1. Substance-use disorders (p. 269)In the United States, there is widespread use of drugs that alter mood and consciousness. Substance-related disorders involve drug use that alters ones psychological state and causes significant physical, social, or occupational problems and sometimes results in abuse or dependence. Substance-use disorders involve abuse or dependence; substance-induced disorders (discussed in Chapter 15) involve withdrawal or delirium.
   DSM-IV-TR defines substance abuse as recurrent use over twelve months that leads to impairment or distress, and continues despite problems. Substance dependence adds the concepts of tolerance (needing increased dosages) and withdrawal (physical or emotional symptoms after reduced intake). Further, intoxication refers to central nervous system effects, following ingestion of a drug that involves maladaptive behaviors or thinking. Dependence is the more serious condition.
   Prescription drugs and legal and illegal substances can lead to abuse or dependence. Such disorders are most prevalent among youths and young adults. Overall lifetime prevalence of drug abuse/dependence (excluding nicotine and alcohol) is 6.2 percent. Women are much less likely to take drugs than men; whites have higher lifetime prevalence for drug abuse than African Americans or Hispanic Americans.
2. Depressants or sedatives (p. 274) Depressants or sedatives cause generalized depression of the central nervous system and a slowing of responses. They induce feelings of calm, but may also make people more social and open because of lowered inhibitions.
   Alcohol-use disorder involves alcohol abuse and alcohol dependence; people with these disorders are referred to as alcoholics, and their disorder is alcoholism. Problem drinking often begins as a way to reduce anxiety and expands to heavier drinking. Some drink daily, others binge. About 35 percent of Americans abstain from alcohol, but 10 percent of the drinkers consume 50 percent of all alcohol consumed in this country. Men drink two to five times as much a women; and heavy drinking is most common between ages 18 and 25. Lifetime prevalence for alcohol dependents is 14 percent. Consumption patterns are associated with cultural and racial background. Low prevalence of alcohol consumption by Asians is likely related to a lack of aldehyde dehydogenase, resulting in an inability to eliminate acetaldehyde and consequent unpleasant physiological reactions. Alcohol abuse is associated with medical costs associated with lowered productivity, spousal abuse, problems in children of alcoholic parents, and 100,000 death a year. Alcohol has short-term physiological effects, such as impaired speech and motor coordination, because it is a central nervous system depressant. Its short-term psychological effects include poor judgment, feelings of happiness, and reduced concentration, but the precise effects are influenced by the situational context. Long-term effects are serious: some drinkers become preoccupied with thoughts of alcohol, experience blackouts, lose control over their consumption, and deteriorate. Most research has been based on male alcoholics, so effect may be different for females. Physiological effects can include liver damage, heart disease, and cancers of the mouth and throat. Moderate use is associated with lowered risk of heart disease.
   Narcotics, which include opium and its derivatives morphine, heroin, and codeine, act as sedatives and are addictive. Tolerance builds rapidly and withdrawal is severe. Twenty-five percent of AIDS cases involve persons who abuse intravenous drugs. Prevalence of addiction decreases with age.
   Synthetic barbiturates are legal medications and are used mostly by middle-aged and older people to induce sleep and relaxation; however, next to narcotics, they represent the largest category of illegal drugs. By themselves, barbiturates can be addictive and can be accidentally overdosed; combined with alcohol, barbiturates can lead to fatal overdoses. Polysubstance use, using more than one chemical substance at the same time, may (among other things) result in synergistic effects that depress the central nervous system and cause death. According to DSM-IV-TR, polysubstance dependence is use of three or more (excluding nicotine and caffeine) at the same time for a period of twelve months, during which time the person meets the criteria for substance dependence for more than one substance.
   One of the most widely prescribed benzodiazepines in the country is Valium, a central nervous system depressant used to reduce anxiety and muscle tension. Three times as many females as males, and whites as compared with blacks use benzodiazepines.
3. Stimulants (p. 280) A stimulant energizes the central nervous system. One example is an amphetamine, which increases alertness and inhibits both appetite and sleep. Tolerance builds quickly, and chronic high doses can lead to aggressive behavior. Lifetime prevalence of amphetamine abuse or dependence is about 2 percent. Caffeine and nicotine are both legal and widely used stimulants. Caffeine has mild effects; nicotine is the single most preventable cause of death in the United States. Although 72 percent of the adult population in the United States reported never having smoked cigarettes, about 30 percent of the U.S. population currently smokes. Nicotine dependence symptoms are unsuccessful attempts to stop, withdrawal symptoms after stopping, and continued use despite such illnesses as emphysema. Cocaine induces feelings of self confidence in users. It is a fashionable drug, and there are from one to three million cocaine abusers in need of treatment in the United States. Cocaine is typically snorted. Crack, a rock like, purified form of cocaine, is smoked, resulting in rapid euphoria followed by depression. Cocaine and amphetamines alter moods by increasing brain dopamine levels. Crack is a major social concern because it is inexpensive, easy to acquire, produces an intense high, leads to rapid addiction, and is associated with crime.
4. Hallucinogens (p. 282) Hallucinogens are not believed to be physically addicting, although psychological dependence may occur. They produce hallucinations, vivid sensory awareness, and perceptions of increased insight. Over 33 percent of the U.S. population has used marijuana, although it is illegal. Technically, the DSM-IV-TR does not consider marijuana a hallucinogen. Marijuana is a mild hallucinogen that produces euphoria, passivity, and memory impairment. There is considerable controversy concerning its short- and long-term physical and psychological effects. Lysergic acid diethylamide (LSD) is a psychotornimetic drug that alters visual and auditory perceptions and can produce flashbacks. It does not produce physical dependence. Phencyclidine (PCP) is an extremely dangerous hallucinogen because it often leads to assaultive and suicidal behavior. Other DSM-IV-TR categories for substance-related disorders include anabolic steroids and nitrous oxide (laughing gas).
5. Etiology of substance-use disorders (p. 285) There are two major perspectives on substance-related disorders, biogenic and cultural, although integration of the two is growing. The genetic transmission of alcoholism is supported by evidence with children of alcoholics adopted by nonalcoholics and by twin research. Although the incidence of alcoholism is fur times higher among male biological offspring of alcoholic fathers compared with the offspring of non-alcoholic father, no specific genes have been found to explain the causes of alcoholism. The search for specific genes has used quantitative trait loci (QTL) and the selective breeding of animals that prefer alcohol. Biological markers for alcoholism have been suggested in the form of neurotransmitter differences and insensitivity to alcohol but firm causal links are yet to be found. There is less research on the hereditary basis for other substances.
   Psychodynamic explanations stress childhood traumas, dependency needs, and the need to release inhibitions concerning repressed conflicts. While reviews of the research show no single alcoholic personality, antisocial behavior and depression have been associated with drinking problems. Emotionality and sociability may also be associated. Longitudinal research indicates that maladjustment in teens may be associated with both abstinence from drug use and frequent drug use.
   Sociocultural explanations note differences in consumption based on sex, age, social class, ethnicity, and religion. France and Italy both have high alcohol consumption, but the U.S. and Russia have high rates of alcoholism. In the United States, European Americans are more likely to use hallucinogens and PCP but less likely to use heroin than African Americans or Latinos, a probable reflection of sociocultural influences. Peer group influences and exposure to adult drinkers predict adolescent drug use.
   Behavioral explanations originally focused on the tension-reducing properties of alcohol. However, the Marlatt et al. (1973) study, in which alcoholics and social drinkers were led to believe they were drinking alcohol when they actually got tonic, showed that expectation has a strong influence on use. Alcohol seems either to increase or decrease anxiety, depending on whether there is a distraction to divert the drinkers attention from his or her anxiety. A longitudinal study showed that adolescents who expected social benefits from drinking drank more and endorsed even more positive expectancies about alcohol. Coping responses 'and expectancy exert a combined effect to predict alcohol and drug use.
   Relapse is a crucial topic for substance-related disorders. Certain feelings and situations increase the risk for relapse, although recent research found that relapse was least likely when users set goals of absolute abstinence and had positive moods, rather than when they were in stress-free environments. Relapse is not merely caused by physiological withdrawal effects; cognitive, behavioral, and biological factors interact. Teaching cocaine users to cope with high risk situations has been successful in reducing relapse for cocaine use.
6. Overall theories of the addiction process (p. 294)Solomon (1977) argues that addiction is an acquired motivation. His opponent process theory says that chronic use decreases the initial effects of a drug but increases the intensity of withdrawal reactions. Motivation for drug use changes from positive to aversive control. Wise (1988) believes that positive and negative reinforcement combine to explain addiction. Finally, Tiffany (1990) suggests that drug use is largely an automatic process, where urges and plans play little role.
7. Intervention and treatment of substance-use disorders (p. 295) A first step in most treatment programs is detoxification, the elimination of the chemical from the body. The second step tries to prevent the person from returning to the substance. Self-help groups, such as Alcoholics Anonymous, which stress support, spiritual awareness, and public self-revelations, are often helpful, but less so than members assert. Chemicals such as Antabuse for alcohol and methadone for heroin treatment can be useful but have the problem of individuals ceasing to take the medication. Naltrexone has been helpful for reducing alcohol and heroin cravings. However, in smoking cessation, nicotine patches hold promise. Reasons for resuming smoking include physiological and psychological factors. Cognitive and behavioral therapies include aversion therapy, covert sensitization, rapid smoking, nicotine fading, spacing of cigarettes, relaxation training, and coping-skills training; reinforcing abstinence has been effective for opiod-dependent person. There is considerable controversy about treatment for controlled drinking for alcoholics. In addition to the problem of retraining patients to drink socially, the researchers themselves have been attacked. Most treatment uses a multimodal effort, including inpatient individual and group therapy followed by outpatient treatment and support groups.
   Prevention programs often seek to educate the public about the negative consequences of substance use. One junior high school smoking-prevention program that used resistance training, information about physical consequences, and information on the social image of smokers was able to reduce the likelihood of students becoming smokers, compared with a control group not participating in the program.
   Treatment is effective but only modestly so. One-third of alcoholic clients are abstinent at one year; most smokers have relapsed within a year of treatment. However, some individuals recover on their own. Treatment is especially beneficial for adolescents who completed treatment and have parental and peer support for non-use. There is no best treatment; the task is to find the best combination of treatments for each individual.