Substance Use Disorders

2. Substance Use Disorders

3. Substance Use Disorders • Some substances can also lead to long-term problems • People who regularly ingest them may develop substance use disorders • Also called “addiction”

4. Substance Use Disorders

5. Substance Use Disorders

6. Depressants • Depressants slow the activity of the central nervous system (CNS) • Reduce tension and inhibitions • May interfere with judgment, motor activity, and concentration • Three most widely used depressants: • Alcohol • Sedative-hypnotic drugs • Opioids

7. Depressants: Alcohol • All alcoholic beverages contain ethyl alcohol • It is absorbed into the blood through the stomach lining and takes effect in the bloodstream and CNS • Short-term: alcohol blocks messages between neurons • Alcohol helps GABA (an inhibitory messenger) shut down neurons and relax the drinker

8. Depressants: Alcohol • The extent of the effect of ethyl alcohol is determined by its concentration (proportion) in the blood • A given amount of alcohol has a lesser effect on a large person than on a small one • Gender also affects blood alcohol concentration • Women have less alcohol dehydrogenase, an enzyme in the stomach that metabolizes alcohol before it enters the blood • Women become more intoxicated than men on equal doses of alcohol

9. Depressants: Alcohol • Levels of impairment are closely tied to the concentration of ethyl alcohol in the blood: • BAC = 0.06: Relaxation and comfort • BAC = 0.09: Intoxication • BAC > 0.55: Death • Most people lose consciousness before they can drink this much

10. Depressants: Alcohol • The effects of alcohol subside only after alcohol is metabolized by the liver • The average rate of this metabolism is 25% of an ounce per hour • You can't increase the speed of this process!

11. Depressants: Alcohol

12. Is All Drug Misuse the Same? DSM-5 has combined two past disorders, substance abuse (excessive and chronic reliance on drugs) and substance dependence (excessive reliance accompanied by tolerance and withdrawal symptoms) into a single category—substance use disorder. Critics worry that clinicians may now fail to recognize and address the different prognoses and treatment needs of individuals who abuse substances and those who depend on substances.

13. Depressants: Alcohol • Alcohol use disorder • In general, people who abuse alcohol drink large amounts regularly and rely on it to enable them to do things that would otherwise make them anxious • Eventually the drinking interferes with social behavior and the ability to think and work • Individual patterns of alcohol abuse vary

14. Depressants: Alcohol • Alcohol dependence • For many people, the pattern of alcohol misuse includes dependence • They build up a physiological tolerance and need to drink greater amounts to feel its effects • They may experience withdrawal, including nausea and vomiting, when they stop drinking • A small percentage of alcohol-dependent people experience a dramatic and dangerous withdrawal syndrome known as delirium tremens (“the DTs”) • Alcohol withdrawal can be fatal

15. What is the personal and social impact of alcoholism?

16. Depressants: Sedative-Hypnotic Drugs • Sedative-hypnotic (anxiolytic) drugs produce feelings of relaxation and drowsiness • At low doses, they have a calming or sedative effect • At high doses, they function as sleep inducers or hypnotics • Sedative-hypnotic drugs include barbiturates and benzodiazepines

17. Depressants: Barbiturates • Widely prescribed in the first half of the 20th century to fight anxiety and to help people sleep • They can cause many problems such as abuse, dependence, and overdose • At low doses, they reduce excitement in a manner similar to alcohol by attaching to the GABA receptors and helping GABA operate • At too high a level, they can halt breathing, lower blood pressure, and can lead to coma and death

18. Depressants: Barbiturates • Repeated use of barbiturates can quickly result in a pattern of abuse and/or dependence • A great danger of barbiturate dependence is that the lethal dose of the drug remains the same, even while the body is building a tolerance for the sedative effects • Barbiturate withdrawal is particularly dangerous because it can cause convulsions

19. Depressants: Benzodiazepines • Benzodiazepines are often prescribed to relieve anxiety • Most popular sedative-hypnotics available • Class includes Xanax, Ativan, and Valium • Benzodiazepines have a depressant effect on the CNS by binding to GABA receptors and increasing GABA activity • Benzodiazepines relieve anxiety without causing drowsiness • Less likely to slow breathing and lead to death by overdose

20. Depressants: Opioids • This class of drug includes both natural (opium, heroin, morphine, codeine) and synthetic (methadone) compounds and is known collectively as “narcotics” • Each drug has a different strength, speed of action, and tolerance level

21. Depressants: Opioids • Narcotics are smoked, inhaled, injected by needle just under the skin (“skin popped”), or injected directly into the bloodstream (“mainlined”) • Injection seems to be the most common method of use, although other techniques have been increasing in recent years • An injection quickly brings on a “rush” – a spasm of warmth and ecstasy that is sometimes compared with orgasm • This spasm is followed by several hours of pleasurable feelings (called a “high” or “nod”)

22. Depressants: Opioids • Opioids create these effects by depressing the CNS • Opioids bind to the receptors in the brain that ordinarily receive endorphins (NTs that naturally help relieve pain and decrease emotional tension) • When these sites receive opioids, they produce pleasurable and calming feelings, just as endorphins do • In addition to reducing pain and tension, opioids can cause nausea, narrowing of the pupils, and constipation

23. Depressants: Opioids • Heroin use exemplifies the problems posed by opioids: • After just a few weeks, users may become caught in a pattern of abuse (and often dependence) • Users quickly build a tolerance for the drug and experience withdrawal when they stop taking it • Early withdrawal symptoms include anxiety and restlessness; later symptoms include twitching, aches, fever, vomiting, diarrhea, and weight loss from dehydration

24. Depressants: Opioids • What are the dangers of heroin abuse? • The most immediate danger is overdose • The drug closes down the respiratory center in the brain, paralyzing breathing and causing death • Death is particularly likely during sleep • Ignorance of tolerance is also a problem • About 2% of those dependent on heroin and other opioids die under the influence of the drug each year • Users run the risk of getting impure drugs • Opioids are often “cut” with noxious chemicals • Dirty needles and other equipment can spread infection

25. Stimulants • Stimulants are substances that increase the activity of the central nervous system (CNS) • Cause increases in blood pressure, heart rate, and alertness • Cause rapid behavior and thinking • The four most common stimulants are: • Cocaine • Amphetamines • Caffeine • Nicotine

26. Stimulants: Cocaine • Most powerful natural stimulant known • Cocaine produces a euphoric rush of well-being • Produces this effect largely by increasing supplies of dopamine at key neurons throughout the brain • Also appears to increase norepinephrine and serotonin

27. Stimulants: Cocaine • High doses of cocaine can produce cocaine intoxication, whose symptoms include mania, paranoia, and impaired judgment • Some people also experience hallucinations and/or delusions, a condition known as cocaine-induced psychotic disorder • As the stimulant effects of the drug subside, the user experiences a depression-like letdown, popularly called “crashing”

28. Stimulants: Cocaine • Cocaine abuse and dependence • Regular use may lead to a pattern of abuse in which the person remains under the effect of cocaine for much of each day and functions poorly in social relationships and at work • Dependence on the drug may also develop

29. Stimulants: Cocaine • Cocaine abuse and dependence • Cocaine use in the past was limited by the drug's high cost • Since 1984, cheaper, more powerful versions of the drug have become available, including: • A “freebase” form where the drug is heated and inhaled with a pipe • “Crack,” a powerful form of freebase that has been boiled down for smoking in a pipe • Currently, 0.5% of all people over the age of 11 in the U.S. manifest cocaine abuse or dependence in a given year

30. Stimulants: Cocaine • What are the dangers of cocaine? • Aside from its behavioral effects, cocaine poses significant physical danger • The greatest danger of use is the risk of overdose • Excessive doses depress the brain's respiratory function, and stop breathing • Cocaine use can also cause heart failure • Pregnant women who use cocaine have an increased likelihood of miscarriage and of having children with abnormalities

31. Stimulants: Amphetamines • Amphetamines: stimulant drugs manufactured in the laboratory • Most often taken in pill or capsule form • Some people inject the drugs intravenously or smoke them for a quicker, more powerful effect • Like cocaine, amphetamines: • Increase energy and alertness and reduce appetite when taken in small doses • Produce a rush, intoxication, and psychosis in high doses • Cause an emotional letdown as they leave the body

32. Stimulants: Amphetamines • One kind of amphetamine, methamphetamine, has had a major surge in popularity in recent years • Almost 6% of all persons over the age of 11 in the US have used this stimulant at least once • Most of the nonmedical meth is made in “stovetop laboratories”

33. Stimulant Use Disorder • Regular use of either cocaine or amphetamines may lead to stimulant use disorder • The stimulant dominates the individual’s life • Leads to poor function in social relationships and at work

34. Stimulants: Caffeine • World’s most widely used stimulant • 80% of the world's population consumes it daily • Most is in the form of coffee; the rest is in the form of tea, cola, energy drinks, chocolate, and over-the-counter medications • 99% of ingested caffeine is absorbed by the body and reaches its peak concentration within an hour • Caffeine acts as a stimulant in the CNS, producing a release of dopamine, serotonin, and norepinephrine in the brain • More than 2 to 3 cups of brewed coffee can lead to caffeine intoxication • Seizures and respiratory failure can occur at doses greater than 10 grams of caffeine (about 100 cups of coffee)

35. Stimulants: Caffeine • Many people who suddenly stop or cut back their usual intake experience withdrawal symptoms, including headaches, depression, anxiety, and fatigue • Studies suggest correlations between high doses of caffeine and heart rhythm irregularities, high cholesterol levels, and risk of heart attacks • High doses during pregnancy also increase the risk of miscarriage

36. Hallucinogens, Cannabis, and Combinations of Substances • Hallucinogens • Produce delusions, hallucinations, and other sensory changes • Cannabis substances • Produce sensory changes, but have both depressant and stimulant effects • Combinations of substances

37. Hallucinogens • Hallucinogens produce powerful changes in sensory perceptions (sometimes called “trips”) • Natural hallucinogens • Mescaline • Psilocybin • Laboratory-produced hallucinogens • Lysergic acid diethylamide (LSD) • MDMA (Ecstasy)

38. Hallucinogens • LSD is one of the most powerful hallucinogens • Brings on a state of hallucinogen intoxication (hallucinosis) • Increased and altered sensory perception • Hallucinations and/or synesthisia • Effects wear off in about six hours • LSD produces these symptoms by binding to serotonin receptors • These neurons help control visual information and emotions, thereby causing the various effects of the drug on the user

39. Hallucinogens • More than 14% of Americans have used hallucinogens at some point in their lives • Tolerance and withdrawal are rare • But the drugs do pose dangers • Users may experience a “bad trip” – the experience of enormous unpleasant perceptual, emotional, and behavioral reactions • Another danger is the risk of “flashbacks” • Can occur days or months after last drug use

40. Cannabis • The drugs produced from varieties of the hemp plant are, as a group, called cannabis • They include: • Hashish, the solidified resin of the cannabis plant • Marijuana, a mixture of buds, crushed leaves, and flowering tops • The major active ingredient in cannabis is tetrahydrocannabinol (THC) • The greater the THC content, the more powerful the drug

41. Cannabis • When smoked, cannabis produces a mixture of hallucinogenic, depressant, and stimulant effects • At low doses, the user feels joy and relaxation • May become anxious, suspicious, or irritated • This overall “high” is technically called cannabis intoxication • At high doses, cannabis produces odd visual experiences, changes in body image, and hallucinations • Most of the effects of cannabis last 2 to 6 hours • Mood changes may continue longer

42. Cannabis abuse and Dependence • Marijuana was once thought not to cause abuse or dependence • One theory about the increase in abuse and dependence is the change in the drug itself • The marijuana available today is significantly more potent than the drug used in the early 1970s

43. Cannabis

44. Cannabis • Cannabis and Society: A Rocky Relationship • For centuries, cannabis played a respected role in medicine, but its use fell out of favor and was criminalized • In the late 1980s, several interest groups campaigned for the medical legalization of marijuana • The U.S. Federal Government has continued to fight and punish the production and distribution of marijuana for medical purposes • However, in 2009, the US Attorney General directed federal prosecutors to not pursue cases against medical marijuana users complying with state laws • Both the Netherlands and Canada permit its use

45. Teenagers and Substance Use

46. Combinations of Substances • People often take more than one drug at a time, a pattern called polysubstance use • Researchers have studied the ways in which drugs interact with one another, focusing on cross-tolerance and synergistic effects

47. Combinations of Substances

48. Combinations of Substances

49. Combinations of Substances

50. Combinations of Substances • Each year tens of thousands of people are admitted to hospitals because of polysubstance use • May be accidental or intentional • As many as 90% of people who use one illegal drug are also using another to some extent