 1970s is not strictly true. However, because a greater proportion of the marijuana sold today is the higher-potency (and more expensive) sinsemilla, the average potency of street marijuana has increased. Short-Term Effects and Uses As is true with most psychoactive drugs, the effects of a low dose of marijuana are strongly influenced both by the user's expectations and by past experiences. At low doses, marijuana users typically experience euphoria, a heightening of subjective sensory experiences, a slowing down of the perception of passing time, and a relaxed attitude. These pleasant effects are the reason this drug is so widely used. With moderate doses, marijuana's effects become stronger, and the user can also expect to have impaired memory function, disturbed thought patterns, lapses of attention, and feelings of depersonalization, in which the mind seems to be separated from the body. At higher doses, marijuana's effects are determined mostly by the drug itself rather than by the user's expectations and setting. Very high doses produce feelings of depersonalization, marked sensory distortion, and changes in body image (such as a feeling that the body is very light). Inexperienced users sometimes think these sensations mean they are going crazy and become anxious or even panicky. Unexpected reactions are the leading reason for emergency department visits by users of marijuana or hashish. Physiologically, marijuana increases heart rate and dilates certain blood vessels in the eyes, which creates the characteristic bloodshot eyes. The user may also feel less inclined toward physical exertion and may feel particularly hungry or thirsty. Because THC affects parts of the brain controlling balance, coordination, and reaction time, marijuana use impairs driving performance. The combination of alcohol and marijuana is even more dangerous: Even a low dose of marijuana, when combined with alcohol, significantly impairs driving performance and increases crash risk. Some states permit the sale of both medical and recreational marijuana. The regulations typically differ for the two types of sales: In Colorado, for example, medical marijuana is taxed at a lower rate and less expensive than recreational marijuana. © Blaine Harrington III/Getty Images Colorado, Washington, Alaska, Oregon, and the District of Columbia permit the recreational use of marijuana. The Supreme Court has held that state laws permitting medical marijuana use cannot supersede federal law. Thus, anyone using marijuana can still be prosecuted under federal drug laws, although the Obama administration indicated that it would not pursue such prosecutions. Research shows benefits for using cannabis to treat muscle spasms in multiple sclerosis and cancer-related pain that is not otherwise relieved by opioid medications. Many cancer patients and people with AIDS use marijuana because they find it effective in relieving nausea and restoring appetite. Additional research is focused on synthesizing compounds that target symptoms without the psychoactive effects of cannabinoids, standardizing doses, and conducting clinical trials on the efficacy of these cannabinoids that conform with procedures used with other drugs that are in development. Long-Term Effects The most probable long-term effect of smoking marijuana is respiratory damage, including impaired lung function and chronic bronchial irritation. Page 233Although no evidence links marijuana use to lung cancer, it may cause changes in lung tissue that promote cancer growth. Marijuana users may be at increased risk for emphysema and cancer of the head and neck, and among people with chronic conditions like cancer and AIDS, marijuana use is associated with increased risk of fatal lung infections. (These are key reasons why the Institute of Medicine has recommended the development of alternative methods of delivering the potentially beneficial compounds in marijuana.) Heavy users may experience learning problems, as well as subtle impairments of attention and memory that may or may not be reversible following long-term abstinence. Long-term use may also affect sperm productivity and quality. Studies show that marijuana use during pregnancy may affect neural development. Children exposed to cannabis in-utero showed cognitive deficits, suggesting that maternal use of marijuana has interfered with the proper development of the brain. Babies born to mothers who used marijuana during pregnancy also had increased startles and tremors as well as difficulty adjusting to light. Their sleep patterns were altered, and they showed increased irritability. As children developed into adolescents, memory, impulsivity, and attention problems emerged. Moreover, THC rapidly enters breast milk and may impair an infant's early motor development. Hallucinogens As shown in Figure 9.2, hallucinogens are a group of drugs whose predominant pharmacological effect is to alter the user's perceptions, feelings, and thoughts. LSD LSD (lysergic acid diethylamide) is one of the most powerful psychoactive drugs. Tiny doses will produce noticeable effects in most people, such as an altered sense of time, visual disturbances, an improved sense of hearing, mood changes, and distortions in how people perceive their bodies. Dilation of the pupils and slight dizziness, weakness, and nausea may also occur. With larger doses, users may experience a phenomenon known as synesthesia: feelings of depersonalization and other alterations in the perceived relationship between the self and external reality. Many hallucinogens induce tolerance so quickly that after only one or two doses their effects decrease substantially. The user must then stop taking the drug for several days before his or her system can be receptive to it again. These drugs cause little drug-seeking behavior and no physical dependence or withdrawal symptoms. The immediate effects of low doses of hallucinogens are determined largely by expectations and setting. Many effects are hard to describe because they involve subjective and unusual dimensions of awareness—the altered states of consciousness for which these drugs are famous. For this reason, hallucinogens have acquired a certain aura not associated with other drugs. People have taken LSD in search of a religious or mystical experience or in the hope of exploring new worlds. During the 1960s some psychiatrists gave LSD to their patients to help them talk about their repressed feelings. A severe panic reaction, which can be terrifying in the extreme, can result from taking any dose of LSD. It is impossible to predict when a panic reaction will occur. Some LSD users report having had hundreds of pleasurable and ecstatic experiences before having a bad trip, or bummer. If the user is already in a serene mood and feels no anger or hostility and if he or she is in secure surroundings with trusted companions, a bad trip may be less likely, but a tranquil experience is not guaranteed. Even after the drug's chemical effects have worn off, spontaneous flashbacks and other psychological disturbances can occur. Flashbacks are perceptual distortions and bizarre thoughts that occur after the drug has been entirely eliminated from the body. Although they are relatively rare phenomena, flashbacks can be extremely distressing. They are often triggered by specific psychological cues associated with the drug-taking experience, such as certain mood states or even types of music. MDMA MDMA (methylenedioxymethamphetamine), and variants called ecstasy (MDMA with a stimulant such as caffeine added) and molly (a powder said to be "purer" than ecstasy), may be classified as a hallucinogen or a stimulant, having both hallucinogenic and amphetamine-like properties. Tolerance to MDMA develops quickly, leading users to take the drug more frequently, use higher doses, or combine MDMA with other drugs to enhance the drug's effects, and high doses can cause anxiety, delusions, and paranoia. Users may experience euphoria, increased energy, and a heightened sense of belonging. Using MDMA can produce dangerously high body temperature and potentially fatal dehydration; several cases have been reported of low total body salt concentrations (hyponatremia). Some users experience confusion, depression, anxiety, paranoia, muscle tension, involuntary teeth clenching, blurred vision, nausea, and seizures. Even low doses can affect concentration, judgment, and driving ability. Other Hallucinogens Most other hallucinogens have the same general effects as LSD, but there are some variations. For example, a DMT (dimethyltryptamine) or ketamine high does not last as long as an LSD high; an STP (4-methyl-2,5-dimethoxyamphetamine) high lasts longer.Page 234 PCP (phencyclidine) reduces and distorts sensory input, especially proprioception—the sensation of body position and movement—and creates a state of sensory deprivation. PCP was initially used as an anesthetic but was unsatisfactory because it caused agitation, confusion, and delirium (loss of contact with reality). Because it can be easily made, PCP is often available illegally and is sometimes used as an inexpensive replacement for other psychoactive drugs. The effects of ketamine are similar to those of PCP—confusion, agitation, aggression, lack of coordination, and distorted perceptions of sight and sound that produce feelings of dissociation from the environment and self—but they tend to be less predictable. Tolerance to either drug can develop rapidly. Mescaline, derived from the peyote cactus, is the ceremonial drug of the Native American Church. It causes effects similar to LSD, including altered perception and feeling; increased body temperature, heart rate, and blood pressure; weakness and trembling; and sleeplessness. Mescaline is expensive, so most street mescaline is diluted LSD or a mixture of other drugs. Hallucinogenic effects can be obtained from certain mushrooms (Psilocybe mexicana, or "magic mushrooms"), certain morning glory seeds, nutmeg, jimsonweed, and other botanical products; but unpleasant side effects, such as dizziness, have limited the popularity of these products. Inhalants Inhaling certain chemicals can produce effects ranging from heightened pleasure to delirium and death. Inhalants fall into several major groups: Volatile solvents, which are found in products such as paint thinner, glue, and gasoline Aerosols, which are sprays that contain propellants and solvents Nitrites, such as butyl nitrite and amyl nitrite Anesthetics, which include nitrous oxide (laughing gas) Inhalant use tends to be highest among younger adolescents and declines with age. Inhalant use is difficult to control because inhalants are easy to obtain. They are present in a variety of seemingly harmless products, from dessert-topping sprays to underarm deodorants, that are both inexpensive and legal. Using the drugs also requires no illegal or suspicious paraphernalia. Inhalant users get high by sniffing, snorting, "bagging" (inhaling fumes from a plastic bag), or "huffing" (placing an inhalant-soaked rag in the mouth). Although different in makeup, nearly all inhalants produce effects similar to those of anesthetics, which slow down body functions. Low doses may cause users to feel slightly stimulated; at higher doses, users may feel less inhibited and less in control. Sniffing high concentrations of the chemicals in solvents or aerosol sprays can cause a loss of consciousness, heart failure, and death. High concentrations of any inhalant can also cause death from suffocation by displacing oxygen in the lungs and central nervous system. Deliberately inhaling from a bag or in a closed area greatly increases the chances of suffocation. Other possible effects of the excessive or long-term use of inhalants include damage to the nervous system; hearing loss; increased risk of cancer; and damage to the liver, kidneys, and bone marrow. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Do you know any young teens who may be at risk for using inhalants? If so, would you try to intervene in some way? What would you tell a young teen to convince him or her to stop inhaling chemicals? Prescription Drug Misuse The National Institute on Drug Abuse describes prescription drug abuse as the use of a medication without a prescription, in a way other than as prescribed, or for the experience or feelings elicited. Over the past decade, misuse of prescription drugs has increased and national surveys now show that prescription medications—such as those used to treat pain, ADHD, and anxiety—are being abused at a rate second only to marijuana and alcohol among Americans age 12 and over. More people died from drug overdoses in the United States in 2014 than in any previous year on record, outnumbering motor vehicle crashes one and a half times. Among high school seniors, abuse of Adderall—the prescription form of amphetamine used to treat ADHD—has become a significant problem. In 2015, 7.5% of seniors reported nonmedical use of Adderall within the past year, up from 5.4% in 2009. More than one in five seniors (21.5%) have used at least one prescription medication without a doctor's orders at least once; 15.0% report use within the previous year. A study of college students found that almost two-thirds (61.8%) were offered prescription stimulants for nonmedical use by their senior year and 31.0% used them. Studying was the predominant motive, and the most common source was a friend with a prescription. Synthetic Recreational Drugs In recent years, herbal or synthetic recreational drugs have become increasingly available. These "designer drugs" are intended to have pharmacological effects similar to those of illicit drugs but to be chemically distinct from them and therefore either legal or impossible to detect in drug screening. The drugs fall into two main groups. One group is marketed as synthetic marijuana and sold as "herbal incense," or "herbal highs," with names such as Spice, K2, Genie, and Mr. Nice Guy. The other group is marketed as stimulants with properties like those of cocaine or amphetamine and Page 235sold as "bath salts" with names such as Zoom, Ivory Wave, and White Rush. Spice and other synthetic mimics of THC are distributed in the form of dried leaves or powder. They are typically smoked, using a pipe or by rolling in a cigarette paper, but can also be ingested as an infusion such as tea, or inhaled. The active ingredients in Spice and similar products are synthetic cannabinoids that act on brain cells to produce effects similar to those of THC, such as physical relaxation, changes in perception, elevated mood, and mild euphoria. Synthetic marijuana went through a period of initial popularity among teens and young adults. In 2011, 11.4% of high school seniors reported having used synthetic marijuana at least once during the year, according to the Monitoring the Future survey conducted by the University of Michigan. Usage dropped sharply beginning in 2013, and had declined to 5.2% by 2015; still, that represented use by 1 in 20 twelfth graders. A similar pattern was seen among full-time college students, with usage reported at 8.5% in 2011, declining to 1.5% in 2015. Spice and similar products have not been included in any wide-scale animal or human studies, and little information is available in international medical databases. The blends of ingredients vary widely, but these products typically contain more than a dozen different plant-derived compounds, which give rise to a variety of drug combinations. Calls to poison control centers for exposure to synthetic marijuana doubled between 2010 and 2011, with patients describing symptoms that include rapid heart rate, vomiting, agitation, confusion, and hallucinations. In March 2011, the U.S. Drug Enforcement Administration (DEA) banned five synthetic cannabinoids used in Spice and similar products. "Bath salts," marketed as cocaine or methamphetamine substitutes, are widely available on the Internet. They contain synthetic cathinones such as mephedrone, methylone, or methylenedioxypyrovalerone (MDPV). Emergency department admissions have increased for bath salts, with MDPV the most common synthetic cathinone found in blood and urine of patients. Similar in effect to MDMA (ecstasy), these cathinones are synthetic versions of the active ingredient found in the stimulant khat, a chewable leaf that is widely used in countries of the Middle East and Africa. The products are sold in small packets of salt-like crystals with warnings like "novelty only" and "not for human consumption." Bath salts can be ingested by smoking, eating, or injecting or by crushing them and snorting the powder. The speed of onset is up to 15 minutes depending on how the drug is ingested, and the effects may last as long as six hours. The effects of bath salts can be severe and include combative violent behavior, extreme agitation, confusion, hallucinations, hypertension, chest pain, and suicidal thoughts. In 2010, poison control centers in the United States received 304 calls about reactions to bath salts; the number rose to 6,138 calls in 2011. In September 2011, the DEA banned three of the drugs found in bath salts; possession or sale of the chemicals or products that contain them is now illegal.